Provider Services
Quality Account
2010-2011
June 2011
Contents
Executive Summary and About Us
3
Part 1: Statement on Quality and Key Achievements
4
Part 2: Priorities for Quality Improvement
Plans for Improvement
Developing our Quality Priorities for 2011/12
2011/12 Quality Improvement Priorities
Quality Improvement Priorities agreed with
Commissioners
Statements of Assurance
Review of Services
Participation in Clinical Audit
Participation in Clinical Research
Use of the Commissioning for Quality and Innovation
Payment Framework (CQUIN)
Registration with the Care Quality Commission (CQC)
Data Quality
6
8
10
11
16
19
19
19
20
Part 3: Review of Quality Performance in 2010/11
Overview
Quality Performance Summary
Update on Quality Priorities 2010/11
Priority 1: Releasing Time to Care in Prisons
Priority 2: Patient Experience
Priority 3: Transforming Community Services
Priority 4: CQUINS
Priority 5: Patient Safety Campaign
22
23
25
27
28
30
Statements from Local Involvement Networks, Health Overview and
Scrutiny Committee and Primary Care Trusts
33
Glossary
37
Appendix 1 Provider Services Board Accountability Framework
41
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Quality Account
2010-11
Executive Summary
This is the first statutory Quality Account for
South Staffordshire Primary Care Trust Provider
Services and highlights our progress to improve
quality. Our Quality Priorities for 2011/12 agreed
with commissioners will be monitored throughout
the year. They will also support the local NHS to
work together to make important changes that will
improve patient experience, safety and
effectiveness.
Local and national service changes and
developments are an ongoing feature of the NHS.
PCT Provider Services is committed to ensuring
that throughout periods where any such change
takes place, the care provided to our patients
remains safe, effective and of a very high quality
to ensure the best patient experience is provided.
During the year ahead, we are working in
partnership with colleagues at NHS North
Staffordshire, NHS Stoke-on-Trent and
Staffordshire County Council towards the
development of the new Staffordshire and Stokeon-Trent Partnership NHS Trust. We will need to
continue to work to develop and agree a way
forward for priority quality issues across the
whole geographical patch for the new
organisation.
Our work to maintain quality will have to take
place against a backdrop of financial challenge
and massive NHS reorganisation for community
providers and commissioning.
We acknowledge that developing our first Quality
Account has been a learning experience for
South Staffordshire PCT Provider Services and
will aim to build on this in the future.
About South
Staffordshire PCT
Provider Services
South Staffordshire Primary
Care Trust (PCT) is one of the
largest PCT’s in the country. It
serves a population of
approximately 615,000 and is
located within the geographical
boundaries of Staffordshire
County Council. The PCT
employs just over 2,000 staff.
The PCT contains a number of
urban centres including Burton
upon Trent, Cannock,
Lichfield, Stafford, Tamworth,
Rugeley and Uttoxeter,
although the geographic area
is largely rural.
The PCT is committed to the
continuous improvement of the
health and well-being of the
community we serve. The
PCT approach to providing
healthcare is based on
focusing on prevention;
targeting resources where
need is greatest; working with
partners on other factors which
impact on ill-health and where
treatment is needed, offering
choice and commissioning
high-quality services with no
delays.
As a provider, South
Staffordshire PCT Provider
Services provides a range of
community services including
two community hospitals – Sir
Robert Peel Community
Hospital in Tamworth and
Samuel Johnson Community
Hospital in Lichfield, district
nursing, health visiting, school
nursing, speech and language
therapy, physiotherapy,
dieticians and many more.
Healthcare is also provided
within 5 local prison
establishments.
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Quality Account
2010-11
Part 1: Statement on Quality and Key Achievements
In High Quality Care for All, Lord Darzi set out a vision for making
quality improvement the organising principle for everything we do in the
National Health Service (NHS).
High Quality Care describes quality as:
• Ensuring care is safe
• Ensuring care is effective
• Ensuring care provides patients with the most positive experience
possible
South Staffordshire Primary Care Trust (SSPCT) Provider Services is
committed to delivering high quality care, equally accessible to all.
Our Aim:
“To be recognised as a respected provider of choice with a reputation for safe,
high quality services.”
Through operational services, governance and engagement and professional
leadership, SSPCT Provider Services drives forward the quality agenda, to
ensure the continual improvement in the quality of services provided, by
ensuring that services are safe for patients, focused on patient need and
experience, and are clinically effective.
New legislation was introduced during 2010 requiring all providers of NHS
services to publish an annual Quality Account. These are reports to the public
from providers of NHS healthcare services about the quality of the services
we provide. They set out: where we are doing well; where improvements in
quality can be made; priorities for improvement in the coming year; and, how
service users, staff and others with an interest in the Trust have been involved
in determining the priorities for the coming year. They aim to enhance
accountability to the public for the quality of NHS services.
SSPCT Provider Services published a pilot Quality Account for 2009/10 in
preparation for this new statutory requirement. This was published on the PCT
website and we asked for feedback on the content and format of our Quality
Account as well as on our Quality Priorities for the year ahead.
This first statutory Quality Account builds on our experience from last year
and the feedback we have received. We have also engaged patient and
community representatives through the membership of Patient Participation
Groups in GP practices across South Staffordshire and through Local
Involvement Network membership. We have also invited formal comment
from LINKs, Health Overview and Scrutiny Committees and engaged staff
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Quality Account
2010-11
through Staff Briefings and our internal quality focussed newsletter Quality
Matters.
We are pleased this report is able to include examples of key quality
improvements and achievements which link to national and local standards
achieved during 2010/11.
Areas where we have seen achievements in quality include:
•
•
•
•
Achievement of quality goals agreed with commissioners
Improvements in capturing patient experience and acting on feedback
Prison healthcare
Falls prevention
Details of all achievements can be found in Part 3.
Progress against these priorities has been monitored and will continue
alongside our priorities for the coming year to ensure high quality, safe and
effective care and treatment for patients is maintained despite the continuing
climate of change for the commissioning of NHS services as well as the
delivery of services.
We can confirm that to the best of our knowledge and belief, the information
contained in this Quality Account 2010/11 is accurate and represents our
commitment to quality improvement.
Geraint Griffiths, Acting
Chief Executive
South Staffordshire PCT
Liz Onions, Acting
Managing Director
South Staffordshire PCT
Provider Services
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Quality Account
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Part 2: Priorities for Quality Improvement
Plans for Improvement
Developing our Quality Priorities for 2011/12
South Staffordshire PCT Provider Services continually monitors, assesses
and reviews all of the services that it provides to patients. The organisation
takes patient feedback and information seriously and this, along with clinical
audit, quality monitoring and staff feedback, informs the delivery of our
services.
When developing these quality priorities we will consider:
• Patient surveys, complaints and compliments to assess the areas that
patients and partner organisations have told us are important
• Areas where we know improvements in patient experience, safety and
clinical effectiveness are needed. For example areas where our own
performance and quality monitoring has highlighted issues
• National targets and performance indicators
• Areas where we have agreed with commissioners to make improvements.
For example through the Quality Schedule and Commissioning for Quality
and Innovation (CQUIN) payment framework
• National advice and guidance
• Issues highlighted by staff at PCT Provider Services, through Incident
Reports and our Risk Register for example
• Following discussions with staff, patients and colleagues from future partner
organisations i.e. NHS North Staffordshire and NHS Stoke-on-Trent.
Proposals for Quality Priorities focus on issues where there was evidence for
improvements to patient experience, safety and effectiveness to be made.
Staffordshire and Stoke-On-Trent Partnership NHS Trust is committed to
quality improvement being at the heart of everything we do as we move
forward on our journey to form the new community provider organisation. The
proposed date for establishment is 1 September 2011.
The new organisation will ensure that the effective governance of quality and
safety is maintained during the transition to new organisational arrangements
and that the new Board will operate best practice in surveillance of quality and
safety.
A quality work stream was set up in October 2010 as part of the Transforming
Community Services project to establish a new community provider
organisation across Staffordshire and Stoke-on-Trent. The work stream has
lead officers from the four organisations and will prepare for integration, scope
functions that need to be established to run the new trust effectively and will
ensure quality issues are challenged and reported to the ‘shadow’ Board of
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Quality Account
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the proposed new organisation – Staffordshire and Stoke-on-Trent
Partnership NHS Trust.
While each PCT has remained accountable for the quality and safety of its
own services throughout 2010/11, work has provided an opportunity to
optimise quality assurance processes and systems for the future.
Early involvement and engagement with staff and patients from the three
existing NHS provider organisations (South Staffordshire PCT, NHS North
Staffordshire and NHS Stoke-on-Trent) is helping shape the future vision and
values of the new Trust. From this a series of priorities, including quality
priorities, will be developed.
This is being achieved by a distinct ‘quality and safety’ project work stream
which will:
•
•
•
•
•
Ensure a documented handover from predecessor organisations
Ensure early peer review of highest-risk services
Clinical engagement
Ensure that quality and safety systems are established in advance of the
new organisation establishment by reporting and being accountable to the
‘shadow’ Board which will consider a Quality and Safety report at its first
and subsequent meetings
Ensure that the new Board develops a new overarching Quality and Safety
strategy for the new organisation.
A clinical summit was held in February with 90 senior professional leads and
clinical managers across Staffordshire and Stoke on Trent to set the scene for
the development of a clinical strategy. This event was the first in a series of
three sessions to develop a year one strategy.
Alongside this a Professional Forum has been established. This is an
Advisory Committee to the Board which will drive and develop clinical and
professional strategy for the trust through strategic representation
collaborating on best practice and service direction.
A review of the quality governance framework is also being undertaken which
includes establishing a culture where quality is measured and monitored for
the organisation to evolve through learning from its experiences. As we
move forward a quality-focused culture will be promoted that includes active
leadership, structured walk rounds, positive feedback to staff, listening,
learning and being responsive to continually improve the quality of services.
Maintaining and improving quality during the transition is critical to enable the
new organisation to meet some of the greatest challenges in the history of the
NHS. Meeting this challenge, the Quality Innovation Productivity and
Prevention (QIPP) challenge – is about achieving the highest possible value
from the resources allocated to the NHS. It is about improving quality whilst
reducing cost by improving productivity and redesigning services wherever
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Quality Account
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possible. The scale of the challenge means that throughout the transition,
quality must remain our guiding principle and should act as the glue that binds
the organisations together.
Whilst the new trust is not in a position to conform the key improvement
priorities for the new organisation until it has full engagement it has
commenced working with our partners on explicit areas for the coming year
e.g. quality visits, Commissioning for Quality Innovation (CQUIN) Scheme for
2011/12, patient safety systems and processes and clinical risk areas.
CQUINs are a range of quality related indicators agreed to further improve
services for the people who use them. These include contributing to improved
safety, clinical effectiveness and service user experience.
2011/2012 Quality Improvement Priorities
As the Executive and Non Executive Directors for the new partnership Trust
come into post over the next few months the quality priorities for 2011/2012
will be developed. It is proposed that a series of workshops are arranged to
engage with staff, patients and other key stakeholders to agree the quality
framework and priorities.
Eight key objectives covering all aspects of the new Partnership Trust’s work
have been proposed and are as follows:
1. To deliver safer care
2. To improve patients’ privacy and dignity
3. To listen and respond to patients and members
4. To create the capacity required to deliver our services
5. To deliver cost improved plans whilst sustaining quality of service provision
6. To develop our workforce
7. To assure the Trust is well governed
8. To improve the integration of patient care across hospital and community
settings
Within these objectives five priorities will be developed for quality
improvement covering patient experience, patient safety and clinical
effectiveness.
In the transitional phase to ensure that quality improvement continues
services will continue to implement the priorities identified in local strategy
until the objectives are agreed for the new organisation. The table below
outlines these priorities:
Safety
1. Reduce falls and the impact of falls for people aged 65 and over
2. Implement Modified Early Warning Score process across wards
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Quality Account
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Effectiveness
1. Reduce number of Community Acquired Pressure Ulcers
2. Reduce number of delayed discharges in Community Hospital Inpatient
beds
Patient Experience
1. Improve the quality of the end of life care
2. Further implementation of the Quality Assurance Ward to Board dashboard
across all community services.
The monitoring and performance management of progress against
achievement of these objectives will continue as per the performance and
governance processes for the Trust until 1st September 2011.
Vision and Values
Vision shared with staff and patients to date includes:
•
•
•
•
•
•
Quality – safe and effective services
Creating seamless services/ removing organisational barriers
Forward thinking (innovative /new)
Co-created/ co-produced services
Staff proud to work in the organisation
Commissioners – that the organisation is the provider of choice
Values shared with staff and patients to date focuses on patient experience,
safety and effectiveness and include:
Quality (Effective, Safe, Good Outcomes)
“We want to provide high quality services which provide an excellent
experience and the best possible outcomes”
Respect (Timely, Compassionate, Dignity, Responsive)
“Our services will be delivered in a compassionate way that protects the
dignity of individuals”
Innovative (New, Groundbreaking, Refreshing, Creative)
“Our organisation will deliver new services which are exciting and support
independence”
Integration / Partnership (Doing things together)
“We will work with patients to deliver services in a seamless way that removes
organisational boundaries”
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Quality Account
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Efficient (Back Office, Right first time, Accountability)
“We will be accountable for the delivery of services that represent best value
for the resources spent”
Dedicated (Enthusiastic, Proud, Motivated)
“Our workforce will be positive role models and advocates for an organisation
that embodies the values it promotes.”
Engagement
We will ensure patients and community representatives will be engaged with
and involved in monitoring the Quality Priorities through any new engagement
model established as a result of a Patient and Public Involvement (PPI)
Stakeholder Event held on 11 April 2011 which specifically discussed ways
the new Staffordshire and Stoke-on-Trent Partnership NHS Trust could
engage, involve and consult with its service users and local communities.
During 2011/12 we will be strengthening our focus on engaging patients with
our plans and priorities. This will also support the new organisation’s move
towards Foundation Trust status, where public members will be able to elect
Public Governors to provide a stronger voice for the community with the
organisation.
Quality Improvement Priorities agreed with Commissioners
The Commissioning for Quality Innovation (CQUIN) scheme is a national
payment framework for locally agreed quality improvement schemes and
makes a proportion of provider income conditional on the achievement of
ambitious quality improvement goals and innovations.
Five CQUIN goals have been agreed with commissioners for 2011/12:
• Patient Experience – improving the experience of patients receiving
community based health services. This will focus on areas identified in the
2010/11 CQUIN with the addition of feedback on the falls services instead
of heart failure
• Safe Care – Care Initiatives – improve the safe care of patients with regards
to pressure ulcers, falls and catheter care
• Continence – improve detection of potential continence issues and improve
the continence care of those patients with an identified need
• Healthcare in prisons – to improve the assessment of patient’s mental
health problems
• Breastfeeding – to achieve the UNICEF UK Baby Friendly Initiative (Stage
2) and reduce the drop off rate of breastfeeding mothers.
Details regarding CQUINs for 2010/11 can be found in Part 3, pages 28 to 30.
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Quality Account
2010-11
Statements of Assurance
Review of Services
During 2010-2011 South Staffordshire Provider PCT provided and/ or subcontracted 164 NHS services.
South Staffordshire Provider PCT has reviewed all the data available to them
on the quality of care in all of these NHS services.
The income generated by the NHS services reviewed in 2010-2011
represents 94.02 per cent of the total income generated from the provision of
NHS services by South Staffordshire for 2010-2011.
The majority of our services are provided in the community; five prisons
across South Staffordshire and at two community hospitals in Tamworth and
Lichfield.
The quality of all our services is reviewed in a variety of ways. Examples from
2010/11 are:
• Provider Management Board - is a sub-committee of the PCT Trust Board.
For full committee structure - see Appendix 1. The Board’s main
responsibilities are to develop, approve, discharge, monitor and report
against the financial framework; contractual framework; strategic
framework; integrated governance framework; performance framework;
workforce development framework; patient engagement framework.
• Integrated Governance Report – a dashboard of quality and operational
performance information reviewed at meetings of the Provider Services
Management Team and Provider Management Board. It contains a set of
key measures of the services we provide and encourages scrutiny with the
aim of maintaining and improving standards.
For example, the dashboard highlights areas of patient safety and
experience, as well as efficiency and effectiveness of services. An example
of the dashboard is shown below.
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Quality Account
2010-11
PERFORMANCE DASHBOARD REPORT
Patient Experience
During 2010/11
PCT Provider
Services
received 116
more contacts
through its
Patient Advice
and Liaison
Service than the
previous year
2009/10
2010/11
96%
Choose and Book Availability
93%
Local Never Events
N/A
0
National Never Events
N/A
0
526
Number of PALS enquiries received
610
160
~ Of which are compliments
78
Number of complaints received
74
Patient Experience
2009/10
PCT Provider
Services
monitors the
number of
incidents
recorded to
identify any
increases and
any trends in
incidents which
could be due to
failure in quality
or safety and in
turn a reduction
of patient
experience
2010/11
Total Number of clinical incidents
880
653
~ Clinical incidents
491
417
3
0
172
3
0
0
~ Equipment
81
79
~ Medication
130
148
~ Health & Safety
2
0
~ Violence & Aggression
0
1
~ Caldicott/ Info Governance
~ Discharge
~ Environmental
~ Other
Total number of non clinical incidents
1
5
1266
1082
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Quality Account
2010-11
PCT Provider
Services
monitors its
performance
against
Department of
Health targets
which are
established to
improve
efficiency and
effectiveness in
services and in
turn improve the
patient
experience.
Currently PCT
Provider
Services Board
monitors any
changes in
waiting times in
order to identify
any problems in
accessing
services for
example.
PERFORMANCE DASHBOARD REPORT
Efficiency & Effectiveness
2009/10
2010/11
VSA04 - % of admitted patients treated within 18 weeks
98.6%
95.3%
VSA04 - % of non-admitted patients treated within 18 weeks
98.5%
99.3%
VSA04 - Number of 15 key diagnostic waits over 6 weeks
0
2
VSA04 - Number of all other diagnostic waits over 6 weeks (Quarterly)
0
2
Percentage of patients seen within 4 hours in Cannock MIU
100%
100%
Percentage of patients seen within 4 hours in Samuel Johnson MIU
100%
100%
Percentage of patients seen within 4 hours in Sir Robert Peel MIU
100%
100%
Percentage of patients offered a GUM appointment to be seen within 48
hours
100%
100%
95.4%
6
96.5%
0
Percentage of first attendances at a GUM service seen within 48 hours of
contacting the service
Cancellation of Elective Care operation non-clinical reasons (Quarterly)
• Quality Inspections – Members of the Professional Development Unit,
Infection Control Team and managers make focused visits to individual
healthcare settings. This helps ensure that patient safety standards are
being maintained and improved.
• Risk Management Systems – In order for Provider Services to be aware of
its risk profile across the entire range of activities, an organisation wide
review is undertaken to ensure that all exposures are duly considered. As
one method alone is not sufficient to identify all hazards and risks faced, a
combination of methods is used during the identification process to ensure
that there are no gaps. Some of the sources of information, both reactive
and proactive, which Provider Services use for identifying hazards and
risks, are complaints, incidents, claims; internal/external audit reports; NHS
Litigation reports; Information Governance Toolkit self-assessments; Care
Quality Commission reports; Medicines and Healthcare Regulatory Agency
(MHRA)/National Patient Safety Association (NPSA) notices and alerts;
Risk Assessments; examination of local experience.
• Provider Services Risk Register - A risk register is a management tool that
enables the organisation to understand its comprehensive risk profile. It is a
repository for all risk information and contains risks, control measures and
actions needed to address the risk.
The Risk Register is reviewed on a monthly basis by risk leads, and by
Provider Management Team, and is monitored by the overarching
Governance Group, and the Board.
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Quality Account
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• Clinical Audit – Information about South Staffordshire PCT Provider
Services Clinical Audit programme is available on page 16.
• Provider Risk Assurance Group - provides overall assurance on risk and
patient safety matters through considering the areas of incidents,
complaints, PALS and litigation and safety alerts.
The group co-ordinates risk management issues across Provider Services
and monitors and reviews the systems in place for risk management,
including managing and monitoring the system in place for issuing safety
alerts and notices through the Central Alerting System (CAS). It ensures the
overarching Governance Group is kept fully informed of all significant
clinical risks, and any associated developments or issues
• Provider Governance Action Group – is the forum through which the
Provider Management Board monitors the operational governance
arrangements, actions and processes in place across the provider services,
and is the mechanism by which the Provider Management Board fulfils its
governance responsibilities.
• Serious Incident Reporting – Provider Services is committed to reducing
risk and improving patient safety by analysing and tackling the root causes
of adverse incidents. The reporting system allows for incidents to be
investigated quickly; for practice to be reviewed, and for trends and patterns
to be identified. As part of the policy, there is a mechanism in place for
reporting and investigating serious incidents (SIs).
For each Serious Incident (SI), an incident investigation team is established,
staff are interviewed, and all relevant information is collected. A ‘Root
Cause Analysis’ investigative process is taken to establish the main cause.
Solutions are determined and an action plan drawn up to prevent
recurrence.
• Patient Experience Steering Group – ensures all patient experience activity
is co-ordinated, promoted, monitored and embedded within all PCT provider
teams
• Quality Patient and Safety Advocates – the role is one of promoting the
patient safety and quality agenda for Provider Services. The group is a
working group which cascades information to colleagues and subsequent
discussion within the Quality and Patient Safety Advocates Group.
• Other committees and working groups – for example health and safety,
infection prevention and control, health records group, medical devices
group, medicines management and National Institute of Clinical Excellence
(NICE), prison operational board, a patient information steering group,
clinical audit group, mortality review and radiation protection committee. All
support the review of quality on an on-going basis and the identification of
priorities for improvement.
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Quality Account
2010-11
PCT Provider Services also manages the healthcare of prisoners in five
prisons in South Staffordshire and is committed to supporting prison
healthcare staff to provide high quality, responsive care that meets patient
needs, irrespective of the setting in which it is provided. Each Prison Health
Care Team has a Clinical Governance Committee and sub structures in place
to develop, deliver and monitor the quality of care being delivered. These
structures and processes are supported by wider organisational governance
functions. At the local prison Clinical Governance Committee the following
areas are reported on and discussed:
• Patient Safety (including risk management, alerts, incidents, serious
incidents)
• Patient Experience (including complaints, Patient Advice and Liaison
Service (PALS) feedback, any patient experience initiatives)
• Clinical effectiveness (including Medicines Management, Clinical Audit)
• The development and review of actions plans following on from HMCIP
Inspections, CQC requirements, and internal Quality Inspections
There are also external quality assurance mechanisms for the whole PCT
Provider Services, which include:
• NHS Litigation Authority (NHSLA) and the Clinical Negligence Scheme –
the NHSLA handles negligence claims and works to improve risk
management practices in the NHS. The Clinical Negligence Scheme for
Trusts (CNST) covers all clinical claims. The Liabilities to Third Parties
Scheme (LTPS) and the Property Expenses Scheme (PES) cover nonclinical claims. Membership of the schemes is voluntary, funding is on a
pay-as-you-go non-profit basis, and organisations receive a discount on
their scheme contributions where they can demonstrate compliance with the
relevant NHSLA ‘risk management standards’. The standards are designed
to address organisational, clinical, and non-clinical/health and safety risks.
Assessment against the standards is a mandatory requirement of scheme
membership.
During 2010/11 PCT Provider Services was visited by a team from NHSLA.
PCT Provider Services is currently at Level 1.
• PEAT Assessment - Hospital visits are undertaken each year by Patient
Environment Action Teams (PEAT) who check patient environment issues
such as cleanliness relating not just to wards but waiting areas, furnishings
and the levels of privacy and dignity of amenities provided for patients. This
year emphasis was also placed on the patient experience.
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Quality Account
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Each inspection was carried out by a Patient Environment Action Team
which consists of NHS staff, including nurses and domestic staff, executive
directors, estate managers as well as patient representatives.
Hospital
Environment
Sir Robert Peel Hospital, Excellent
Tamworth
Samuel Johnson
Good
Hospital, Lichfield
Food
Excellent
Privacy and
Dignity
Excellent
Excellent
Excellent
Participation in Clinical Audit
During the period April 2010 to March 2011, there were 11 National Clinical
Audits relevant to the PCT, and participated in 7 of them. This represents
64% of all the National Audits relevant to services provided.
The National Clinical Audits that the PCT participate in were:
• RCPH National Childhood Epilepsy Audit
• National Parkinson’s Audit
• National Falls & Bone Health Audit
• National Audit of Psychological Therapies
• National Audit Elective Surgery
• Care of the Dying – Liverpool Care Pathway x2 (at two community
hospitals)
We did not participate in all National Audits due to audits being relevant to
new services only recently established and awaiting clarity on whether an
audit is relevant to our services or not.
There was no requirement to report on the following three national confidential
enquiries for 2010/11:
• National Confidential Enquiry into Patient Outcome and Death
• Confidential Enquiry into Maternal and Child Health
• National Confidential Enquiry into Suicide and Homicide by People with
Mental Illness.
This is because they are not relevant to PCT Provider Services as they are
acute focussed, or sometimes relevant to Ambulance Trusts, Mental Health
Trusts or even Strategic Health Authorities.
The reports of seventeen local clinical audits have been reviewed by Provider
Services, where changes to practice have occurred as a direct result of
clinical audit. Some examples of changes to practice are detailed in the table
below.
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Quality Account
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Note: Local clinical audits are carried out by individual healthcare
professionals evaluating aspects of care that they themselves have selected
as being important to them and/or their team.
Examples of Local Audits include:
Parkinson’s Disease Community Nurse Specialist – NICE guidance
suggests that people with Parkinson’s disease should be offered an
accessible point of contact with specialised services and this should be
provided by a Parkinson’s Nurse Specialist. An audit was established to
identify and assess waiting times from referral to first appointment with the
nurse specialist and findings revealed patients did have access to a nurse
specialist in a local clinic setting rather than having to travel to a hospital
provider. Although positive results were found, an action plan has been drawn
up to ensure further improvements can be made for follow up and future
appointments.
School Medical Rooms, Cannock Chase – school nurses conducted an
audit to determine the availability of a specific medical room in each school
where a confidential service to children, young people and their families could
be provided. Results demonstrated that just 69 per cent of schools in the
district had a dedicated room and therefore concerns regarding privacy and
dignity of patients as well as infection control were raised. An action plan led
to school nurses highlighting the importance of an accessible medical room to
Head Teachers and providing adequate facilities for pupils in their care
resulting in improved facilities for young people across the district.
Wheelchair Referrals – an audit to identify all referrers to the Wheelchair
Service and any potential delays showed that inappropriate referrals were
being made and there were some delays in triaging. An action plan is now
ongoing to ensure that there will be a better response time from the service to
service users and more appropriate referrals are made into the service. Better
triage mechanisms have also been established to ensure more urgent
referrals are seen in a timely manner and are better prioritised.
Smoking Cessation Uptake – the PCT Stop Smoking Service – Time to Quit
– conducted an audit to identify the smoking cessation uptake in perceived
hotspots in primary care. Results showed the service achieved more than the
Department of Health set target and more than half of all smokers accessing
the service achieved success at four weeks. Findings revealed that where
greater support is provided there will be more success and as a result review
meetings every two weeks are now held with service users and a designated
support worker is also offered.
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Quality Account
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Patient Case Study – Stop Smoking Service
Stephen Griffiths, of Rugeley, decided
to contact South Staffordshire PCT Provider Service
Stop Smoking team Time to Quit after failing to keep
up with Lichfield Diamonds, a girl’s football team he is
assistant coach for.
He said: “I realised I had to do something after the
chairman of the club had me running around like a
headless chicken with the girls. I could hardly breathe
after five minutes and I was doubled up in pain. I
thought how can I train these girls if I can’t even do it
myself.”
Stephen began smoking when he was just
15 years old and would smoke as many as 40 roll up
cigarettes a day. Since seeking help from Time to
Quit, Stephen has transformed his appearance
as well as his health by shedding four stone and is grateful to the Time to Quit team for
their support and encouragement.
The 46-year-old said: “I’m a lorry driver so all I do everyday is sit on my bum, it’s easy to
get bored so I would eat and smoke and by the time I got home I was tired, so I would just
lie on the sofa or go to bed. Now I can’t wait to get home from work to get out and go to the
gym.”
“I feel a million times better, so much healthier and I’ve got so much energy. I’m even
planning to put my name down for a triathlon next year.”
He added: “The one-to-one support and encouragement was brilliant and although I think
you need to be ready to give up personally, the motivation you receive from the people at
Time to Quit really helps and I would never have done it without them.”
18
Quality Account
2010-11
Participation in Clinical Research
During 2010/11, South Staffordshire PCT Provider Services approved one
research proposal. This research project is a clinical trial looking at the
effectiveness of treatments for wound care. It is due for completion late 2012.
In line with Government policy and Department of Health guidance to move
care closer to home, we would anticipate increased opportunities to take part
in clinical research.
In addition as part of our steps to establish Staffordshire and Stoke-on-Trent
Partnership NHS Trust we are committed to supporting research through
appropriate structures and governance frameworks.
Use of the Commissioning for Quality and Innovation (CQUIN) Payment
Framework
A proportion of South Staffordshire PCT Provider Services income in 2010/11
was conditional on achieving quality improvement and innovation goals
agreed between South Staffordshire PCT Provider Services and any person
or body they entered into a contract, agreement or arrangement with for the
provision of NHS services, through the Commissioning for Quality and
Innovation Payment Framework.
Details of the agreed goals and achievements for 2010/11 can be found in
Part 3, pages 28 to 30.
Details of the agreed goals for 2011/12 can be found in Part 2, on page 10.
Registration with the Care Quality Commission (CQC)
South Staffordshire PCT Provider Services is required to register with the
Care Quality Commission and its current registration status is Registered
Without Conditions. South Staffordshire PCT Provider Services has no
conditions on registration.
The Care Quality Commission has not taken enforcement action against
South Staffordshire PCT Provider Services during 2010/11 or been subject to
any periodic reviews. Provider Services has not participated in any special
reviews or investigations by the CQC during the reporting period.
In August 2010, the CQC carried out unannounced visits to Sir Robert Peel
Hospital, Tamworth and Samuel Johnson Hospital, Lichfield as part of its
dedicated inspection programme to assess cleanliness and infection control.
The CQC found no cause for concern regarding the PCT’s compliance.
A report of this visit can be found on the CQC website www.cqc.org.uk under
Care Directory, along with confirmation of the PCT’s current registration.
19
Quality Account
2010-11
An application has been submitted to the CQC in readiness for the new
Staffordshire and Stoke-on-Trent Partnership NHS Trust commencing 1 July
2011. This refreshes and collates all the regulated activities and locations
across the new Trust and has been an opportunity to ensure consistency of
the application and understanding of the Regulations.
Data Quality
South Staffordshire PCT Provider Services will be taking the following actions
to improve data quality:
Work is ongoing to improve the recording of community data, focusing on
areas such as records with valid NHS Number and GP Practice Code as well
as data coverage and recording by staff.
Improvements to data quality will also be part of the work to create a new
Trust – Staffordshire and Stoke-on-Trent Partnership NHS Trust - to ensure
all data is collated across the new organisation’s geographical area.
NHS Number and General Medical Practice Code Validity
South Staffordshire PCT Provider Services submitted records during 2010/11
to the Secondary Uses Service for inclusion in 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:
100 % for admitted patient care
100 % for outpatient care
100 % for accident and emergency care
included the patient’s valid General Medical Practice Code was:
100 % for admitted patient care
100 % for outpatient care
100 % for accident and emergency care
Information Governance Toolkit attainment levels
SSPCT handles large amounts of personal information about patients every
day, and the good management of this information is crucial to delivering high
quality care.
Information Governance provides a framework which determines the way in
which the PCT processes and handles this information. It acts as a catalyst
for reviewing information assurance and incorporating improvements into the
planning process.
The term “information governance” refers to the policies and practices in place
to ensure the confidentiality and security of the records of patients and service
users to help deliver the best care possible.
20
Quality Account
2010-11
The framework is embedded into organisations through an annual self
assessment which provides assurance in the following areas: - Information
Governance Management; Confidentiality and Data Protection; Information
Security; Clinical and Corporate Information Assurance and Data Quality.
Information Governance should not be seen in isolation but as an integral part
of the business, ensuring that we meet legal requirements while supporting
business improvement and continuity.
This framework makes sure that information is:
• Held securely and confidentially
• Obtained fairly and lawfully
• Recorded accurately and reliably
• Used effectively and ethically and
• Shared appropriately and legally.
The PCT’s Information Governance toolkit (IGT) 2009/10 (Version 7)
submission for data protection and confidentiality assurance was 82% (Green)
with an overall IGT score of 79%.
Version 8 was implemented in July 2010 and a major change in this version
requires specific evidence to be provided against each requirement. This has
resulted in an increase in work related to locating the relevant information and
highlighted the need to secure relevant information through the application of
records management principles.
While the PCT have maintained a fair level of scoring regarding IGT Version
8, coming in at overall final score of 64% (Red) we have failed to achieve level
2 on all elements of Statement of Compliance requirements, therefore the
Trust is rated overall as not satisfactory.
An action plan for the key elements (elements failing to meet level 2) will take
into account the Transforming Community Services agenda in splitting off the
Providers element of the Information Governance Toolkit.
The Information Governance steering group are required to address the entire
Information Governance Toolkit and assist in collating the evidence for
submission across the whole of the PCT (including commissioning, provider
with a separate submission for each of the five prison sites).
South Staffordshire PCT Information Governance Assessment Report score
overall for 2010/11 was 64% and was graded Not Satisfactory.
Clinical Coding error rate
South Staffordshire PCT Provider Services was subject to the Payment by
Results clinical coding audit during the reporting period by the Audit
Commission and the error rates reported in the latest published audit for that
period for diagnosis and treatment coding (clinical coding) were:
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Quality Account
2010-11
Primary diagnosis Incorrect 0%
Secondary diagnosis Incorrect 0%
Primary procedures Incorrect 0%
Secondary procedures Incorrect 0%
Part 3: Review of Quality Performance in 2010/11
Overview
South Staffordshire PCT Provider Services agreed its objectives in June 2010
at the PCT Provider Management Board. These objectives reflect the PCT’s
overall corporate roles and functions:
• Engaging with the local population to improve health and well-being
• Commissioning a comprehensive and equitable range of high quality,
responsive and efficient services with allocated resources
• Directly providing high quality, responsive efficient services where this gives
best value for money
PCT Provider Services objectives which reflect the corporate objectives and
include quality of care were:
• Improve children’s health
• Increase life expectancy and reduce health inequalities
• Improve access to services
• Improve the quality of patient experience
• Improve care for people with long term conditions
• Improve end of life care
In last year’s pilot Quality Account, we outlined the following as Quality
Priorities for 2010/11:
•
•
•
•
•
Releasing Time to Care in Prisons
Patient Experience
Transforming Community Services
Commissioning for Quality and Innovation Payment Framework (CQUINs)
Patient Safety Campaign
Quality Performance Summary
Alongside the priorities set for 2010/11, we also monitor quality in a wide
range of other ways. Some of our main measures are discussed at meetings
of the Provider Management Board and its committees. (See Statement of
Assurances, Review of Services, page 11)
As we move to establish Staffordshire and Stoke-on-Trent Partnership NHS
Trust, these issues will be monitored by its new governance structure.
22
Quality Account
2010-11
Update on Quality Priorities 2010/11
Priority 1: Releasing Time to Care in Prisons
PCT Provider Services is committed to supporting prison healthcare staff to
provide high quality, responsive care that meets patient needs, irrespective of
the setting in which it is provided.
During 2010, a Prison Releasing Time to Care Audit was developed and
implemented in collaboration with the Prison Healthcare Departments at Her
Majesty’s Prison (HMP) Drake Hall, HMP Stafford, HMP Featherstone, Her
Majesty’s Prison Young Offending Institute (HMPYOI) Brinsford, and HMPYOI
Swinfen.
The HMP/HMPYOI Prisons Releasing Time to Care Audit (2010) is an
innovative piece of work, unique to South Staffordshire PCT, which is thought
to be the first Trust in the country to use the methodology in a prison setting.
The aim of the audit was to illustrate and assess the breadth of prison nursing
in order to shape future plans and promote equity in services across the
HMP/HMPYOI Prisons.
The findings of the Releasing Time to Care audit supported the necessity to
increase the face to face contact ratio, revisit the skill mix and delegation of
staff in order to provide the right care in the right place by appropriately
qualified staff in a timely and responsive manner. Recommendations have
been reviewed by each establishment and where appropriate action plans
were developed. Outlined below are some examples of how services have
developed:
• A skill mix review is currently underway across all of the establishments and
will be completed in July 2011. The review will focus on staffing numbers
and levels of competency across the cluster of prisons ensuring the skill mix
of staff to enable us to deliver the full range of services commissioned.
• The prison health care structure has been strengthened with a specific
member of staff supporting the delivery of quality across all prisons.
• Prison health care departments are now included in our Quality Inspection
schedule using the PCT Quality Matters tool. This tool incorporates
Essence of Care benchmarks and action plans from other inspections e.g.
HM Chief Inspector of Prisons (HMCIP), PEAT inspections. Following on
from the inspection each establishment has an action plan which is
developed locally and monitored through the PCT governance structure.
Each establishment is inspected by the quality team with a follow up peer
led review of action.
• Nurse led triage has now been developed and implemented.
• The Health Care Assistant role in some establishments now includes the
administration of medication which is supervised by a nurse.
23
Quality Account
2010-11
In-house Physiotherapy Service for Prisoners
Prisoners in South Staffordshire are now receiving a unique ‘in-house’
Physiotherapy service developed by health professionals.
The service originated as a Physiotherapy pilot in three large prisons (two
men’s prisons and one women’s prison) to identify the needs of prisoners
and the cost efficiencies of providing a local in-house Physiotherapy service.
Claire Ward, Physiotherapy Professional Lead, said: “We feel that everyone
should receive equity of services and to achieve this we have worked with
our commissioners to identify that each prison is a village, with a population
and have the same or more health needs of any other community.”
The service aims to see any referral for Physiotherapy within four weeks of
referral and PCT Physiotherapy staff work closely with the prison GPs and
other healthcare staff to review patients.
Jo Leach, Senior Physiotherapist, Prison Project said: “Working with
prisoners in prison saves time and is less expensive than taking them to
hospital for treatment. It is one of the safest environments as it has all the
security back up anyone would need and procedures are in place to address
inappropriate behaviour.”
She added: “This pilot provides the opportunity for prisoners to be seen in
their own environment and as part of the normal day. Assessments are
carried out within healthcare at scheduled appointment times which provides
protected time for one to one discussions”.
“We provide a full assessment of their condition and range of treatment
options including physiotherapy intervention, advice and education of their
condition to understand it and to learn to manage it in the long term as well
as preventing other symptoms.”
The physiotherapists have a number of challenges to provide an effective
service such as the logistics of effective exercise in a confined spaced such
as a cell and findings ways to overcome conditions such as attention deficit
disorder (ADD), development co-ordination disorder (DCD), dyslexia or
sequencing disorders common among prisoners.
“To overcome these difficulties the physiotherapist needs to be sensitive of
individual challenges and modifies programmes to meet individual needs,”
Jo said.
Claire said: “We feel this service offers better outcomes for prisoners and in
working in the multi-disciplinary/multiagency team, identifies further
improvements to make a real difference to prisoner health and well-being.”
24
Quality Account
2010-11
Priority 2: Patient Experience
A robust mechanism for gathering patient experience data was developed
during 2010/11, underpinned by the Patient Experience Strategy which sets
out how we listen, respond to and capture patient and carer feedback on their
experiences, views and opinions of PCT Provider Services. This feedback is
through:
• Complaints Management
• Patient Advice and Liaison Service (PALS)
• Direct patient and carer feedback including real time feedback, patient
stories, focus groups.
Outcomes from patient feedback on our services include:
Feedback
Lengthy waits in Cannock Minor
Injuries Unit for patients waiting to be
seen during busy periods.
Patient story relating to care and
treatment on an inpatient ward
Concerns raised regarding lack of
privacy at a community clinic.
Action
Following analysis of staff rotas and
the number of patients attending,
additional staff have been recruited to
cover busy periods
In order to improve communication
with patients and relatives, quality
rounds have been introduced in an
afternoon where ward sisters are
available to talk to patients, their
relatives and carers.
Signs have been put in place to
advise patients they can discuss any
confidential issues in a private area
with staff, whenever possible.
Lack of external signs to a community
clinic resulted in patients being
late/missing appointments.
Additional signs have been
purchased and erected in the vicinity
and on the building.
Communication and message taking
processes within a community
nursing team have been reviewed.
A new system has been adopted and
will ensure that all visit requests are
actioned.
25
Quality Account
2010-11
The top 16 queries to the Patient Advice and Liaison Service during 2010/2011:
160
140
Number of
queries to
PALS during
2010/11
120
100
Compliments
Access to services
Appointments
Aids/Appliances & Equip
Quality of care
Communication
Information for patients
80
Complaints
Staff attitude
60
Waiting times
Parking
40
Pain relief/management
Pers Records/Patient info
20
Service prov/PCT commissioning
Hotel Services/Environment
0
Admis/transfer/discharge/arrang
Chronic Disease Self-Help Course Success
During 2010/11 dozens of patients have taken advantage of joining a self
help course run by PCT Provider Services to cope better with long term
conditions such as diabetes and depression.
The Chronic Disease Self Management course is a
six week programme designed to encourage
people to take an active and informed role in their
care. It aims to support people in increasing their
confidence, improving the quality of their life and
better manage their condition.
Previous courses have seen members become
life-long friends. Andrea Tabberer, from Burton;
Arlene Thompson, of Branston and Jenny Brannan,
of Tutbury, (pictured) are three members of an 11
strong group who were either referred to attend the course by their GP or
decided to enrol after seeing a poster in their GP Practice.
Foster parent Andrea, who has diabetes, said: “The course is so motivating
and you are surrounded by like minded people who understand your point of
view and how you’re feeling. It is extremely helpful to know you are not
alone.”
Arlene, who suffers from depression and anxiety, added: “We found it so
reassuring to be among people who feel the same and have similar worries,
we decided to continue to meet up once the course finished and now we
meet up once a month for a coffee and a chat.”
26
Quality Account
2010-11
Priority 3: Transforming Community Services
Community services are an important part of the care provided by the NHS
and for many of our patients. More care is now provided in the community
than ever, meeting the needs of people, who want their care delivered close
to their home.
The Government has said all community provider services must be separated
from the commissioning arm of Primary Care Trusts (PCTs) and the PCT has
needed to look at ways to provide high quality integrated services for all
people living in Staffordshire and Stoke-on-Trent.
A series of staff and stakeholder workshops to discuss integration and a
‘neighbourhood’ way of working have been held, one carer supported the
need for more integrated services between the NHS and Social Care and
Health:
“We’re all part of an orchestra.
Everyone is playing a great tune in their
section but it’s not the same tune as
everyone else.”
Colin Bootle
Carer, Staffordshire
The three existing PCTs in Staffordshire; NHS North Staffordshire, NHS
Stoke-on-Trent and South Staffordshire PCT have worked hard to find a
solution that will allow the NHS to continue to develop services in an
increasingly challenging environment.
Plans are now in place to establish Staffordshire and Stoke-on-Trent
Partnership NHS Trust by joining together the community services of each of
the three PCTs and the Adult Social Care and Health of Staffordshire County
Council.
Factors taken into account in arriving at the proposed new organisation
include:
• Create an organisation which can focus on improving the quality of health
and social care provided while also improving productivity
• Ensure organisation change impacts positively, enhancing the quality and
safety of services across Staffordshire and Stoke-on-Trent.
During 2010, a period of engagement on the development of a new Trust was
held and proposals were supported by key stakeholders and members of the
public.
27
Quality Account
2010-11
The new Partnership NHS Trust looks forward to providing high quality
integrated community services for patients and clients across Staffordshire
and Stoke-on-Trent.
Priority 4: Commissioning for Quality and Innovation Payment
Framework (CQUIN’s)
Goals and progress for 2010/11:
CQUIN
Patient Experience - two
questionnaires were sent out to
establish an initial baseline and then
subsequent analysis was undertaken
against the initial findings to assess
improvements in the following areas;
• Inpatient services
• Community services (wound
care/dermatology; diabetes;
continence; chronic obstructive
airways disease (COPD); and
heart failure)
Tissue Viability - All grade 3 to 4
pressure ulcers are investigated by
the tissue viability team and reports
are produced quarterly of the findings
Progress
• In five of the six areas surveyed
the results are all in excess of 90
per cent satisfaction with the
services and staff attitude.
• Inpatient results show a reduction
in satisfaction levels compared
with the baseline survey. All
patient comments and results
have been fed back to the Hospital
Manager and Modern Matron who
will develop an action plan to
address the main areas of concern
including - contact
information after discharge and
liaison during discharge planning.
• All community results have been
shared with relevant heads of
service and action plans are being
developed to address any areas
for improvement.
• Development of a tissue viability
training programme on the
prevention and management of
pressure ulcers
• Work is to be undertaken with
social services to develop
guidelines and to investigate
training within homes in a bid to
address the trend for patients to
develop pressure ulcers within
residential homes
• Work has started with community
nursing teams in conjunction with
the Community Practice Educators
to look at trends of pressure ulcer
development within teams and to
undertake reflective practice
exercises in order to improve the
28
Quality Account
2010-11
•
•
•
Nutritional Assessment upon
admission to inpatient wards Improving the assessment of patients
nutritional status and screening.
•
•
•
Falls assessment upon admission to
inpatient wards - Improving falls
prevention and reducing falls risks.
•
•
•
quality of care
With the Strategic Health Authority
(SHA) the tissue viability team is
developing a campaign in relation
to prevention of pressure ulcers
within the community as there are
still a high number of patients
developing pressure ulcers who
are not known to community
nursing services
A business ‘invest to save’
proposal is being worked on with
the Occupational Therapy service
around posture management
which is a major cause of pressure
ulcer formation across the PCT
Patient information leaflets in
relation to pressure ulcer
prevention and management are
also now available for patients.
Embedded the use of a nationally
recognised nutritional screening
tool (MUST) for all patients who
are admitted to community
hospital
Tool is used to inform an
individualised care plan aimed at
improving nutritional status and
potentially reduce unnecessary
increased length of stay and
enhance recovery
Clinical audit has been used to
monitor the effectiveness of the
implementation and has provided
very positive results.
Development of a risk screening
tool which has been used to
identify patient’s potential risk of
falls and to inform the referral
process to specialist falls services
A quarter of patients visited in their
own home by nursing services
have been referred to a specialist
falls services for prevention care
to reduce the likelihood of a fall
A patient information leaflet on
falls prevention in the home is now
available and is issued to patients
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Quality Account
2010-11
Baby Friendly – to achieve Stage 1 of
the UNICEF Baby Friendly Initiative
•
•
Pain Management - All patients dying
at home will have an agreed pain tool
completed and records will
demonstrate improved pain control
•
•
identified at risk.
As of publication of this Quality
Account, confirmation from UNICEF
of achievement of Stage 1 during
2010/11 was still awaited.
Effective materials have been
developed to support the education
of pregnant women.
Pain assessment tool developed
and implemented in the
community nursing
documentation. The tool is based
on The Liverpool Care Pathway
(which is validated)
Evidence so far demonstrates that
patients have seen greater pain
control through robust
assessment.
Priority 5: Patient Safety Campaign
The national campaign has been running within the PCT since 2008, following
sign up by the PCT Chief Executive.
The overall aim of the campaign was to:
“To make the safety of patients everyone’s highest priority”.
And:
“No avoidable death and no avoidable harm”.
The campaign focussed on the safety culture in the NHS and the engagement
of clinical staff as well as enabling behavioural change leading to safer, better,
healthcare. Each organisation was asked to concentrate on two themes:
1
2
Reducing Harm from Medicines
Leadership for Safety
A small ‘campaign’ group was initially established to consider what was
involved, and how this differed to the ‘7 Steps to Patient Safety’ national
guidance. The review showed that the leadership development element of the
campaign built on previous work, while the Reducing Harm from Medicines
brought a new dimension, giving a tangible project to demonstrate
improvements.
By January 2010, it was clear that many of the issues the campaign group
was trying to support, develop and facilitate were already being addressed
elsewhere within the PCT. Therefore, it was agreed to suspend the campaign
group but all actions outstanding had a full explanation as to where they were
being addressed within the PCT, or where they would be followed up.
Ongoing monitoring of the action plan continues through the Quality
30
Quality Account
2010-11
Assurance and Risk Group and work to progress and further develop this will
continue into 2011/12.
PCT Provider Services is committed to learn from incidents and mistakes to
improve quality of care for patients, and has adopted a fair and open culture
to reporting incidents and whistle blowing.
Between 1 April 2010 and 31 March 2011, 1,735 incidents have been
reported by PCT Provider Services staff through the incident reporting
system. Of those, 150 related to services provided externally to the PCT, such
as Social Services and residential homes. The remaining 1,585 incidents
have given Provider Services a unique opportunity to address risk issues and
to introduce changes where appropriate. It also provided the opportunity to
share the learning resulting from incident investigations.
Some examples of changes made to systems to improve quality of care as a
result of incident reporting include:
Incident
Action/Outcome
Patient misidentification
(wrong patient taken for a
procedure in theatre)
• Written Standard for patient identification now
included in Standard Operating Procedure
• Standard to be laminated and affixed to the
two notes trolleys
• Notes trolley to be labelled for Surgical and
Endoscopy
• Copy of theatre list now affixed to inside of
trolley
Medication incidents in
• Pill timers have been introduced
hospital
• Training sessions to support the introduction of
the new medicines code of practice
• Notices on drug trolleys – ‘Do Not Disturb’.
• Auditing of drug charts
Patient Falls on Inpatients • Ward staff try where possible to nurse all
Wards
patients known to be at risk of falls in the same
bay so that it is easier for staff to monitor
• Volunteers are now on the wards and offer
support with general ward duties, diversional
therapy, and company at the bedside
• Bed sensors are in use on the wards
• Benchmarking has been undertaken against
the national publication ‘Patient Safety First –
The How to Guide for Reducing Harm from
Falls’. This exercise has identified that in terms
of the national guidance, this PCT has already
implemented the majority of the suggestions.
Revised surgical
• Immediate changes were implemented to the
procedure
checking procedure in theatre to ensure that
all paperwork matches the consent form
signed by the patient
31
Quality Account
2010-11
Number of incidents
Clinical incident categories by Quarter
40
28
30
20
31
20
20
16
16
Number of incidents
0
0
0
Medication
Equipm ent
Apr-10
30
May-10
Other
Jun-10
38
40
28
20
20
13
10
10
6
3
6
2
0
1
0
0
0
0
0
Clinical
incidents
Medication
Equipm ent
Jul-10
Number of incidents
4
2
Clinical incidents
35
30
25
20
15
10
5
0
Other
Sept
23
19
11
14 14
11
6
Medication
3
0
Equipment
Oct
50
40
30
20
10
0
Aug
Discharge
29
Clinical incidents
Number of incidents
9
8
10
Nov
1
0
0
Discharge
0
0
Other
Dec
45
25
17
7
Clinical incidents
11 14
12
5
Medication
4
0
Equipment
Jan-11
Feb
1
0
Discharge
1
0
0
Other
Mar
32
Quality Account
2010-11
Statements from Local Involvement Networks, Health and Scrutiny
Committees and Primary Care Trusts
Providers of NHS services are required to invite comments from the relevant
Local Involvement Network, Overview and Scrutiny Committee and
commissioning PCT.
The development of this document has reflected the feedback we have
received.
Statements;
South Staffordshire Primary Care Trust
As the commissioner of services at South Staffordshire PCT Provider
Services, the PCT is pleased to comment on the Quality Account 2010/11 for
the provider.
The PCT notes the considerable work that has taken place to enable the PCT
Provider to develop into the Staffordshire and Stoke on Trent Partnership
NHS Trust. This work is still under development and the PCT looks forward to
working with the provider through the transition.
The provider describes a robust process for developing their priorities in
respect of quality improvements. A number of key areas are identified as
important to inform this work and the PCT would support this approach, along
with early involvement and engagement with staff to help shape the future
vision. The PCT looks forward to seeing the clinical strategy and the quality
governance framework that are currently under development by the provider.
The PCT is cognisant to the challenges faced by the provider in respect of
developing improvement priorities for the coming year at the same time as
developing a new partnership organisation.
The PCT and provider have worked collaboratively to develop quality
improvements through the Commissioning for Quality Innovation Scheme
(CQUINS). Quality improvements for 2011/12 have been developed to reflect
priority areas for improvement proposed by both the PCT and the provider.
The CQUINS established for 2010/11 have been achieved by the provider in
the majority of cases and significant evidence of quality improvement has
been shared with the PCT.
The provider describes a number of processes for monitoring the overall
quality of their services. This includes quality inspections to individual
services that the PCT is also invited to participate in. This has proved to be a
useful spot check on service provision. Reports on findings and
improvements are regularly shared with the PCT.
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Quality Account
2010-11
The PCT is aware that the provider has a well established approach to
reporting and investigation of serious incidents. The PCT would encourage
the provider to further strengthen its processes for feeding back to staff who
have raised serious incidents to ensure they are fully engaged in the process.
The provider shared its annual plan for clinical audit with the PCT at the
beginning of 2010/11. Regular reports on progress against the plan have
been received and discussed. It is useful to see changes in practice as a
result of the findings of clinical audit.
The involvement of the provider in clinical research has been disappointing in
2010/11 and the PCT would hope to see an improved participation in 2011/12.
The PCT commends the initiative in prison healthcare to release time to care.
The resulting changes to staffing skill mix for the benefit of prisoners are most
welcome.
The PCT acknowledge that to the best of our understanding, the data
provided within this quality account is accurate.
Staffordshire County Council Overview and Scrutiny Committee
We are directed to consider whether a Trust’s Quality Account is
representative and gives comprehensive coverage of their services and
whether we believe that there are significant omissions of issues of concern.
Our approach has been to review the Trust’s draft Account and make
comments for them to consider in finalising the publication, before providing
this final commentary.
There are some sections of information that the Trust must include and some
sections where they can choose what to include. We focused on what we
might expect to see in the Quality Account, based on the guidance that trusts
are given and what we have learned about the Trust’s services through health
scrutiny activity in the last year. We also considered how clearly the Trust’s
draft Account explains for a public audience (with evidence and examples)
what they are doing well, where improvement is needed and what will be the
priorities for the coming year. We were expecting this year’s Quality Accounts
to demonstrate increasing patient and public involvement in the assessment
and improvement of the quality of services that health trusts provide.
We are pleased that, as a result of our comments, the Trust has:
•
•
added an executive summary;
added a brief summary of key quality achievements and a statement of
accuracy to Part 1;
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Quality Account
2010-11
•
•
•
•
•
•
liaised with the other Primary Care Trust provider services in the
county to give a consistent explanation about the governance of quality
during the transition to the new Partnership NHS Trust;
clarified the Review of Services and added text to explain the
performance dashboard report;
included reference to national confidential enquiries and examples of
local audits;
improved the explanation about participation in clinical research;
added information on information governance; and
included some case study examples with images.
We would have liked to see:
•
•
•
•
•
the list of services retained;
a brief summary of any key quality issues in Part 1;
a list of all 17 clinical audits;
an explanation of how data quality and information governance are
relevant to care quality; and
greater clarity on the extent to which the 2010/11 Commissioning for
Quality and Innovation (CQUIN) goals were achieved (with the
percentage of income achieved).
Local Involvement Network for Staffordshire
An early approach was made to Staffordshire LINk by Provider Services,
South Staffordshire PCT for the LINk’s involvement in shaping the Trust’s
Quality Account for 2010/11 “we need to make sure that the opinions and
experiences of patients and local communities influence the plans that we
make for improvement and that our Quality Accounts tell people what they
want to know about their hospital”. Staffordshire LINk appreciated this early
involvement and promoted the opportunity for LINk participants/organisations
to submit any comments in relation to what is important to them, what the
Trust does best and what they thought could be done better, with articles on
the LINk website and LINk Bulletin as well as the opportunity to attend a
meeting with Trust representatives to go through the first draft account.
A draft of the Quality Account was presented to a group of LINk participants
by two representatives of the Trust which enabled discussions, comments and
input from the LINk into the format of the account and suggestions for
improvements to the way the information was presented. LINk participants
appreciated being able to contribute to this early consultation phase in the
production of the Trust’s Quality Account and it is gratifying to note that
feedback provided by LINk participants has been incorporated into the final
draft version of the Trust’s Quality Account.
The overall impression of this final draft is that it is easier for the reader to
identify what has been achieved during 2010/11 and what the Quality agenda
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Quality Account
2010-11
is for 2011/12. There is clear reference to the involvement of voluntary
agencies and the new Staffordshire and Stoke on Trent Partnership NHS
Trust however in earlier pages there is sudden reference to the new Trust,
local readers will understand this but remote readers may not and suggest
therefore that a reference be made in earlier pages to a fuller explanation
which appears at the end of the account.
The addition of a contents page and a professional Executive Summary
introduces the reader to a very informative document. The patient case
studies are positive and appropriate. It is not clear how informative the
Dashboard is in the current format (pages 12 and 13) are for the reader.
On the whole the Quality Account is clear and laid out in a logical manner.
Perhaps it is understandable that there are few Improvement Plans in specific
areas but nevertheless, the Quality Account deserves some praise from
Staffordshire LINk for the straightforward manner in which it is presented.
36
Quality Account
2010-11
Glossary
This section contains a large number of abbreviations and technical terms
used in the Quality Account.
CAS: Central
The Central Alerting System brings together the Chief
Alerting System
Medical Officer’s Public Health Link (PHL) and the Safety
Alert Broadcast System (SABS). It enables alerts and
urgent patient safety specific guidance to be accessed at
any time.
Clinical Audit
A quality improvement process that seeks to improve
patient care and outcomes through systematic review of
care against explicit criteria and the implementation of
change. Put more simply: clinical audit is all about
measuring the quality of care and services against agreed
standards and making improvements where necessary.
See www.hqip.org.uk
CNST: Clinical
The Clinical Negligence Scheme for Trusts handles all
Negligence
clinical negligence claims against member NHS bodies
Scheme for
where the incident in question took place on or after 1
Trusts
April 1995 (or when the body joined the scheme, if that is
later). Although membership of the scheme is voluntary,
all NHS Trusts (including Foundation Trusts) and Primary
Care Trusts (PCTs) in England currently belong to the
scheme.
Commissioners
Commissioners are responsible for ensuring adequate
services are available for their local population by
assessing needs and purchasing services. Primary Care
Trusts (PCTs) are the key organisations responsible for
commissioning healthcare services in England. South
Staffordshire PCT purchase community care services from
PCT Provider Services for the population of South
Staffordshire.
CQC: Care
Care Quality Commission is the independent regulator of
Quality
health and social care in England. It regulates health and
Commission
adult social care services, whether provided by the NHS,
local authorities, private companies or voluntary
organisations. See www.cqc.org.uk
CQUIN:
A payment framework introduced in the NHS in 2009/10
Commissioning
which means that a proportion of the income of providers
for Quality and
of the NHS services is conditional on meeting agreed
Innovation
targets for improving quality and innovation. See
www.institute.nhs.uk/cquin
Essence of Care Essence of Care aims to support localised quality
(EOC)
improvement, by providing a set of established and
refreshed benchmarks supporting front line care across
care settings at a local level. The benchmarking process
37
Quality Account
2010-11
Foundation Trust
(FT)
High Quality
Care for All
HMCIP: HM
Chief Inspector
of Prisons
(HMCIP) for
England and
Wales
HMP: Her
Majesty’s Prison
Service
HMP YOI: her
Majesty’s Prison
Service and
Young Offender
Institute
Information
Governance
Toolkit
Integrated
Governance
Report
LINk: Local
Involvement
Network
Liverpool Care
Pathway
outlined in Essence of Care 2010 helps practitioners to
take a structured approach to sharing and comparing
practice, enabling them to identify the best and to develop
action plans to remedy poor practice. See www.dh.gov.uk
An NHS Foundation Trust is part of the NHS in England
and has gained a degree of independence from the
Department of Health and local Strategic Health Authority.
All community service providers should become a
Foundation Trust by 2013.
Report published in June 2008 as the final part of Lord
Darzi's NHS Next Stage Review. It responds to the 10
SHA strategic visions and sets out a vision for an NHS
with quality at its heart. See www.dh.gov.uk
HM Chief Inspector of Prisons is independent of the
Prison Service and reports directly to the government on
the treatment of prisoners, the conditions of prisons in
England and Wales and such other matters.
See www.hmprisonservice.gov.uk
See www.hmprisonservice.gov.uk
This is a tool to support NHS organisations to assess and
improve the way they manage information, including
patient information. See
www.igt.connectingforhealth.nhs.uk
This is a dashboard of quality and operational
performance information reviewed at meetings of the
Provider Management Board. It contains a set of key
measures of the services we provide and encourages
scrutiny with the aim of maintaining and improving
services.
Local Involvement Networks in England are made up of
individuals and community groups working together to
improve local services. There job is to find out what the
public like and dislike about health and social care. They
will then work with the people who plan and run these
services to improve them.
The Liverpool Care Pathway is an integrated care
pathway that is used at the bedside to drive up sustained
quality of the dying in the last hours and days of life. It is a
means to transfer the best quality for care of the dying
from the hospice movement into other clinical areas, so
that wherever the person is dying there can be an
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Quality Account
2010-11
LTPS: Liabilities
to Third Parties
Scheme
MUST:
Malnutrition
Universal
Screening Tool
Never Events
NHS LA: NHS
Litigation
Authority
NICE: National
Institute for
Health and
Clinical
Excellence
NPSA: National
Patient safety
Agency
Overview and
Scrutiny
Committees
PES: Property
Expenses
Scheme
PEAT: Patient
Environment
Action Team
Pressure Ulcers
equitable model of care.
See www.nhsla.com
The MUST tool has been designed to help nurses to
identify adults who are underweight and at risk of
malnutrition, as well as those who are obese.
Never Events are serious, largely preventable patient
safety incidents that should not occur if the available
preventative measures have been implemented.
See www.nhsla.com
The National Institute for Health and Clinical excellence
provides guidance, sets quality standards and manages a
national database to improve people’s health and prevent
and treat ill health. It makes recommendations to the NHS
on new and existing medicines, treatments and
procedures and on treating and caring for people with
specific diseases and conditions. It also makes
recommendations to the NHS, local authorities and other
organisations in the public, private, voluntary and
community sectors on how to improve people’s health and
prevent illness and disease. See www.nice.org.uk
The National Patient Safety Agency is an arm’s length
body of the Department of health, responsible for
promoting patient safety wherever the NHS provides care.
See www.npsa.nhs.uk
Overview and Scrutiny Committees in local authorities
have statutory roles and powers to review local health
services.
See www.legislation.gov.uk
PEAT is an annual assessment of inpatient healthcare
sites in England with more than 10 beds. PEAT is self
assessed and inspects standards across a range of
services including food, cleanliness, infection control and
patient environment (including bathroom areas, décor,
lighting, floors and patient areas). NHS organisations are
each given scores from 1 (unacceptable) to 5 (excellent)
for standards of privacy and dignity, environment and food
within their buildings. See www.npsa.nhs.uk
Pressure ulcers are also known as pressure sores or bed
sores. They occur when the skin and underlying tissue
become damaged. In very serious cases, the underlying
muscle and bone can be damaged. See
www.nhs.uk/conditions/pressure-ulcers
39
Quality Account
2010-11
Productive Ward
Risk
Management
Systems
TCS:
Transforming
Community
Services
Part of the Releasing Time to Care series, the Productive
Ward focuses on improving ward processes and
environments to help nurses and therapists spend more
time on patient care thereby improving safety and
efficiency. See www.institute.nhs.uk
These enable staff across the organisation to identify and
report risks to the quality of care. The organisation is then
better able to manage these risks, focusing on addressing
those issues that are more likely to have a greater
adverse impact on patient experience, safety and
effectiveness.
Effective and efficient community services are the
foundation of healthcare in the NHS. The challenge facing
the health and social care sector is to drive up quality and
drive down costs. The TCS initiative is about delivering
improved quality and productivity, as well as building on
preventative approaches to reduce costs associated with
lifestyle-related disease and preventable complications.
The TCS programme sets out a far-reaching plan to
resolve some issues by improving services; developing
the people who provide them; aligning systems to
underpin the transformation. See www.dh.gov.uk
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Quality Account
2010-11
Professional Leads
Medicines
Management / Nice
Implementation Group
Provider
Governance
Action Group
Clinical
Audit
Group
Essence
of Care
Patient
Experience
Steering
Group
Patient
Information
Steering
Group
Safe
Guarding
Adults &
Children
Falls Group
Provider
Risk
Assurance
Group
Medical
Devices
Group
South Staffordshire PCT Provider
Services
Board Accountability Framework 2010/11
Appendix 1
Prison
Health
Operational
Group
Health
Records
Working
Group
Relevant
Estates &
Cleaning
subgroups
Assessment
Group
Infection
Control Group
Provider Management
Board
Policy
Consistency
Panel
Quality &
Patient
Safety
Advocates
Mortality
Review
Group
JSP
Workforce
Policy
Group
Health &
Safety
Group
Workforce &
Development
Committee
Provider Management Team
Information about this Quality Account
Copies are available from www.southstaffordshirepct.nhs.uk, by email
jessie.dickson@southstaffspct.nhs.uk or in writing from: Managing Director
Office, Edric House, Wolseley Court, Towers Plaza, Wheelhouse Road,
Rugeley, Staffordshire, WS15 1UW
Our Quality Account is also available on request in large print.
Please contact us on the address above or by e-mail at
jessie.dickson@southstaffspct.nhs.uk to request a large print
version of the Quality Account.
Please also contact us if you would like to request a copy of our Quality
Account in another language for people in South Staffordshire.