SOMERSET COMMUNITY HEALTH
QUALITY ACCOUNT
2010/11 TO 2011/12
„Providing World Class Local Community Services‟
SOMERSET COMMUNITY HEALTH
QUALITY ACCOUNT
2010/11 TO 2011/12
CONTENTS
Page
Part 1
1
Foreword from the Chief Operating Officer
1
2
Introduction
3
Priorities for Improvement: Improving Quality Further in
2011/12
4
Part 2
3
Part 3
4
Review of Quality Performance in 2010/11
Patient Safety
Clinical Effectiveness
Patient Experience and Satisfaction
Improving Quality Further: Progress Against Priorities
Identified for 2010/11
18
24
26
32
Statements Provided by:
o The Local Involvement Network
o The Overview and Scrutiny Committee
o NHS Somerset (commissioning Primary Care Trust)
APPENDICES
APPENDIX 1
NHS Somerset Quality Account Response Letter
36
APPENDIX 2
Notice relating to Somerset Community Health Quality
Account
40
“Achieving high quality care for all should be the ambition that we all share. Placing
quality at the heart of the NHS has sparked an uprising of energy, enthusiasm and
creativity across the service, which cannot be extinguished”
Professor the Lord Darzi of Denham - High Quality Care for All
1
FOREWORD FROM THE CHIEF OPERATING OFFICER
I am delighted to introduce the second annual Quality Account for Somerset
Community Health. The Account which covers the period 2010/11 to 2011/12
sets out the progress we have made during the past year, with respect to
delivering excellent standards of care to patients
across Somerset.
Somerset Community Health has a vision of
ensuring that patient safety and quality is at the
heart of everything we do. Our Board to Patient
philosophy for embedding quality into the patient
experience remains central to us. This ensures that
patients experience an excellent standard of care,
whilst we adhere to the highest standards of patient
safety and clinical effectiveness. Our organisationwide commitment to placing quality at the centre of
service delivery has also ensured that we have
maintained the focus on the preservation and
improvement of quality standards at a time of limited
financial flexibility.
Judith Brown, Chief Operating Officer
Somerset Community Health recognises the importance of valuing and
empowering staff, by equipping them with the skills which they need. In
striving to deliver world class community services, Somerset Community
Health is fortunate to have dedicated, hard-working staff who take a pride in
their work and in their organisation. Our staff can be proud of the excellent
quality of care that they deliver to patients across the whole of Somerset, and
of the efforts that they make every day in delivering the highest standards of
quality and patient safety. The 2010 NHS Staff Survey results show that
Somerset Community Health staff rated their organisation more favourably
than the national average for key indicators of service quality including the
percentage of staff that would recommend the Trust as a place to work or
receive treatment, and the percentage of staff agreeing that their role makes a
difference to patients.
Somerset Community Health remains committed to the Quality Improvement,
Productivity and Prevention (QIPP) agenda in optimising the quality of care
delivered to patients, whilst adopting an innovative approach to service
delivery and maximising levels of productivity and efficiency. Our recognition
last year, that there would be a need for continued innovation in order to raise
standards of both quality and efficiency has been exemplified through the
extended use of technology to facilitate the expansion of telehealth and
telecare, notably by the Somerset Community Health community matrons‟
team. This has also underpinned our belief in empowering patients with long
term conditions, to manage their own care and to live as independently as
possible. The telecare and telehealth initiatives have enabled greater
numbers of patients to assess their own levels of health and wellbeing, and to
manage their own care, with increasing confidence.
1
Initiatives which we implemented last year, to reinforce the Board to Patient
ethos, have continued. These include “Frontline Fridays”, which involve senior
managers from the Chief Officer‟s Group spending time with clinical staff on
the frontline, in order to understand at first hand the clinical role and the
quality of care delivered to patients, and Patient Safety Walkarounds by senior
managers and Non Executive Directors, to review quality and safety issues
within community hospitals.
As patient safety and quality measures are integral to the arrangements for
regular reporting to the Somerset Community Health Committee, we maintain
a focus on the reliability and accuracy of the data contained within the Quality
Account throughout the year, and to the best of my knowledge the information
contained within this Quality Account is accurate.
The Somerset Community Health Quality Account has been reviewed and
approved at senior manager level, but remains a living document, which will
be subject to further development and improvement, through engaging and
seeking the views of patients, staff and other key local partners.
Judith Brown
Chief Operating Officer
Somerset Community Health
2
2
INTRODUCTION
2.1
The aims and objectives of Somerset Community Health are underpinned
by the central philosophy of ensuring that we deliver the highest standards
of quality of care and safety to our patients
2.2
Our Aims are:
To be the provider and employer of choice for community based
NHS services
To deliver a portfolio of World Class community services focused on
quality and patient safety
To listen to local communities when designing and developing
services
To learn from the individuals who use our services
2.3
Our Objectives are:
To ensure that the safety of the individual is paramount
To ensure individuals are always valued and treated with respect
To deliver high quality outcome focussed services using best
practice
To ensure care is delivered by competent, compassionate and
motivated staff
To focus on the delivery of accessible, local services
To ensure services are responsive and provide choice
To deliver care in line with national, local and professional standards
and guidance
To promote a culture of continuous quality improvement and
innovation
To use technology to deliver better healthcare
To be financially successful
3
3
PRIORITIES FOR IMPROVEMENT: IMPROVING QUALITY FURTHER
IN 2011/12
3.1
Somerset Community Health remains ambitious in its aim to deliver ever
higher standards of care to patients and to improve the quality of the
patient experience. In 2011/12, we will seek to build upon the excellent
care which our patients have come to expect from us, and to raise
standards yet further.
3.2
A challenge for the year ahead will remain the maintenance of the pace of
these improvements during a climate of limited financial flexibility and
increased demand.
3.3
Somerset Community Health has made excellent progress with the quality
agenda and for the year ahead will continue this focus. The organisation
will continue to measure performance - reporting against the priorities via
its balanced scorecard, and using associated national quality measures
such as National Patient Safety Agency and NICE compliance.
3.4
Areas identified for particular focus during 2011/12 are set out in Table 1
below, with links drawn to the three principal quality improvement
categories contained within the Quality Account:
Table 1: Priority Areas for Quality Improvement during 2011/12
Priority
Care Planning
Description
Somerset Community Health will
undertake a comprehensive review
of existing care planning
arrangements, with a view to
identifying and sharing good
practice across the organisation
and ensuring that patient centred
care plans are produced for all
patients, on the basis of effective
and meaningful engagement and
involvement.
Progress will be reviewed in
community hospitals through the
use of unannounced internal
inspections at which the level and
extent of patient engagement with
their individual care plans will be
assessed and where appropriate
action plans addressed to improve
performance.
4
Categories
Clinical
effectiveness,
Patient
Experience
Priority
Description
Somerset Community Health will
review the implementation of these
improved care planning
arrangements during the year and
will report progress to the Patient
Safety, Quality Improvement and
Development Group and the
Clinical Working Group.
Categories
Learning
Disabilities
Somerset Community Health will
work closely with all healthcare
providers and, in particular with
Somerset Partnership NHS
Foundation Trust to ensure that it
meets the six criteria relating to the
needs of people with a learning
disability, based on the
recommendations set out in
„Healthcare for All‟.
Patient
Experience
Somerset Community Health will
measure progress during 2011/12
against the action plan for the
implementation of these standards
and will report to the Patient Safety,
Quality Improvement and
Development Group and the
Clinical Working Group.
Infection
Control
Somerset Community Health will
participate in the NHS South West
Quality and Patient Safety
Improvement Programme, with a
specific focus on the reduction of
catheter urinary tract infections.
Patient Safety
Progress against this will be
monitored through the Infection
Control Working Group.
Privacy
and Dignity
Somerset Community Health will
continue to actively promote and
maintain excellent standards of
privacy and dignity, by asking
patients and relatives for their views
and directly responding to any
concerns that they may have.
5
Patient
Experience
Priority
Description
Categories
A series of local listening events will
be held in order to work with
communities to see how we can
improve the hospital environment or
the standard of care that we give in
the community hospitals.
Somerset Community Health will
share details of the findings of these
listening events and the resultant
actions with local patient bodies.
Nutrition
Somerset Community Health will
continue to deliver the highest
standards of nutritional care to
patients. During 2011/12 we will
ensure that at least 90% of all
inpatients admitted to our
community hospitals have a
nutritional assessment, using a
validated tool such as MUST, within
24 hours of admission.
Clinical
effectiveness,
Patient Safety
Progress against this standard will
be measured on a monthly basis,
and will be reported via the
framework for Commissioning for
Quality and Innovation.
Dementia
Somerset Community Health will
demonstrate that it meets at least
the level one standards of “South
West Dementia Partnership:
Improving care for people with
dementia or mild cognitive
impairment whilst in hospital”
relating to:
Respect, dignity and
appropriate care
Agreed assessment, admission
and discharge processes, with
care plans specific to meet the
individual needs of people with
dementia and their carer
6
Clinical
effectiveness,
Patient
Experience
Priority
Description
Categories
Ensuring that people with
dementia or suspected
cognitive impairment who are
admitted to hospital and their
carers/families have access to
a specialist older peoples
mental health liaison service
Ensuring that the hospital and
ward environment is dementia
friendly, minimising the number
of ward and unit moves within
the hospital setting and
between hospitals
Meeting nutrition and hydration
needs
Ensuring that the hospital and
wards promote the contribution
of volunteers to the wellbeing of
people with dementia in
hospital
Hospitals and wards ensuring
quality of care at the end of life
Ensuring that appropriate
training and workforce
development are in place to
promote and enhance the care
of people with dementia in
hospital and their carers /
families
Progress against this standard will
be measured on a monthly basis,
and will be reported via the
framework for Commissioning for
Quality and Innovation.
Insulin related Somerset Community Health will
incidents
aim to reduce the rate of insulin
related incidents in its community
hospitals through improved access
to training and support.
Progress against this aim will be
monitored on a monthly basis and
will be reported to the Patient
Safety, Quality Improvement and
Development Group and the
Clinical Working Group.
7
Patient Safety
Priority
Stroke
Description
Categories
Somerset Community Health will Clinical
aim to ensure that people who have effectiveness
had a stroke access high-quality
rehabilitation and, with their carer,
receive support from stroke-skilled
services after transfer from the
acute hospital and for as long as
they need it.
Progress against this aim will be
monitored on a quarterly basis and
will be reported to the Patient
Safety, Quality Improvement and
Development Group and the
Clinical Working Group.
Assurance
3.5
Arrangements which Somerset Community Health has in place to
optimise, and provide assurance regarding quality and patient safety
include:
Clinical Quality Framework
3.5.1
The Clinical Quality Framework used by Somerset Community Health to
assure and improve the quality of our services is based on to the following
principles:
Provision of effective clinical leadership at all levels within the
organisation.
Safeguarding of basic standards of care outlined by the
independent regulator the Care Quality Commission
Promoting evidence based best practice
The need to measure quality improvements through the provision
of reports and analysis against balanced scorecards and quality
dashboards at organisational and strategic levels.
Rewarding the delivery of high quality care through the framework
for Commissioning Quality and Innovation (CQUIN)
Ensuring that we learn from incidents and complaints and implement
action plans to change practice where necessary
Demonstrating evidence of public involvement in planning, design
and evaluation of services
8
Demonstrating evidence of patient satisfaction and responding to
feedback
Making information available to the public through annual Quality
Accounts
Care Quality Commission Registration
3.5.2
Somerset Community Health is required to register with the Care Quality
Commission and its current registration status is without conditions. The
Care Quality Commission has not taken enforcement action against
Somerset Community Health during 2010/11.
Somerset Community Health has participated in special reviews or
investigations by the Care Quality Commission relating to the following
areas during 2010/11:
Inspection of Cleanliness and infection control in community
hospitals
Somerset Community Health intends to take the following action to
address the conclusions or requirements reported by the Care Quality
Commission:
Ratify the anti-microbial prescribing policy, make the policy available
on the Somerset Community Health intranet and circulate to all staff
Develop pocket antibiotic prescribing guides, for distribution to all
nursing and medical staff
Anti-microbial prescribing policy pocket guides to be circulated to all
medical practitioners working in community hospitals
Regular antibiotic prescribing data to be circulated to each hospital
and discussed at monthly hospital liaison meetings with medical staff
An audit programme to be developed with the clinical audit team in
order to audit compliance with the policy
Medicines management training and infection control training to be
reviewed and the responsibilities around prescribing to be
strengthened
General awareness of staff roles in respect of anti-microbial
prescribing to be improved
Progress against the local and organisational action plan to be
updated and monitored on a monthly basis to ensure full compliance
within target dates
9
By 31 March 2011 Somerset Community Health had made the following
progress in taking such action:
The anti-microbial prescribing policy has been ratified, cascaded to
all teams across Somerset Community Health, and made available
on the intranet
The antibiotic prescribing guides have been developed and checked
against the Somerset prescribing formulary for compliance.
Laminated pocket versions of the guides were launched at the
community hospital working group meeting in September 2010. A
programme of road shows was delivered for all nursing and medical
staff at each community hospital
Countywide prescribing data has been established as a standing
agenda item at the infection control group meeting. Individual
hospital prescribing data is collated and distributed on a monthly
basis
A anti-microbial prescribing audit proposal has been developed and
agreed, and pilot arrangements commenced in February 2011
The training programme for medicines management has been
revised to include the anti-microbial policy and guides
Revised medicines management and infection control training has
been approved
Actions arising from an incident at Bridgwater Community Hospital
have been completed, including additional training and roll out of the
Clostridium Difficile pathway to medical and nursing staff,
implementation of revised communications pathways, review of
medicines management competences, and additional infection
control training for link practitioners. Lessons learned from the
incident have been shared with all community hospital matrons
A comprehensive system, for gathering supporting evidence to provide
assurance of compliance against the Care Quality Commission‟s
registration outcome measures has been implemented across all
individual services provided to patients by Somerset Community Health.
Somerset Community Health has implemented a broad range of
mechanisms for maintaining assurance regarding compliance with the
registration quality outcome measures. These measures are in place
across all services provided. The measures, include the compilation of
evidence to support the demonstration of compliance with the standards,
reciprocal peer review of evidence by healthcare professionals, and a
programme of internal inspection, and aim to promote the identification
10
and organisation-wide adoption of examples of good practice. The focus
of the activity is to ensure that patients receive the highest quality of care.
Clinical Audits
3.5.3
During 2010/11, two national clinical audits and no national confidential
enquiries covered NHS services that Somerset Community Health
provides.
During the period Somerset Community Health participated in all the
national clinical audits and national confidential enquiries for which it
was eligible.
The national clinical audits and national confidential enquiries concerned
were as follows:
The National Audit for Falls and Bone Health in Older People
National Adult Diabetes Audit
Somerset Community Health provided responses in respect of all
questions covered by both audits in which it was eligible to participate
The reports relating to all applicable national clinical audits were reviewed
by the Somerset Community Health in 2010/11 and the organisation
intends to take the following actions to improve the quality of healthcare
provided in the relevant areas:
Develop robust processes and documentation for identifying people
who have fallen or who are at risk of falling
Develop a Falls Prevention Policy for Somerset Community Health to
encompass all relevant clinical areas
Audit compliance with the Falls Prevention Policy and make
recommendations for further improvements
Identified inpatients at risk of falls by a coloured wrist band
Develop an integrated falls pathway for Somerset Community Health
Strengthen systems to identify and manage fallers, including those
whose primary diagnosis is not a fall and who currently do not
receive targeted Falls services/assessment/intervention
Provide additional information and education for staff
Review and agree a falls programme based on best evidence
11
Review processes in place for sharing information
Improve information for patients in respect of bone health,
osteoporosis and falls
The reports of nine local clinical audits were reviewed in 2010/11. These
were:
MRSA Compliance with Somerset Community Health Policy in
Somerset's Renal Units
NICE CG88 Lower Back Pain Guidelines Clinical Audit
Re-audit of inpatient Medicines Administration Records Chart
Audit of Compliance with Level 1 Falls Assessment Tool
Re-audit of Patient and Carer Satisfaction of the Heart Failure
Service and treatment choice
Safeguarding Knowledge and process within Child Services
Diabetic Retinopathy Screening Service DNA (did not attend) Audit
Part 1 Audit of Awareness and understanding of Policy for the
Management of Clinical Diagnostic Tests
CG54 Antenatal Postnatal Mental Care Pathway audit
Somerset Community Health intends to take the following actions to
improve the quality of healthcare provided:
Re-audit of MRSA compliance to be included in the 2011/2012 Audit
Programme
The findings of the report on the inpatient Medicines Administration
Records (MAR) Chart to be widely disseminated to staff within the
community hospitals via Community Hospital Matrons
Emphasise to staff the importance of the completion of the following
areas:
Duration recorded on MAR Chart
Start date for each separate administration on MAR Chart
Omission reason documented in the Nursing Evaluation
Record
Resuscitation status on MAR Chart
12
Ensuring that it is documented if patient is wearing a red
wristband
The findings of the report on Audit of Compliance with the Level 1
Falls Assessment Tool to be widely disseminated to staff within the
community hospitals via Community Hospital Matrons
Revised Falls Prevention Policy to be widely publicised to all staff
groups
Ensure that all staff are appropriately trained in falls prevention and
how to complete the level 1 screening assessment tool appropriately
Ensure that all staff members are aware of their own personal
responsibilities regarding Falls Prevention
Update the Level 3 module of child protection training to meet the
national level 3
Commence three monthly group child protection clinical supervision
sessions for both Integrated Therapy Staff and Community Right
Steps staff, led by the Named and Locality Safeguarding Children
Nurses
Revise the current Somerset Community Health Clinical Supervision
Policy following the organisational changes in April 2011
Ensure that the information written into the patient‟s appointment
letter highlights the issue of non-cancellation of appointments
Posters to be displayed in all clinic sites detailing the results of the
audit and highlighting need to cancel
Somerset Community Health‟s Management of Clinical Diagnostic
Tests and Screening Procedures Policy to be made available and all
staff to sign to confirm that they have read and understood it
Further training made available to staff to enable them to carry out
diagnostic tests and/or screening procedures according to the policy
NHS Evidence
3.5.4
NHS Evidence allows everyone working in health and social care to
access a wide range of health information to help them deliver quality
patient care. NHS Evidence provides free access to clinical and nonclinical information, at local, regional, national and international levels.
Information includes evidence, guidance and Government policy.
Somerset Community Health has made NHS Evidence readily accessible
to its staff by making the search facility available on its intranet site.
13
The Patient Safety, Quality Improvement and Development Group
(SQUID)
3.5.5
SQUID draws together all aspects of the quality and patient safety
agenda, with a view to ensuring that Somerset Community Health is a
learning organisation with respect to quality and patient safety.
SQUID brings together clinical and non clinical staff to ensure that there is
full integration across all key areas of the patient safety and quality
agenda, to optimise the spread of best practice and mutual learning.
Issues which fall under the remit of SQUID include:
Patient Safety
Patient Engagement
Clinical Effectiveness and the development of practice standards
High Risk Clinical issues
Serious untoward incidents
Complaints and commendations
Implementation of NICE guidance
Serious Untoward Incidents
3.5.6
All Serious Untoward Incidents (SUIs) for Somerset Community Health
are reported to the Head of Risk, who provides the link for notification and
monitoring with NHS Somerset.
All incidents are reported using the Trust‟s Datix system and reporting of
incidents generally increased month on month during the last year.
Significant work has been undertaken to improve the „user friendliness‟ of
the system and the reporting template, and regular training is provided for
staff.
Robust investigations are undertaken, working to predetermined Terms of
Reference and using the Root Cause analysis framework from the
National Patient Safety Agency. The resultant actions plans, one
organisational and one local, are monitored either through the Patient
Safety Assurance Group or via SQUID. All action plans require the
submission of evidence in order to provide assurance of completion.
Learning is shared throughout the organisation, generally via SQUID.
14
In addition, debrief sessions are held in the clinical area involved to
ensure that staff involved or on the periphery are provided with timely
feedback from the incident and the resultant actions to be taken.
Over the last year, investigations have been undertaken into incidents
relating to care provision and medication incidents. As a result, changes
in clinical care have been made across the Trust and adherence to the
changes is monitored through the audit process.
Safeguarding Children
3.5.7
Somerset Community Health has a statutory duty, under Section 11 of the
Children Act 2004, to protect children from harm as part of the wider work
of safeguarding and promoting their welfare.
Somerset Community Health takes its responsibility for safeguarding
children and young people very seriously and takes all the necessary
steps to ensure that consistent best practice is adhered to across the
organisation.
Somerset Community Health has a team of Safeguarding Nurses who are
committed to ensuring the current service is of a consistent high quality
across the whole of the organisation. There is an internal safeguarding
forum and a senior representative attends the Local Safeguarding
Children‟s Board.
The organisation has well established relationships across agencies
which facilitate a partnership approach to safeguarding children. Somerset
Community Health has recently reviewed its systems, structures and
processes for safeguarding children and has taken a number of steps to
strengthen guidance and improve practice to include lessons that have
been learnt from Serious Case or Health Reviews. Child protection
processes have become more transparent and are subject to regular
assessment and scrutiny.
As at 31 March 2011, the uptake rates for Safeguarding Children for
Somerset Community Health staff were as follows:
Level 1: 82%
Level 2: 92%
Level 3: 91%
Safeguarding Vulnerable Adults
3.5.8
Somerset Community Health is committed to protecting vulnerable adults
from abuse, ill-treatment and exploitation. The organisation has a Lead
for Safeguarding Vulnerable Adults, an internal safeguarding forum and
also has senior representation at the multi-agency Safeguarding
Vulnerable Adults Board.
15
An agreed Somerset Multi-Agency Safeguarding Adults Policy is available
to all staff. A training strategy has been written and additional training
sessions have been developed in order to meet the training requirements
for all staff. The training focuses on Safeguarding Vulnerable Adults, The
Mental Capacity Act and the Deprivation of Liberty Safeguards and
includes lessons learnt from Serious Case Reviews and incidents.
Somerset Community Health has recently reviewed its systems,
structures and processes for safeguarding vulnerable adults and has
taken a number of steps to develop guidance to improve practice.
As at 31 March 2011, the uptake rate for Safeguarding Vulnerable Adults
for clinical staff employed by Somerset Community Health was 93%.
Benchmarking our Performance
3.5.9
Somerset Community Health is represented on the national Steering
Group of the NHS Benchmarking Network and participates in
benchmarking exercises to compare its services with other community
services providers nationally. The findings of these exercises provide
valuable comparative information which has helped inform reviews of
individual services to improve the quality and efficiency of care delivered.
Commissioning for Quality and Innovation Payment Framework
(CQUIN)
3.5.10
A proportion of Somerset Community Health‟s income in 2010/11 was
conditional on achieving quality improvement and innovation goals agreed
between Somerset Community Health and any person or body they
entered into a contract, agreement or arrangement with for the provision
of NHS services, through the Commissioning for Quality and Innovation
payment framework.
Further details of the agreed goals for 2009/10 and for the following 12
month period are available electronically at:
http://www.somerset.nhs.uk/community/about-us/our-performance/
Data Quality
3.5.11
Somerset Community Health recognises the important role of data quality
in providing confidence in the accuracy of information used to inform
decisions relating to service improvement. Data quality indicators, relating
to the timeliness and accuracy of coding are routinely reported to the
Somerset Community Health Committee. Additional measures which
permit the regular monitoring of data quality include:
the use of the NHS number
the clinical coding error rate
16
the use of GP medical practice
the Information Quality and Records Management score
3.5.12
Somerset Community will be taking the following actions to improve data
quality in 2011/12:
continuing with the automation of data collection and information
analysis, focusing on any community based services which operate
manual or paper-based data collection systems
ensuring that the data for these services is accessible by the central
information team for Somerset Community Health, in order that it
may be subject to the same rigorous data quality checks and
validation processes
continuing to undertake targeted and supportive work with services,
to understand the reasons behind any adverse variances in respect
of data completeness or accuracy
The Somerset Community Health Information Governance Assessment
Report overall score for 2010/11, as reported via the report for Somerset
Primary Care Trust, was 73% and was graded Satisfactory.
Somerset Community Health was not subject to the Payment by Results
clinical coding audit during 2009/10 by the Audit Commission.
Somerset Community Health submitted records during 2010/11 to the
Secondary Uses service for inclusion in the Hospital Episode Statistics
which are included in the latest published data. The percentage of records
in the published data which included the patient‟s valid NHS number was:
53% for admitted patient care
70% for outpatient care
48% for accident and emergency care.
The percentage of records which included the patient‟s valid General
Medical Practice Code was:
99.9% for admitted patient care
99.9% for outpatient care
98.9% for accident and emergency care
17
4
REVIEW OF QUALITY PERFORMANCE IN 2010/11
PATIENT SAFETY
4.1
Infection Control
4.1.1
Somerset Community Health remains fully committed to the prevention
of healthcare - associated infections (HCAI) and to ensuring
compliance with the Health Act: (Revised 2008) code of practice for the
prevention and control of healthcare associated infections, across all of
the services managed by the organisation. Effective infection
prevention and control is integral to gaining public confidence and
improving the quality and efficiency of our clinical services.
4.1.2
The importance of this work is demonstrated by the dedicated Infection
Prevention and Control (IPC) Team, who work across Somerset
Community Health and provide advice and support to other external
organisations.
4.1.3
Annual infection prevention and control training is mandatory for all staff,
and is also part of the induction programme for new staff, to ensure that
all staff are proactive in promoting and implementing best practice.
Somerset Community Health also attained a position of full compliance
with the standards set out in the Care Quality Commission‟s Hygiene
Code.
4.1.4
Somerset Community Health had no MRSA bacteraemia in its community
hospitals during the whole of 2010/11. This compares to one case during
2009/10. During the same period, there were 13 cases of clostridium
difficile recorded in Somerset‟s Community Hospitals, against a target for
the year of no more than 16 cases. This equates to around 0.12 cases
per 1000 bed days, and represents a reduction from 19 cases during
2009/10 (0.15 per 1000 bed days).
4.1.5
Figure 1 shows that Somerset Community Health recorded two cases of
Clostridium Difficile in April 2010, followed by one case in May and June
2010, and subsequently sustained a cumulative position which was better
than its target for the remainder of the year.
18
Figure 1 – Cumulative Actual Number and Target for Clostridium
Difficile Cases in 2010/11
18
16
14
12
Cumulative Actual
Cumulative Trajectory
10
8
6
4
2
0
Apr - 10
May - 10
Jun - 10
Jul - 10
Aug - 10
Sep - 10
Oct - 10
Nov - 10
Dec - 10
Jan - 11
Feb - 11
Mar - 11
4.2
Hospital cleanliness
4.2.1
All of Somerset Community Health‟s community hospitals undertake a
monthly hospital cleanliness audit, the results of which are co-ordinated
by the Somerset Community Health Infection Control Nurse.
4.2.2
All hospitals should aim to achieve a standard of 95% or higher. The
monthly standards achieved by Somerset Community Health are set out
in Table 2 and Figure 2 below:
Table 2: Community Hospital Cleanliness Audit Scores for 2010/11
Month
April 2010
May 2010
June 2010
July 2010
August 2010
September 2010
October 2010
November 2010
December 2010
January 2011
February 2011
March 2011
Standard Achieved
97%
97%
98%
97%
97%
98%
97%
90%
97%
98%
98%
98%
19
Figure 2: Community Hospital Cleanliness Audit Scores for 2010/11
Actual Performance
Standard
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Apr - 10
May - 10
Jun - 10
Jul - 10
Aug - 10
Sep - 10
Oct - 10
Nov - 10
Dec - 10
Jan - 11
Feb - 11
Mar - 11
4.2.3
Table 2 and Figure 2 show that Somerset Community Health exceeded
the required standards in every month during 2010/11, with the exception
of November 2010. This was due to the audit not being undertaken at
Williton Community Hospital during that month, which consequently
resulted in a reported audit score of 0% for that hospital.
4.3
Hand hygiene
4.3.1
Somerset Community Health undertakes monthly audits of hand hygiene
standards across all of its community hospitals. The audit covers all
health professionals, whether employed by the hospital or visiting from
another Trust.
4.3.2
Table 3 and Figure 3 provide details of the scores achieved during
2010/11.
20
Table 3: Hand Hygiene Audit Scores for 2010/11
Month
April 2010
May 2010
June 2010
July 2010
August 2010
September 2010
October 2010
November 2010
December 2010
January 2011
February 2011
March 2011
Standard Achieved
99%
99%
99%
100%
100%
100%
100%
98%
99%
100%
100%
100%
Figure 3: Hand Hygiene Standards Achieved in 2010/11
Actual Performance
Standard
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Apr - 10
May - 10
Jun - 10
Jul - 10
Aug - 10
Sep - 10
Oct - 10
Nov - 10
Dec - 10
Jan - 11
Feb - 11
Mar - 11
4.3.3
Table 3 and Figure 3 show that the required hand hygiene standard was
exceeded in every month during 2010/11.
4.4
Medication incidents
4.4.1
A prescribed medicine is the most frequent treatment provided for patients
in the NHS. GPs in England issue more than 660 million prescriptions a
year and it is estimated that 200 million prescriptions are written in
hospitals.
4.4.2
Over 1.25 million items of medication are supplied to Somerset
Community Health‟s hospitals in a year. Managing medicines is therefore
a key component of patient safety.
21
4.4.3
Figure 4 below shows the monthly number of medication incidents
resulting in harm, per 1000 bed days, for Somerset Community Health
during 2010/11.
1.00
0.90
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
Apr - 10
May - 10
Jun - 10
Jul - 10
Aug - 10
Sep - 10
Oct - 10
Nov - 10
Dec - 10
Jan - 11
Feb - 11
Mar - 11
4.4.4
Figure 4 shows the monthly rate of medication incidents resulting in harm,
for Somerset Community Health during 2010/11, was zero in the majority
of months, and never exceeded 0.36 incidents per 1000 bed days in any
month.
4.4.5
All reported medication incidents are evaluated by the Somerset
Community Health Risk Management Team and are reviewed by the
Chief Pharmaceutical Lead.
4.4.6
Any serious incidents, or identified trends are investigated and quarterly
Medication Incidents reports are submitted to SQUID for review, and are
also considered by the Somerset Community Health Committee.
4.5
Slips, Trips and Falls
4.5.1
For the period 1 April 2010 to 31 March 2011, a total of 1,309 slips, trips
or falls were recorded, equivalent to 12.48 per 1,000 occupied bed days.
During the same period in 2009/10 there were 1,189 incidents recorded,
equivalent to 11.28 per 1,000 occupied bed days.
4.5.2
Figure 5 below details the comparative numbers of slips, trips and falls
reported in community hospitals between 1 April 2009 and 31 March
2011.
22
Figure 5: Community Hospital Reported Slips, Trips and Falls
between 1 April 2009 and 31 March 2011
160
140
120
100
80
60
40
20
0
Apr
May
Jun
Jul
Aug
Sep
2009/2010
Oct
Nov
Dec
2010/2011
Jan
Feb
Mar
Average 2010/11
4.5.3
Figure 5 illustrates the increase in the number of falls reported during
2010/11, compared to 2009/10. This was principally as a result of an
initiative which was launched by Somerset Community Health in July
2010, promoting the proactive reporting of incidents. Somerset
Community Health staff are encouraged to report all incidents and
awareness training is routinely provided.
4.6
Staff Wellbeing and Development
4.6.1
Somerset Community Health recognises the importance of valuing and
empowering staff, by equipping them with the skills which they need in
order that they can remain at the forefront of delivering the highest quality
of care to patients. During 2010/11, the training rates for Somerset
Community Health staff in respect of key areas of the mandatory training
programme were:
4.6.2
Infection Control:
96%
Basic Life Support:
94%
Safeguarding Vulnerable Adults (Clinical Staff):
93%
The NHS Staff Survey results for 2010 showed that encouraging progress
was made by Somerset Community Health across a broad range of areas
relating to the delivery of patient care, staff wellbeing, and job satisfaction.
A summary of some of the key outcomes from the NHS Staff Survey for
2010 is included in Table 4 below:
23
Table 4: Key Outcomes from the Staff Satisfaction Survey for 2010
Measure
Percentage of staff feeling satisfied with
the quality of work and patient care they
are able to deliver
Percentage of staff agreeing that their role
makes a difference to patients
4.6.3
Somerset
National
Community Average
Health
71%
71%
90%
89%
Levels of Staff job satisfaction (range from
1 to 5)
3.63
3.58
Staff recommendation of the Trust as a
place to work or receive treatment (range
from 1 to 5)
Percentage of staff appraised
3.59
3.45
85%
77%
Percentage of staff receiving job relevant
training, learning and development
77%
79%
Percentage of staff able to contribute to
improvements at work
64%
67%
Staff motivation at work (range from 1 to 5)
3.89
3.81
The staff sickness absence rate for Somerset Community Health during
2010/11 was 4.47%. This compares to 4.74% during 2009/10.
CLINICAL EFFECTIVENESS
4.7
Venous Thromboembolism Assessments
4.7.1
In order to reduce avoidable death, disability and chronic ill health,
patients admitted to community hospitals in Somerset receive an
assessment for Venous Thromboembolism (VTE).
4.7.2
During 2010/11, 95% of patients admitted to community hospitals run by
Somerset Community Health were assessed for venous
thromboembolism, against a required standard of 90%.
4.8
Productive Ward
4.8.1
The Productive Ward is currently operating in all community hospitals.
24
4.8.2
Each hospital collects measurable baseline data and each ward team
identifies patient safety initiative models of improvement to consider and
develop. Care delivery areas currently under review include the ward
handover, the roll out of Patients‟ Own Medication, and safety checks for
patients at risk of falls.
4.9
Operational Effectiveness
4.9.1
Somerset Community Health recognises that its effectiveness in delivering
key operational standards has a significant bearing upon the patient‟s
experience of care. Operational standards which are monitored on an
ongoing basis are set out in Table 5 below:
25
Table 5: Operational Effectiveness Standards Achieved by Somerset
Community Health in 2010/11
Indicator
Actual
Standard
Performance
as at 31
March 2011
Babies being breast fed at the 6–8 week point
48.3%
48%
Minor Injury Units: Patients waiting under four
99.9%
98%
hours from arrival to discharge or admission
Diabetic Retinopathy Screening: Percentage of
92.0%
80%
eligible people screened
Average Length of Stay in community
20.1 days
15 days
hospitals, Excluding Day Cases and Stroke
Wards (a)
Bed Days Lost Due to Delayed Transfers of
4.0%
3.5%
Care (b)
Staff Appraisal
96%
95%
National Child Measurement Programme:
Participation rate (proportion as a percentage)
of eligible pupils in
Reception Year
93.3%
91.1%
Year 6
87.2%
87.2%
(a) Reducing the average length of stay is a standing agenda item at key
forums such as the community hospitals working group, as well as
being an integral element of multi-disciplinary team meetings and
patient handover arrangements.
(b) The principal issues affecting discharge from community hospitals is a
continued shortage of available nursing home places. Detailed action
plans have been developed by the community hospital matrons to
reduce levels of delayed discharges, with the involvement of locality
managers. The longer term trend for delayed discharges remains
downwards.
The admission, during 2010/11, of a number of patients with complex care
needs has affected the degree of progress possible in respect of both of
these issues. Improvements to monitoring arrangements, implemented at
the beginning of 2011/12, have seen the average length of stay and the
rate of delayed discharges in community hospitals both fall from the levels
as at the end of March 2011.
4.10
4.10.1
Patient Experience and Satisfaction
Somerset Community Health values the views of patients, carers, and
service users, and takes very seriously comments and complaints about
the services which it provides. As an organisation, we want to hear from
people who use our services, so that we can address any shortfalls and
issues and build improvements into our policies, processes, and
procedures.
26
4.10.2
Somerset Community Health evaluates the patient experience through a
variety of methods, including:
Patient Satisfaction Surveys
Complaints, Concerns, Commendations and Patient Advice and
Liaison Service contacts
Locality Listening Events
Patient Satisfaction Surveys
4.10.3
In order that Somerset Community Health can evaluate patient feedback
and learn from the patient experience, every patient will receive a patient
satisfaction questionnaire to complete and return, or on completion of an
episode of care or on discharge.
4.10.4
All service areas will participate in the scheme by April 2011 and
performance will be monitored through the contract review process. The
learning from patient responses is considered on a monthly basis by the
Patient and Public Involvement Group and on a quarterly basis by the
Safety, Quality Improvement and Development Group.
4.10.5
By eliciting patients‟ views regarding the service which they receive and
by acting on patient feedback, Somerset Community Health aims
iteratively to improve the quality of care which it delivers to patients across
the county.
4.10.6
Patients are asked for their opinion in respect of six statements relating to
the care which they received, on a scale ranging from “Strongly Agree” to
“Strongly Disagree”. As at 31 March 2011, a total of 643 patients had
provided a response. The six statements, together with the percentages
of patients who agreed or strongly agreed, are set out in Table 6.
27
Table 6: Percentage of Patients Agreeing or Strongly Agreeing with
Statements from Feedback Questionnaires during the Period 1 April
2010 to 31 March 2011
% Agreeing
or Strongly
Statement
Agreeing
(Standard:
90%)
The team providing my care treated me with dignity and
99%
respect
I was able to ask questions about my care or treatment
The treatment areas at the hospital or clinic were both clean
and tidy
I was confident that the member of staff cleaned their hands
before starting my treatment
The amount of time I waited before receiving my treatment
or care was acceptable to me
Overall I was pleased with the level of care I received
97%
99%
97%
95%
99%
4.10.7
As FORMIC is implemented more widely across the organisation,
Somerset Community Health is undertaking work to refine the detail of the
feedback sought from patients, and to determine in greater detail how the
quality of service delivered to patients may be improved.
4.10.8
Positive service user comments included:
“I just have to say how valuable Cardiac Rehab has been to me putting
me back on the right road after my procedure. When being told you have
heart disease it shatters your confidence, but the team answered many
questions to put my mind at rest and also put me in the picture as to what
was going on health wise. Well done Somerset Community Health.”
(Cardiac Rehabilitation Service)
“Excellent Service and Very knowledgeable and thoughtful”
(Dietetics Service)
Physical and emotional care superb, night staff very patient, despite their
long shifts and heavy looking work schedules. The whole building very
bright and clean with good artwork on display in otherwise dull corridors.
(Minehead Community Hospital)
“I believe that the level of care provided by the nurses involved in the
Somerset Community Health Care Trust cannot be bettered. They are
always friendly, cheerful, professional and willing to help in any way that
they can.” (District Nurse Service)
28
“I have found this service invaluable and having it so close to home has
been a huge benefit. The advice and support given has been excellent.”
(Diabetes Service)
“I am very pleased with the services provided” (Podiatry Service)
PALS, Complaints and Commendations
4.10.9
Somerset Community Health is required to investigate complaints and
concerns about its services and staff in accordance with the NHS
Complaints Regulations. The learning from patient responses is
considered on a monthly basis by the Safety, Quality Improvement and
Development Group, and on a quarterly basis by the Integrated
Governance Committee.
4.10.10
Examples where the outcomes of complaints and concerns investigations
have led to improvements in service provision include:
The Tissue Viability Service has improved the ordering and
availability of K2 compression bandages, in order to ensure that they
maintain appropriate stock levels.
The Musculoskeletal Interface Service has reviewed the patient
information leaflets to ensure that patients understand the
information that is provided prior to their out patient appointment.
The Patient Information Leaflets will also by the Patient Information
Group, which includes lay users within its membership, for further
review
Bridgwater Community Hospital has reviewed the ward level
record keeping to ensure that record keeping guidelines are adhered
to, that the Falls Assessment is updated regularly. All staff will also
be able to access awareness training for patients with dementia, and
consider alternative conditions, other than urinary tract infections,
when considering reasons for patients‟ increased confusion and
aggression. Action has also been taken to ensure the effective
handover of relevant patient information between staff and relatives
Frome Minor Injury Unit - A complainant was visited at home by
the Head of Quality Improvement and Patient Experience to discuss
her outstanding issues in more detail. The complainant‟s clinical
records were personally reviewed by the Head of Quality
Improvement and Patient Experience, and the findings of the
complaints investigation were discussed with the complainant. This
meeting provided reassurance to the complainant that the complaint
had been fully investigated, and staff had been made aware of the
need to take a more detailed history in future prior to deciding
whether to provide an X-ray.
29
Frome Minor Injury Unit - An elderly patient incorrectly attended
the community hospital, rather than the adjacent Minor Injury Unit,
with bladder retention. Unfortunately there was a delay before this
was identified and the patient could be booked on to the Minor Injury
Unit‟s computer system and the assessment/examination could
begin. The booking of patients into a Minor Injury Unit has been
reviewed, and staff have been made aware of the situation, in order
to ensure that patients are booked in for assessment and
examination in the Minor Injury Unit promptly
Concern was expressed regarding the type of oxygen cylinders in
use at Williton Community Hospital after a complainant claimed
that a fresh cylinder was given to her mother to use, when in fact it
was either empty or very low. Although the investigation did not
reveal a fault with the cylinder a new order was placed for cylinders
with integrated regulators to remove need to change regulator prior
to use. Williton Community Hospital now has 20 such cylinders in
stock at all times
A complaint was received from a prisoner at HMP Shepton Mallet
that he had received test results before his General Practitioner had.
The Prison Healthcare service has since reviewed its processes,
including the scanning of results to the clinical staff, and a telephone
results system has been established
Public Involvement Activities, including Listening Event Feedback
4.10.11
As well as reflecting on the patient experience to date by means of the
Patient Satisfaction Survey, and complaints, concerns and
commendations, Somerset Community Health aims proactively to engage
patients, carers and members of local communities in planned Listening
Events. Four Listening Events were held in 2010/11.
4.10.12
The following is a selection of comments received from members of the
public about our services:
“In fact talking to a representative of the organisation, pointing out the
aspects of the service and its place in the 21st Century has enlightened
me! Very encouraging. The lady in question was based in cardiac
services – a credit to you. A really worthwhile 10 minutes.”
(Cardiac Rehabilitation Service)
“Very happy with Taunton services”
(Health Visitor service and Community Paediatric Nurse service)
“Physio treatment at Williton Hospital great”
(Physiotherapy Service, Williton Community Hospital)
“The district nurses who visited me after my operation were very kind and
considerate.”(District Nurse Service)
30
“Diabetes nurse very good do not need to see the GP as they look after
me very well” (Diabetes Service)
“Frome Hospital appointments good - physio good here and a scan at
Frome excellent service at the hospital” (Frome Community Hospital)
4.11
Patient Environment Action Team (PEAT) Inspections
4.11.1
PEAT inspections are one of the ways in which standards delivered within
hospitals are assessed. The three principal areas for assessment are:
Hospital Environment
Food
Privacy and Dignity
4.11.2
The inspections were introduced to the NHS in 2000 and are overseen by
the National Patient Safety Agency. Although the PEAT inspections are
required to take place annually, Somerset Community Health undertakes
PEAT inspections of its hospitals throughout the year, to ensure that high
standards are being maintained.
4.11.3
The results of the latest PEAT inspections undertaken by the National
Patient Safety Agency in 2010 were that:
All 12 of Somerset Community Health‟s hospitals were rated as
“Excellent” for Food
Four hospitals were rated as “Excellent” for Privacy and Dignity, with
the remaining eight being rated as “Good”
All 12 hospitals were rated as “Good” for the Hospital Environment
4.12
Single Sex Accommodation
4.12.1
Every patient has the right to receive high quality care that is safe,
effective and respects their privacy and dignity. Somerset Community
Health is committed to providing every patient with same sex
accommodation, because it helps to safeguard their privacy and dignity
when they are often at their most vulnerable.
4.12.2
Somerset Community Health is proud to confirm that mixed sex
accommodation has been eliminated across the organisation. Patients
who are admitted to any Somerset Community Health‟s hospitals are
provided with single sex accommodation which is defined as separate
sleeping areas for men and women and segregated toilet and bathroom
facilities for men and women.
31
4.12.3
Sharing with members of the opposite sex will only happen by exception
based on clinical need (for instance when no other alternative is available
and patient safety would be compromised) or when patients choose to
share (for instance in palliative care).
4.12.4
Somerset Community Health had no reported breaches of the single sex
accommodation standards during 2010/11.
4.13
Improving Quality Further: Progress Against Priority Areas Identified
for 2010/11
4.13.1
The Somerset Community Health Quality Account for 2009/10 to 2010/11
set out as range of key areas on which the organisation aimed to focus
during 2010/11, in order to improve quality further. These key areas, and
the progress made in respect of each of them, are outlined in Table 7
below:
32
Table 7: Priority Areas for Quality Improvement during 2010/11
Priority
Monitoring
Clinical
Quality
Description
From April 2010, there will be an
additional focus contractual reviews
on the monitoring of clinical quality
through
agreed
performance
measures. This will include a range
of areas to include patient safety
incident reporting, breaches of single
sex
accommodation,
timely
investigation of serious untoward
incidents and clinical outcome
measure including infection control,
pressure area care and falls rates.
Categories
Clinical
Effectiveness,
Patient Safety
Embedding
Clinical
Policies and
Procedures
Safety will be embedded into all Patient
Safety,
clinical
tasks
including
the Clinical
development of clinical policies, Effectiveness
retrospective reviews of incidents
and the development of Standard
Operating Procedures for high risk
areas.
27
Progress
Quality Review meetings have been
instituted and are held regularly between
Somerset Community Health and NHS
Somerset, focusing on a broad range of
patient safety, quality and clinical
effectiveness measures.
Somerset
Community Health adopts an integrated
approach to the monitoring of quality
standards as part of internal reporting
arrangements
to
the
Somerset
Community Health Committee, and
regular monitoring and performance
management of these key indicators is
firmly established.
Standard Operating Procedures have
been developed for high risk areas, and
have been approved by the Somerset
Community Health Patient Safety Quality
Improvement and Development Group
(SQUID). SQUID has also overseen the
development, review and approval of
clinical policies and has ensured that
retrospective review is undertaken of
incidents, including the implementation of
actions arising.
Priority
Clinical
Outcomes
Description
The patient safety initiative will
continue to be rolled out to all
community hospitals together with
the productive hospital programme.
A focus on outcomes will be required
to deliver time released through
service
redesign
to
improve
efficiency and release time to care.
During 2010 the „Global Trigger Tool‟
will be implemented in all community
hospitals.
This tool is used to
retrospectively review patient notes
to detect adverse events. It is our
intention to build on this innovation
and create a similar tool to be used
in community services.
Care
Evidencing good practice is essential
Quality
to maintaining registration and will be
Commission prioritised to ensure that service
registration managers are maintaining evidence
to demonstrate that we are meeting
all of the required standards.
28
Categories
Clinical
Effectiveness
Progress
The patient safety initiative and productive
hospital
programme
have
been
implemented
in
all
of
Somerset
Community Health‟s community hospitals.
The „Global Trigger Tool‟ has also been
implemented across all community
hospitals and a review of the tool is
currently being undertaken.
Patient
Safety, Somerset
Community
Health
has
Clinical
equipped all of its services with reporting
Effectiveness
templates to facilitate the collection of
evidence to support the demonstration of
compliance with all applicable registration
outcome measures. A system of peer
review of evidence and internal inspection
operates across the organisation, to
identify and replicate examples of good
practice in the delivery of high quality care
and collation of evidence. Further work is
being undertaken to store all evidence
electronically, via a bespoke package,
enabling central review and comparison of
evidence between services.
Priority
Patient and
Public
Involvement
Description
Categories
In order to deliver the strategy for Patent
Patient and Public Involvement, Experience
Somerset Community Health will
maintain engagement with patients,
service users, the public and staff
and to consider and then act upon
local feedback.
The patient
satisfaction
questionnaire
will
continue to be rolled out to include all
service areas by April 2010
29
Progress
Somerset
Community
Health
has
implemented a rolling system for
collecting patient feedback, in the form of
a
generic
patient
satisfaction
questionnaire. All services collect patient
feedback during one week every six
months, with the exception of community
hospital inpatients, for which monthly
feedback is collected. This provides an
indication of patient satisfaction levels and
helps services maintain and improve the
quality of service delivered. Patients are
given the opportunity to comment on their
own level of satisfaction at the point of
discharge or completion of a package of
care. Reports of patient satisfaction are
reported to the Patient and Public
Involvement Group.
Priority
Patient and
Public
Involvement
Description
Categories
Somerset Community Health plans Patent
to proactively engage patients, Experience
carers and members of local
communities in a series of planned
listening events held on a six
monthly basis across each of the
eight localities. Each Locality Event
will be themed to raise awareness
locally of service developments and
give the public an opportunity to
influence
service
design
and
redevelopment.
These will put
patients and the public firmly at the
centre of service delivery and
provide a valuable source of real
time views and public opinion
30
Progress
In 2010/11 Somerset Community Health
developed a programme of outreach
events in order to raise patient awareness
of service developments and to obtain
patient feedback. Somerset Community
Health attended or held Locality Listening
Events in Frome, West Mendip,
Wincanton, and Taunton. In addition, a
wide range of services were represented
at local conferences and workshops. The
information obtained at these events is fed
back to services and presented to the
Information Governance Committee on a
quarterly basis. Following feedback from
the public and in discussion with staff
groups, in 2011/12 it has been decided to
move away from generic Listening Events
and for services/Localities to hold their
own specific Listening Events.
Priority
CQUIN
Description
We
will
implement
quality
improvement measures derived from
the framework for Commissioning for
Quality and Innovation
Categories
Patient
Experience,
Patient
Safety,
Clinical
Effectiveness
Progress
In 2010/11, Somerset Community Health
worked towards the attainment of a range
of quality improvement standards, as part
of the CQUIN framework. These were:
Reducing avoidable death, disability
and chronic ill health, through
ensuring that all patients admitted to
our community hospitals receive an
assessment for Venous
Thromboembolism: In Quarter 4 of
2010/11, 95% of patients admitted to
community hospitals run by Somerset
Community Health were assessed for
venous thromboembolism, against a
required standard of 90%
Maintaining and building upon our
current high levels of patient
satisfaction and extending patient
feedback mechanisms across all of the
care services which we deliver: In
Quarter 4 of 2010/11, 96% of service
users responding to a questionnaire from
the Emotional Health and Wellbeing
service indicated that they were either
“satisfied” or “very satisfied”.
31
Priority
Description
Categories
Progress
In response to national findings
regarding the importance of ensuring
nutritional care for patients,
implementing a high quality
programme of nutritional assessment
for all patients in our community
hospitals: In Quarter 4 of 2010/11, 87%
of patients received the four nutritional
assessment standards outlined in the
CQUIN framework. This will remain an
area for focus for Somerset Community
Health in 2011/12.
Making further improvements to the
quality of stroke care received by
patients in Somerset, with improved
access to stroke rehabilitation: In
Quarter 4 of 2010/11, 97% of stroke
patients received the four aspects of care
associated with stroke rehabilitation,
including the provision of 7-day-a-week
rehabilitation care from staff with strokespecific training.
32
Priority
Description
Categories
Progress
Extending our role in the reduction in
the incidence of smoking across the
county, through the referral of smokers
to the Somerset Smoking Cessation
Service: During 2010/11, Somerset
Community Health staff referred 590
smokers to the Somerset Smoking
Cessation Service
Making further improvements to care
planning arrangements, in accordance
with national best practice:
Considerable work has been undertaken
by Somerset Community Health, to
ensure that care planning arrangements
are in accordance with national best
practice. Embedding patient engagement
into the care planning process and the
patient-centeredness of care planning
remains a priority for Somerset
Community Health in 2011/12.
Improving services for patients with
dementia who are cared for within our
Community Hospitals: In Quarter 4 of
2010/11, 95% of patients with dementia
admitted to Somerset Community Health‟s
community
hospitals
had
a
multidisciplinary team review and a
rehabilitation plan with agreed goals within
four days of admission.
33
Priority
Improving
Efficiency
Description
Categories
Somerset Community Health has Patient
produced plans to consider how Experience
optimal use can be made of
technology, such as the development
of mobile working facilities for
peripatetic community based staff, in
order to free up more time for the
delivery of frontline care for patients.
34
Progress
Somerset
Community
Health
has
developed a mobile working device for
use by community-based staff, in respect
of which a pilot scheme was initiated in
2010/11.
The pilot encompassed
community matrons and district nurses,
and aimed to reduce the replication
associated with the recording of patient
information, and facilitate the elimination
of
paper-based
records
where
appropriate. The mobile working device
has been well-received by staff and plans
are in place for its extension to other
services.
4.13.2
Somerset Community Health continues to operate robust arrangements to ensure that
it:
delivers excellent standards of care to patients across the county
actively seeks out examples of best practice, both locally and nationally
sets standards which put it at the leading edge in the delivery of high quality
community healthcare
shares learning throughout the organisation in order to raise quality standards
across all areas of care
4.13.3
In working to deliver our organisational aims and objectives, and in striving to deliver
ever higher standards of care to our patients, Somerset Community Health will
maintain a focus on ensuring that quality and patient safety are at the heart of
everything that we do.
Lee Cornell
Lead Officer for Information and Performance
June 2011
35
APPENDIX 1
36
37
38
39
APPENDIX 2
40