Quality Accounts
2010/2011
Tameside and Glossop Community Healthcare
Business Group
About Quality Accounts
Why we are producing a Quality Account?
Tameside and Glossop Community Healthcare Business Group (T&GCH) has a
long-standing commitment to ensure quality of care and a patient centred approach
is embedded in everything we do. We are keen to share information about the quality
of our services, and develop our plans to improve even further, with patients, carers,
families and services users.
All NHS Trusts are required to produce an annual Quality Account. The requirement
is set-out in the Next Stage Review in 20081.
What are the required elements of a Quality Account?
The National Health Service (Quality Accounts) Regulations 2010 2 specified the
requirements for all quality accounts.
The key requirements are as follows:
Part 1
A statement from the Chief Executive,
A statement from the Director and Deputy Director
Part 2
Our Quality Priorities for 2011/12: Priorities for improvement – these are
commitments that an organisation makes to improve the level of quality within it.
Statements of assurance relating to the quality of services: Statements about the
organisation – these are expected to allow readers to compare different
organisations.
Part 3
Review of quality performance – this demonstrates how the organisation has
performed to date.
How did we produce our Quality Account?
The Quality Accounts Toolkit 2010/113 provides advisory guidance for providers of
NHS services on producing Quality Accounts for 2010/11. We have used the
requirements as a template around which our Quality account was built.
In addition to ensuring that we have all the mandatory elements of the account, we
have worked with the service users, commissioners and staff to ensure that the
account gives an insight into our organisation.
1
Darzi. Next Stage Review, June 2008, Department of Health.
2
The National Health Service (Quality Accounts) Regulations 2010.
3
The Quality Accounts Toolkit 2010/11. DoH Dec 2010.
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Quality Account 2011 Version 5
Contents
Part One: Our Commitment
Statement from the Chief Executive
Statements from the Director and Deputy Director
Part Two: Achieving Quality
Our Quality Priorities for 2011/12
Statements of assurance relating to the quality of services
Part Three: How we performed in 2010/11
Achieving Patient Safety
Achieving Clinical Effectiveness
Patient Experience- Shaping our services
Statements from others
“The key values of Tameside and
Glossop Community Healthcare are to
be trusted, high quality, local and
professional. These values are intrinsic
to everything that we do”
Tameside and Glossop Community Healthcare Lymphedema Service
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Quality Account 2011 Version 5
Our Commitment
Part One: Our Commitment
Forward from the Chief Executive, NHS Tameside and Glossop.
I am delighted to introduce the first annual Quality Account for
Tameside and Glossop Community Healthcare, who, until April
2011, were known as the Provider Division and were part of NHS
Tameside and Glossop.
The Tameside and Glossop Community Healthcare Quality
Account for 2010/2011, sets out the progress which has been
made during the past year, in delivering excellent standards of
care to patients across Tameside and Glossop. This account
provides a summary of Tameside and Glossop Community
Healthcare‟s wider approach to quality improvement, and details progress against
the priorities set last year, and describes the process.
Tameside and Glossop Community Healthcare has an overriding vision of ensuring
that patient safety and quality is at the front of everything they do. The Board to
patient philosophy for embedding quality into the patient experience remains central,
ensuring that patients experience an excellent standard of care, whilst adhering to
the highest standards of patient safety and clinical effectiveness. The organisation
wide commitment to placing quality at the centre of service delivery has ensured that
the focus on preservation and improvement of quality standards has been
maintained at a time of limited flexibility.
Tameside and Glossop Community Healthcare recognise the importance of valuing
and empowering staff, by equipping them with the skills they need in order that they
remain at the forefront of delivering the highest quality care to patients. Staff can be
proud of the excellent quality of care that they deliver to the patients of Tameside
and Glossop, and, of the efforts they make every day in delivering the highest
standards of quality and patient safety. Through their hard work, dedication and
commitment, real improvements have been made and significant programmes
introduced to build on the culture and capabilities around quality.
A number of examples of activities taking place throughout the organisation have
been highlighted in Part Three of this account. Key achievements have focused on
maintaining privacy and dignity through such activities as providing same sex
environments for people who use the services; the Productive Community Series
and Transforming Community Services.
In this account, Tameside and Glossop Community Healthcare have set out what
they plan to do to deliver their priority areas, so they can build on what was achieved
to date, and strive to continuously improve the quality of services they provide.
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Our Commitment
Finally, I confirm that, to the best of my knowledge, the information in this Quality
Account is a true and accurate narrative of Tameside and Glossop Community
Healthcare‟s achievements during the reporting period.
Tim Riley
Chief Executive
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Our Commitment
Statement from Director and Deputy Director of Tameside and Glossop
Community Healthcare Business Group
We are delighted to present our first Quality Account for T&GCH. Until recently (April
2011) we were known as the Provider Division, which was part of NHS Tameside
and Glossop. Following the implementation of Transforming Community Services
(TCS), our services will have joined Stockport Foundation Trust by the time our
Quality Account is published.
The Department of Health‟s TCS programme was targeted to complete on 31 st
March 2011. One of the major changes, as a result of TCS, is the separation of
commissioning service from the provision of services with effect from April 2011.
TCS is a key component of the Quality Innovation, Productivity and Prevention
agenda, which is crucial to achieving the efficiency savings set out in the White
Paper4. T&GCH will continue to deliver high quality care services that focus on
prevention and self care.
The Quality Account provides an opportunity to share with you the information
relating to the work that we undertake to ensure constant improvement in the
delivery of quality and safety of the care experienced and the outcomes for service
users.
As community healthcare providers we are very much a part of the community that
we serve. We aim to ensure that our service users receive the highest possible
quality care in a safe and clean environment, ensuring they receive the same care
and attention as if they were a member of our own families.
As part of our wider community role, we work hard to train the healthcare
professionals of tomorrow by providing a variety of student placements across the
health economy. We support local community initiatives, which include working in
partnership with Age UK, local schools and colleges to provide work experience to
local people.
Our high standards of quality and safety have been acknowledged over the past year
and in previous years by successfully winning or being finalists in a number of
prestigious national awards. In 2010, we had two winners in the Nursing Times
Awards and a further three finalists. We were finalists in the NHS Leadership Awards
and the Health and Social Care Awards.
4
Equity and excellence: Liberating the NHS. Secretary of State, July 2010
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Our Commitment
Our Services are unconditionally registered with the Care Quality Commission, which
means we demonstrate the assurance that we provide in relation to safe and high
quality care.
It is our highly motivated staff that make these achievements possible, by working
together to ensure that the service user is pivotal to all our decision making and the
delivery of the best possible care and treatment.
We are always striving to improve our services and service user experience. To
ensure that we can learn from our mistakes we have a positive culture of sharing the
lessons learnt from incidents, therefore seeking continuously to improve the quality
of our services.
This Quality Account sets out facts and information about the quality of our services.
We hope that you will find it a useful and easy document to understand, which
provides you with information and helps you to choose the best health service to
meet your requirements.
If you have any feedback or suggestions in relation to the Quality Account please do
let us know by telephoning 0161 304 5300.
To the best of our knowledge the information in this report is accurate.
Nikki Leach
David Kay
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Part Two: Achieving Quality
Tameside and Glossop District Nurses
Welcome to Tameside and Glossop
Community Healthcare Business Group
Quality Account for 2010/11. The Quality
Account provides an opportunity to
communicate
the
organisation‟s
successes and transparently sets out the
challenges to our service users, the
community, our staff, our partners and
other stakeholders. It provides an
opportunity to demonstrate to the public
and service users, that services are safe
and that they can expect high standards
of care.
Our vision is to be a leading first class community service. Our aim is to ensure all
members of the public receive first class community services, which are personal to
their needs.
Our mission is to ensure that we work together to improve the health and lives of
local people by delivering a range of first class services that you trust.
Our Strategic Goals are to:
 Provide first class personalised services
 Have a committed and dedicated skilled
workforce
 Develop
and
maintain
effective
partnerships to provide first class
services
 Have efficient and effective governance
 Ensure financial stability
 Have reliable and timely business
intelligence
 Show service users and the public that
services are safe and that they can
expect care excellence
Tameside and Glossop’s Community Keep Fit
Class
Achieving Quality
Our Quality Priorities for 2011/12
Our quality priorities for improvement for the coming year April 2011 to the end of
March 2012 are;
Priority 1: Patient Safety:
 To maximise safety for service users and ensure
that clinical incidents are proactively reported
across the Business Group and Trust.
 To demonstrate improvements to safety and
quality as a result of shared learning.
The National Patient Safety Agency (NPSA) is very clear that in their view a Trust
with high rates of incident reporting is a safer Trust. Reporting to the NPSA all
patient safety incidents and prevented incidents provides the opportunity to ensure
that the learning gained from the experience of a patient in one part of the country is
used to reduce the risk of something similar happening to future patients elsewhere.
The more incidents reported and the more information available relating to the
reported incidents, enables more action to be taken, thus helping to make healthcare
safer.
Between 1st April 2010 and 30th September 2010, NHS Tameside and Glossop
(T&G PCT) submitted three months of patient safety incident data to the NPSA
national reporting and learning service (NRLS). Table one demonstrates our position
against the lowest and highest reporting PCTs. The information has been extracted
from the NRLS Organisation Patient Safety Incident Reports - data workbooks March
2011.
Table One: Position against Lowest and Highest Patient safety incident reporting PCTs
Reporting period 1st April 2010
and 30th September 2010
T&G PCT
Highest reporting PCT
Lowest reporting PCT
Number of
months reported
3
6
1
Reported
Incidents
197
1638
1
Rate per 10000
population
8.72
21.09
0.04
Information source: NRLS Organisation patient safety incident reports. Organisation Patient Safety
Incident Reports - data workbooks March 2011
The areas within which we report the highest number of incidents relate to;
1. Patient Accident; which is 51.27% (n101). This figure reflects the proactive
nature of our fall prevention initiative at Shire Hill intermediate care unit and
the Lakes, which are our inpatient rehabilitation units.
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2. Patient transfer and discharge; which is 13.2% (n26). A number of these
incidents relate to the late notification of new births from hospitals outside of
our area. There is currently a working group who are looking at this issue
particularly with the child health department and the hospitals. Equally there
has been a lot of work undertaken to review and redesign information
contained on hospital discharges and referrals to ensure the smooth and
timely transfer of patients into our care.
3. Medication which is 10.66% (n21).All medication incidents are reported. The
incidents relate to the late administration of medication, immunisation
incidents such as a faint or refusal and prescribing incidents.
The degree of harm attributed to all our reported patient safety incidents is captured
in table two. We encourage staff to report all incidents and to share the learning from
near misses and incidents across all services.
Table Two: the degree of harm
The degree of
harm attributed
to the number
of reported
incidents
None
Low
Moderate
Death
N
%
N
%
N
%
N
%
140
71.1
26
13.2
30
15.2
1
0.5
Information source: NRLS Organisation patient safety incident reports. Organisation Patient Safety
Incident Reports - data workbooks March 2011
So far, our reported patient safety incidents and prevented incidents have informed
the following:
 The review of clinical practice guidelines and policies in relation to record
keeping, pressure ulcer reporting and medicine management.
 The review of communication pathways and record keeping in relation to multi
professional involvement.
 The planned development of care coordinators.
Our quality priority will be to increase the number of reported patient safety incidents
and prevented incidents to 18 incidents per 10000 population.
Priority 2: Patient experience- shaping services:
 To develop service users experience survey which demonstrates an increase
in the number of respondents who feel they have been treated with respect
and dignity whilst in our care.
 To increase the number of respondents who answer „Yes Always‟ to being
satisfied with the care provided.
We will involve service users and the public wherever
possible in improving and shaping services. We will
endeavour to seek the views of our local community and
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service users, through surveys and most importantly by listening to their complaints,
compliments and concerns.
In 2010/11 3,026 satisfaction surveys were distributed of which 433 (covering 24
services) were returned (14.31%). 95.15% of those responding were satisfied or very
satisfied with the service they received. Less than 1% of respondents were
dissatisfied or very dissatisfied by the service they received with the remaining
respondents either not completing the question or not having an opinion either way.
95.52% reported being treated with dignity and respect all of the time with a further
1.18% saying that they were treated with dignity and care some of the time. 2.59% of
respondents failed to answer the question. The questionnaire invited those
responding to comment on the whether they received the care that mattered to them
and about their experiences. The quantitative and qualitative responses were
collated in two reports and shared with the teams. Action plans will be produced as
indicated appropriate by feedback by services. An overview of the responses will be
shared with service users who specifically requested feedback shortly.
“Individual care, respect; explained every course of treatment”
(Patient experience comment for MSK Physiotherapy)
“I felt confident at all times with the service”
(Patient experience comment for District Nursing)
“I am extremely impressed with the school nursing service.
Although this is not high visibility nursing it is essential that this
service should be maintained”
(Patient experience comment for School Health)
In 2011/12 Tameside and Glossop Community Healthcare Business Group will be
integrating service user satisfaction surveys carried out at Shire Hill and The Lakes,
which are our inpatient rehabilitation units, with those undertaken in community
delivered services.
The target for 2011/12 is to maintain our satisfaction level of 95.52%, whilst
increasing the number of respondents. Our key performance indicator is 80% of
service users report to be satisfied with our services.
Priority 3: Clinical effectiveness:
 To ensure that, where national clinical guidelines have been produced by the
National Institute for Health and Clinical Excellence (NICE) which are relevant
to the care we provide, that we can demonstrate we are using or planning to
use them in every day service delivery.
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
To achieve the target we will review and develop an implementation plan for
the relevant NICE guidelines. The results of the implementation will be
reported and subsequently audited via our Governance and Performance
framework.
The implementation of NICE guidelines will ensure that the following categories are
addressed:
 Patient and Carers will
 receive care in line with the best available evidence of clinical and costeffectiveness;
 empower patients to be accountable for their care, knowing how they
will be cared for in a consistent evidence-based approach, thus
building patients confidence in NHS services; and
 improve their own health and prevent disease.


Healthcare Professionals will
 provide care that is based on the best evidence available;
 meet the standards set by regulatory bodies and consider NICE
guidance when exercising their clinical judgement;
 be confident in the care approaches to deal with patient queries
effectively; and
 efficiently target resources and efforts at the areas that offer the most
significant health improvement.
Our organisation will
 meet the NHSLA risk management standards and benefit from reduced
claims and risk management premiums
 meet the requirements in the NHS operating framework for England for
2011/12
 identifiy disinvestment opportunities, cost savings or opportunities for
re-directing resources
 meet government indicators and targets for health improvement and
reducing health inequalities.
 provide a focus for multi-sector partnership working on health.
Our quality improvement will be supported and measurable by the adoption of NICE
forward planner and implementation and audit tools.
How will we review and monitor these priorities?
This Quality Account will be monitored through our governance and performance
processes. This will include regular reports to the Quality Group and Quality Board.
These priorities will also be an integral part of our Quality Improvement Plan for the
coming year.
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Quality
measures
are
incorporated
into
our
performance dashboards and
reflected
in
our
key
performance indicators. The
dashboard reflects a list of
National Indicators for Quality
is reviewed monthly by the
Business unit and senior
managers
within
the
pathways and is presented at
our Business Group Board.
It is broken down into the
different pathways, which
focus
on
specific
performance
areas,
and
quality
indicators
are
reviewed monthly to ensure
regular scrutiny of quality.
A simple traffic light system helps identify areas that are underperforming and are
reviewed by the Quality Board, Quality group and Pathway business meetings. By
reviewing data at all levels, the Quality reporting framework allows individual
services and pathways to take action to improve quality in their areas as part of a
continuous cycle.
In order to provide additional assurance and top level ownership of this Quality
Account, Stockport Foundation Trust will receive monthly reports on performance.
We will also provide our local LINks and other third parties with regular performance
reports to ensure we maintain our open and honest approach to Quality Accounts.
Statements of assurance relating to the quality of services provided
Review of services.
During 2010/11, Tameside and Glossop Community Healthcare Business Group
provided Forty-nine NHS services. Tameside and Glossop Community Healthcare
Business Group have reviewed all the data available to them on the quality of care in
all of these services. There is an established service review programme to ensure
inclusion of all services within in the quality measure. Quality and performance
information is provided monthly to all pathways and is reported monthly to Business
group board.
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The income generated by the NHS services reviewed in 2010/11 represents 100 per
cent of the total income generated from the provision of NHS services by Tameside
and Glossop Community Healthcare Business Group for 2010/11.
The Director and Deputy Director have undertaken a number of question and answer
sessions in all service areas. These sessions provided the opportunity to talk to
frontline staff, managers and partner agencies and provide first hand information
about improvements made, to discuss any further improvements required and to
share information and suggestions. It has led to some very valuable initiatives and
cost savings, one of which is the implementation of the Productive Community and
Productive Ward programme across our services.
Participation in Clinical Audits
Clinical audit is a process of systematically evaluating care against
agreed standards. Audit should be followed by changes designed to
improve conformity with the standards and then by re-evaluation to
demonstrate such improvement. This is known as the audit cycle.
Clinical audit involves improving the quality of patient care by looking
at current practice and modifying it where necessary. We take part in
regional and national clinical audits. Sometimes there are also National
Confidential Enquiries, which investigate an area of healthcare and recommend
ways of improving it.
During 2010/11 T&GCH has contributed to three national clinical audits and one
Regional audit. We have not been involved with national confidential enquiries.
The national clinical audits and regional clinical audits T&GCH participated in during
2010/11 are as follows
National Clinical Audit
Falls and Bone Health for Older people
Continence Care
Sentinel Stroke Audit
Regional Clinical Audit
Record Keeping Audit: Information Governance
Participation
Yes
Yes
Yes
Participation
Yes
T&GCH has reviewed the reports produced from clinical audits and a number of
actions to improve the quality of care delivery have been identified which have been
taken or will be taken. These are:
 UNICEF Breast Feeding Training was delivered to frontline staff and basic
breast feeding awareness was provided to all staff.
 Dignity in care training and the establishment of dignity in care champions in
each service. The introduction of a self assessment dignity in care workbook
and an accreditation process leading to an award. These actions are part of
the dignity in care campaign which is provided in T&GCH and our partner
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

agencies. The dignity in care campaign is covered in more detail in section
three.
Record keeping audit across all services during 2011/12
A plan to review and refine the archiving of records systems.
During 2010/11 Tameside and Glossop Community Healthcare Business Group
reviewed and redesigned the Governance structures including Clinical Audit. There
is a simplified and clearer process in relation to clinical audit and the reporting of the
outcomes. It is anticipated, that the audit activity within the services will greatly
increase in the forth-coming year.
Participation in Clinical Research
We recognise the importance of involving service users in clinical research. Being
able to use their direct experience helps us to provide better services and improve
quality. Research ensures that our service users benefit from new innovations,
leading edge thinking and sharing with academic and healthcare partnerships.
Research does not only benefit our services users, it encourages health
professionals to seek solutions and be aware of new developments via research.
The number of patients receiving NHS services provided or sub-contracted by NHS
Tameside and Glossop for the period April 2010 to March 2011, that were recruited
during that period to participate in National Institute for Health Research (NIHR)
research approved by a research ethics committee was 544 patients.
Goals agreed with Commissioners
A proportion of income in 2010/11 was conditional on achieving quality improvement
and innovation goals agreed between Tameside and Glossop Community
Healthcare Business Group and NHS Tameside and Glossop through the
Commissioning for Quality and Innovation (CQUIN) payment framework. We
achieved 30 of the 35 targets set within the seven identified CQUIN themes.
Of the 5 targets not met in year:
 One related to access to specialist community services 24 hours a day. This
could not be met as services are not commissioned at this level.
 Two related to a failure to train staff in brief advice interventions for clients
who smoke and to subsequent referrals to the Smoke Free service. Also
highlighted, was a shortfall of 3.4% of staff were not trained and although
referrals increased dramatically in quarter 4 there were insufficient referrals at
the beginning of the year to meet the target.
 The final two elements were not achieved but investigation indicates that this
was a coding issue rather than a service delivery issue.
Improvement plans are in place to enable us to meet these goals, and this will be
monitored through Business group board.
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The CQUINS are formulated in response to the national priorities set out in the NHS
operational framework. They are set by the commissioners to reflect locally agreed
targets.
The quality initiatives to support our drive for quality and safety are
 Productive Community Series: which has been implemented across services.
The fundamental aim is to free up time to help deliver quality, patient focused
care to every service user. This includes making practical changes, focussing
on a multi disciplinary approach to a variety of different requirement aspects
to make the most of the time and resources within the community.
 Pressure Ulcer incidents: this initiative focuses on the early identification,
reporting and management of pressure ulcers. It identifies the level of care
and roles and responsibilities across the Primary and Secondary care. It
promotes and encourages the proactive intervention and the reporting of all
level two and above pressure ulcers.
 Community Nursing review: throughout 2010/11 the recommendations and
actions from the review have been implemented, where possible, to release
time to care. This includes single point of contact pilot for district nursing,
Mobile technology for data recording, GP communication agreement, moving
the district nursing service to a 24/7 service, development of care packages,
and the embodiment of the Productive Community Series within the service.
 Performance data: there has been considerable work undertaken to improve
the performance data collected and utilised by the services. This is proving
invaluable in identifying quality and improvement opportunities for further
development and savings.
Further details of the agreed goals for
2010/11 and for the following 12 month
period are available on request from:
Tracy Wood
Tameside & Glossop Community Healthcare
New Century House
Progress Way
Windmill Lane
Denton
M34 2GP
Tel: 0161 304 5429
tracy.wood@nhs.net
Tameside and Glossop Headquarters
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Care Quality Commission Registration
The Care Quality Commission (CQC) regulates and inspects health and social care
organisations. If it is satisfied the organisation provides good quality and safe care, it
registers it „without conditions‟
T&GCH was registered with the CQC. The current registration status is „without
conditions‟. The CQC has not taken enforcement action against Tameside and
Glossop Community Healthcare Business Group during 2010/11. We have worked
hard to achieve unconditional registration with the CQC and continue to work with
partners and stakeholders to maintain services that can demonstrate quality and
safety outcomes.
Please note that our registration is as part of NHS Tameside and Glossop, this is
currently going through the process of deregistration and re registration as we move
to become part of Stockport Foundation Trust, as part of TCS.
Data Quality
Good quality information underpins the effective delivery of patient care and is
essential if improvements in quality of care are to be made. We understand the
importance of ensuring that information held within our organisation is of the highest
quality possible so that it enables us to make informed, accurate and timely
decisions about our patient care and our community involvement.
We will be taking the following actions to improve data quality.
 Improve the accuracy and numbers of patients who have their Ethnic
Category completed on their record.
 All patient surveys for 2011/12 will include identifying respondents in the 7
protected characteristic groups as part of our equality and diversity pledge.
 Work is on-going with services to ensure that data capture mechanisms
include the above categories as required within the Community Minimum
Dataset. This includes the NHS number as well as the above.
T&GCH did not submit records during 2010/11 to the Secondary Uses Service for
inclusion in the Hospital Episode Statistics, which are included in the latest published
data.
Tameside and Glossop Community Healthcare Business Group Information
Governance Assessment Report score for 1 April 2010 to 31 March 2011 was 60%
(overall score) and was graded „red‟ from the Information The IG Self-audit
comprises 41 requirements and the threshold for a “green” rating is set at 70%. In
previous years a score of 40% to 70% attracted an “amber” rating, but in 2010-11
this was abolished. In previous years the PCT has scored “green” but changes in
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some of the 2010-2011 requirements means that the PCT will achieve “green”
several months after the Self-audit deadline. In order to fulfil the CfH Statement of
Compliance regarding an organisation‟s ability to utilise the NHS N3 secure network,
a score of 2 or above is required for each of 22 key requirements. The PCT achieved
this. The internal audit report of 2010/11 IG control design, operation and overall
conclusion were each declared to provide „significant assurance‟.
Tameside and Glossop Community Healthcare Business Group were not subject to
the Payment by Results clinical coding audit during1 April 2010 to 31 March 2011 by
the Audit Commission. Community services are excluded from Payment by results
framework
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How We Performed in 2010/2011
Part Three: How we performed in 2010/11
Achieving Patient Safety
We are committed to ensuring patient safety is an integral part of our work and that
we have systems in place to continuously improve and enhance safety.
Our agreed targets for 2010/11 were;
Reduction in healthcare associated infection rates
Root Cause Analysis (RCA) investigation is undertaken
for every occurrence. The lessons learned from such
investigation is shared with colleagues and new
processes initiated if necessary.
Target : No more than 7 MRSA bloodstream infections,
Outcome: There were 7 cases apportioned to non acute care, of MRSA
Bacteraemia in 2010/11. The RCA suggests that of the 7 cases there are two cases
that were acquired whilst in the community and of these two cases, one is
apportioned to T&GCH Business Group.
MRSA Bacteraemia Surveillance 2010/11
MRSA Bacteraemias 2010/11
8
7
6
5
4
3
2
Target
Actuals
1
0
Target Achieved
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How We Performed in 2010/2011
Target: No more than 14 cases of Clostridium Difficile infection in our inpatient units.
Outcome: There were 12 cases of C.Difficile in 2010/11. The target of 14 was not
breached.
Clostridium Difficile Infection (CDI) Surveillance 2010/11
Clostridium Difficile Infections in the Inpatient
Units 2010/11
16
14
12
10
8
6
4
Target
Actuals
2
0
Target Achieved.
Target: 80% of Provider Division employees will attend mandatory Infection
Prevention training in the two years from1 st April 2009 to 31st March 2011
Outcome: March 2011, 91.74 % of staff attended Infection Prevention Mandatory
Training. Infection Prevention mandatory training is supplemented, as all staff are
encouraged to complete the National Infection Prevention E-learning Programme.
Target Achieved
What we did to prevent, reduce and control infection
 We promote hand hygiene and cleanliness to staff, patients, carers and all
service users.
 We undertake peer review of hand hygiene competencies
 We have embedded the Essential Steps to safe, clean care assessment
framework for all appropriate staff. This is a mandated assessment.
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How We Performed in 2010/2011






We undertake MRSA screening for all emergency/unplanned admissions to
our inpatient rehabilitation units
We undertake root cause analysis to identify the causal factors and possible
mode/source of all known MRSA and Clostridium Difficile infections within the
community.
The infection prevention and control team are working fastidiously with the
wider Primary Care Providers to address and reduce further the number of
community acquired Clostridium Difficile infections.
We have an environmental infection prevention & control audit, with action
plans.
We have a infection prevention environmental cleaning campaign „Sparkle‟
We have a revised and updated uniform policy
Target : Reduction in falls
Falling can cause serious injuries,
fractures (broken bones) and even death
particularly in people aged 65 years and
over. Falls are the leading cause of
accidental deaths in older people and
result in more than 60,000 broken hips
each year. We have taken steps to
reduce the risk of patient‟s falls by
introducing sensory alarm technology.
The sensory equipment was installed on
Staff at Shire Hill assisting a patient with
the beds and chairs in most rooms in
rehabilitation exercises
Shire Hill.
These alarms active when
movement is detected thus alerting staff
when a patient, identified as at risk, tries to get up without supervision. This was in
response to audit findings that demonstrated most falls are unwitnessed and happen
in patients‟ bedrooms.
At the commencement of the project, in April 2008, the number of falls experienced
at rehabilitation unit stood at 19 falls per 1000 bed days. The project has seen the
number of falls reduce to 12.6 falls per 1000 bed days, a reduction of 30% over this
period.
“Just knowing it’s there is wonderful, I wouldn’t be without it”
Patient‟s opinion on the Falls Sensory Equipment
To ensure the project is evidenced based it was developed in line with the National
Service Framework for Older People, standard 6, NICE guidelines and NHSLA.
Target was achieved
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Achieving Clinical Effectiveness
Health Mentors
The Health Mentors project was undertaken to provide health & wellbeing help and
advice for children and young people. It offers an accessible, personalised service,
which addresses adverse local healthy lifestyle issues in Tameside & Glossop. The
objectives were to achieve 13,500 early interventions across the programme by
December 2011, currently the service has delivered 7952 brief advice interventions
which include;
 Smoking
 Healthy weight
 Alcohol and drugs
 Emotional health and wellbeing
 Risk of repeat teenage
conceptions
The programme was to support the
delivery of the Tameside Children and
Young People Preventative Strategy (2008- The Branding from the Health Mentor Website
11) which confirms the approach to early
intervention needs of 4 – 16 yr olds to reduce high demand for more intensive
resources in later years.
The health mentor project is underpinned by the Government‟s Children‟s Plan,
"Building Brighter Futures," which sets out the vision of achievement of goals for
children through to 2020, including improvements in the integrated local delivery of
early intervention and preventative services, and Every Child Matters which includes
“be healthy” with the aims of physical activity, emotional health, sexual health,
healthy lifestyles and choosing not to take drugs. Progressing early intervention
services builds on earlier public health strategies, such as “Choosing Health” 5, which
introduced the health trainer programme.
The service is a pioneering national pilot which provides one to one and group
behaviour change sessions, tailored to the young person‟s needs. It works in
partnership with School & Child Health Services, Schools, Children‟s Centres,
Extended Schools, Youth Services and Primary Care.
The programme is different because it takes a whole family approach to promote
health changing behaviour and improves the accessibility of the service. For
example, self-referrals can be made at www.healthmentors4life.net
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DH, Delivering Choosing Health: making healthier choices easier. Lon 2005
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The programme aligns with the emerging national health trainer programme to
ensure that there is consistency of approach and that training and competencies are
applied.
The programme has been marketed to children & young people, parents & carers to
promote self referrals and to relevant professionals, notably in schools.
As a national pilot it has significant outcomes to report.
 It has proved to be flexible and responsive, adapting to the individual needs of
children, young people and families. For example, between January-June
2011, the service received 120 referrals for reduced repeat teenage
pregnancies against a target of 72.
 The number of young women contacted at risk of having repeat conception
was 120 against a target of 72. None of the young women referred have gone
on to have a repeat conception to date.
 Number and percentage of children and young people who have a personal
health plan maintaining change for 3 months is 50%
 The number of new contacts for brief advice or brief interventions is 20 per
week
 Client evaluation shows 100% satisfaction with Health Mentors service.
Other benefits include shared learning across the partnership which is realised from
actions agreed at the regular Steering Group meetings which supports and oversees
the development of the programme.
This programme won the prestigious Nursing Times 2010 for Child Health
MSK Podiatry
We were the first community healthcare service,
nationally to provide a „one stop shop‟ for the
assessment and provision of foot orthoses on a
`just in time basis. ` This required the
transformational development of the Foot Orthotic
Service in the Community.
The service adopted makes use of the latest
computer aided design and manufacturing
technology. The success of this system has been
significant, helping to double the number referrals
seen and reducing waiting times of up to 12 weeks
by a third. It has also helped prevent significant
Preparing a patient for an MSK
Podiatry Assessment using the latest
technology
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numbers of referrals to secondary care especially in high-risk areas such as diabetes
and rheumatoid arthritis.
Current estimates of the number of users of orthotic services are in excess of 1.2
million patients in the UK. With a reduction in resources, Tameside & Glossop
Community Healthcare required a transformational change of its Foot Orthotic
service to keep up with high levels of demand.
Aims and objectives:
 To increase patient choice
 To offer quality, bespoke orthoses
 To be able to manufacture orthosis in a timely manner
 To offer patients a „one stop shop‟
 To maintain / improve patient satisfaction levels
 To respond to and meet increasing demands for orthoses by increasing
productivity
 To reduce ongoing costs
 To be assured re quality of devices issued
 To enable senior clinicians to be released to see complex high risk patients
The service required a new Foot Orthotic system which could be operated by an
assistant with appropriate training and without the need for assistance from a
qualified podiatrist. This system also needed to be able to be implemented in a
Community setting and to give improved longevity to foot orthoses.
Prior to the introduction of the system 64% patients waited up to 12 weeks after their
initial appointment to be seen by the senior podiatrists. This was because the
existing system required limited numbers of specialist senior staff to administer it and
it had much slower production times. More junior staff now conduct such treatment,
which has allowed faster access, improving the patient pathway to 98.5% seen in
12 weeks or less.
Commissioners were involved at an early stage to consider the specification and
funding of the service.
GP Practices and Tameside Metropolitan Borough Council Social Services were
consulted to consider the pathways for referral of patients in the Community.
Patient Representatives were consulted as part of the design of the service, which
has led to a self-referral process open to community patients which has improved
access to our services.
Orthoses can now often be made in an initial assessment appointment removing the
need for numerous fitting appointments which were previously needed using older
methods of manufacture.
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The system uses a digital scan of the patient‟s feet, which can be manipulated to
alter the action of the foot orthoses. The digital images are sent to a CAD CAM mill
that grinds the orthoses from solid blocks of material.
The images are saved on a hard drive and may be accessed in the future should
second pairs be required.
This led to improved orthotic delivery times and increased engagement between
both community based staff and biomechanics specialists.
Patient experience- shaping services
Dignity in Care
Following a successful funding bid
last year, Tameside & Glossop
Community Healthcare aimed to
improve
patient
experience
concerning dignity in care. A nurse
led team was created and using the
ten elements of the Government‟s
dignity challenge they were asked
to identify patient experiences with
residents of local care homes.
A selection of the Dignity in Care Materials
The initiative investigated patient issues
that led to low standards of dignity in care. A unique partnership was established
between internal and external stakeholders to ensure residents received the highest
standards of care, delivered with dignity and respect.
The Partnership provided the necessary skills & experience to address these issues.
The small details led to the big differences, often with no costs attached. For
example, asking patients how they would like to be addressed by staff, made a big
difference to how they felt.
The work addressed the personalisation
agenda as identified in 'Putting people first: a
shared vision and commitment to the
transformation of adult social care', the
ministerial concordat launched on 10
December 2007. People are able to live their
own lives as they wish; confident in the
knowledge that their services are of high
quality, safe and promote their own individual
needs for independence, well-being, and
dignity.
The award winning Dignity in Care Team at
the Nursing Times Awards 2010
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“They don’t make you feel like you are just a patient, they really
look after you without making you feel patronised at all”
Patient‟s opinion on the care delivered through Dignity in Care
The work undertaken by the team was different due to the extensive involvement
and participation of patients, families, staff, public, internal and external
stakeholders.
A unique observation tool was developed to help TGCH and Tameside Metropolitan
Borough Council to benchmark each other‟s care homes, clinics and inpatient units.
Multi inter-professional training amongst partners improved standards of patient
care. The benefits were realised by partners achieving a Dignity Challenge and
accreditation to the Dignity in Care Award. Joint work with Manchester City Council
developed the distinctive „Daisy‟ branding which was used across both boroughs to
symbolise Dignity in Care. The pilot demonstrated its relevance to nursing especially
in the success of inter-professional partnerships.
For nursing education Dignity is now included as mandatory training for all staff,
written into job descriptions and Care Quality Commission guidelines. A designated
lead and team has been established to support staff. Regular satisfaction surveys
improve quality of care.
The training, policies and procedures coupled with the sign up of Dignity Champions
has helped to share management best practice across the nursing network. This
work can be embedded in any organisation and most definitely could be used to
improve practice in all elements of care.
A pilot area was chosen and included, 5 local care homes, 2 PCT clinics and 2 PCT
in patient units. The pilot project has been completed. The principles and lessons
learnt are being rolled out to a much wider audience and are being embedded in all
organisations who deliver care to residents of Tameside & Glossop.
The accreditation process included providing evidence against the ten standards of
the Dignity challenge, patient experience survey, and Observation visits, of which all
parts had to be completed and passed.
The successful completion of the pilot means there are significant results to report.
For example, an audit of our patient experience survey and the evidence
demonstrated in the workbook showed 85% of our residents now feel that they
receive care with dignity and respect. This is a significant improvement and premises
that have demonstrated high standards of dignity have been publically
acknowledged with a daisy plaque.
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The attached patient satisfaction survey at Shire Hill showed the following the ratings
after the initiative:
 Staff approachable – 94%
 Satisfied with environment – 90%
 Satisfied with overall experience – 89%
Whilst the project was well received by external providers
and stakeholders , many nurses within our own
organisation were affronted when challenged about dignity
as they felt it was an integral part of nursing and that care
couldn‟t or shouldn‟t be delivered without dignity. The
project challenged all areas of dignity including where care
was delivered as well as how, and if that care was
personalised.
Staff and Services are
rewarded for dedicated
Dignity practices
There was acknowledgement by the staff there were areas
that could be improved and many were identified on the
patient survey e.g. continuity of staff in a clinic setting would
help personalise care.
The profile of dignity in care has been raised through a 100% increase in sign up of
champions in many areas and an increase in awareness through our internet links.
Education is the key to delivering customer care, dignity and respect to all staff and
how to change staff attitudes and behaviours.
Our branding represents a standard which sees small changes leading to the biggest
differences for patient care. Best practice has been acknowledged and shared with
all partners including all nursing staff
Single Sex Accommodation
Tameside and Glossop Community Healthcare Business Group services were able
to declare their compliance with the national target for single sex accommodation.
During the past 12 months work has been undertaken to address the concerns about
mixed sex accommodation.
In Shire Hill and The Lakes, work has been undertaken
related to the planned use of facilities to reduce the
occasions where different genders have to share the
same facilities. Where it has not been possible to ensure
that people of one gender will not be walking through an
area occupied by people of the opposite gender this has been limited to areas such
as corridors. Toilets and bathrooms are clearly designated as being for one gender
only.
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PEAT (Patient Environment Action Team)
PEAT is an annual assessment of inpatient healthcare sites in England with more
than ten beds. The assessment was established in 2000 (managed by the NPSA
since 2006) and is a benchmarking tool to ensure improvements are made in the
non-clinical aspects of a patient‟s healthcare experience. PEAT highlights areas for
improvement and shares best practice across the NHS. The annual assessment took
place in February. Amongst the assessors is a patient representative. All scores are
supplied to the National Patient Safety Agency. The report will be made available in
June 2011.
All inpatient facilities assessed early in 2010 in Tameside and Glossop Community
Healthcare Business Group were scored as „Good‟ or „Excellent‟. This included the
intermediate care facilities and rehabilitation unit, and shows our commitment to
improving the care environment and premises, to improve cleanliness, environment,
food, privacy, and dignity.
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Statements from others:
NHS Tameside and Glossop
NHS Tameside & Glossop is pleased to endorse Tameside & Glossop Community
Healthcare‟s first Quality Account which provides information with regard to the
quality of the services it provides to the public. Based on the knowledge NHS
Tameside & Glossop commissioners have of Tameside & Glossop Community
Healthcare‟s provider services, we can confirm this Quality Account is a true and
accurate reflection of the 2010/11 progress made against the identified quality
standards. The report celebrates the successes and improvements in quality, but is
balanced in that it recognises those areas which require further development and
important. Looking forward to 2011/12
Tameside & Glossop Community
Healthcare must maintain a continuous and relentless focus on reducing HCAI
especially C Difficile, although as commissioners we must remain cognizant of the
fact that this is a „health-wide‟ economy problem and not just that of an individual
provider.
The Trust has complied with all contractual obligations and has made good progress
over the last year, with evidence of significant improvements in key quality
measures. NHS Tameside and Glossop as commissioners, monitor the quality
performance of the provider services monthly, through performance review
meetings. Performance data in relation to quality is presented and verified, and
action plans supported to address areas of less than optimum performance.
NHS Tameside & Glossop is supportive of the process Tameside & Glossop
Community Healthcare has taken to engage with patients, staff and stakeholders in
developing a set of quality priorities and measures for 2011/12 and applaud their
continued commitment to quality improvement. Rationale for the priorities for
2011/12 is clear and there is evidence of user involvement in the decision making.
NHS Tameside & Glossop supports the overall broad quality priority areas for quality
improvement identified by Tameside & Glossop Community Healthcare in this
Quality Account and looks forward to the detailed action plans which will identify the
desired outcomes for patients following these improvements in systems and
processes.
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