CitiHealth NHS Nottingham
QUALITY ACCOUNT 2010/11
30 June 2011
Health at the heart of the city
Contents
Page
Part One
Introduction from the Chief Executive and Statement on Quality
1
Part Two
Review of Quality Performance
3
includes statements of assurance from the Board
2.1 Review of services
3
2.2 Patient Safety
3
2.3 Clinical Effectiveness
10
2.4 Patient Experience
20
2.5 Participation in Clinical Audit and National Confidential Enquiries
24
2.6 Research
29
2.7 Commissioning for Quality and Innovation (CQUIN) framework
29
2.8 What others say about us
31
Care Quality Commission Registration
2.9 Statement on Data Quality
32
Part Three
Priorities for improvement
33
3.1 Patient Safety
33
3.2 Clinical Effectiveness
36
3.3 Patient Experience
39
Part Four
Commentary from other organisations
40
4.1 NHS Nottingham City
40
4.2 Nottingham LINk
40
4.3 Local Authority Health and Adult Social Care Select Committee
41
Part Five
Our commitment to you
Health at the heart of the city
42
Part 1 – Board Statement on Quality
Welcome to the first Annual Quality Account for Nottingham CityCare
Partnership CIC. We will be looking back to our quality achievements
during our final year as CitiHealth NHS Nottingham, as well as looking
forward to our new quality aspirations as a social enterprise
organisation.
This has been an eventful time for us as we have
transformed from an NHS organisation to a
Social Enterprise company whilst still meeting all
of our many quality challenges and maintaining
and improving patient safety, patient experience
and clinical effectiveness.
Our commitment to quality is paramount. It is
exemplified in our vision to provide “better health
and complete care, owned and delivered locally”
as well as in one of our six strategic objectives to “provide services that are equitable, accessible
and of high quality.” The Board and the organisation
continually assess and strive to improve the services
so they are responsive to the needs of our local
communities as well as to the commissioners of
those services.
We recognise that it is important to have the right
approach but even more vital are the successful
outcomes generated from the vision.
Patient safety is a top priority in CityCare and in
our Quality Account we are pleased to report that
along with the health and social care workforce
in Nottingham we achieved a “good” rating for
providing children safeguarding services by
Ofsted in October 2010. Safeguarding children
is taken very seriously in CityCare and is
everyone’s business, so we were especially
satisfied that interagency and individual hard
work had been recognised. Another notable
success occurred when we were declared one of
the highest reporters of low harm incidents in the
region by the National Patient Safety Agency,
who asked if we would provide support to other
organisations to develop in this area.
In our first Quality Account we have chosen to
highlight clinical effectiveness by focusing on
the high impact actions for nurses and midwives;
though the actions are not exclusively owned by
those groups and all our services have contributed
to the actions set out in this Department of Health
initiative. The high impact actions cover the
issues of pressure ulcers, falls prevention,
nutrition, promoting normal birth, end of life care,
reducing sickness and absence among staff,
improving discharge processes and reducing
urinary tract infections in the patient population.
There have been considerable achievements
across the high impact actions initiative but some
notable successes have been the contribution
by the organisation to research and development
with consistently high rates of staff involvement
in many projects. For example one of our
Health at the heart of the city
1
occupational therapist Dr Phillippa Logan had
research published in the British Medical Journal
on the work undertaken into falls prevention.
This work has been instrumental in improving
the falls prevention service as well as leading to
the support of many other organisations in their
efforts to reduce falls in the elderly population.
The perceptions of patients/users and their carers
as they experience our services is fundamental
to enabling us to understand how to improve the
quality of care provided. There has been significant
progress in this area throughout the year. We now
have patient surveys set up for every service
undertaken on a regular basis. There is a system
for taking the themes forward and translating them
into change in services. There is however also much
room for improvement and we recognise that we
are at the beginning of a journey in getting to
know all the voluntary and third sector organisations
and many groups which work on behalf of different
health service users in the community in Nottingham.
There is also a need to ensure that we tackle
individual complaints and issues actively and
promptly in a transparent and equitable way. We
are committed to acting on people’s concerns
over the next year to ensure that there is
meaningful engagement and participation in
decision making at all levels and in the
development of our services.
To the best of my knowledge, the information in
this document is accurate, and a true account of
our quality of services.
Lyn Bacon, Chief Executive
Health at the heart of the city
2
Part 2 – Review of Quality Performance
This section includes nationally mandated statements of assurance by
the board in addition to locally decided sections, which were included
following consultation internally and with other external organisations.
2.1 REVIEW OF SERVICES
During 2010-2011 CitiHealth provided and/or
sub-contracted 55 NHS services.
CitiHealth has reviewed all the data available to it
on the quality of care in 53 of these NHS services
in line with the requirements of the commissioners of
these services. The contract for the other two
services has recently been split and performance
data for them is currently being collated for
reporting next year.
The income generated by the NHS services
reviewed in 2010-2011 had a contract value of
£54.3m for 2010/11 and is 100 per cent of the
total income, generated from the provision of
NHS services by CitiHealth for 2010-2011.
2.2 PATIENT SAFETY
CitiHealth NHS Nottingham recognises the
importance of ensuring systems and processes
are in place to record, monitor, report and
analyse any concerns relating to patient safety.
We propose we review how we have performed in
the following areas including lessons learnt and
improvements made.
Safeguarding of Children and
Vulnerable Adults
The delivery of safe services is extremely important
to the organisation. During 2009/10 we invested
a significant amount of time training our staff in
safeguarding vulnerable people.
We work with partner organisations to make sure
all people in our care are safe. We review all our
incidents and complaints to ensure no safeguarding
concerns go unreported and work closely with
social care.
Safeguarding adults
2010-11 was an important developmental year for
CitiHealth Adult Safeguarding. The introduction
of a professional lead has been instrumental in
bringing about closer liaison with patient safety;
improved access to expert professional advice
and increased presence, participation and
development of the multi-agency adult
safeguarding policy and procedures.
The constitution of the Adult Safeguarding
Steering Group, (November 2010) has been key
in delivering on an organisational action plan for
adult safeguarding and has provided the basis for
Health at the heart of the city
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During the year we took part in a Department of
Health pilot, developing a Standardised Framework
for assessing Adult Safeguarding against a set
of National Standards. The organisation scored
‘effective’ in the majority of areas; the self
assessment highlighted where improvements
would be welcome around developing training
for staff, gaining service user satisfaction, and
developing a system for ‘flagging’. These are
being addressed as part of the ongoing
safeguarding adults work programme.
Safeguarding children
A Quality Assurance Schedule was completed
for NHS Nottingham City during February
2011. This was a self assessment to provide
assurances to commissioners that our
safeguarding children governance and
structures met the required standards.
During 2010-11 we completed our annual
Markers of Good Practice assessment and
Section 11 audit. This is a process led by NHS
East Midlands whereby we rate our services
against key standards. We received positive
feedback on this assessment from NHS East
Midlands. Good areas of practice were identified
within the Common Assessment Framework
(CAF), record keeping, safeguarding supervision
and safeguarding training. The areas for
development highlighted were embedding
the evidence and learning from serious case
reviews, providing training to staff on making
a referral to social care, and the importance of
completing family chronologies. Training was
changed in response to these requirements.
© NHS Photo Library
developing improving quality services into the
future. For the first time we have been able to
collect data on the numbers of adult
safeguarding referrals which will be important in
monitoring CityCare’s recognition of and
response to adult safeguarding from this point
forward. We will be looking to increase on the 33
referrals that were made between September
2009 and September 2010.
Safeguarding and Looked After
Services Inspection
Safeguarding and Looked After Services in
Nottingham have been judged as “good”
following an inspection undertaken in December
2010 by Ofsted and the Care Quality Commission.
The report confirmed that the agencies of
Nottingham Children’s Partnership, of which
CityCare is a member, are well prepared to meet
the challenge, with good training programmes
in place for staff at all levels, focusing on early
intervention. The city’s strategic plan explicitly
highlights safeguarding as top priority suitably
undertaken with joint resources.
The contribution of health agencies to keep
children and young people safe - GRADE 2 (GOOD)
There is an effective round-the-clock on call
safeguarding service, which ensures that
health staff are able to speak to a health
professional for advice and support or if
they need to escalate a safeguarding referral
with social care staff. The only domestic
violence specialist nurse provides a highly
valued service but is often stretched.
Health at the heart of the city
4
Community based staff who co-locate with
other agencies and those based and working
in children centres have reported improved
communication and information sharing and
enhanced working with colleagues in all
agencies leading to improved identification
of vulnerable families and children.
There has been good joint safeguarding
referral training with Children’s Centres
and Family Nurse Partnership staff which is
enhancing the mutual understanding of roles
and responsibilities. The referral form is now
electronic which has helped to improve
services access.
Leadership and Management GRADE 2 (GOOD)
This is reinforced by strong health leadership.
Joint workforce development is good.
All staff in contact with children and young
people have been subject to Criminal Records
Bureau clearance (CRB) and no new staff take
up post until they are appropriately cleared.
Partnership working GRADE 2 (GOOD)
Good practice is identified in the level of
safeguarding training provided across
agencies with a key focus on early intervention
and prevention through the use of Common
Assessment Framework and other early
intervention approaches. Robust MAPPA
and MARAC are in place with good attendance
by participating agencies.
Serious Incidents investigated
and reports
There is no single definition of a serious
untoward incident; they can broadly be
described as:
An accident or incident when a patient,
member of staff, or member of the public
suffers serious injury, major permanent harm
or unexpected death, (or the risk of death or
injury), on our premises or other premises
where health care is provided
Where actions of health service staff are likely
to cause significant public concern
Any event that might seriously impact upon
the delivery of service plans and/or may attract
media attention, and/or result in litigation,
and/or may reflect a serious breach of
standards or quality of service
All NHS organisations are required to report
serious untoward incidents and provide
investigation reports to their coordinating
commissioner.
33 serious incidents were reported from 1 April
2010 to 31 March 2011. This is an increase from
the previous year. The increase is accounted for
by the new requirement to report all grade three
and four pressure ulcers as serious incidents.
The table below highlights the category of
incidents reported. It includes the infection
prevention and control incidents which need to
be investigated within four weeks rather than
12 week target for all other serious incidents.
Serious Incident reporting
Incident type
Serious incidents can include death, prisoner
death, fire, disruption to service, sexual assault,
attempted suicide, serious self-harm, serious
accident or injury, unexplained serious injury,
security breach, confidentiality breach, serious
allegation against staff, serious medication
errors, pressure ulcers and loss of patient data.
Number
Pressure ulcer grade 3 or 4
21
Confidential information leak
2
MRSA bacteraemia
5
Unexpected death
1
Prisoner in receipt of care
2
Suicide
1
Communicable Disease
and Infection Issue
1
Table 1: Number and category of incidents
Health at the heart of the city
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Of the incidents reported 19 were closed within
the 12 week target. Eight incidents have
investigations that are ongoing and are within
target for closure. Three incidents remain open
over the target but these relate to prison incidents
which are subject to an independent investigation
commissioned by NHS Nottingham City as part
of the Prison Ombudsman investigation.
Of the three remaining incidents, one was closed
over the 4 week target and two are still under
investigation. Due to the complexity of some
investigations there are circumstances, for example,
where care is provided over more than one
organisation, which may delay the incident
investigation so that it cannot be closed within
the four week target.
CitiHealth NHS Nottingham did not report any
serious untoward incidents as never events in
2010/11, a never event is ‘defined as serious,
largely preventable patient safety incidents that
should not occur if the available preventative
measures had been implemented by healthcare
providers’ (NPSA Never Events Framework
2010-11, March 2010).
Learning from investigations
All serious incidents have a root cause analysis
investigation and action plans are developed
and monitored by the Governance Committee,
only being signed off once all actions are
complete. Learning from our patient safety
incidents is shared with staff to improve patient
safety. This is done in a variety of ways.
Safety First – This is our newsletter to staff
which is produced monthly and is cascaded to
all staff by email. All incidents are anonymised.
Our patient safety committee meets monthly
and members represent all our clinical services.
All incidents are reviewed and discussed and
learning shared through team meetings.
Individual feedback to staff following an
incident report and incidents are discussed
in team meetings.
The organisation realises the importance of
learning lessons. Whenever an incident is reported
a thorough investigation is carried out and reports
made outlining areas for improvement. In the
cases of some of the more significant incidents
this information is anonymised and shared with all
grades of clinical staff through team meetings.
The governance team supported the development
of team managers in the organisation to enable
them to better support all staff in the reporting
and management of incidents for example by
providing structured and impromptu training.
We continually use staff feedback to update and
improve processes. For example, as a result of
feedback from our staff we revised and updated
the incident report form to include sections
detailing information needed on the investigation.
We ran a number of drop in sessions for staff,
covering 115 staff, where we discussed the new
incident report form.
Achievements in the last year
We are one of the highest reporters of incidents
to the National Patient Safety Agency. The vast
majority of our patient safety incidents are classed
as no harm or low harm incidents. We are committed
to building a Safety Culture by encouraging
reporting of incidents and supporting the
recognition of lessons that can be learned from
incidents and ensuring that lessons are shared and
implemented to improve safety for all patients.
The NHS Litigation Authority Risk
Management Standards
The NHS Litigation Authority Risk Management
standards for NHS Trusts providing Acute,
Community, or Mental Health & Learning
Disability Services and Independent Sector
Providers of NHS Care aim to reduce the risk
to patients through the establishment and
upholding of systems and processes to
strengthen service delivery. We have achieved
Level 1 compliance, (the first of three levels of
achievement); which is about having the right
policies and procedures in place, and these to
be in line with best practice guidance.
Health at the heart of the city
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Infection Prevention and Control
From April 2010 to March 2011 NHS Nottingham
City Primary Care Organisation had two targets
in relation to health care associated infections.
The targets were as follows:
To not exceed 115 cases of Clostridium
difficile infection.
To not exceed 10 MRSA bactera
Patients are attributed to the Primary Care
Organisation target if:
Patients are attributed to the Primary Care
Organisation target if:
They reside in Nottingham and are registered
with an NHS Nottingham City GP
They reside in Nottingham and are registered
with an NHS Nottingham City GP
They are registered with an NHS Nottingham
City GP but an in-patient for over 72 hours
anywhere in the country.
They are identified with Clostridium difficile in
the first 72 hours of admission to hospital and
are registered with an NHS Nottingham City GP.
They are registered with an NHS Nottingham
City GP but an in-patient for over 48 hours
anywhere in the country.
They are identified with MRSA within the first
48 hours of admission to hospital and are
registered with an NHS Nottingham City GP.ia
cases.
Health at the heart of the city
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Clostridium difficile (C difficile)
and that the patient’s symptoms have
resolved. It also allows data collection to
occur about individual cases and ensure
that isolation and the principles of infection
prevention and control were adhered to in
order to prevent further spread.
The data collected has shown that awareness
of C.difficile infections and surveillance has
improved with a 44% increase in the number
of samples being processed by the laboratory.
The antibiotic guidelines produced in 2008
have had the desired effect of reducing
Cephalosporin and Quinolone prescribing.
During 2010-11 the NHS Nottingham City
Primary Care Organisation target for C difficile
infections has been exceeded, although the
rates nationally and locally are much lower than
when the targets were first set back in 2007.
Since 2007 the Infection Prevention and Control
Team have reviewed the serious incidents and
cases and the findings from these incidents.
The reviews of cases indicated the following:
Elderly patients being prescribed a number
of courses of antibiotics for non specific
infections in quick succession.
Anti-motility drugs such as Loperamide being
prescribed for patients when an infectious cause
for their diarrhoea had not been excluded.
Samples not being sent for testing when
patients developed diarrhoea.
By analysing the data and trying to establish
themes in relation to development of C.difficile
infections the Infection Prevention and Control
Team have developed C.difficile reduction
strategies in line with the national guidance
circulated in 2008 by the Department of Health,
Clostridium difficile: How to Deal with the Problem.
This work has continued and in primary care
areas of work over 2010-11 have concentrated
on the following:
Antibiotic prescribing – reducing the
prescribing of Quinolones and Cephalosporins.
New antibiotic guidelines and script switch to
alert clinicians to alternatives when they were
prescribing have been utilised.
Surveillance - timely samples to the laboratory
to decrease the potential for C.difficile to go
untreated and further complications to develop.
New testing methodology for C.difficile to
prevent false positive cases and a definition
to apply to all cases to ensure only the true
positive cases are captured.
Monitoring and management of C. difficile –
all cases that developed were reviewed to
ensure the correct treatment has been given
The ongoing monitoring of cases now seems to
highlight that changes are occurring in relation to
the causal factors for development of C.difficile.
The number of serious incidents relating to
C.difficile infections has reduced and ribotyping
of strains would seem to suggest that less virulent
strains are now causing infections rather than
the 027 strain that was being isolated in 2007.
MRSA
The MRSA target was met and the total number
for the Primary Care Organisation was nine.
The number of pre-48 hour admission cases was
five. All cases are reviewed and a root cause
analysis investigation completed within 20 days
of the case being reported. The investigation and
lessons learnt were shared with the following:
The clinician leading the care
The Infection Prevention and Control Committee
for dissemination to all clinical services
The wider health economy at a monthly meeting
to ensure common themes are discussed and
actions put in place to address any themes.
In an effort to effectively decolonize patients who
have confirmed skin carriage / nasal carriage in
the community the Infection Prevention and
Control Team undertake the following;
Review all cases from the laboratory that are
registered with an NHS Nottingham City GP to
ensure they are on the correct treatment and
screening regime.
Health at the heart of the city
8
© NHS Photo Library
Review all patients on discharge from NUH
that are registered with an NHS Nottingham
City GP to ensure they are also on the correct
treatment and that treatment and screening
regimes are completed.
The aim of this follow up is to try to prevent
future more serious infections occurring.
Medication
The Organisation has been working hard over
the last 12 months to reduce significant medication
errors during the year and have utilised learning
from the National Patient Safety Alerts to strengthen
our systems and processes to ensure patients
receive the right treatment at the right time. 16.2%
of CitiHealth incidents reported to the National
Reporting and Learning System (NRLS) were
classed as medication related which was lower
than the overall within our cluster in the latest
National Reporting System report.
There have been focused areas of work around
medicines management notably with HMP
Nottingham Prison where the Acting Head
of Prison Healthcare, Prison Pharmacist and
Head of Patient Safety reviewed the medication
incidents to identify ways in which medication
errors could be avoided. Furthermore, the Prison
Pharmacist has developed a support package for
nurses regarding medication. The work has resulted
in a slight reduction in medication incidents and
the majority remain no or low harm incidents.
The organisation has a comprehensive system
for co-ordinating all medical device alerts and
other safety notices. This electronic system
provides a clear audit trail of alerts issued and
action taken across the organisation. During the
year a total of 114 alerts were issued compared
with 118 the previous year. This figure includes
medical device alerts, National Patient Safety
Alerts and Estates and Facilities specific alerts.
The appropriate assessment and action has
been taken in respect of each of the notifications
and plans have been developed to ensure that
where the organisation is not compliant with the
recommendations this is rectified within the
required timescale.
Health at the heart of the city
9
Raising awareness of pressure ulcer prevention
through the provision of continued training for
registered nurses and health care assistants.
Raising awareness of High Impact Actions
and root cause analysis findings by the
presentation of scenarios via the Tissue
Viability Link Nurse System.
Implementing and facilitating the recognition
of the new pressure ulcer staging system
(EUPUAP, 2009).
Developing and facilitating the Skin Bundle
documentation within Nottingham University
Hospitals NHS Trust.
Meeting CQUIN targets within primary care.
2.3 CLINICAL EFFECTIVENESS
Our clinical effectiveness has been reviewed
against the outcomes identified in the national
NHS High Impact Actions for nurses and
midwives. These not only have the potential for
improving patient care, but also reducing cost.
High impact action number 1:
Your skin matters. No avoidable
pressure ulcers in NHS provided care.
Achievements
The NHS Institute for Innovation and Improvement
identifies a number of High Impact Actions as drivers
to delivering enhanced quality care to patients
(DH, 2009). One of those actions; Your Skin Matters
aims to ensure there will be no avoidable pressure
ulcers in NHS provided care. The structure of
this initiative has been pioneered across Nottingham
by Sarah Pankhurst, Service Head, Nottingham
Tissue Viability Team. The team provides a
service to both primary and secondary care.
A number of key challenges led to the successful
implementation of the Root, Cause, Analysis (RCA)
process into the primary and secondary care settings.
Sustaining an accurate pressure ulcer
monitoring system.
Implementing a reporting mechanism for all
acquired stage 3 and stage 4 pressure ulcers.
Developing a structured flow chart for the root
cause analysis reporting process across the
District.
Implementing SystmOne and the incorporation
of the Braden Risk Assessment tool and a
core care plan for pressure ulcer prevention.
Developing a root cause analysis investigation
report template.
Carrying out the root cause analysis, by
identifying a timeline of the care provision;
recognising critical issues and contributory
factors; identifying main causal factors;
making recommendations and assisting in
the development of an action plan following
the root cause analysis process.
High impact action number 2:
Staying safe – preventing falls.
Demonstrate a year on year reduction
in the number of falls sustained by
older people in NHS provided care.
Achievements
In 2010 the British Medical Journal published
research by Dr Philippa A Logan on the
Nottingham Falls services: ‘Community falls
prevention for people who call an emergency
ambulance after a fall: Randomised controlled
trial’ which showed that services to prevent falls
in the community reduced the fall rate by 55%
over the subsequent year and improved clinical
outcome in the high risk group of older people
who call an emergency ambulance after a fall
but are not taken to hospital.
Marie Ward, Falls Clinical Specialist with Nottingham
CityCare and Nottinghamshire County falls
services, developed a ‘falls tool’ for residents in
care homes across Nottinghamshire which was
presented at the Trent Falls Symposium 2010.
Since September 2010, 96.4% (54 out of 56) of
patients reviewed at 6 months have experienced
25% less falls following intervention by the team.
The local target is 70%.
The service is actively involved with the following
audit and research projects:
Health at the heart of the city
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Pressure Ulcer Incidence - Nottingham City 2010-11
1.20%
1.00%
0.80%
0.60%
0.40%
0.20%
0.00%
CQUIN Target
Incidence
Q1
Q2
Q3
Q4
1.05%
1.05%
1.04%
0.90%
1.03%
0.63%
1.02%
0.78%
Figure 1: Demonstrates the successful achievement of CQUIN targets by the service each quarter.
The target was set to reduce the incidence of pressure ulcers of grade 2 or higher.
Audits
Nottingham CityCare Falls Audit (measuring
care delivered against national Guidelines
NICE Falls and Osteoporosis guidelines).
RCP Falls and Bone Health National Audit 2010.
objective of this joint working project is to
improve the quality and productivity of the
management of patients at increased risk of
falling or fracturing within the PBC group.
It is designed to support:
Research
SAFER 2 national research project with East
Midlands Ambulance Service - An evaluation
of the clinical cost effectiveness of new
protocols for emergency ambulance personnel
to assess and refer older people who have
fallen to appropriate community services.
Nottingham CityCare Falls Services have
been involved with Nottingham University/
Nottingham University Hospitals completing a
Systematic review of chair based exercise to
reduce falls risk.
Other projects in 2010 - 11
Better Balance Better Bones Project Nottingham City Central Practice Based
Commissioning group (PBC), GlaxoSmithKline,
ProStrakan and Shire and Nottingham CityCare
Falls Service are engaged in joint working to
enhance the management of falls and
osteoporosis to a standard of care defined by
NICE (TA 160,161 & 204)), NOGG (2008). The
The earlier and improved identification of
patients at risk of falling and/or fracturing,
and development of services and treatment
protocols for management and support.
The optimisation of osteoporosis
management, including guideline review.
Validation of existing risk registers with data
quality improvements where appropriate.
Active identification and management of
patients identified as at risk with appropriate
education and services in place to support
healthcare professionals.
Improvements in fracture patient management
and community follow up.
Equitable, cost effective service delivery
across all practices within the PBC group.
Improving the quality of referrals to secondary
care and community services.
The Falls Prevention Service provides a ‘rolling’
education and training programme for staff in
Day Centres, Care Homes (ASH and Private)
Health at the heart of the city
11
and staff in health and social care (including
Homecare services) as well as staff in Warden
Aided accommodation across the City of
Nottingham, (893 trained over 2 year period).
We provide Postural Stability evidence based
exercise groups to clients across five sites
across the city of Nottingham.
Three times a year we provide a ‘chair based
exercise’ trainers programme which is
accessed by staff from Care Homes, Day
Centres, Voluntary sector and others.
We are working in partnership with Age UK,
on a two year ‘Nottingham City Signposting
Service’ project funded by Supporting People
(Housing).The project provides a multi-agency
approach to people over 60 years of age to
access a range of preventative services
through a single point of access. Partners
include health, housing, ASH, fire, voluntary
sector and others.
Health at the heart of the city
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High impact action number 3:
Keeping nourished – getting better.
Stop inappropriate weight loss and
dehydration in NHS provided care.
Improving sip feed guidance to impact
on treatment and outcomes for service
users.
In 2007 the cost of malnutrition and associated
disease to the NHS was estimated at in excess
of £13.0 billion, about 80% of which was in England.
The majority of those identified as being either
malnourished or at risk of malnutrition were
living in the community. There is evidence that
malnourished patients:
Visit their GP more often
The 2011 guidelines incorporate NICE guidance
for nutritional support in adults a review of
current literature, particularly two systematic
reviews suggesting positive benefits when oral
nutritional supplements are used with patients
who are underweight (BMI < 20). They have
been developed to provide clear evidence-based
guidance about how and when to use oral
nutritional supplements effectively in adults.
Nutritional screening, using a nationally
recognised and validated tool, forms an intrinsic
part of the guidelines, combined with a clear
pathway detailing appropriate actions to be
taken. Patient advice leaflets to help improve
nutritional intake using everyday foods and
information on the practical use of sip feeds
are included.
High impact action number 4:
Need more prescriptions
Have more hospital admissions and remain
in hospital for longer
Have increased morbidity and mortality
Have reduced quality of life
Promoting normal birth. Increase
normal birth rate and eliminate
unnecessary Caesarean Sections.
During the year the community midwifery service
provided a range of initiatives which aim to
reduce Caesarian Section rates:
Nottinghamshire Oral Nutritional Supplement
(Sip Feed) Guidelines for Adults were originally
written in 2000, and following their implementation
there was a decrease in the prescription of sip
feeds. However the level of spending on sip
feeds has increased in recent years, and there is
evidence that some patients continue to receive
them when they are no longer required, whilst
others are not prescribed them when they would
be appropriate.
Therefore a multidisciplinary review of the
original guidelines took place, led by
Nottingham Community Nutrition and Dietetic
Service. The revised guidelines then underwent
a large scale consultation exercise, involving
GPs and other health professionals throughout
Nottinghamshire. Subsequently additional
changes were made, prior to submission to
the Area Prescribing Committee for approval.
Promoted normality as a philosophy of care,
with Midwives acting as informed advocates
offering a continuous and consistent message
at each point of contact prior to labour
Promoted normal birth workshops as part of
preparation for labour with a focus on first
time mothers as we know this is our greatest
opportunity to reduce section rates
Facilitated normal birth wherever possible at
home, and with the maternity team in the
hospital setting
Supported Vaginal Birth After Caesarian
(VBAC) and timely referral for specialist advice
with regard to External Cephalic Version
(ECV) for women with breech presentation
Gave women accurate information following
a Caesarian Section to support normal birth
in subsequent pregnancies where appropriate
Encouraged women to contribute to their
birth plan
Health at the heart of the city
13
To increase Home Birth rates we:
Reported the local Caesarian Section rates to
our staff to extend ownership of the shared goal
Ensured women don’t get conflicting advice
from different agencies through healthy
pregnancy and normal birth information
being available in Children’s Centres.
In addition, to increase normal birth:
We use the framework of the Optimum Care
Pathway to optimise the potential for normal
birth through the midwifery lead professional
role and assessment of risk
Support choice of place of birth with
evidence-based information that is consistent
and balances benefit and risk
Manage expectations, addressing concerns
and fears, to support appropriate choice of
maternity team antenatal care
Recommend medical intervention only when
it is of benefit to the mother or baby through
appropriate use of evidence-based
intrapartum guidelines
Ensure that where specialist care is needed,
care is optimised to facilitate normal birth
whenever possible
Develop a shared philosophy in normality
Offer home birth as a choice option in line
with Maternity Matters
Have an established home birth service that is
delivered 24 hours a day by midwives on call
Can demonstrate 1:1 midwifery care in the
home setting
Audit our care against NICE standards
Support safe midwifery practice with an on
call Supervisor of Midwives
Can evidence working with a third sector
provider to support women with hypno-birth
techniques in labour
Support women with identified risk factors
who choose home birth against medical
advice through managed care plans that
minimise risk in collaboration with obstetricians
Our home birth data below indicates how the
initiatives are translated into positive outcomes.
250
200
200
150
148
2009-10
2010-11
100
50
0
Home birth rate April-March
Figure 2: Highlights our figures for home births,
demonstrating an increase this year in home birth
rates since 2009-10.
Health at the heart of the city
14
High impact action number 5:
Important Choices; Where to die when
the time comes. Avoid inappropriate
admissions to hospital and increase
the number of people who are able to
die in the place of their choice.
The key challenges of end of life care in Nottingham
City are improving the skills of professionals to
identify death and dying issues; for professionals
to proactively approach the subject of end of life care
with patients and their carers and the challenge to
change perceptions of end of life care as a service
primarily for patients with a cancer diagnosis to
available care for all patients. The end of life care
team work with specialist services including
Chronic Obstructive Pulmonary Disease (COPD),
Heart Failure and Neurology teams.
Research has shown that identifying patients
significantly increases a patient’s outcome of
preventing unwanted admissions and achieving
a preferred place of death. Between April 2010
and March 2011 the number of patients on the
palliative care register has increased 215%
from 250 patients on the palliative care registers
to 789. Therefore 50% of all expected deaths
in Nottingham City are identified on GP
practice end of life care registers.
221 patients have been offered an Information
Prescription to communicate their prognosis
and allow patients to make choices about their
future care; there were a further 64 patients
who were not eligible for the Information
Prescription because of issues relating to
capacity to make decisions about their care.
267 information prescriptions have been
offered to carers of patients with end of life
care needs to support them during their care
and into their bereavement.
317 patients have a completed end of life
care index card which shows that 276 patients
had their preferred place of care recorded
and communicated with other health care
professionals. 236 patients achieved their
preferred place of care which is 75% of all
patients referred to the District Nursing
service for end of life/palliative care.
High impact action number 6:
Fit and well to care. Reduce sickness
and absence in nursing and midwifery
to no more than 3%.
CitiHealth NHS Nottingham commenced the
financial year with a challenging local Sickness
Absence Target of 3.5% by October 2010 and
3.0% by April 2011. This was set against NHS
East Midland’s Sickness Absence Target of 3.5%
over the next two years. CitiHealth’s Board
recognised that this is a point of concern for
both staff and service users.
A considerable amount of work has been
undertaken to reduce the overall sickness
absence rates and to identify the underlying
causes of sickness absence. Human Resources
have worked closely with senior managers to
implement the 2009/2010 Sickness Absence
Management Action Plan working alongside
the Healthy Workforce Strategy.
April 2010 saw the national introduction of the
“fit note” which replaced the old “sick note” and
aimed at focusing on what an employee may be
able to do at work rather than what they could
not do. This linked in with the Management of
Absence Policy and with the agreed Phased
Health at the heart of the city
15
Return to Work Programmes and an Early
Interventions Strategy.
The organisation implemented a robust training
strategy with line managers booked onto
sessions throughout the year.
Sickness Absence is reported monthly to the
Board. The rolling average for the ten month
period up to December 2010 was 4.51% which
was above the region’s PCT average of 4.38%.
Whilst many of our reporting levels through
2010/2011 were within the NHS East Midlands
average range, the organisation recognises that
there is significant room for improvement.
A number of systems and processes were put in
place to manage and reduce sickness, including:
Issuing services with a sickness absence
reduction target/trend line for their area,
against which they are performance managed
on a monthly basis.
Continuation of management absence
training for managers.
Referral to the Musculoskeletal (MSK) Team
for staff with musculoskeletal injuries, as part
of a return to work programme, or in some
cases as a preventative programme.
Managing health at work course – a six week
programme looking at managing health and
work for staff who have been off on long term
sick or are experiencing signs of stress.
Stress management workshops for staff and
managers.
Staff engagement events to follow up on the
outcome of the healthy workforce survey and
the national staff survey.
Deploying social marketing techniques to
encourage staff well-being, for example using
flyers and holding health and well being
workshops.
Health4Health
CitiHealth’s employees benefited from a new
Healthy Workforce programme in 2010-11,
called Health4Health, supporting both physical
and mental well-being.
The official launch of Health4Health took place
on 18 March 2010. Dr Steve Boorman was the
keynote speaker. Dr Boorman commended the
organisation in leading the way for having an
excellent healthy workforce strategy.
Activities and programmes have run throughout
the year. These have included staff offers,
a ‘work survival course’
and health walks. We
have also launched a
new Healthy Workforce
intranet section, a
new musculoskeletal
service for staff and
stress busting
massages.
In July 2010 a
six week ‘Work
Survival’ pilot
programme was
conducted. Thirteen
employees attended, with seven
employees completing the programme. The pilot
worked well and received positive feedback. The
outcome of this was to launch the ‘Fit for Work
Programme’ for the wider workforce. Workshops
were free to all employees and provided three
levels of support:
Work Survival - Courses aimed specifically
at helping employees to manage their
health and work.
Support into work – one to one help for
employees from a health professional to
tackle health issues and stay in work.
Working for Health – Independent advice
and support for organisations to help
develop and retain a healthy workforce.
Ongoing reviews of policy, procedure and
guidance continues to support staff whilst
absent from work.
Health at the heart of the city
16
17
High impact action number 7:
Ready to go – no delays. Increase the
number of patients in NHS care who have
their discharge managed and led by a
nurse or midwife where appropriate.
During the last year the following projects
have been ongoing:
We have joined the discharge operational
group led by Nottingham University
Hospitals. This is a cross City/County
health and social care group set up to look
at the discharge pathways from Nottingham
University Hospitals. A pathway has been
developed to ensure all incidents relating
to discharge are fed back constructively to
Nottingham University Hospitals who are
ensuring that the feedback gets back to
ward level to ensure processes are
improved.
The development of the in-reach worker
within the Crisis Response pilot as part of
the Intermediate Care service. This person
is employed by Nottingham CityCare
Partnership but is based within Nottingham
University Hospitals. The Band 4 employee
works across the GP admission wards and
emergency department to actively find
patients who can be discharged back to
the community, avoiding a hospital
admission or facilitating an early discharge.
This constitutes 46% of the referrals to Crisis
Response. There have been identified cost
savings for both health and social care.
Community Matrons will follow patients
into Nottingham University Hospitals
when admitted. Liaison with emergency
department or ward staff enables the
decision for discharge to be made in a
more timely and appropriate manner.
Current difficulties for Matrons are knowing
when their patients have been admitted.
Health at the heart of the city
18
High impact action number 8:
Over 2010-11 the organisation has addressed
this by developing:
A standardised guide for the review of urinary
catheters. Teams report on a monthly basis
the number of patients with catheters on the
caseload and the numbers who have had an
assessment and as a result of the assessment
have had a catheter removed.
A discharge pathway for patients being
transferred from hospital to home with a
urinary catheter.
A troubleshooting guide for carers and staff to
alert carers and clinicians to review a patient’s
care if they develop an infection, rather than
just prescribe antibiotics to treat the infection.
Leaflets for patients with supra pubic and
urethral catheters to assist them with the day
to day management and how they can
prevent infections.
Protection from infection – Demonstrate
a dramatic reduction in the rate of
Urinary Tract Infections (UTIs) for
patients in NHS provided care.
In response to the concerns raised nationally
about the high level of urinary tract infections
(UTIs) from which patients were suffering, the
organisation has over 2010-11 begun to review
the patient pathways associated with both
urinary catheters and patients with a history
of recurrent urinary tract infections. In
conjunction with this NHS Nottingham City also
developed a local commissioning for quality
innovation (CQUIN) target relating to urinary
urethral catheter care.
Urinary Catheter Care Pathway
Locally evidence from root cause analysis
investigations had shown that there were issues
with the care and management of urinary urethral
catheters. The issues identified were as follows:
No standardised review of the need for the
urinary catheter.
No discharge pathway identified for patients
with urinary urethral catheters.
Day to day management of catheters was
by patients or by carers. Registered nurses
were only involved at the time the catheter
was due for change or if problems developed
with the catheter such a blockage or leaking
from the site.
Recurrent Urinary Tract Infection
Pathway
Within CitiHealth, the Urology and Continence
Advisory Services were seeing an increase in the
number of patients being referred by clinicians
due to recurrent urinary tract infections.
Both departments have worked together to
develop the following:
The key challenges over 2010-11 were to
ensure that if patients had urinary urethral
catheters a definite need had been identified
with a clear management plan and with roles
and responsibilities of individual services
clearly defined.
A clear pathway for clinicians indicating what
treatments should be tried and when patients
should be referred.
An in depth questionnaire to aid clinicians
with the referral process
Health at the heart of the city
19
2.4 PATIENT EXPERIENCE
worked well and what could be better and these
were themed under specific headings.
Nottingham CityCare Partnership is committed
to improving the experience of people using
our services. We have worked hard this year
to develop internal processes that are better
co-ordinated, consistent, monitored and
effective. We have established the following
processes enabling patients/service users to
tell us about their experience of our services,
what we do well and how we can improve.
To improve access, the survey is available in 42
community languages, large print and Braille.
Patient/Service User Satisfaction
Survey
Involving people using our services and staff,
we developed a standard satisfaction survey
and a co-ordinated system to capture, collect,
understand and act on patient experience.
A standard survey and service improvement
action plan were piloted and rolled out across
all services from January 2011.
People were invited to regularly rate our
performance on issues important to them,
like being well supported, informed, involved
in decisions, treated with dignity and respect,
confidentially, having particular needs met and
overall satisfaction. People also told us what
We know there are limitations to using surveys
as a method of collating patient experience with
some individuals and groups and we are
exploring ways to address this.
Establishing Systems to Capture and
Report Patient Experience
Survey results were collated using an ‘in
house’ data system, enabling us to assess our
performance on specific areas at both service
and organisation level including actions to
improve patient experience.
In addition to surveys we have also developed
monthly reporting via health centres capturing
patient comments, concerns and compliments
around our services. To date around 200
comments have been collated and are being
analysed for trends and improvement actions.
Data collated centrally and manually has proved
to be labour intensive. We are therefore looking
at options to improve efficiency, effectiveness
and quality of patient experience data.
Health at the heart of the city
20
Satisfaction Survey Results to Date
1465 people responded to our patient
satisfaction survey between January and March
2011 and feedback exceeded our 85%
satisfaction target (‘good’ or ‘excellent’).
Overall Satisfaction
Very Poor, 2, 0%
Poor, 4, 0%
Here is a summary of how service users rated
our performance:
OK, 71, 5%
Good, 376, 26%
No Comment 73.5%
Excellent 939, 64%
How well would you rate the support
you received?
Very Poor, 1, 0%
Poor, 13, 1%
Overall satisfaction of services was rated
as good or excellent by 90% of people.
No Comment, 35, 2%
OK, 87, 6%
Excellent 943, 65%
Good, 386, 26%
Figure 5: Charts Overall Satisfaction
91% said the support they received was
good or excellent.
Figure 3: Highlights service users rating of the
support they received
How well were you kept informed?
Very Poor, 3, 0%
Poor, 8, 1%
OK, 99, 7%
No Comment 35, 2%
Excellent 865, 59%
Good, 455, 31%
Additional
feedback:
How well…
Our
Satisfaction
Satisfaction Achieved
Target
Were you
involved in
decisions
85% Good or
Excellent
88%
Were you treated
with dignity and
respect
92%
Was confidentiality
respected
92%
Were your particular
needs met
88%
Table 2: Additional feedback from service users
90% said their experience of being kept
informed was good or excellent.
Figure 4: Highlights how service users rated their
experience of being informed.
Service changes and improvements
made as a result of patient and public
feedback
Services collate responses internally. Patient
feedback from the surveys was collated and
themed by teams who developed action plans
in response to this.
Health at the heart of the city
21
Results are forwarded to the Head of Patient and Public Engagement who centrally collates,
coordinates, monitors and reviews patient satisfaction surveys, so that the organisation can
monitor these results and actions and respond accordingly.
The top five areas where patients told us we did well:
Providing information
Providing support/care
Having friendly, knowledgeable, skilled, well presented staff
Being treated with dignity and respect
Being listened to, involved in decisions and able to have a say
What works well?
Other
Information Provided
Particular needs(eg. Disability, Language, Culture)
Support/Care Provided
Resources eg Products & Equipment
Facilities - availability, quality and usefulness
Cleanliness
Ease of Access
Location
Ease of getting an Appointment
Time of Appointment
Wait for an Appointment
Friendly, helpful, knowledgeable, skilled well presented
Confidentiality respected
Treated with Dignity and Respect
Listened to involved in decisions, Able to have a say
0
50
100
150
200
250
300
350
Figure 6: Highlights service users perspective of what works well
The top five areas where patients told us we could do better:
Providing information
Providing support/care
Make it easier to get an appointment
Improve access to services
Reduce waiting times for appointments
No adverse comments were made about cleanliness
Individual services are progressing
actions in response to their feedback
and this is monitored quarterly by the
Head of Patient and Public Engagement
to ensure feedback is acted upon.
What could be better?
Other
Information Provided
Particular needs(eg. Disability, Language, Culture)
Support/Care Provided
Resources eg Products & Equipment
Facilities - availability, quality and usefulness
Cleanliness
Ease of Access
Location
Ease of getting an Appointment
Time of Appointment
Wait for an Appointment
Friendly, helpful, knowledgeable, skilled well presented
Confidentiality respected
Treated with Dignity and Respect
Listened to involved in decisions, Able to have a say
0
10
20
30
40
50
60
Figure 7: Highlights service user suggestions for improvement
Health at the heart of the city
22
Draft Patient Public Engagement
Strategy and Action Plan
As a result of Transforming Community Services
and establishing Nottingham CityCare
Partnership, we have drafted a Patient and
Public Engagement Strategy and Action Plan
and are consulting with patients, service users,
carers and the public about this.
PALS and Complaints reports
The Complaints Team successfully handled 81
complaints about CitiHealth NHS Nottingham
in 2010/2011 in accordance with the 2009 NHS
complaints regulations. Complaints Officers
have agreed the details of each complaint with
the complainant, negotiated timescales and
complaints handling, allocated them to
Investigating Officers and drafted response
letters for approval and sign off.
Complaints about the Prison Healthcare Service
presented challenges in terms of the numbers
received (21 or 26%) and complainants moving
from one establishment to another. The Complaints
Team has worked in partnership with the Prison
Healthcare Service to ensure that most complaints
are handled in-house with only the most
intractable complaints being handled by
the Complaints team.
Sometimes complaints are a result of problems
with staffing levels which may be temporary or
longstanding. During the year we saw an increase
in complaints received about the Community
Midwifery Service including complaints about
continuity of care, and difficulties in arranging
appointments; at that time the service was
having difficulties recruiting midwives due to a
shortage of qualified midwives. In response the
service set up a programme to employ newly
qualified midwives direct into the community;
they were supported through a national
preceptorship programme (a process to
support newly qualified staff through the
transition from student to accountable practitioner).
The Complaints Team has also managed the
Patient Advice and Liaison Service and 83
enquirers have been helped with information
and advice about a number of services,
including a significant number of enquiries
about podiatry and physiotherapy appointments.
Health at the heart of the city
23
2.5 PARTICIPATION IN
CLINICAL AUDIT
Clinical audit is a quality improvement process.
It aims to improve patient care and outcomes
through a review of care against clear criteria
and making changes in light of this.
During 2010-2011, no national confidential
enquiries and two national clinical audits
covered NHS services that CitiHealth provides.
During that period CitiHealth participated in 50%
national clinical audits and 100% national
confidential enquiries of the national clinical
audits and national confidential enquiries which
it was eligible to participate in.
The national clinical audits and national
confidential enquiries that CitiHealth was eligible
to participate in during 2010-2011 are as follows:
National Audit of Psychological Therapies
for Anxiety and Depression
National Audit of Falls and Bone Health
in Older People
The national clinical audits and national
confidential enquiries that CitiHealth participated
in during 2010-2011 are as follows:
National Audit of Psychological Therapies
for Anxiety and Depression
The national clinical audits and national
confidential enquiries that CitiHealth participated
in, and for which data collection was completed
during 2010-2011, 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.
National Audit of Psychological
Therapies for Anxiety and Depression 100%
The reports of 1 national clinical audits were
reviewed by the provider in 2010-2011 and
CitiHealth intends to take the following actions to
improve the quality of healthcare provided:
Health at the heart of the city
National Audit of Continence
Care 2010
Promote documenting of duration of
symptoms, nocturnal symptoms, and
faecal incontinence frequency through
training sessions
Research potential standardised measures
to record functional ability and cognition
Promote increase in rectal examinations
through training and through dissemination
of new clinical guidelines for Manual
Removal of Faeces and Digital Rectal
Examinations
Improve links to geriatric medicine
though Geriatrician who now attends
Multidisciplinary Team meetings and
invite to Link Nurse Day
Promote assessments of Quality of Life
using a validated symptom score/
standardised assessment scale by
discussing use of ICIQ (currently used
by the Continence Advisory Service but
not District Nurses)
Promote documenting type and cause of
incontinence through training sessions
Practice Pharmacists to raise awareness
with GPs (as part of prescribing audit of
continence products) of minimising
medicines which may exacerbate urinary
incontinence
Discuss ways of recording/ collating
patient suggestions with District Nursing,
potentially using PALS
Explore re-establishing user group
Discuss whether patient satisfaction survey
used by Continence Advisory Service
could be used within District Nursing
Promote discussions with patients/ cares
on type and cause of continence through
training sessions.
Promote provision of copies of treatment
plans to patients and carers through
training sessions.
Obtain details from PALS of relevant support
groups and psychological/ emotional
support available as part of long-term
faecal incontinence management
Table 3: National Audit of Continence
Care actions.
24
The reports of 15 local clinical audits were reviewed by the provider in 2010-2011 and
CitiHealth intends to take the following actions to improve the quality of healthcare provided:
Bilingual Co-Worker
Client Access
Report written and sent to Assistant Director of Adult Services, Human
Resources, Service Head and Education & Development Manager.
Meetings held and an action plan developed to put systems in place
to improve access to the Bilingual Co-worker role for service users,
and for the team to access the role appropriately.
Contraceptive and Sexual
Health (CASH) Blue Forms
Chlamydia Screening Office to offer training to pharmacists to
include collecting vital partner information.
Altering the blue form to show if patients decline to give partner
information.
Amendments to the audit tool (to include questions about whether
the patient has declined partner information and confirm whether
treatment was given instead of what treatment given) in preparation
for re-audit May 2011.
Children’s Continence
Circulating the Paediatric Continence Service Newsletter to GPs and
Community Paediatricians via email.
Considering shorter training packages or training on specific topics
such as toilet training so staff are not away from their clinical workload.
Looking at the option of developing e-learning packages.
Looking at the way the Continence Advisory Service as a whole
deliver training as they move into a social enterprise.
Closer liaison with Community Paediatricians and GPs.
Developing a pathway of care for children with continence problem
in the community in conjunction with medical staff.
Follow up letter for all referrals.
Continuing Care Decision
Support Tool (DST)
Nurses to be reminded of the need to complete the ‘Lead
co-ordinator name’ on the DST.
Feedback the re-audit results to the whole Continuing Care Team.
Alert nurses to change of form with regards Assessor’s details no
longer on the front page of the DST tool.
Take learning from the re-audit regarding different interpretation of
questions by different people to Clinical Audit Team meeting and build
into future practice by producing guidance notes for all data collectors.
Remove legibility questions from the audit tool.
Community Macmillan
Bereavement Standards
Only details of deceased patients whose deaths the team have been
made aware of to be included in the Bereavement File.
Health at the heart of the city
25
All staff to improve their documentation of bereavement follow-up
once entries are made into the Bereavement File.
Follow up telephone calls to bereaved relatives and carers to be
made as soon as is reasonably possible to contact them following
notification of the patient’s death. Subsequent calls to also be
recorded by date in the Bereavement File.
If a home visit or support in a clinic setting is deemed appropriate,
the team will offer a one off appointment followed by signposting,
referral on to other agencies or telephone follow up.
Guidelines will be formulated to standardise the written contents of
condolence cards and letters (in the form of letter templates).
Documentation in Bereavement File to be developed to capture details
of the support offered/provided as accurately as possible.
Community Macmillan
Referrals Not Seen
Ensure all information relating to the referral is securely tagged together.
Enter the date and relevant Referral Not Seen code on the front page
of the notes.
Document an agreed action plan in the patient’s records the reason
not seen.
Inform the referrer when the patient is not seen and the reason why if
appropriate.
Develop a standard “Referred Not Seen” letter.
Ensure all team members are aware of service referral criteria.
Include a copy of the service leaflet for professionals when writing back
to referrers when referral was inappropriate or declined by the patient.
Monitor the number of inappropriate referrals and those declined by
patient.
Essential Steps to
Safe Clean Care
Services to disseminate the findings from the audit across the clinical
staff groups and to highlight the issues around single use items and
the appropriate changing of gloves and aprons during procedures in
accordance with the Aseptic non-touch technique policy.
All new staff should have the process explained as part of their
induction process.
Infection Prevention and Control Team to standardise the tool to enable
comparisons to be made across all services.
Locality Leads to launch the new tool with services and to continue
with the audits across clinical teams.
Hand Hygiene
Raise awareness of Uniform and Hand Hygiene Policies.
Audit to be re-designed and re-launched in April 2011.
Health at the heart of the city
26
Contraception
Implant Retention
Overall the service has successfully implemented implant removal into
the drop in clinics but still have a long way to go to reduce and maintain
the waiting list. It is probable that a waiting list initiative will be needed
to reduce it but this is expensive and not a long term solution.
Maintaining high standards of counselling, providing support to patients
who do suffer problem side effects to encourage them to retain their
device with emphasis placed on ‘six months’ as the time required for
trying this method should enable continuing to provide a good service.
The service are considering keeping a small stock of alternative
medication for treatment of problem bleeding within clinic so these
alternatives could be more easily offered.
Musculoskeletal
Physiotherapy Patient
Results shared with MSK Physiotherapy team September 2010.
Results shared with the service lead/s and Assistant Director of Adult
Experience Audit Services.
Results shared with commissioner responsible for MSK Clinics
Record Keeping –
Generic (33 services)
Chase outstanding reports and outcomes forms through Assistant
Directors
Set up a time-limited group to discuss and action findings of the audit,
including reviewing trends from action plans to identify any action
required at organisational level, and identifying changes needed to the
audit tool/ guidance to ensure clarity and consistency of results
Sub-group to report to Governance Compliance Group
Record Keeping –
Infection Prevention
& Control
Access to SystmOne
Patient documentation has been reviewed to include: Patients address,
Patient postcode, Patient telephone number, Occupation, NHS number,
Signature sheet
Written guidance now in place for: Guidance on storage of filing
cabinet keys, Documented named persons with permission to
access patient notes, Tracking of records Corrections and use of
abbreviations discussed at team meeting
Team needs to review the records to include patient title and
organisational address.
Record Keeping –
Safeguarding Children
Improve documentation to incorporate demographic and diversity
information
Revise documentation to incorporate staff identification information
Address changes at team meeting and at individual supervision sessions
to increase awareness that information needs to be recorded
Review organisation policy for transportation and transfer of records
and adapt to fit service
Health at the heart of the city
27
Safeguarding Children Health Visitors’ Supervision
Safeguarding Children Nurse Specialists to ensure that database
reviewed prior to supervision sessions in order that files are
supervised within timescales
Documentation revised to incorporate staff identification information
Address at team meeting and at individual supervision sessions to
increase awareness that information needs to be recorded
Safeguarding Children Nurse Specialists to ensure that High Support
Files taken to supervision sessions in order that all files reviewed within
timescales
Address at team meeting and at individual supervision sessions to
ensure that photocopying completed and documentation attached to
High Support Files for administration staff to file
Design post-supervision action plan to be attached to each file for
administrative purposes
To investigate highlighting files which breach timescales, electronically,
by contacting IT Department to discuss options and possibilities
Transfer of Care Processes
Following the audit, the Transfer of Care policy was revised and
ratified in March 2011.
A re-audit is planned for September 2011
Table 4: Local Audit Actions
Health at the heart of the city
28
2.6 PARTICIPATION IN CLINICAL
RESEARCH
Clinical Research influences the safety and
effectiveness of medications, devices/equipment,
diagnostic products, treatments and interventions
intended for patients. These may be used for
prevention, treatment, diagnosis or for relief of
symptoms in a disease.
The number of patients receiving NHS services
provided or sub-contracted by CitiHealth in
2010-11 that were recruited during that period to
participate in research approved by a research
ethics committee was 149.
CitiHealth was involved in conducting 51 studies
in 2010-11: 20 NIHR portfolio studies and 31 non
portfolio studies. The studies involved a wide
variety of community specialties including post
stroke community rehabilitation, falls prevention,
tissue viability, smoking cessation and
community midwifery.
2.7 GOALS AGREED WITH
COMMIS SIONERS
Commissioning for Quality and
Innovation (CQUIN)
CQUIN is a payment framework which enables
commissioners to reward excellence by linking
a proportion of providers’ income to the
achievement of local quality improvement goals.
Use of the CQUIN payment framework
During 2010/11 1.5% of CitiHealth NHS
Nottingham’s income was conditional on achieving
optional quality improvement and innovation
goals agreed between CitiHealth and NHS
Nottingham City, through the Commissioning
for Quality and Innovation (CQUIN) payment
framework.
The table facing describes the detail of the
targets set by our commissioners NHS Nottingham
City Primary Care Trust (the local targets) and
also those set by NHS East Midlands (the
regional targets). In order to achieve the targets
we set up a robust process with a task and finish
team consisting of the CQUIN leads in each area,
and staff from the Business Unit. Most importantly
the frontline staff embraced the work involved
and this resulted in an excellent outcome with
most goals set achieved. Despite the hard work
required to achieve the targets and the fact that
they were optional for providers we have set a
benchmark and will be keen to see further gains
in the next year.
Further details of the agreed goals for
2010/11and for the following 12 month
period are available electronically at
http://www.institute.nhs.uk/world_class_commiss
KEY TO TABLE 5 OPPOSITE
Target not met; 0% payment
Target not met, but intermediate threshold
applicable and met; 50% payment
Target met or exceeded; 100% payment
Quarterly target not applicable
Result not yet known
Health at the heart of the city
29
CitiHealth CQUIN 2010/2011
CQUIN Ref.
Indicator Description
Q1
Q2
Q3
Q4
Target Result Target Result Target Result Target Result
Percentage of community
provider drug delivery devices
25%
27%
50%
52%
75%
79% 100%
that have been safety checked
in the appropriate time period
Incidence of grade 2 or higher
CR3 - Pressure Sores
pressure sore in older people Baseline Baseline 1.04% 0.90% 1.03% 0.63% 1.02%
treated in a community setting
CR4 - Dietetics City
19 days 18 days 17 days 16 days 16 days
CR4 - Dietetics County Waiting times for treatment
Baseline Baseline 60 days 32 days 55 days 27 days 50 days
CR4 - Physiotherapy
and therapy services
23 days 23 days 22 days 22 days 21 days
CR4 - OT
23 days 10 days 22 days 14 days 21 days
Percentage of Long Term
CR5 - LTC Care Plan
Condition (LTC) patients with
Baseline Baseline 100%
100%
100%
100%
100%
a personal health/care plan
The percentage of people
discharged from hospital and
benefitting from intermediate
CR6 - 91 days Status
care/rehabilitation enablement Baseline Baseline 65%
78%
70%
81%
75%
who have not been readmitted
to hospital by day 90
Percentage of staff(with face to
face patient contact, excluding
CL1a - Brief Intervention administrative staff) from identified
10%
18%
30%
55%
60%
69%
75%
teams trained to conduct stop
smoking brief intervention
Percentage of specialist nurses
for identified conditions/disease
CL1b - Cessation
areas to be trained to conduct
10%
21%
30%
71%
60%
75%
75%
smoking cessation intervention
using New Leaf protocol and guidance
Percentage of work days lost
CL2 - Sickness Absence to long term sickness absence
Annual Indicator- Result due May 2011
1.82%
Percentage of adult patients
with Indwelling urinary catheters
CL3a- Assessment
receiving an assessment of need
15%
22%
50%
64%
75%
75%
95%
in relation to the catheter
Percentage of adult patients
whose Indwelling urinary catheters
CL3b - Removal
have been appropriately
15%
100%
50%
100%
75%
100%
95%
removed following an assessment
of need in relation to the catheter
Percentage of patients using
services have been involved in
CL4a - PPI Surveys
the agreed patient satisfaction Scoping Scoping Design Design
Pilot
Pilot Roll out
surveys (asking additional questions
beyond contract requirement)
Percentage of services that have
CL4b - PPI Services
made service improvements on Format Format Identify Identify SummarySummary Final
the basis of patient feedback
Percentage of all eligible patients
that have been offered an
CL5a - EOL Patients
Information Plan or there is
15%
27%
30%
35%
45%
64%
60%
documentation that an Information
Plan has been offered and declined
Percentage of all eligible carers of
EoL patients that have been offered
CL5b - EOL Carers
an Information Plan or there is
10%
40%
45%
56%
50%
64%
55%
documentation that an Information
Plan has been offered and declined
Percentage of Chlamydia
CL6 - Chlamydia
contacts converted to screens
30%
26%
40%
29%
50%
25%
60%
within identified services
Increase the number of Common
CL7 - CAFs
Assessment Framework initiated
10
3
15
10
19
9
10
by midwives
Percentage of all eligible women
that have been asked about
CL8a - MWsDV
Domestic Violence at pregnancy 25%
32%
50%
100%
75%
100%
100%
booking visit (Midwifery)
Percentage of all eligible patients that
have been asked about Domestic
CLBb - HVsDV
Violence at Health Visitor birth visit 25%
100%
100%
100%
100%
100%
100%
Percentage of staff (with face to
face patient contact, excluding
CL9 - Alcohol Training
administrative staff) from identified 10%
19%
30%
26%
60%
73%
75%
teams trained to deliver brief
advice (alcohol)
Percentage of staff (with face to
face patient contact, excluding
CL10 - Warmth Training administrative staff) from identified
10%
0%
20%
20%
35%
49%
50%
teams trained to identify and refer
patients to the Healthy Housing
CR1 - Drug Devices
100%
0.78%
14 days
25 days
20 days
11 days
100%
78%
81%
75%
0
91%
100%
Roll out
Final
63%
60%
28%
21
100%
100%
76%
88%
30
Table 5: CQUIN target achievements 2010-11
2.8 WHAT OTHERS SAY
ABOUT US
Statement on Care Quality Commission
(CQC) registration
The CQC is the independent inspector and
regulator for health and social care organisations,
ensuring we meet essential standards in quality
and patient safety.
CitiHealth NHS Nottingham is required to
register with the Care Quality Commission and
its registration status for the year 2010/11 was
Registered. CitiHealth NHS Nottingham
registered without condition to provide its
regulated activities across its registered locations.
CityCare Partnership is registered without
condition to provide its regulated activities
across its registered locations. The Care Quality
Commission has not taken enforcement action
against Nottingham CityCare Partnership to date.
Full details of our registration can be found on
the Care Quality Commission on line directory
here www.cqc.org.uk
CitiHealth NHS Nottingham participated in a
Nottingham-wide review of Safeguarding and
looked after Children by Ofsted and the Care
Quality Commission during April 2010-March
2011: Nottingham was given a ‘good’ rating.
The Care Quality Commission has not taken
enforcement action against CitiHealth NHS
Nottingham during April 2010 - March 2011.
Since April 2011 Nottingham CityCare
Partnership became newly registered with the
Care Quality Commission and its current
registration status is registered. Nottingham
Health at the heart of the city
31
2.9 STATEMENT ON DATA
QUALITY
On going data quality improvement inline with
Data Quality Improvement Plan (DQUIP) agreed
with commissioners in line with section 5 and
clause 32 of the NHS Community Contract.
Priorities for data quality improvement for
2010/11 included collecting key information on
first and follow appointments by GP practice for
all applicable services.
31 tasks identified in the initial DQUIP had been
completed by 31 March 2011.
Information Governance Toolkit
attainment levels
The NHS Nottingham City (which includes
CitiHealth NHS Nottingham) Information Governance
Toolkit Assessment Report for 2010/2011 scored
72% overall and was graded Green ‘Satisfactory’.
The Information Governance Toolkit Assessment
was audited by East Midlands Internal Audit
Service and received Significant Assurance.
Clinical coding error rate
CitiHealth NHS Nottingham was not subject to the
Payment by Results clinical coding audit during
April 2010-March 2011 by the Audit Commission.
Monthly meetings are held with the lead
commissioner to monitor progress against the
DQUIP priorities.
The initial focus was to ensure that all services
had clear metrics relevant to their service
specifications and could collect the basic data sets
required. This provided evidence to support and
under pin their clinical and cost effectiveness.
The priority going forward is developing systems
and processes for more proactive checking of data
quality in a way that provides on going assurance
to patients and evidence to commissioners of
continuing data quality improvement.
NHS Number and General Medical
Practice Code Validity
CitiHealth NHS Nottingham 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, as this is not applicable to
us as a community service.
Health at the heart of the city
32
Part 3 – Priorities for Quality Improvement 2011/2012
3.1 PATIENT SAFETY
Review training strategy.
Safeguarding Children and Vulnerable
Adults
Safeguarding Adults
2011-12 presents an opportunity for Nottingham
CityCare to build on and develop the progress
achieved last year under the supervision of the
Adult Safeguarding Steering Group which directly
reports to the Governance Committee and also
via the work of the Adult Safeguarding Lead.
Initiatives for 2011-12:
We intend to carry out an evaluation of service
user satisfaction.
We will carry out an assessment against the
Adult Safeguarding Assessment Framework
which was developed by the Department of
Health as part of the earlier pilot.
We intend to deliver essential training to all
relevant staff.
As part of our CQUIN we intend to deliver
basic dementia care training to all patient
facing staff – this will comply with Quality
Standard 1 in the Dementia Quality Standard
(NICE June 2010).
We will collaborate with the Walk in Centre
and Nottingham Emergency Medical Services
to further the work of the Adult Safeguarding
Steering Group.
Health at the heart of the city
33
Serious Incident Reporting
Safeguarding children
Nottingham CityCare will ensure the
implementation and recommendations
of the findings of the recent Safeguarding
and Looked After Children Inspection.
We will ensure that we implement the
recommendations from the Markers of
Good Practice Assessment and continue
to take part in our annual assessments.
Explore opportunities to work closer with
Adults and Children’s social care.
Nottingham CityCare continues to make
a tangible shift to early intervention
through use of the Common Assessment
Framework, leading to improved
identification of need and integrated
delivery of health and social services.
A review of the current model of
Safeguarding Supervision is underway.
Nottingham CityCare will increase its
closer partnership working with Nottingham
Emergency Medical Services (NEMS)
and the Local Authority.
To ensure the views of children and young
people are recorded in a way that provides
assurance that they have been heard and
their wishes and feelings are being taken
appropriately into account in planning.
Ensure unconditional registration with CQC
plan for the new organisation April 2011.
HR department to establish a robust
Electronic Staff Record (ESR) system
for collection of safeguarding training
records for staff and CRB checks.
As one of the highest reporters of incidents to the
National Patient Safety Agency, the Governance
Team will continue to improve the way that
information is made available to teams so that
they are able to see trends that need to be
addressed. The vast majority of our patient
safety incidents are classed as no harm or low
harm incidents. We are committed to continuing
to build a Safety Culture by encouraging
reporting of incidents and supporting the
recognition of lessons that can be learned from
incidents and ensuring that lessons are shared
and implemented to improve safety for all patients.
We are cascading web reporting so that staff
can report incidents directly on line. The Head
of Patient Safety will also be training staff and
supporting the investigation of incidents and
complaints using the Root Cause Analysis tools,
to clearly identify system failures and support
the development of the improvement of those
systems. Four training sessions will be delivered
to staff Team Leaders and clinical managers and
the Head of Patient Safety will continue to support
managers in more complex investigations.
As part of Serious Incident investigation training
several of our senior managers will also be
provided with training in Being Open which
involves specialist training in communicating
with patients, their families and carers following
a patient safety incident in which the patient was
harmed.
We will also be producing ‘spotlights’ to
highlight areas of good practice and lessons
learned to share across all services.
Health at the heart of the city
34
Infection Prevention and Control
Medicines Management
MRSA
The increased reporting of incidents, but with
reducing seriousness, will remain a focus of our
activity during 2011/12. Our Lead Pharmacist will
be a member of the Patient Safety Committee and
will review any significant medicine related
incidents within 5 working days of their occurrence
and agree if any immediate actions are required.
Any incidents with actual harm greater than low
harm will be investigated and a written action plan
produced and approved by the Lead Pharmacist.
To continue to review all cases and review the
themes from root cause analysis investigations to
ensure that change occurs. Change is monitored
through the Health Economy County Wide
Infection Prevention and Control Committee.
C- Difficile
During 2011-12 the antibiotic guidelines have been
revised and will be launched to both non-medical
and medical prescribers. We will review an
electronic audit tool which has been developed by
pharmacists locally, with a view to auditing the
implementation of the guidelines within primary care.
We will implement the definition of what constitutes
a ‘positive case’ with the Infection Prevention
and Control Team; individually reviewing all
community and pre-72 hour admission cases.
The Lead Pharmacist will also work with the
Head of Patient Safety to support services in
developing action plans in response to any
patient safety alerts relating to medication.
Other key priorities for medicines management
for Nottingham CityCare for 2011-12 are to:
Implement the new Non-Medical Prescribers
(NMPs) policy, by ensuring full dissemination of
the policy and monitoring the use of the policy
Deliver a rolling programme of medicines
management training to staff within care
homes (includes refresher and new staff
training on an 18 month rolling programme).
Medicines management technicians will
conduct compliance reviews of medication
with patients/services users with Long Term
conditions.
Health at the heart of the city
35
3.2 CLINICAL EFFECTIVENESS
These areas for improvement align with the
NHS High Impact Actions identified from
page 10.
evidenced based and patient-centred
primary/secondary care falls services.
Referral for falls assessment will be included in
the Fracture Liaison Service pathway.
High impact action number 1:
Your skin matters. No avoidable
pressure ulcers in NHS provided care.
Implementation of pressure ulcer incidence
collection via SystmOne (a computerised
health record).
Restructuring of the feedback mechanism to
the District Nursing Teams.
Introduction of a two hour mandatory training
programme for all registered nurses and
health care assistants. This will incorporate all
aspects of pressure ulcer prevention but also
consider the themes of the RCA findings in
relation to care provision.
Review of the current documentation around
risk assessment and core care plans currently
accessible on system 1.
Consider the introduction of Skin Bundles
across District Nursing Services.
High impact action number 2:
Staying safe – preventing falls.
Demonstrate a year on year reduction
in the number of falls sustained by
older people in NHS provided care.
In partnership with Nottinghamshire county falls
services/secondary and commissioners we will
develop a single point of access for patients who
reach the Emergency Department and need a
falls assessment. (A high percentage of these
patients do not get referred to services).
Review the Falls Services, (linking with Nottingham
University Hospitals rehabilitation unit) further
streamlining processes to ensure effective,
© NHS Photo Library
This initiative will be taken forward by the
achievement of the following objectives:
High impact action number 3:
Keeping nourished – getting better.
Stop inappropriate weight loss and
dehydration in NHS provided care.
A multidisciplinary group has been set up to
facilitate implementation of the sip feed
guidelines across Nottinghamshire; the group
will develop a full implementation plan.
Prescribing costs of sip feeds will be monitored,
as it is envisaged that they will be prescribed
more appropriately and their usage better
monitored due to the guidelines and this in turn
should result in reducing costs over time.
It is expected that the implementation of the
guidelines should increase referral for patients
with complex needs who require dietetic input.
The service will monitor referral rates for this type
of referral in order to assess if this occurs.
Health at the heart of the city
36
High impact action number 4:
Promoting normal birth. Increase
normal birth rate and eliminate
unnecessary caesarean sections.
Midwifery services have now transferred and will
be delivered by Nottingham University Hospitals;
therefore this will not form such a significant part
of our development planning for normal birth.
The Family Nurse Partnership will however in its
support for young teenage pregnant women
continue to work to promote normal birth.
High impact action number 5:
Important Choices; Where to die when
the time comes. Avoid inappropriate
admissions to hospital and increase
the number of people who are able
to die in the place of their choice.
The Nottingham End of Life Care Team offer
teaching, advice and support to health and
social care professionals to tackle these issues
to empower staff to take end of life care forward
with a positive supportive approach. The team
has developed key documents to support
professionals to face these challenges.
The team are training professionals in the use
of the Gold Standards Framework Prognostic
Indicator guidance using a Read code search
in GP practices to identify patients with organ
failure, or frail/dementia to increase the number
of patients on the palliative care register.
The Information Prescription is a communication
tool that incorporates preferred priorities of care
for patients and their carer and provides patients
and carers with the appropriate material they
require when facing challenging care decisions
at the end of their lives.
The End of Life Care Team is introducing a new
service to offer alternative choice for patients that
is not hospital or their own home, but care in a
hospice-like environment in a local care home
where they can receive respite care and terminal
care preventing an admission for the patient.
High impact action number 6:
Fit and well to care. Reduce sickness
and absence in nursing and midwifery
to no more than 3%
Our aim for 2011/2012 remains to bring sickness
absence down to the commissioner’s target
of 3% across all services not just those within
Nursing and Midwifery. It remains an important
focus for us and is also important for our staff.
Work has already commenced on reviewing
our ESR data and a decision has been made
to move from monthly to weekly reporting, to
ensure more timely data is available to managers.
Working alongside the revised Sickness Absence
plan with new departmental trajectories, it is
proposed that Organisational Development and
Occupational Health work with managers to
identify causal effects within targeted areas of
high concern.
There is a commitment to introducing
“Management Self Service” within the Electronic
Staff Record thus placing the management of
absence with managers and ensuring managers
are fully responsible for the management of
absence levels within their area.
We believe investing in our employees and
improving the working environment is also an
investment in patient care.
The team are introducing the palliative card index
which is a SystmOne template that records key
points in the patient’s end of life care pathway. This
enables professionals to plan and implement care
to ensure that patients’ wishes and needs are
met to facilitate their preferred priorities for care.
Health at the heart of the city
37
High impact action number 7:
High impact action number 8:
Ready to go – no delays. Increase the
number of patients in NHS care who
have their discharge managed and led
by a nurse or midwife where appropriate.
Protection from infection – Demonstrate
a dramatic reduction in the rate of
Urinary Tract Infections (UTIs) for
patients in NHS provided care.
There should be an increase in the number of
patients who have their discharge facilitated from
community-led services due to the following
initiatives:
During 2011-12 the major priorities are as
follows:
The Community In-reach pilot aims to test the
impact that a community in-reach team can
have on reducing the numbers of patients
with a 14 day length of stay or more and
preventing the admission of people directly
into long term care at the point of discharge
from hospital. It is expected there will be a
50% reduction in the number of patients
with a length of stay over 14 days. Initially
the service will focus on one ortho-geriatric
ward at the Queen’s Medical Centre but may
expand during the pilot in light of available
capacity and lessons learnt. This will be
starting in June 2011 – March 2012. The
pilot incorporates audit and qualitative
service evaluation.
The Crisis Response Team is to be
mainstreamed from 1 June 2011. This will
enable out of hours and weekend cover.
Crisis response will be piloting clinicians
working up to 10pm within Intermediate
care to see if the number of out of hours
discharges from Nottingham University
Hospitals (NUH) can be increased.
Development of a pilot to enable specialist
information to be available at NUH to help
decision making for discharge of COPD
patients.
Implement the pathway and troubleshooting
guide for catheter care further to ensure it
is embedded within care delivery. This will
require an audit of practice to be undertaken
and further work around implementation of
findings.
To implement and embed within practice the
recurrent UTI management pathway.
To start to review the hospital admissions as
a result of UTIs particularly from care home
environments to try and reduce the number
to admissions and ensure the incidence of
infections is reduced.
Health at the heart of the city
38
3.3 PATIENT EXPERIENCE
The Board is committed to continued improvements in the experience of people using Nottingham
CityCare services. Based on our work last year, we wish to prioritise the following four areas within
Patient Experience:
Patient Satisfaction Survey and Service
Improvement Action Plans
We will build on the current process of seeking
and acting upon patient satisfaction/ feedback by:
Making electronic hand held devices and on
line surveys available in addition to current
paper surveys.
Improving access for children and young
people, people from black and minority ethnic
groups, people with disability and learning
disability, cognitive impairment and other seldom
heard groups to feed back their experience.
This fits with the organisation’s duty to meet
the Equality Delivery System standards.
Improving Processes for Collating and
Reporting Patient Experience
Patient Public Engagement Strategy
and Action Plan
Feedback from patients, staff, communities and
the public will inform our final Patient Public
Engagement Strategy and Action Plan.
Meridian Patient Feedback System and
Hand Held Devices.
From 2011 the Meridian system will improve the
access, quality and reporting of our patient experience
data. Meridian will provide an integrated web-based
system capturing patient feedback through the
inputting of survey data and real time data
collection for those who can complete surveys
using hand held devices or via our website.
In addition to formal complaints, we will continue
to collate comments, concerns and compliments.
Our intention is to triangulate patient surveys,
incident reports, PALS data, complaints and
comments, concerns and compliments data, to give
us a fuller understanding of patient experience
including actions for improving patient safety
and experience.
Patient Experience Group (PEG),
Membership Panel and Strengthening
Partnerships
As a newly established Community Interest
Company, we will facilitate a PEG and Membership
Panel inclusive of diverse and seldom heard groups.
We will strengthen our relationships with patient/
carer groups, LINks/HealthWatch and voluntary/
community groups.
These forums will provide an invaluable insight
into patient experience including suggestions
for innovation and improvements.
Mystery Shopper /Patient Safety and
Experience Walkarounds
To ensure the business of the organisation is
informed by the experience and views of people
using our services, we will develop a programme
of activities supporting Board Members and the
Senior Management Team to take part in ‘walk and
talk’ events with staff, patients and service users.
PALS and Complaints
Following the setting up of a dedicated complaints/
PALS function in CityCare from April 2011,
there will be a new programme to integrate the
outcomes and learning from complaints and
PALS issues into the services. There will be
more focus on capturing the issues that are
raised in the health centres at reception desks
on a routine basis that have not in the past been
logged. There will be increased scrutiny of all
complaints to identify links with incidents and
vice-versa. There will be improved reporting to
the Governance Committee and the Board with
trend analysis and tracking of learning from
complaints and PALS issues and the changes
made to services as a result of this activity.
Health at the heart of the city
39
Part 4 – What other people think of our Quality Accounts
4.1 COMMIS SIONING
PRIMARY CARE TRUST –
NHS NOT TINGHAM CITY
NHS Nottinghamshire City monitors quality
and performance at CityCare Partnership CIC
throughout the year. The information contained
within this quality account is consistent with
information about CitiHealth NHS Nottingham
supplied to commissioners throughout the year.
4.2 LOCAL INVOLVEMENT
NETWORK (LINK)
NottinghamCity LINk – response to
CitiHealth Quality Account
There are monthly quality and contract review
meetings to review and monitor performance,
governance arrangements and quality
standards and there is frequent ongoing
dialogue as issues arise.
Nottingham City LINk welcome the opportunity
to comment on the Quality Account for CitiHealth
NHS Nottingham at its meeting on Wednesday
16th March 2011. We appreciate the level of
information along with face to face meetings
of the two organisations during the year and
welcome the oppportunity to extend and build
on the relationship with the new CityCare
Partnership.
CityCare Partnership works constructively with
commissioners and other partners to develop
integrated care pathways that improve the
health of the local community. Quality goals and
indicators are jointly agreed in order to reduce
health inequalities and improve the health of
Nottingham and Nottinghamshire residents.
We congratulate CitiHealth on the work it has
undertaken to ensure that, in this initial year of
Quality Account production, a clear commitment
to quality service delivery for the local community
has been established. We welcome the clarity
and format of the Quality Account which is
comprehensive and easy to read.
When significant incidents or complaints occur,
robust investigations are carried out so that
lessons are learned and improvements can be
made. These are shared in a systematic way with
staff and monitored appropriately. Complaints are
treated seriously and genuine efforts are made
to improve services in the light of patient
feedback.
In conclusion, Nottingham City LINk believes,
based on its knowledge of CitiHealth, that the
report is a fair reflection of the services provided
and looks forward to the continuation of the
relationship that has developed between our
two organisations.
CityCare Partnership has demonstrated a
high level of commitment to improving clinical
effectiveness with significant achievements
against the high impact actions initiative and
a commitment to enable patients / service
users to feedback their experiences of services
so that good practice can be continued or
improvements made.
Health at the heart of the city
40
4.3
NOT TINGHAM CITY COUNCIL HEALTH AND ADULT SOCIAL
CARE SELECT COMMIT TEE COMMENT
The Health and Adult Social Care Select
Committee believes that the Quality Account
2010-11 is a fair reflection of the services
provided by CitiHealth NHS Nottingham /
Nottingham CityCare Partnership, based on
the knowledge the Committee has of CitiHealth
NHS Nottingham / Nottingham CityCare
Partnership.
The information contained in the Quality Account
is presented in clear and accessible language.
We welcome the ‘good’ Ofsted / Care Quality
Commission rating for safeguarding and looked
after children services and the clear evidence of
partnership working. As a committee we have
had a particular interest in ensuring that adults
are also properly safeguarded and appreciate
the introduction of a professional lead in this
area and the fact that it will be a priority in 2011-12.
We recognise the challenge in achieving the
target to reduce cases of Clostridium Difficile
and the organisation’s commitment to take
action to lower the number of cases.
Falls prevention has been an area of interest
for the Council’s scrutiny councillors for several
years while reducing the rate of falls has
remained a challenge. It is a relief to see the
rate beginning to reduce and the continuing
commitment to finding ways to prevent falls in
NHS provided care.
The Committee has been kept well informed
throughout the process of Transforming
Community Services and has appreciated the
opportunity to comment on proposals and plans.
Scrutiny councillors were consulted through the
Nottingham City and Nottinghamshire County
Joint Health Scrutiny Committee on changes to
improve maternity and newborn services. The
Joint Committee will continue its interest in
promoting normal birth as Nottingham University
Hospitals NHS Trust (NUH) delivers midwifery
services.
We welcome closer working with NUH on
discharge pathways. The Joint Health Scrutiny
Committee carried out a review on dementia
care in hospital in 2010-11 - discharge planning
and the need for a close relationship between
hospital and community provision was raised
as a concern. In relation to the need to improve
services to dementia patients and their carers,
we are also pleased to see that it will be a
priority to deliver dementia care training to all
patient-facing staff and that there are plans to
reduce inappropriate admissions to hospital and
increase the number of people who are able to
die in the place of their choice.
We recognise the organisation’s commitment to
engaging patients and the public and in responding
to their views and experiences, but would hope
that next year’s Quality Account more explicitly
demonstrates the involvement of patients and
the public in determining priorities and reflecting
what quality means to them for the year ahead.
We would also suggest that the use of case
studies and / or quotes from patients and carers
could make the document more accessible to
the public.
We welcome the developing relationship with
Nottingham Emergency Medical Services
(NEMS) and the City Council to provide high
quality integrated and efficient services and
look forward to developing our relationship
with Nottingham CityCare Partnership in the
coming year.
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Part 5 – Our commitment to you
This first Annual Quality Account has featured a review of 2010/11 and a look
forward to 2011/12. There has been a transformational change for the organisation
from CitiHealth NHS Nottingham to the inception on 1 April 2011 of Nottingham
CityCare Partnership CIC (Community Interest Company).
As a brand new social enterprise with a workforce
of more than 1,200 we are determined and committed
to continually improving the quality of the care
we provide. We are proud of our achievements
but not complacent, as there are many challenges
and improvements to be made in the coming year.
CityCare is accountable first and foremost to
the people it serves and as a social enterprise
is enthusiastic about the investment that we
will make back into our community. There is
important work to be done in building relationships
with our many stakeholders, a requirement to be
cost effective, productive, and innovative and to
focus on the prevention agenda, but safe and
quality services are paramount and what
patients demand and deserve.
Nottingham CityCare Partnership CIC will respond
to people by listening and acting. We look
forward to your participation on this journey.
We would like to thank all the stakeholders,
patient and community groups who gave their
feedback and suggestions for the content of this
report, particularly the Local Authority Health and
Adult Social Care Select Committee, the NHS
Nottingham City Patient Experience Group,
Nottingham LINk, the BECONN Service, Friends
of Clifton Cornerstone and the Pakistan
Community Centre.
Thanks also to all the staff involved in producing
this document.
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If you have any comment, questions or want to be involved with our next Quality Account,
please call our Head of Patient and Public Engagement on 0115 883 9324.
Nottingham CityCare CIC is registered as a company limited by guarantee Company Registration Number: 07548602
www.nottinghamcitycare.nhs.uk
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