Community Health Services
Quality Account 2010-11
YOUR HEALTH, OUR BUSINESS
June 2011
CONTENTS
PART 1: Quality throughout the organisation
Statement from the Managing Director ……………………… Page 3
An overview of quality ………………………………………….. Page 5
PART 2: Looking forward to 2011/12
Priorities for improvement ……………………………………… Page 12
Statements of assurance from the Board ……………………. Page 16
PART 3: Looking back at 2010/11
Review of quality performance ………………………………… Page 25
Statements from other organisations ………………………… Page 34
Appendix 1 - Quality Framework …………………………..
Appendix 2 - Key Quality Indicators …………………………..
Appendix 3 - Glossary of terms ………………………………..
Page 40
Page 43
Page 44
PART 1: QUALITY THROUGHOUT THE ORGANISATION
STATEMENT FROM THE MANAGING DIRECTOR
Welcome to the first Quality Account produced by Telford and Wrekin Community Health
Services. I would like to extend my appreciation to all the staff for their hard work during the
past year. This account shows some but not all of the work undertaken by our diverse range
of clinical, medical, allied health, administrative, secretarial and clerical staff. It is our first
account of how Telford and Wrekin Community Health have delivered excellent services;
much recognised by those we serve.
2010/11 has been a challenging year with much change and uncertainty whilst we continued
to transform our organisation to be user centred; with quality at its heart. Despite this; we
have made progress in being able to benchmark the quality of the services we provide.
Improving quality has been a key aim for the organisation and through the Quality Assurance
Group we have developed a framework of quality improvement that enhances the safety,
experience, effectiveness and outcomes for our patients served.
This quality account demonstrates where quality is central to the delivery of care for all staff,
as we strive to provide high quality effective health services, tailored to meet the needs of the
people and communities. This is achieved by adhering to the values dear to us; to provide
high quality services that are safe, effective and valued by users, to improve user experience
of all services through development of routine and systematic engagement and feedback
mechanisms, to work in partnership with commissioners, partners, and other stakeholders to
deliver integrated services and to establish effective management information systems
Representatives from other organisations such as Shropshire County Community Services
have contributed to the content of the account with a look forward section of quality account
common for both organisations; in anticipation of combining into a new provider organisation
across Shropshire, Telford and Wrekin on 1st July 2011. Therefore the priorities for
2011/2012 have been jointly agreed with Shropshire County Community Services.
4
Fran Beck – Managing Director (Telford and Wrekin
Community Services)
I declare to the best of my knowledge the information
contained within this quality account is an accurate
reflection of the work carried out by Telford and Wrekin
Community Services in our quest for quality.
Signed:
Fran Beck - Managing Director
Date: 23rd June 2011
5
AN OVERVIEW OF QUALITY
These accounts give an overview of the quality of the services that we deliver to our
communities. It looks ahead to how we intend to improve quality over the next 12 months,
highlights some key areas where things have gone well in the last 12 months and areas
where we recognise that we need to do more.
This account cannot include every area or every service, however seeks to give a broad
picture that focuses on the three domains of quality – patient safety, effectiveness of care and
patient experience.
The looking forward section gives details on quality for the new Shropshire Community Health
NHS Trust when services will be combined from the community health services of Shropshire
County PCT and NHS Telford and Wrekin, on 1 July 2011. The looking back section reviews
Telford and Wrekin’s community health services as an arms length provider within NHS
Telford and Wrekin.
WHERE WE LISTENED
KEY POINT
When it comes to reviewing the quality of our services and setting priorities for future quality
improvement, listening to our staff and our patients is vital. Patient feedback is collected in a
variety of ways and coordinated via a User Engagement Group. This group reports to the
Quality Assurance Group and has representation from our clinical leaders across all services.
The group have developed a user engagement strategy and associated action plan to ensure
that patient stories are heard. As a result, we have implemented a systematic approach to
user engagement across all operational services supported by the development of a Patient
and Public Involvement (PPI) toolkit. We have also used this forum to share good practice
and highlight learning from services experiences of patient and public involvement.
Methods of patient and public involvement have been wide ranging from feedback postcards
to patient stories and face-to-face consultation on elements of services redesign. An example
of where service users have influenced quality is evidenced within children’s services where a
questionnaire was used to establish service user views.
6
EXAMPLES WHERE SERVICE USERS IMPROVED QUALITY:
The response from service users resulted in the following service changes being
implemented.
Referral criteria reviewed
Assessment of needs – agreed and planned review dates for all of the family
Assessment would have a multiagency approach
Awaiting national guidance to also inform decision making panel approach
Aim to plan to provide a 4 week pre-planned rota with crisis measures agreed on an individual
basis.
Revised parent carer agreement letter to parents
Further examples below show where we listen and continue listening:
 All community health services carry out patient satisfaction surveys.
 Complaints made to departments or to the PCT complaints manager are dealt with on a
case by case basis. These are resolved at a local level, in a timely way and through
discussion with the complainant to ensure that they are involved in and satisfied with the
way their complaint is handled.
 Positive feedback received through compliments is shared with staff. It is as important to
celebrate the positive as to learn from the negative.
7
 Websites such as NHS Choices and Patient Opinion, where patients can comment
about the care they have received, are reviewed regularly. Any issues or concerns are
highlighted to the appropriate department to look into and service improvement actions are
taken as appropriate.
 Focus groups, consultation events and public meetings are organised to seek views
and input into specific areas of work.
WHERE WE LISTENED TO STAFF
Staff feedback is also actively sought as follows:
 The national NHS staff survey is carried out on an annual basis.
The results of this survey are discussed with the unions and
department managers to develop an action plan of areas where the
survey results show we need to improve.
A SAFE, EFFICIENT, EFFECTIVE AND INNOVATIVE ORGANISATION
INCIDENTS & ALERTS
Incidents are reported onto an online system available to all staff. Alerts about patient safety
are distributed and reported using the same system. All alerts for 2010/11 with a deadline
prior to 31 March 2011 were actioned. All staff has access to an online reporting system
called Datix and report incidents and receive Safety Alerts via Datix. Managers have to
respond on the system and state what action they have taken to prevent re-occurrence of
issues. Each alert received is assessed for relevance and is acted on according to the type
and nature of the notice. 74 alerts were distributed during 2010/11 in total.
55 – Medicine & Healthcare products Regulatory Authority (MHRA)
5 – National Patient Safety Alerts (NPSA)
9 – Department of Health
5 internal alerts
KEY POINT
At the end of the year, all notices received in year had been actioned or remained in progress
where the deadline may not be reached.
8
PRODUCTIVE COMMUNITY SERVICES
The Productive Series 1 , developed by the NHS Institute for Improvement and Innovation, is a
series of programmes that support NHS teams to redesign and streamline the way they
manage and the way they work. The aim is to create extra time to spend with patients, as
well
as
improving
the
quality
of
care
delivered
whilst
reducing
costs.
The programme aims to achieve change across the organisation. It engages front line teams
in improving quality and productivity.
Teams work through a series of modules to ‘build a house’ (see figure 1). Clinical leadership
development is encouraged at all levels throughout the teams with different clinicians having
responsibility for different modules.
(Figure 1)
Underpinning both programmes is a patient perspective module, which was launched jointly in
Shropshire and Telford and Wrekin in November 2010.
The ‘Productive Community Services’ programmes audit patient experience and other areas
on a regular basis and are therefore able to respond to required changes. All teams display
their audits results and can show how well they are doing and where things can be improved.
The programme will form a key part of the future organisation’s drive for quality and
productivity improvement.
1
http://www.institute.nhs.uk/quality_and_value/productivity_series/the_productive_series.html
9
COMMISSIONING FOR QUALITY AND INNOVATION
The Commissioning for Quality and Innovation (CQUIN) payment framework enables
commissioners to reward excellence, by linking a proportion of healthcare providers' income
to the achievement of local quality improvement goals. The CQUIN scheme is agreed
between commissioners and provider organisations based on improving and developing
services and care for patients. It is an incentive payment linked to the value of the contract.
The scheme is made up of several goals that link to quality. NHS Telford & Wrekin
commissioners had 7 CQUIN goals for Community Health Services to achieve in 2010/11
covering the following areas: Patient Experience (using continence, COPD, diabetes and
wound care services); smoking cessation – brief interventions in outpatient services; falls risk
assessments; nutritional assessment; dementia care pathway implementation; end of life care
– the number of patients who have died being managed on the Liverpool Care Pathway; and
pressure ulcer care.
KEY POINT
Of these, four were fully met, two were partially met and one - smoking cessation – was not
met. Those that were partially met were falls prevention, where progress was made but not as
much as expected and dementia care where there were technical problems with the CQUIN
itself. These will form further work for 2011/12.
MEETING FUTURE CHALLENGES
Quality, Innovation, Productivity and Prevention (QIPP) is the principle by which the NHS
is focusing on maximising quality of healthcare whilst improving the experience of patients
and the public. Examples of how Telford and Wrekin’s community health services are
addressing the challenges of QIPP are given throughout this quality account and include
quality improvements made through audit, risk reduction, CQC compliance and achievement
of CQUIN targets.
EVIDENCE OF QIPP
In practice QIPP has also been achieved in the development of Advanced Primary Care
Services for Rheumatology in order to meet a wide range of needs, offering more choice, and
more efficient care closer to home to improve service user outcomes and also a review of
traditional referral processes to establish a more responsive user focused service.
10
Dissemination of NICE guidance: All NICE guidance has been disseminated monthly
throughout the organisation, including NICE newsletters. The information includes all
published
guidance;
providers
affected
by
the
guidance;
funding
considerations;
implementation support tools including costing and impact tools, commissioning guidance and
audit support.
Quality Assurance: Further assurance work is in progress to ensure that services are
compliant with NICE Guidance and other regulatory requirements. Commissioners will also be
formalising their approach to monitoring the implementation of NICE guidance through quality
review meetings. This will include the new NICE Quality Standards.
KEY POINT
Quality Framework (Appendix One):
The Domains of the organisations Quality Framework are underpinned by NICE Quality
Standards which sets out the evidence based characteristics of a high quality service. Each
Domain encompasses the three parts of the NHS definition of quality (effectiveness, patient
experience and safety). The quality framework found within the appendices demonstrates
where Telford & Wrekin were compliant within quality programme areas and where more work
is needed. The key areas of improvement for 2011/12 to be addressed within the new
combined organisation includes a number of policies found to be inadequate at NHSLA
assessment; requiring further detail and aggregation, the Telford & Wrekin clinical supervision
policy for staff and a review of the efficacy of the current risk assessment tool.
Safeguarding Children & Adults
Children:
Telford and Wrekin Community Health Services (T&WCHS) has a responsibility to safeguard
the welfare of children. All those who come into contact with children and their families in their
everyday work, including those people who do not have a specific role in child protection,
have a duty to safeguard and promote the welfare of children.
11
KEY POINT
This is done by having in place policies, procedures, training strategies, supervision and
access to advice from Designated and Named professionals who are specialists in
safeguarding and child protection. The protection of children is everybody’s business and the
process is carried out through multi-agency working.
T&WCHS supports national legislation and guidance, together with policies and procedures
and should be read in conjunction with electronic Safeguarding Children Board Procedures
found at www.telfordpct.nhs.uk / www.telfordsafeguardingboard.org.uk. The procedures are
constantly updated to respond to current legislation, guidance and research.
Adults:
Similarly, T&WCHS is committed to safeguarding the well-being of vulnerable adults receiving
services. We work closely with the local authority to ensure concerns are acted upon and
referrals into the adult protection process are made in a timely fashion. The following weblink
takes you to the NHS Telford & Wrekin Adult Safeguarding Home Page where links to other
sites, such as the Multi Agency Adult Protection Policy and Procedures are found.
http://www.telford.nhs.uk/Services/A-Z-of-Services/Safeguarding-Vulnerable-Adults/
PART 2: LOOKING FORWARD TO 2011/12
PRIORITIES FOR IMPROVEMENT
Priorities for demonstrating quality and improvement in the services that we provide have
been chosen for 2011/12. They link to the following three domains of quality and they must
be present equally and simultaneously to ensure quality in care 2 :
1. Patient safety
2. Clinical effectiveness
3. Patient experience
Our priorities for 2011/12 are as follows:
 To reduce the number of avoidable hospital admissions
 To reduce the number of healthcare acquired infections (‘superbugs’) in our
community services
 To reduce the number of falls in community hospitals
 To increase the ways in which we collate patient feedback
 To improve and standardise the care of patients who have, or are at risk of
developing, a pressure ulcer in the community
These priorities have been selected through discussions with staff, commissioners, patients
and public and include priorities for both children’s and adult services. These discussions
were launched at a quality account workshop and took into account:
-
Themes identified through patient feedback via the Trust’s complaints system and Patient
Advice and Liaison Service (PALS).
-
Existing quality indicators 3 set nationally and agreed locally with commissioners.
-
Priority areas identified within the Trust’s future business plan as a Community NHS Trust.
PRIORITY: To reduce the number of avoidable hospital admissions
Rationale: Patients want to remain in their own homes where possible, so avoiding hospital
admission would result in a better patient experience.
Providing care closer to people’s
homes is a key aim of the community trust and is also a priority for commissioners. This
priority links to all the domains of quality – patient safety, effectiveness of care and the patient
experience.
2
3
Quality Governance in the NHS - A guide for Provider Boards - National Quality Board, March 2011
See Appendix 2 for a list of the key indicators
13
KEY POINT
How this will be achieved and measured: Existing initiatives across the county 4 , and
projects, include amongst others:
 Enhanced Care Teams - teams of nurses and therapists who work together according to
the needs of the patient, providing assessment, care and treatment with a focus on
admission avoidance and helping patients to manage their own conditions;
 Community Matrons - specialist nurses who work with patients with multiple long term
conditions, aiming to prevent hospital admissions and reduce length of hospital stays;
 DAART services, providing Diagnostics, Assessment and Access to Rehabilitation and
Treatment;
 The Frail and Vulnerable scheme;
 The Virtual Ward scheme, which aims to create more beds in the community;
 The use of Telehealthcare, enabling patients to be able to communicate with healthcare
staff without the need for admission.
A number of developments are planned to extend and improve such services, to provide more
alternatives to hospital admission and to reduce delayed discharges from hospital. At the
time of publication, the method for measuring admission avoidance was under review.
Admission avoidance data is currently collected and this will be used to provide evidence of
these initiatives being effective in reducing hospital admissions. Progress against this priority
will be reported on in the next Quality Account.
(Priority lead: Deputy Director Integrated Community Services)
PRIORITY: To reduce the number of healthcare acquired infections
(‘superbugs’) in our community services
Rationale: Cleanliness and the risk of infection when accessing any health service are a
concern to patients. Monitoring the number of ‘superbugs’ such as Clostridium difficile and
Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia remains a priority amongst
NHS organisations. Reporting and being aware of cases ensures that we continue our work
to reduce the risk of superbugs spreading. This priority links to ‘patient safety’.
4
Details of these services can be found on the Trusts’ websites at www.shropshire.nhs.uk or www.telford.nhs.uk
14
KEY POINT
How this will be achieved and measured: The Infection Prevention and Control team
carries out an annual audit programme of compliance with infection prevention and control
policies across all community services.
The results of this are reported through internal
governance arrangements and published within the infection prevention and control annual
report, available on the PCTs’ websites. The report also includes progress against specific
national infection rate targets and local monitoring of hand hygiene and cleanliness
standards, using national audit tools to measure performance.
The specific infections
monitored may alter depending on the national guidance that is developed. Over the next 12
months, we will start to plan the implementation of the Department of Health initiative ‘Saving
Lives’ High Impact Actions 5 – an evidence-based approach that relates to key clinical
procedures or care processes that can reduce the risk of infection if performed appropriately.
Progress against this priority will be reported on in the next Quality Account.
(Priority lead: Head of Infection Prevention and Control)
PRIORITY: To reduce the number of falls in community hospitals
Rationale: The reduction of falls is a nationally recognised indicator and a High Impact
Action 6 .
Reducing the number of falls in our community hospitals, and the number of
fractures caused by falls, remains a high priority for the trust. Falls have a high impact on
patients’ quality of life and their level of independence. This priority links to ‘patient safety’
and is part of a national approach for delivering safe care through a Quality, Innovation,
Prevention and Productivity work stream (QIPP).
5
6
See glossary of terms at Appendix 3
See glossary of terms at Appendix 3
15
KEY POINT
How this will be achieved and measured: A number of measures have been implemented
to achieve a reduction in falls (see page 15).
In addition to these, slippers are being
purchased for patients who do not have suitable footwear, and training for staff is to start for a
package that has been developed for preventing falls in care homes. All incidences of falls
within our community hospitals are reported via the Datix incident reporting system as a
clinical incident. The number of falls is monitored on a monthly basis and a year on year
reduction in falls of 20% remains a key performance indicator. Progress for 2011/12 will be
reported on in the next Quality Account.
(Priority lead: Deputy Director Integrated Community Services)
PRIORITY: To increase the ways in which we collate patient feedback
Rationale: We have identified the need for more ‘real’ patient experience information; linked
to ‘patient experience’. There are concerns amongst patients, reiterated to us at the quality
account workshop by patient representatives and by Community Involvement in Care and
Health (CInCH), that making a complaint and taking part in a survey – especially during a
hospital stay – will compromise their care. Increasing and improving the ways in which we
collect patient feedback will allow us to better understand and respond to patient needs, and
improve experiences as a result.
KEY POINT
How this will be achieved and measured: Patient feedback will continue to be collected via
patient questionnaires, complaints, patient incidents, via the Patient Advice and Liaison
Service (PALS), quality reviews, and focus groups with users of specific services. Teams will
be asked to not only audit how they have collated patient experience data, but also how they
have responded to the feedback where a response was required.
Handheld ‘Patient
Experience Trackers’ (PET) are to be trialled in the community hospitals – this will allow for
anonymised, ‘real time’ feedback from patients around aspects such as cleanliness, meals
and staff attitude, without any fear of their comments having a detrimental effect on their care.
It will also give staff immediate feedback that can be acted on straight away or in a very short
timescale, to quickly put things right. Regular reports will be run and displayed for both staff
and patients to see the results – encouraging both patient reporting and staff response. In
16
addition to this, we intend to do more work with staff and patient representatives over the next
12 months to develop further ways in which we gather such feedback.
Priority lead: Deputy Director of Strategy and Corporate Development)
PRIORITY: To improve and standardise the care of patients who have, or are at
risk of developing, a pressure ulcer in the community
Rationale: Pressure ulcers have a significant impact on the health of an individual. Their
treatment can require significant use of NHS resources, including acute hospital admissions.
The care and reduction of pressure ulcers is a High Impact Action 7 , a nurse sensitive
indicator 8 and is supported by National Institute for Health and Clinical Excellence (NICE)
guidance. Pressure ulcers are also part of the local CQUIN payment scheme and again form
a priority nationally as part of the Safe Care QIPP work stream. Locally, wound care audits
carried out within community services have highlighted the need for more awareness and
training for staff in order to reduce pressure ulcers that are acquired when using our services.
This priority links to ‘effectiveness of care’.
KEY POINT
How will this will be achieved and measured: All community nurses are to carry out a
Waterlow Score 9 as part of the initial patient assessment. All patients assessed as being at
risk of developing a pressure ulcer will have an evidence-based plan of care. This will be
measured through a wound care audit. All community nurses will undertake training in the
prevention and management of pressure ulcers – this will be recorded in their appraisal. We
will ensure that there is enough equipment, and sufficient access to this equipment, for
relieving pressure ulcers. All pressure ulcers that are of a certain severity (grade 2-4) are
reported as a clinical incident.
This allows for the number of pressure ulcers within
community services to be monitored.
The number of incidences of pressure ulcers are
reported through a dashboard system on a monthly basis. Full root cause analysis is carried
out for any pressure ulcers that are grade 3 or 4. This process highlights any issues that
require further attention, for example patterns of care, improvement in the supply of
equipment and ways to improve patient compliance.
As staff awareness and reporting
improves, the numbers of reported pressure ulcers are expected to increase initially (as
7
See glossary of terms at Appendix 3
See glossary of terms at Appendix 3
9
Assessment to identify the risk of a patient developing a pressure ulcer
8
17
demonstrated on page 25). Success against this priority will be measured through the uptake
of training and results of wound care audits. Over time the aim is to reduce the numbers of
pressure ulcers acquired in the community, this forms part of the CQUIN target around
pressure ulcers for 2011/12. Progress against this priority will be reported on in the next
Quality Account.
(Priority lead: Deputy Director of Quality and Nursing)
STATEMENTS OF ASSURANCE FROM THE BOARD
Service provision and review
During 2010/11 Telford and Wrekin Community Health Services provided and/or subcontracted 48 NHS services. Telford and Wrekin Community Health Services has reviewed all
the data available to them on the quality of care in 48 of these NHS services.
The income generated by the NHS services reviewed in 2010/11 represents 87% of the total
income generated from the provision of NHS services by Shropshire County PCT Community
Health Services.
Participation in audits and research
We are committed to undertaking audit and research and believe that these processes will
help us to improve patient care and outcomes through systematic review of care against
agreed criteria. During 2010/11, 3 national clinical audits and 0 national confidential enquiries
covered Telford and Wrekin Community Health Services.
During that period Telford and Wrekin Community Health Services participated in 100% of
national clinical audits and 100% national confidential enquiries of the national clinical audits
and confidential enquiries where eligible to participate. The national clinical audits and
confidential enquiries that Telford and Wrekin Community Health Services were eligible to
participate during 2010/11 are as follows:

National audit of continence care for all adults

National audit of falls and bone health in older people

National diabetes audit
Telford and Wrekin Community Health Services were not eligible to participate in any national
confidential enquiries during 2010/11.
The national clinical audits that Telford and Wrekin Community Health Services participated
in, and for which data collection was completed during 2010/11, are listed below alongside
the number of cases submitted to each audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or enquiry.
Audit
National audit of continence care for all adults
National audit of falls and bone health in older people
National diabetes audit
Participation
Yes
Yes
Yes
% Cases submitted
100%
100%
100%
19
The reports of three national clinical audits were reviewed in 2010/11 and Telford and Wrekin
Community Health Services intends to take the following actions to improve the quality of
healthcare provided.
ACTIONS
a) Following review of the National audit of continence care for all adults:

To develop behavioural competencies around catheter and infection control, linked
with skills for health, essential steps and Royal Marsden competencies

To ensure the use of standardised assessment tools to measure and record functional
ability for older patients and their mental state

Revision of all existing continence related policies to ensure compliance with NICE
guidance and “Good Practice in continence services” (DH 2000)

To develop an integrated continence care pathway

To increase patient participation through existing user groups and develop a
questionnaire for patients/carers

To develop and deliver a continence care training programme to care homes and
agencies
b) Following review of the National audit of falls and bone health in older people

To develop a Falls Prevention policy in order to reduce the number of falls and falls
related injuries within community services, reduce admission and length of hospital
stay, educate staff, patients and carers about reducing risk of falls and achieve targets
set in High Impact Action and the Commissioning for Quality and Innovation payment
framework.
Clinical audit activity has taken place within all Telford and Wrekin Community Health
services during 2010/11 and has involved healthcare professionals from a wide range of
disciplines. All projects are prioritised based on clear rationale and drivers. Projects are
assessed according to four levels of priority:
1.
National Priority (external must do’s)
2.
Trust Priority (internal must do’s such as risk)
3.
Service Priority
4.
Clinician Interest
20
The reports of 16 local clinical audits (excluding infection control audits) were reviewed in
2010/11 and Telford and Wrekin Community Health Services intends to take the following
actions to improve the quality of healthcare provided:
Audit
Hand washing facilities audit
Action
Ensuring all clinical staff have access to alcohol hand
gel.
Ensure that staff visiting patients and clients in their own
homes carry liquid soap, paper towels/hand wipes and
gels and are aware of ordering system.
The infection prevention and control nurses need to be
involved when planning or developing new services e.g.
clinics or piloting new equipment.
Re-audit of antenatal and The importance of completing consent forms fully and
newborn
hearing
screening obtaining signed consent will be reinforced.
consent
Audit will be undertaken again in 18 months time.
Clinical record keeping audit x 3
Reinforce the use of NHS number as the unique patient
identifier.
To improve documentation and ensure consistency in
record keeping within services.
Special investigations audit
Use the audit findings to inform the development of an
ASD care pathway
CDC assessments
Home start project
Evaluation of the
constipation service
children's
Diagnosis and management of
cerebral palsy
Referrals to child development
centre for short assessment audit
ROS evaluation
Speech and language therapy
outcomes
SSLIC evaluation
Involve multidisciplinary team in assessment and
diagnosis of children with ASD
Continue to press for a decision on Community
Paediatricians being able to prescribe Desmopressin and
laxatives
Undertake new review of ASD assessment pathway at
the CDC
All children and young people on the caseload will
receive as a minimum an annual review of their
assessed needs. They will receive a written copy of the
assessment/reassessment along with an agreed date for
review
Neuro-imaging is recommended for every case of CP to
identify the cause. A clinical guideline has been devised
with key points for the paediatrician to remember
Include ‘behaviour’ as a topic in the two day workshops
run at Monkmoor Campus. Upload a Shropshire Autism
Service Directory to the internet.
Communicate results of survey to individual doctors at
the time of appraisal.
Appointed consultants to
undertake training in carrying out appraisals
SALTs to state clearly in their report what type of CDC
assessment
required
and
evidence.
Sufficient
information to be provided in the referral letter from the
doctor
To work towards improving the child’s understanding of
information given in clinic. To improve the flexibility
around appointments.
21
Autistic spectrum disorder audit
Re-audit of immunisations
Records
Prior to every autumn term, medical officer for
Severndale School to obtain immunisation records for all
children due a 14+ medical from Child Health.
Pilot different methods of service delivery and evaluation
with the aim of maximising the number of children able to
access SSLIC
Improve the recording of key information such as
ethnicity and gender across all areas, draw up central
clinician signature list at CAMHS, draw up approved
abbreviations list at CAMHS
Infection, Prevention and Control Audits
These audits were carried out by the infection, prevention and control team to the various
services listed below.
Service/Dept
Date of Audit
APCS - Limeswalk Oakengates
13/04/10
Belmont Sexual Health
11/05/10
Hollinswood STI Clinic
28/09/10
GUM - RSH
26/10/10
PRH - Sexual Health Clinic (GUM)
09/11/10
Pre-audit assessment visit - Stepping Stones Centre
08/11/10
Pre-audit assessment visit - Matthew Webb House,
Dawley
09/11/10
Pre-audit assessment visit - Monkmoor Centre
08/12/10
APCS - Hollinswood
09/12/10
Participation in clinical research.
The number of patients receiving NHS services provided or sub contracted by Telford and
Wrekin Community Health Services in 2010/11 that were recruited during that period to
participate in research; approved by a research ethics committee was 16.
22
CQUINS
A proportion of Telford and Wrekin Community Health Services income in 2010/11 was
conditional on achieving quality improvement and innovation goals agreed between Telford
and Wrekin Community Health Services and any person or body they entered into a contract,
agreement or arrangement with for the provision of NHS services, through the Commissioning
for Quality and Innovation payment framework.
The agreed goals for 2010/11 related to the following topics:
 Patient Experience
 Dementia Pathway Implementation
 Nutrition Assessments and Care Plans patients admitted to Community Hospitals
 Falls Risk Assessments – patients assessed as at risk of fall and number of acute
admissions avoided
 End of Life Care – Number of patients who have died being managed on the Liverpool
Care Pathway for the dying
 Smoking – Brief Intervention in Outpatients
 Tissue Viability – Pressure Ulcers
A proportion of Telford and Wrekin Community Health Services income in 2010/11 was
conditional on achieving quality improvement and innovation agreed with commissioners was
circa £400,000. The CQUIN out-turn delivered all of this payment. Further details of the
agreed goals for 2010/11 and for the following 12 month period are available on request from
fran.beck@teflordpct.nhs.uk
Registration with the Care Quality Commission (CQC)
Telford and Wrekin Community Health Services is required
to register with the Care Quality Commission and its
current
registration
status
is
‘registered
without
conditions’. Furthermore CQC has not taken enforcement
action against Telford and Wrekin Community Health
Services during 2010/11 nor is it subject to periodic
reviews by the CQC.
23
Data Quality
Telford and Wrekin Community Health Services operates Patient Administration Systems
(PAS) using a number of databases which include SEMA, Lorenzo, Graphnet, Lillie, Soft
Options and MESALS.
KEY POINTS
Telford and Wrekin Community Health Services will be taking the following actions to improve
data quality:
-
Further improving the quality and timeliness of data entry onto Lorenzo system
-
Continued monitoring of data entry onto various database system
-
Sharing of monitoring data with staff, and continued awareness raising through team
meetings
Internal audit reviewed the process of performance reporting to the provider board in 2010,
with the final report presented in May 2010. The recommendations made were around setting
targets where none currently exist, and also ensuring that the most up to date, relevant and
timely information was included in reports, with all data being checked back to source for
accuracy and where data has been estimated for this to be made clear in any reports. These
recommendations have been implemented – projected activity is now compared with a target
based on reference costs and progress is monitored month on month. Reports presented to
the board in 10/11 have been extended where appropriate to provide a wider range of
information, and where there are any issues around data quality this has always been made
clear in the accompanying report.
Progress has been made over the last 12 months in improving the quality of data recorded on
the Lorenzo system as follows:

Guidance on the use of different contact types has been developed and issued to
all clinical and managers to ensure that consistent data input across the
organisation is achieved.

Data completeness – gaps in activity recorded on Lorenzo were identified as being
an issue in terms of quality. Monthly reports have been developed identifying all
activity split by individual members of staff, and these have been shared with staff.
In addition, monthly team meetings for each directorate have included data
completeness and activity targets as a regular agenda item. Data comparison
month by month showing variations in projected activity outturns for the year are
24
also shared with managers, together with a comparison with the target figure
(based on the service reaching the national average reference cost). This has
increased focus on activity and resulted in an improvement in the projected outturn
efficiency figures. Out of 19 service areas using Lorenzo, improvements in
projected outturns have been reached in 16 teams, with the improvement
representing several thousand extra contacts in some areas such as community
nursing and children’s speech and language therapy.

Data timeliness – improvements have been made in some areas, particularly
children’s therapy services, school nursing, community nursing and adult
physiotherapy where data is generally input within 21 days of the patient contact.
However there are some services where timely data input is more of a problem and
this will remain a focus for 2011/12.

Data quality for all services will remain a high priority for the coming year to ensure
that all data recorded represents an accurate reflection of the patient journey. The
close work with the Information department to develop more sophisticated reports
will continue to enable further areas of data quality to be explored.
Telford and Wrekin Community Health Services did not submit records during 2010/11 to the
secondary uses service for inclusion in the Hospital Episode Statistics which are included in
the latest published data.
Information Governance (IG)
Telford and Wrekin Community Health Services achieved a minimum level 2 against all 41
requirements of the Information Governance (IG) Toolkit and scored 68% overall. This
complies with the Operating Framework standard for 2010/11 and met the IG Assurance
Statement for organisations using NHS Connecting for Health Services in 2010/11. The PCT
scored 66% and met the ‘Satisfactory’ criteria in both the Clinical and Corporate Information
Assurance initiatives.
Clinical coding error rate
Telford and Wrekin Community Health Services was not subject to the Payment by Results
clinical coding audit during 2010/11 by the Audit Commission.
PART 3: LOOKING BACK AT 2010/11
REVIEW OF QUALITY PERFORMANCE
Introduction
The Trust has worked towards a number of quality indicators over the period 1 April 2010 to
31 March 2011. The summary below highlights some specific areas within the three domains
of quality – patient safety, effectiveness of care and patient experience. These areas were
identified and agreed on through discussions with staff, patient representatives and
commissioners at the quality account workshop and subsequent discussion with key clinical
staff. They were chosen as being those areas which users of our services would view as
being most important when it comes to demonstrating quality improvement, those where we
wish to highlight particular achievements, and those where we have identified the need for
more work and attention.
PATIENT SAFETY
 Reduction of ‘Superbugs’
Key Points:
The target for MRSA bacteraemia was met. A huge amount of work continues to take place
to minimise the risk of infection spreading and ensure a safe service.
Prevention of infection is a fundamental aspect of all care afforded to patients and is at the
heart of patient safety. The ever shorter hospital stay coupled with an increasing proportion
of healthcare being provided in the community has meant greater attention being paid to the
control of infection in the various community settings.
MRSA
In 2010/11, primary care organisations were for the first time set a specific Methicillin
Resistant Staphylococcus aureus (MRSA) bacteraemia objective, based on cases amongst
the population for which the PCT is responsible. This includes MRSA acquired in acute
hospitals (within or outside the local health economy) or within the community.
For 2010/11 the MRSA bacteraemia target for NHS Telford and Wrekin was to have no more
than 5 cases. We achieved this target, reporting a total of 2 cases for the year.
25
Key interventions to prevent the occurrence of MRSA included:
-
Maximising MRSA screening
-
Revised community antibiotic guidelines
-
Infection
prevention
and
control
training
programmes
included
screening
and
management of MRSA
-
Increased hand hygiene audits
-
Strengthening of root cause analysis
CLOSTRIDIUM DIFFICILE
Clostridium difficile
For 2010/11, the national Clostridium difficile target for NHS Telford and Wrekin was to have
no more than 103 cases. A local stretch target was also agreed with the Strategic Health
Authority for no more than 53 cases.
With a cumulative total of 55 cases for 2010/11, (compared to 55 cases in 2009/10) NHS
Telford and Wrekin achieved the national targets for reducing the number of Clostridium
difficile infections this is the same figure as last year and represents a 46% reduction over
2008/09 figures when 102 cases were recorded. NHS Telford and Wrekin narrowly missed to
achieve the local stretch target by two cases.
The table below details the total number of cases since 2008/09 together with the proportion
of those which were acquired in an acute hospital and those acquired in the community.
Total cases of Clostridium difficile from 2008 to 2011 and proportion deemed to be acute and
community acquired
Year
Total Number of
Acute Acquired
Cases
Community
Acquired
2008/09
102
67 (66%)
33 (34%)
2009/10
55
30 (55%)
25 (45%)
2010/11
55
18 (33%)
37 (67%)
The percentage of samples deemed to be acquired within the community has increased over
the last two years. This is not unexpected due to the change in April 2009, in the definition
used to determine hospital or community acquired cases from 48 hours to 72 hours after
admission to the acute hospital.
26
KEY POINT
Some of the actions in 2010/11 specifically targeted at reducing Clostridium difficile included:
 Continuation of 7 day rapid testing for Clostridium difficile and use of typing to search
for clusters or linked cases
 Infection Prevention and Control training programmes included management of
individual cases of Clostridium difficile
 Increase in hand hygiene audits and emphasis on the need to use soap and water, not
hand gel, with Clostridium difficile
 Infection control team together with Medicines management working with GP’s around
antibiotic and Proton Pump Inhibitor (PPI’s) prescribing
 Reinforced public health messages regarding inappropriate use of antibiotics, through
media campaign
Further information and detail around work undertaken by the Infection Prevention and
Control team for 2010/11 can be found in their annual report, available at
www.shropshire.nhs.uk or www.telford.nhs.uk
27
 Staff training
Key Points: Training and development opportunities continue to be scheduled for staff, to
ensure they have the essential skills and expertise to do their job effectively and provide a
safe and effective service to patients. Work is ongoing to ensure attendance at mandatory
training.
For mandatory training, attendance is very good in some subject areas such as Life Support,
Conflict Resolution and Safeguarding Children.
Where attendance is lower, uptake is
monitored regularly and work is ongoing to make improvements such as introducing elearning packages and providing training at work bases to ensure that clinical efficiency and
training go hand in hand.
Some of the new training courses offered in the last 12 months, where it was identified as
being an essential skill were:
 Health Exercise Nutrition for the
Really Young (HENRY) training
 Breastfeeding management training
 Cervical Cytology Courses for new
smear takers
 Certificate in Diabetes Care
 Raising Awareness of Dementia
 Falls Awareness
 Intravenous Therapy Update
 Palliative Drugs & Symptom
Management
 PEG Training for registered nurses
 Sexual Health Training (condom distribution
scheme)
 Spirometry Study Day
 Continence Training which includes various
titles relating to this
 Travel Health Update
 Men’s Health Day
 Managing Minor Injuries
28
EFFECTIVENESS OF CARE
 Pressure ulcers
Key Points:
Targets around pressure ulcers were met. Systems continue to be developed to ensure that
staff are trained, that care pathways are followed, and that equipment is available.
Improving and standardising care for patients who have, or are at risk of developing, a
pressure ulcer in the community remains a priority for the organisation for 2011/12.
Some of the work that has taken place over the past 12 months includes:
-
Pressure ulcer guidance is up to date and available to all staff
-
An evidence based acute and chronic wound care pathway has been developed
-
Training in the prevention and management of pressure ulcers is available
-
Training and guidance is available to staff on reporting of pressure ulcers, and root cause
analysis where required
-
Action plans from all root cause analysis are shared with front line staff
-
Initiative to ensure staff have immediate access to evidence based wound products
-
A health economy Tissue Viability Forum has been set up which is chaired by the Tissue
Viability Specialist
 Data quality
Key Points:
As discussed previously, steady progress is being made in recording data onto the ‘Lorenzo’
clinical IT system in a timely and accurate. The new organisation is looking at the efficacy and
quality of current information systems to ensure that they are fit for purpose.
The recording of activity within current systems is required within 21 days of patient contact
for contracting purposes. Failure to meet this requirement would result in not being paid for
the activity, leading to a cost pressure to providing the clinical service.
Monitoring the time between a patient being seen and the information being entered onto the
Lorenzo has become a quality indicator for all teams.
A target is set of 100% of all
information being entered onto Lorenzo within 21 days.
29
PATIENT EXPERIENCE
Patient satisfaction
Through the establishment of a User Engagement Group, which reports to the Quality
Assurance Group and has representation from clinical leads across all services, we have
developed and overseen implementation of a User engagement strategy and associated
action plan.
As a result, we have implemented a systematic approach to user engagement across all
operational services supported by the development of a Patient and Public Involvement (PPI)
toolkit with associated training and a PPI data collection form informing a centrally held
database.
We have also used this forum to share good practice and highlight learning from services
experiences of patient and public involvement. Methods of patient and public involvement
have been wide ranging from feedback postcards to patient stories and face-to-face
consultation on elements of services redesign.
An example of this is as follows:
Following a questionnaire within Children’s respite services the following service changes
were implemented:
Referral criteria reviewed
Assessment of needs – agreed and planned review dates for all of the family
Assessment would have a multi agency approach
Awaiting national guidance to also inform decision making panel approach
Aim to plan to provide a 4 week pre-planned rota with crisis measures agreed on an individual
basis.
Revised parent carer agreement letter to parents
Patient Advice and Liaison Service (PALs)
During the past year, the PALs team have been actively raising awareness of the service by
having local drop in surgeries at the Civic offices at the town centre and local libraries on a
monthly basis. They have also received numerous invitations to speak to local support
groups.
30
All queries regarding PALs are logged and reviewed. There have been a total of 281 PALs
during the period March 2010 to April 2011.
For community services the number of related PALs reports are highlighted in the table
below. All queries have been resolved.
Areas of enquiry
Wheelchair
Services
Sexual Health
Services
Access and waiting
3
More
information/More
choice
Building Closer
Relationships
Safe, high quality,
coordinated care
1
Totals
7
CAMHS
2
2
1
3
2
3
Further information about NHS Telford and Wrekin’s Patient Advice and Liaison Service can
be found on our website at www.telford.nhs.uk under the heading ‘Have your say’, or by
contacting
the
PALs
Lead,
Sharon
Smith
on
01952
580478,
via
e-mail
to
Sharon.smith@telfordpct.nhs.uk
31
Complaints
Under a new complaints process, the investigating manager/complaints manager have
continued to make early contact with each complainant to agree on an individual basis how
their case is to be handled and an appropriate timescale for response. Once the investigation
into the complaint has been completed the investigating manager / complaints manager will
meet with the complainant to feed back the findings of the investigation and offer an apology if
appropriate. During 2010/11 a total of 39 complaints were received relating to community
services (compared to a total of 32 complaints the previous year). :
Complaints received by Service area during 1 April 2010 to 31 March 2011
Children’s Services – 16 complaints




CAMHS – 9 complaints
SaLT – 2 complaints
Children’s Respite – 4 complaints
Telford CDC – 1 complaint
Adult and Older Peoples Services – 14 complaints





SWPS – 4 complaints
Community Rheumatology Service – 3 complaints
Health Improvement – Adults (re; NHS Fit for Men programme) – 1
complaint
District Nursing – 4 complaints
SET – 2 complaints
Child and Family Services – 4 complaints




HIMP – Obesity (re; National Children’s Measurement Programme) – 1
complaint
Health Visiting – 1 complaint
School Nursing – 1 complaint
Imms & Vaccs – 1 complaint
Occupational Health – 5 complaints
All complaints have been dealt with using an improved person-centred approach. This has
meant that complainants have felt that their complaint has been taken seriously and that the
organisation has listened to their complaint. Learning from complaints is also used to improve
service quality.
32
Compliments
In contrast 59 compliments were received in 2010/11. From 1 July 2010 a system was
introduced to capture information about compliments received by Telford & Wrekin
Community Health Services – compliments include letters of thanks and donations.
Some examples of compliment letters received:
‘I would like to say a big thank you to the District Nurses for the excellent care and attention I
have received at home during the last 16 weeks.’
‘Thank you very much for fixing my child’s wheelchair so quickly yesterday when the tilt
mechanism got stuck”
‘Thank you so much for helping me understand and beat this horrid illness. You definitely
deserve this; you have helped me and my future.
33
STATEMENTS FROM OTHER ORGANISATIONS
Comments on the Quality Account from Telford & Wrekin Local Involvement Network
(LINk).
Telford & Wrekin Local Involvement Network (LINk) is pleased to have this opportunity to
comment on the Community Health Services Quality Account. In the last twelve months we
have received feedback from more than 4000 patients and service users about their
experiences of all local healthcare services, including community services.
We were directly involved in designing questions to be used on the handheld Patient
Experience Trackers which involved us in discussions with members of the public about their
experiences of community services.
In 2010 we were also pleased to assist the Primary Care Trust establish the Community
Services Integration Project by taking part in the Community Engagement Group and are
looking forward in the year ahead together with CInCH to helping the newly formed
community health trust to extend user group participation.
However, given this recent level of involvement, we are disappointed by the short notice given
to the LINk to contribute to the Quality Account as there is a clear timetable for this and while
we recognise the significant disruption caused by the separation from the PCT, we would ask
that the national timetable is adhered to in the future.
In terms of the way the report is presented we feel that it would be useful for the quality
account to summarise at the outset specifically who benefits from the services and what the
actual outcomes of the service have been as this would help balance what otherwise comes
across as a report about policies and systems.
Based on feedback we receive from service users and carers in Telford & Wrekin, our
understanding is that overall there is a relatively high level of satisfaction and appreciation of
community health services. Where concerns are expressed these most often relate to
communication issues between the acute trust and community services – particularly in
relation to hospital discharge arrangements.
34
For that reason we would urge the newly formed trust to ensure that in future the quality
account provides insight into relationships being forged with other organisations as although
partnership working is referred to several times in the report; there are few examples of who
the partners are, what difference the collaboration makes and where improvements are being
sought to ensure integrated delivery of services. This would help reinforce the pivotal role
played by community services in ensuring intersectoral multi-agency collaboration in what is
now a mixed economy of healthcare provision.
We were pleased to read of the trusts intentions to engage service users more effectively and
would welcome the opportunity to work with the trust in enabling it to involve service users
and the organisations which represent them in strategic decision-making as well as in
designing service improvements. The very successful health and community development
course designed by the trust’s community engagement team that was run in conjunction with
Telford College of Arts and Technology deserves mention in the quality account as the
community health champions have not only been effective catalysts for change, but also
because the initiative demonstrates a commitment to community leadership.
At a more fundamental level, communities need information before they can become engaged
and we would ask the trust to use the annual quality account as a prime opportunity to
communicate what it does in a straightforward way as we believe there is limited public
awareness about what these are and an appendix listing the forty-eight services would be a
helpful addition to the report.
An expanded glossary would also helpful to explain what the thirty or more acronyms and
abbreviations that are used l – especially on page 18 and also in the appendix - as this makes
the report less accessible than it need be. The quality account would also be more meaningful
if it focused on what difference it made and to whom. For example reference is made to:
Patient Satisfaction Surveys - it would be helpful to know when and where these surveys
took place and the outcome of the data collected
Complaints received - it would be more informative to understand the number of complaints
and if they were satisfactorily resolved. A case study from beginning to end with comments
from the complainant would highlight the care and sensitivity used to resolve complex issues.
35
Dementia care pathways – it would be helpful to know what the “technical problems” were
regarding the CQUIN payment and whether these were resolved
National Clinical Audits – information about the outcomes from the pieces of work outlined
as and when this takes place would be helpful as we believe that the local involvement
network can contribute to the audit process and also to quality assurance processes being put
in place.
Priorities for 2011/2012
We note your priorities for 2011/2012 and will follow these through with interest during the
year focussing on the best outcome for patients. One priority we would value working closely
with you on during 2011/2012 is the area “increasing the ways in which you collate patient
feedback “where we do have the expertise to be of added value to patients”.
Telford & Wrekin LINk would have liked to see Mental Health Promotion as a priority area as it
is a new area for community services to be funded for taking into account the New Mental
Health Strategy.
We would also urge the trust to acknowledge that pressure sores are largely preventable in
whatever setting the patient is being cared for and to identify how improvement to basic
nursing practice key to ensuring prevention. We would also ask the trust to raise awareness
that pressure sores have to be reported as an indicator of neglect of vulnerable adults so that
a more holistic approach to care can be achieved.
Finally, we hope that the newly established service is able to build on and extend the good
practice which has been developed across the two areas despite severe financial constraint
as we are concerned about the pressures that the trust will experience as a result of an
ageing population and increasing numbers of families and older people being affected by
poverty and/or a reduction in services or eligibility for social care which may well have an
impact on community health and wellbeing.
Telford & Wrekin Local Involvement Network (LINk).
36
Telford & Wrekin Health Scrutiny Committee - Response to Community Health Services
Quality Account 2010-11
Thank you for providing the Telford & Wrekin Community Health Service Quality Account
2010/11 for information and comment.
As the deadline for responding with comments was very short, the Committee has not had an
opportunity to review the Quality Account in detail or to agree collective comments.
However, monitoring elements of the Community Health Service and the Community Trust
may form part of the Health Scrutiny Committee 2011/12 work programme, or that of the Joint
Health Overview & Scrutiny Committee.
Members of the Committee would like to highlight the importance of close working with
hospitals and partners on developing care plans for discharged patients, particularly those
who live alone or are vulnerable, the development of falls prevention strategies with partners,
and reducing hospital and community acquired infections, and the need for monitoring
performance in these areas.
Cllr Derek White
Chairman of the Telford & Wrekin Health Scrutiny Committee. June 2011
37
Joint PCT Statement on Telford & Wrekin Community Services Trust Quality Account
2010/11
Both Commissioning Organisations monitor the quality and performance of the commissioned
services delivered by the Trust, and review both performance and governance data via the
monthly Clinical Quality Review meeting attended by both clinicians and managers.
Based on the knowledge that both PCTs have of Telford & Wrekin Community Services we
believe that the Quality Account is reflective of the achievements within the year.
The
document also demonstrates the commitment of the newly established Shropshire
Community NHS Trust to strive for excellence as a listening and learning organisation and in
the delivery of safe effective clinical care.
We recognise the improvements to quality and innovation within the provider by the partial
achievement of the contractually agreed ‘Commissioning for Quality and Innovation (CQUIN)
Scheme for 2010/11’. The agreed CQUIN scheme for 2011/12 reflects the ethos of the PCT
to work in partnership with the Trust to ensure high quality safe clinical effective services and
excellent patient experience and outcomes as a key priority.
The PCT supports the priorities for improvement identified by the Trust and the promise to
deliver high quality care and effective clinical outcomes.
Accuracy of Information
The PCT has taken the opportunity to check the accuracy of data provided within the Quality
Account in relation to the services commissioned from the Trust and believes it is a true
reflection.
Dr Caron Morton
Interim Director for Quality Assurance and Improvement
cmorton@nhs.net
38
Acknowledgements
Key Authors:
Jo Banks, Deputy Director Specialist Services for Children & Young People, NHS Telford &
Wrekin Community Health Services
Helen Couth, Head of Clinical Governance, NHS Telford & Wrekin.
The content of this report has been put together with contributions from a range of staff
across the organisations. Thanks go to all staff for their contributions, and to commissioners,
patient representatives and other stakeholders who have given their time to shape the
document through their input and feedback – this involvement has been very valuable in
producing this account and will shape the improvement of future accounts.
For further information about the PCT and its services, please visit www.telfordpct.nhs.uk
NHS Telford and Wrekin
Halesfield 6
Telford
Shropshire
TF7 4BF
Headquarters: 01952 580300
Patient Advice and Liaison Service (PALS) – 01952 580300
39
Appendix 1: Quality Framework
GAP ANALYSIS
1 CQC and NHSLA
standards
2 Staff
3 Services
A Safety
All services will be fully compliant with CQC
and NHSLA requirements, e.g. child protection
and infection control.
See action plan
All recruitment activity is compliant with safer
recruitment.
All staff access appropriate training including:
~ safeguarding
~ infection control
~ risk management and assessment
COMPLIANT
All services have been formally risk assessed.
See action plan
Business continuity plans have been
developed for all services and tested.
B Effectiveness
All services compliant with requirements
demonstrating effectiveness e.g. use evidence
based measures, NICE guidance.
COMPLIANT
All staff are competent to fulfil their role, e.g.:
~ appropriate qualifications and experience,
on going CPD
~ support and supervision
See action plan
C User Experience
All services compliant with requirements promoting use of user
experience feedback in redesign and improvement of services.
COMPLIANT
All relevant NICE guidance is incorporated in
practice.
Safety alert guidance is implemented.
Regular audits are completed to check
compliance with procedures.
COMPLIANT
Information about services will be clearly
understood by users and referrers.
Referral processes will be simple and well
understood by all referrers.
Referrers will receive timely feedback on
progress of referrals.
All waiting time measures will be met.
Pathways will be straightforward with no
'bottlenecks' or duplication.
COMPLIANT
Goal based outcomes measures are introduced by all services
to systematically measure user experience of services.
See action plan
4 Processes
All assessments, planning, interventions and
review processes in every pathway will have
risk management and assessment built in.
See action plan
Incident reporting will be consistent for all
services and analysis completed to identify
lessons learnt.
Processes ensure that relevant Never Events
do not occur (see Never Events worksheet).
5 Recording
Records will be completed and maintained at a
high standard of orderliness, legibility and level
of detail required to manage needs and risks.
See action plan
Records will be easily understood and provide
an effective working tool for the users needs to
be assessed, supported and monitored.
COMPLIANT
6 Audit and Review
A robust audit programme will be in place to
routinely and systematically review compliance
with the above.
COMPLIANT
A robust audit programme will be in place to
routinely and systematically review compliance
with the above.
COMPLIANT
Staff routinely asks users for feedback as part of CPD.
Staff are treated fairly.
COMPLIANT
Users receive timely information about the service and what
will happen next.
They will have opportunity at all times to ask questions, seek
clarification or request a more flexible service response to
meet the agreed goals.
Users are advised of the processes for:
~ queries
~ complaints
~ raising concerns
~ compliments
These will be dealt with openly and promptly.
Learning will be identified.
COMPLIANT
Wherever possible users will hold their records or copies.
If appropriate they will contribute to the record. User feedback
on their records will be sought to drive improvements.
Ethnicity recorded on records where this is provided by
patients.
COMPLIANT
A robust audit programme will be in place to routinely and
systematically review compliance with the above.
COMPLIANT
40
ACTION PLAN
1 CQC and NHSLA
standards
A Safety
The following policies were found to be
inadequate at the NHSLA assessment:
- Professional registration
- Pre-employment checks
- Security management
- Safeguarding adults
- Inoculation incidents
- Medicines management
- Clinical diagnostic testing
- Claims
- Aggregation and learning from incidents
A paper will be provided to QAG identifying
how these gaps are met.
Lezli Feeney (31 January 2011)
2 Staff
3 Services
4 Processes
5 Recording
B Effectiveness
C User Experience
Further work will be done to develop
supervision practice and process. This will be
discussed at the January QAG.
Jo Banks (January 2011)
Risk assessments are not routinely conducted
for all patients seen in their own homes. A new
initial patient risk assessment form is being
developed and its completion will prompt staff
to complete formal risk assessments in
essential areas, e.g. manual handling lone
working.
Deputy Directors and Lezli Feeney (March
2011)
See A3 (safety & services) above.
See A3 (safety & services) above.
Outcomes measures will be defined for all activity.
Deputy Directors (March 2011)
Wherever possible users will hold their records or copies.
If appropriate they will contribute to the record. User feedback
on their records will be sought to drive improvements.
Ethnicity recorded on all records.
Business Support Unit (September 2011)
6 Audit and Review
41
MEASURES AND LEAD
SUPPORT
1 CQC and NHSLA
standards
A Safety
B Effectiveness
C User Experience
Compliance with:
~ CQC
~ NHSLA Standards
(Lezli Feeney and Helen Couth)
Safer Recruitment procedures
(Human Resources)
Training:
~ mandatory training
~ essential skills
~ appraisals
~ KSF
(DEL Service)
Risk Assessment Code of Practice
(Lezli Feeney)
Business Continuity Planning
(Sarah Amos)
Compliance with:
~ CQC
~ NHSLA Standards
(Lezli Feeney and Helen Couth)
Clinical staff seek user feedback
(Sian Huszak)
Human Resources policies
(Human Resources)
4 Processes
Incorporate risk management into all
processes
Incident Reporting Code of Practice
Serious Untoward Incidents
Never Events
(Lezli Feeney)
Compliance with:
~ CQC
~ NHSLA Standards
(Lezli Feeney and Helen Couth)
All staff have:
~ contracts
~ job descriptions
~ qualified for their role
~ on going CPD
~ line management support
~ relevant supervision
(Human Resources and the DEL Service)
NICE guidance
(Helen Couth)
Safety alerts
(Nicki Dipple)
Audit and Review Plan
(Julie Bone)
Service review
Mapped pathways
Stakeholder consultation
Performance measures, e.g. waiting times
Exception review, e.g. incidents, purple cards
(Managers with relevant leads)
5 Recording
Records Management Policy
(Alan Ferguson)
Records Management Policy
(Alan Ferguson)
6 Audit and Review
Audit and Review Plan
(Julie Bone)
2 Staff
3 Services
Defined goal based outcomes measures for all services
(Sian Huszak)
Leaflet Guidelines
(Alan Ferguson)
Flexibility to meet user needs
(Sian Huszak)
Policies for:
~ PALS - Mark Crisp
~ Complaints - Mark Crisp
~ Compliments – Mark Onions
Being Open Policy
(Lezli Feeney)
Learning from the above
(Lezli Feeney)
Patient held records
Patient engagement
As above
(Sian Huszak)
42
Appendix 2 – Quality Indicators
Accident and emergency waiting times
Outpatients waiting longer than the 13 week standard
Delayed transfers of care
6 week Diagnostic waiting times
Statutory waiting for SEN and LAC children
18 week referral to treatment waiting times for patients
Staying Safe – Preventing Falls
Reduce Sickness absence in the nursing workforce to no more than 3%
Pressure Sores developed under the care of the PCT
Formal and informal complaint
Serious incidents excluding pressure sores
Ethnic coding data quality
Use of NHS Number
Lorenzo data entry within 21 days
MRSA Bacteraemia
Pre 48hr cases involving PCT provider services
Four week smoking quitters
43
Appendix 3 – Extended Glossary of Terms
High Impact Actions
The first set of eight high impact actions sets out the opportunity to improve quality of care
and patient experience while working in an efficient and effective way. For each action the
gains can be huge and nurses and midwives can lead on each of these actions to further
improve the prevention, productivity and efficiency needed in the NHS.
The high impact interventions are:

No avoidable pressure ulcers

Preventing falls

Keeping nourished

Promoting normal birth

End of life care – where to die when the time comes

Reduce sickness and absence in nursing and midwifery workforce – no more than 3%

No delays in discharge

Protection from infection
Nurse Sensitive Indicators
These indicators have been co-produced and developed with key partners and support the
key themes on outcomes focused care. The Indicators support the High Impact Actions and
other quality initiatives. The seven indicators include:
 Your skin matters
 Staying safe: preventing falls
 No unanticipated weight loss
 No dehydration
 Promoting spontaneous vaginal delivery
 Important choices: where to die when the time comes
 Fit and well to care
 Reduction of indwelling urinary catheters
Allied Health Professional - clinical health care professions distinct from medicine, dentistry,
and nursing. For example physiotherapists and occupational therapists.
Commissioning – the planning and purchasing of services.
Lorenzo – information technology (IT) software system for clinical settings, used by
community health services in Telford and Wrekin Community Health Services.
Quality Account - A Quality Account is a report about the quality of services provided by an
NHS healthcare service. The report is published annually by each NHS healthcare provider
and available to the public.
Community Health Services – Community health services are services provided by the NHS
outside of a hospital setting.
NHS Choices – A website providing information available from the National Health Service
on conditions, treatments, local services and healthy living.
Productive Community Services - Productive Community Services is an organisation-wide
change programme which helps systematic engagement of all front line teams in improving
quality and productivity.
Quality Improvement Productivity Prevention (QIPP) - QIPP is a large scale
transformational programme for the NHS, involving all NHS staff, clinicians, patients and the
voluntary sector and will improve the quality of care the NHS delivers whilst making up to
£20billion of efficiency savings by 2014-15, which will be reinvested in frontline care.
National Institute for Health & Clinical Excellence (NICE) - The National Institute for
Health and Clinical Excellence provides guidance sets quality standards and manages a
national database to improve people's health and prevent and treat ill health.
Quality Framework - A framework for evaluating the quality of services across the
organisation.
Quality Assurance - Quality assurance is the systematic monitoring and evaluation of the
various aspects of a service to maximise the probability that standards of quality are being
attained by the organisation.
Audit - An evaluation of a person, organisation, system, process, enterprise, project or
product.
Data - Refers to qualitative or quantitative attributes of a variable or set of variables; as a
result of measurement; such as graphs, images, or observations.
Pressure Ulcers - Pressure ulcers, also sometimes known as bedsores or pressure sores,
are a type of injury that affects areas of the skin and underlying tissue. They are caused when
the affected area of skin is placed under too much pressure
Root Cause Analysis - is a systematic method of problem solving aimed at identifying the
root causes of problems or events.
45