The Sussex Beacon
Quality Account 2010-11
‘Meeting the changing needs of people living with HIV’
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Contents
PART ONE
1.1 Statement from the Chief Executive
PART TWO
2.1 Priorities for improvement
Patient safety
Clinical effectiveness
Patient experience
2.2 Statements relating to the quality of services provided
Review of services
Participation in clinical audit
PART THREE
3.1 Review of quality performance
Review of Patient Safety
Infection control
Incident reporting
Risk Management
Patient Falls
Medicine safety
Organisational improvements in quality
A safe stay
Environment
Driving further improvements
Review of Clinical Effectiveness
General view
Areas of clinical audit
Inspections
Review of Patient Experience
How we measure the patient’s experience
Complaints
Patient and Public involvement
The Voice
3.2 Who has been involved in setting the content of the Quality Account and the priorities
for 2011-12?
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1.1
Statement from the Chief Executive
This Quality Account provides a summary of priorities for improvement 2011-12, followed by a review of our
performance against selected quality measures during 2010-11.
The Sussex Beacon is committed to quality improvement at all levels of the organisation, through regular and
thorough review of efficiency and effectiveness of services. We have worked hard over the years to ensure
best practice and safe working systems that continue to evolve and provide evidence to support our quality
service delivery, through achievement of recognised standards including the Care Quality Commission.
Within our clinical practice we have aimed to deliver high quality specialist care for patients, focusing on
improving clinical standards and effectiveness. We have continually reviewed services as a result of service
user and stakeholder feedback in order to improve the client experience. Greater service user involvement has
allowed for innovative service development that has been responsive to the needs of clients.
More broadly, we have focused on improving our internal governance, implementing integrated risk
management and audit across the organisation and widening the remit of the Clinical Governance Committee.
This year we have developed an equitable employment strategy along with training provision for staff. We
have improved our financial systems and controls in order to strengthen financial resources and to secure
sustainable funding that will safeguard continuity of care.
We believe this report demonstrates the improvements made over the last twelve months, working with and
involving our trustees, staff and service users. We are committed to continuous quality improvement and to
ensuring the organisation continues to develop quality initiatives and adapt its ways of working for the better.
Part 2.1
Priorities for Improvement
Introduction
To help us select our priorities for quality improvement, we have worked closely with our staff, service users
and stakeholders to help in guiding our focus, whilst responding to the many changes within the statutory
regulatory bodies such as the Care Quality Commission.
Patient Safety
Improving Medications Management Standards
Goal:
To ensure that clinical prescribing and the administration of medications are safe and accurate at all times.
Rational:
With the improvements made in clinical incident reporting it has been found that approximately 40% of all
incidents reported are to do with medication errors. Though it must be stressed that all are of a minor level
and have not resulted in any harm to patients it is an area that should be improved as there is always a risk.
Measures:
Increased audit shall monitor medications management closely and allow for improved/timely interventions.
Additional training will be provided to clinical staff throughout the year and the team will be informed of any
incidents as an opportunity to reflect and learn. Administration will be carried out in the patient’s room with
the patient present to ensure clarity.
Target:
A 90% reduction in reported medical errors
Reporting:
The
Board
of
Trustees;
Care
Quality
Commission;
Staff
Group.
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Improving Infection Control Standards - Hand Hygiene
Goal:
To increase awareness of the importance of correct hand hygiene when in a clinical setting for not only staff
and visitors but patients too.
Rational:
All care settings are striving to manage the increased prevalence of infections acquired whilst in clinical
environments. The NHS and the CQC both prioritise their guidance, standards and regulations in the reduction
of infection. As an organisation The Sussex Beacon adheres to protocol and procedures in the effort to
minimise potential harm to patients, to comply with national standards and to ensure clear monitoring and
reporting. This is part of an already existing framework of activity implemented to fight acquired infections.
Measures:
The importance of hand hygiene will be discussed with all clients during their admission and any risks
identified will be addressed by the department’s Infection Control Champion.
Target:
100% of all eligible patients admitted to the clinical unit shall receive assessment and information regarding
the importance of hand hygiene.
Reporting:
Activity regarding infection control is reported to the Governance Committee and the Board of Trustees but
also through the Staff Group and Service User Forum.
Clinical Effectiveness
Improving Patient’s Sexual Health
Goal:
To offer greater opportunity for patients to talk safely about experiences and issues, access advice and be
referred appropriately and timely for on-going help. This falls into four general processes:
 Screening and assessment carried out one to one with an experienced practitioner
 Completion of a tool designed using nationally recognised risk identifiers
 The provision of information and advice
 Early detection of risk and early testing and treatment to reduce onward transmission of infection.
Rational:
As a designated centre for providing care for those with an HIV diagnosis it is important that the Sussex Beacon
offers opportunity for clients to explore not only issues relating to their HIV but also the wider implications of
sexual health.
The purpose of the screening interview is to particularly cover areas that may not have been addressed since
diagnosis or patients have found difficult to talk about in clinic settings or that patients require more time to
explore.
The Sussex Beacon is especially suited to conducting such an interview as it offers a safe and supportive
environment with staff that are experienced in working with people living with HIV.
The Sussex Beacon team will be able to contribute positively to the national strategy for Sexual Health and HIV,
helping to support local initiatives as well as complying with national guidelines produced by organisations
such as BHIVA – British HIV Association and BASH - British Advisory for Sexual Health.
Measure:
Number of patients having completed the screening process compared to the total number of patients
admitted.
Target:
95% of eligible patients admitted will complete a sexual health screening interview,
99% of patients identified at risk will have an individualised care plan, information and appropriate referral to
on-going services.
Reporting:
To Clinical Governance Committee and through our stakeholders’ forums.
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Improving Patient Participation in Planning Individualised Care - Care Planning
Goal:
To enable patients to fully participate in the planning and reviewing of care plans and interventions, ensuring
understanding and informed consent at all times whilst allowing further opportunity for patients to be
empowered to manage their care.
Rational:
Patients should be at the centre of all approaches to care and should be offered and encouraged to take as
active a role as they wish in planning their aims and outcomes. This has to be a flexible approach as some
people who are unwell will not wish to focus on this until feeling better.
Measure:
The care plans brought in last year introduced standards and a formulated approach, which offers clinical
direction and a process of review. These now need to be adapted to enable patients to be able to write on and
participate in the review process. Care planning will be initiated and reviewed with the patient in their room;
the plans will be in the patient’s room and reviewed by staff together with the patient wherever possible.
Audits will be carried out to provide evidence of activity and patient feedback questionnaires will specifically
ask patients to feed back their experiences in this area.
Target:
All patients will be offered the opportunity to participate in their individualised care planning system.
Reporting:
Reports will be made to the Board of Trustees; Care Quality Commission; Staff Groups.
Improving Patient Access to Emotional and Mental Health Support
Goal:
To ensure that service users at The Sussex Beacon are being offered psychological support, where required.
Psychological support being defined as ‘any form of support which is aimed at helping people living with HIV to
enhance their mental and their cognitive and emotional wellbeing’. This process will lay the ground work to
enabling The Sussex Beacon to adopt the British HIV Association’s National Standards for Mental Health due
for release at the end of the year.
Rational:
Emotional wellbeing and mental health are important for everyone. Going through difficult times is part of life,
but from time to time can be very difficult to deal with. Furthermore, some people also experience mental
health problems, such as depression or anxiety; where emotions such as low mood, feeling helpless,
hopelessness and grief carry on for some time and can return again and again through life. Being diagnosed
and living with a serious illness like HIV is likely to have a big emotional impact, and people with HIV, as a
group, have higher rates of mental health problems than those seen in the general population. It is important
that people living with HIV have access to needs assessments throughout their disease progression and that
they have choice to engage with types of support best suited to them.
Measure:
This assessment process will be led by The Sussex Beacon Clinical Nurse Specialist (CNS) and will take the form
of a functional assessment tool, an interview and a post interview statement tool. The CNS will have a ‘prompt
sheet/questioner’ that she will fill in and use as a point of reference. However, the main objective is to gather
information through conversation. The functional assessment tool is a validated measure that is registered on
the FACIT web site and will be used to help focus the service user before the questionnaire. The quantative
measures will take the form of the validated measures used in the FACIT tool and the number of referrals. The
qualitative measures will come from the questionnaire and the dialogue generated. The services being
referred into include Heath Management CBT Services, Psychology, Psychiatry and Person Centred
Counselling.
Reporting:
To Clinical Governance Committee; Staff Group, Service User Forum, and sharing experiences with
stakeholders.
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Patient Experience
Improving Patient Discharge Process
Goal:
By improving the patient discharge process we will reduce the number of patients that experience delays in
returning home or ensure that patients feel as prepared as possible, improve the quality of discharge
documentation and improve the experience of patients and their families.
Rational:
The discharge of patients into the community is an important step in the care process. Discharge needs to be
planned carefully, communicated to other healthcare providers for the continuing care purposes and be
sensitive to the needs of the patients and their families and carers.
Measure:
Changes to the care planning system; service user representative input into the design of discharge
paperwork; staff training and audit.
Target:
Improvement in service user feedback questionnaire.
Reporting:
To Clinical Governance Committee; Staff Group; Service User Forum, and sharing experiences with
stakeholders.
Improving availability and quality of information available for patients
Goal:
By improving the range of information available to patients we will reduce patients’ knowledge deficit whilst
offering patients more choice and opportunities in which to gain understanding and explore issues.
Rational:
Patients require information to enable them to understand their environment, manage their conditions and
make informed choices. This information must be available at all times and in a medium that is readily
understood.
Measures:
Feedback from patient surveys and service user representatives will be used to design and decide which areas
of information need to be improved. Leaflets and other mediums will be designed and introduced as part a
collaborative process between staff and service user representatives.
Target:
Improvement in service user feedback questionnaires.
Reporting:
To Clinical Governance Committee, Staff Group, Service User Forum, and sharing experiences with
stakeholders.
Part 2.2
Statements Relating to the Quality of Services Provided
Review of Services
During 2010-11 The Sussex Beacon provided 2630 medical/nursing bed nights as part of contract agreements
with Brighton & Hove PCT, West Sussex PCT and East Sussex PCT.
Data on performance is regularly provided to the commissioning PCT’s as reviewed accordingly. 100% of the
income generated from the Service Level Agreement contracts for this time period has been used to fund the
provision of our NHS services.
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Participation in Clinical Audit
During 2010-11, The Sussex Beacon has participated in supporting the development of national audit tools
produced by Help the Hospices. This work has formed the foundation for the development of an internal audit
framework that checks clinical standards, quality and safety.
Audits include:

Random spot check audits in areas such as medication administration, infection control and
environment
 Regular annual audits such as LCP review, medical gases safety and compliance with CQC standards
 Small regular internally designed audits to look at key areas regularly such as sluice room safety,
cleanliness of clinical environments.
The HTH audit tools are robust and fully referenced documents that are managed and developed by an
experienced group of clinical practitioners from across the country and will continue to be used to set The
Sussex Beacon’s core audit framework.
PART 3
Review of Quality Performance
Review of Patient Safety
Infection Control
The reduction of infections acquired whilst in care is a priority for The Sussex Beacon and targets are set to
drive and measure the improvements. We have developed a lead role in Infection Control Management by
joint working with the PCT infection control teams nationally led initiative – ‘Infection Control Champion’.
Investment into this program has enabled us to improve our auditing, our clinical environment, our staff’s
knowledge, our outbreak strategies and our patient / visitors’ awareness. The result has been that there have
been no reportable infection outbreaks in this period despite the continuing prevalence of reported cases of
MRSA, Norovirus and Clostridium amongst our neighbouring health services providers. Our aim is to continue
the development of this activity and involve patients and visitors in adopting good hand hygiene practices.
Incident Reporting
With the introduction of a new incident reporting process last year we have been able to monitor events more
closely and improve on reporting throughout the organisation. We have had no ‘serious untoward incidents’
to report during this period and incidents reported have fallen into the minor category. Each incident has a
root cause analysis process applied, which allows us to look at why the incident occurred and if anything could
be done to prevent it from happening again.
Risk Management
This year has seen the introduction of annual organisational risk review as part of a new Risk Management
Strategy.
The purpose of this Risk Management Strategy is to set out a strategic action plan for The Sussex Beacon for
the years 2010-12. It has been adopted as part of the strategic management process across The Sussex
Beacon to enhance its values, promote safety and quality of service and the achievement of its objectives.
The Sussex Beacon Risk Management Strategy objectives are to:
•
•
•
Clearly identify objectives, roles and responsibilities for managing risks
Improve co-ordination of risk management throughout The Sussex Beacon and its services
Ensure we anticipate and respond to changing social, environmental and legislative requirements
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•
•
•
Prevent injury, damage and losses and reduce related costs
Integrate risk management into the culture of The Sussex Beacon
Raise awareness of the need for risk management by all those connected with The Sussex Beacon
and the delivery of its services
Implement annual strategic risk assessment and review.
•
These objectives have been achieved by:
•
•
Establishing clear objectives, roles, responsibilities and reporting lines for risk management
Providing a policy and framework for the regular and consistent management of risks across the
organisation
•
Ensuring monitoring and reviewing arrangements happen on an on-going basis
•
Providing mechanisms for the allocation of resources to identified priority risk areas to prevent
injury, damage and losses
•
Providing opportunities for shared learning on risk management across The Sussex Beacon
•
Reinforcing the importance of effective risk management as part of the everyday work of
employees/volunteers by offering training
•
Incorporating risk management considerations into future strategic reviews of The Sussex
Beacon.
There is now in place a comprehensive system that identifies and assesses the impact of possible risks to
patients when using our services. These plans are regularly reviewed and evaluated, enabling The Sussex
Beacon to proactively consider the risk to patients, take appropriate steps to minimise those risks and ensure
that patient safety remains central within our activity, culture and philosophy.
Patient Falls
This is an area of national concern throughout NHS led services and we remain vigilant in managing this issue
within The Sussex Beacon. We have had no reported falls during this period – which is partly reflective of the
risk assessments carried out on admission and also on-going improvements to the environment such as new
hand rails within the bathroom areas.
Medicine Safety
We have had no serious incidents with medication that have required reporting to the Care Quality
Commission. New and improved auditing has indicated that systems and practices are in place, are fit for
purpose and that a good standard is being maintained. Incident reporting has highlighted that a number of
minor incidents are happening such as missed doses or incorrect transcription of prescriptions and although
the rates are not above national levels it is an area that has been identified as a priority for improvement over
the forthcoming year.
Organisational Improvements in Quality





Development of clinical audit across the services using nationally recognised audit tools
Development of Patient Feedback Questionnaire and improved pick up rate from less that 5% in 2009
to nearly 70% in this time period – allowing for improved responses to patient indented issues
Development of service user forum and integration of service reps within the organisational /
operational systems – allowing for improved communication between services users and managers
Implementation of new ways to inform and engage services users at all points of care
Development of volunteer support services that engage the local community in helping to maintain
and enhance services.
A safe stay
The Health and Safety Committee monitors safety and reporting, which is to NHS standards with no RIDDOR
reported incidents and no CHAS reported incidents in this period. Health and safety risk assessment is the
foundation to maintaining a safe environment and is reviewed annually/6 monthly along with risk assessments
being carried out for any new changes to environment or practice.
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Environment
The acquisition of a government grant has enabled us to carry out work on upgrading the clinical environment
with a specific focus on supporting the delivery of high quality experience and service within palliative and
‘end of life’ care. Specifically:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Improving quality of life
Promoting dignity
Enabling improved privacy
Encouraging independence
Increasing therapeutic value of garden area
Enabling hospices to be more responsive to needs of people using hospice care
Enhancing physical environment to allow better nutrition
Supporting cultural diversity
Improving hospices’ ability to meet multiple complex needs
Enabling people to be cared for at end of life in a comfortable and safe environment of their
choosing.
Quality Improvements:
Phase 1 created wheelchair access to the garden, allowing patients to leave the unit and access our tranquil,
therapeutic garden. Phase 2 involved the refurbishment of 2 bedrooms/bathrooms providing an improved
environment to support end of life care. Whilst also improving our ability to meet the multiple complex needs
of our patients and enabling people to be cared for in a comfortable and safe environment of their choosing.
High spec hoists and electric beds provide greater levels of independence and dignity and require less manual
handling of patients. New baths and showers promote independence and dignity, also allowing patients with
limited mobility to bath safely. New equipment and room design have radically improved hygiene. Phase 3
created a bereavement/family/counselling room, increased space for doctors and made the unit non-smoking.
Friends, families and carers now have a private space to meet, consult or even stay overnight, allowing us to
better meet their needs. We have created a larger office space making desk space for doctors and have made
the unit non-smoking, creating a much better and healthier environment for staff, patients and visitors.
The project enables The Sussex Beacon to provide better end of life care for patients, thereby creating an
alternative for those who do not wish to die at home or in hospital. The Sussex Beacon provides a highly
specialised environment for people who are HIV positive and who feel stigmatised and isolated by the disease,
providing privacy and dignity for people who wish to be cared for in a supportive environment.
Driving further improvements
Despite continuing improvements in incident reporting there are some that, for a variety of reasons, still go
unreported. Our aim as an organisation is to eliminate all avoidable harm. The first goal on this journey is to
reduce the number of harm events occurring to our patients and although they are relatively low they do offer
an opportunity to reflect on events and learn. This happens as part of the multi-disciplinary process and shall
be incorporated into regular team meetings.
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Review of Clinical Effectiveness
General View
This section describes just some of the ways in which The Sussex Beacon has improved its effectiveness and
arrangements.
Clinical effectiveness is made up of a range of quality improvement activities and initiatives:

The assessment and use of evidence, guidelines and standards to identify and implement the best and
most cost effective practice.
 The use of quality improvement tools, (such as audit) to review and improve services.
 Information systems to assess current practices.
 Development and use of systems of learning both in specific areas and across the organisation.
The Implementation of the Liverpool Care Pathway national tool for the management of the patient’s dying
process. We have provided training to staff in support of this process and implemented the tool with the
support of specialists to enable staff to work in a safer, structured and more accountable way. On-going audit
enables the process to remain relevant to practice and is evidence based.
Working with the National Audit Tools Group of Help the Hospices has enabled us to develop an effective audit
that is evidence based and nationally recognised. Audit has directly influenced practices within our service and
enables us to prioritise and demonstrate improvements to care.
The introduction of a new patient questionnaire has meant that we have been able to have direct patient
feedback of their experiences, which we as a team can use to help influence our practices. It has been very
useful over the past year and we are adapting the questionnaire to improve on the quality of data we receive
and help demonstrate that we take patients’ comments seriously.
Supported development of the service user forum has created a system by which managers and service users
can share information and guide future developments. The introduction of service user representatives within
all service areas has added another layer of feedback in which patient issues and ideas can be addressed, an
example of which is the collaborative work done between managers and service user representatives in
producing a new patient guide and welcome pack, which is much more user friendly and effective.
Areas of Clinical Audit











Infrastructure for the Management of Infection Control Annual Audit
Accountable Office Random Safety Audit carried out every 8 weeks
Controlled Drugs Management and Governance Annual Audit
Inpatient Admission Annual Audit
Documentation Audit
Information Governance Audit
Infection Control PCT Annual Audit
Infection Control Help The Hospices Annual Audit
Accountable Officer Annual Audit
General Medications Administration Annual Audit
Medical Gases Management Audit.
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Inspections
The Care Quality Commission has not inspected our services this year and we are currently registered with
them without condition.
The Board of Trustees carried out an inspection this year in which they inspected the environment,
infrastructure and interviewed a range of clinical staff and patients. This was reported as a very positive and
informative visit with no immediate recommendations.
The Accountable Officer carried out an un-announced spot check on services in relation to the management
and administration of Controlled drugs which included interviews with all staff on duty at the time and a report
submitted to the Clinical Governance Committee, which showed 100% compliance with standards.
Review of Patient Experience
How we measure the patient’s experience
Patients are asked to complete a questionnaire at the end of their stay, which is completed anonymously and
placed in a collecting box on departure or posted to us following departure. They are asked to comment on
their experiences regarding their clinical care, their nutritional and entering needs and the privacy and
cleanliness of their environment. There is also a section in which they can write any comments they wish to
convey to The Sussex Beacon Management.
The uptake of patients completing the questionnaire has been approximately 70%, which is considered very
high and has enabled us to use this feedback effectively to influence change. An annual report is made
available for patients and staff to see how this information is used. The measurements are subject to review by
the Clinical Governance Committee and the actual questionnaire has been reviewed by the service user group
with the result that changes to the measures and questionnaire shall be implemented this year.
Complaints
We have received no formal complaints within this time period despite an overhaul of the complaints policy
and procedure. This has made us focus on ensuring patients are aware of how to complain and that they have
many choices in which to choose to do so. Information is now available in every welcome pack, leaflets are in
every room, service user representatives attend the unit every week and anonymous comments boxes are
available.
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Patient and Public Involvement
A service user forum has been set up with the aim of establishing an independent and representative forum,
which would have a fundamental role across all our services. The forum’s objective is to properly gather and
make use of patient feedback, the aim being that their direct experiences would help us to improve services
and communication between service users and staff.
Service users are experts in their own illness and the care they need. They can provide a different perspective
about their illness and give alternative approaches to treatment and care. Forums are held six times a year and
are attended by at least four service user representatives and a service user support trustee, alongside any
interested service users. The forums are confidential and the managers and CEO are called in to update the
forum and to discuss any issues arising. Forum reports are discussed at the managers meeting and dedicated
time is allocated at the board of trustees meetings for discussion of service user issues.
“I feel we are better informed now about changes in the organisation which as a service user I feel is incredibly
important for my own peace of mind. I also feel that we can make a difference, having one of my ideas taken
forward by fundraising was really empowering”
The service user group has evolved into a vocal group of members. The meetings have been well attended by
service users, other than service user representatives, who just wish to listen or make suggestions. Service
user reps have been very proactive in gathering feedback from all service users. The service user forum has
had a very influential impact on the organisation as a whole; on service provision and planning, fundraising and
communication strategies.
For example, service users identified a lack of IT skills, and a fear of enrolling on mainstream courses, as a
major obstacle to personal development and coping with chronic health. In response, The Sussex Beacon
introduced “ Pathways to Skills” a series of courses aiming to help the long term sick and socially isolated gain
the basic IT skills needed to enrol on further training courses, or to volunteer, as a means to eventual
employment.
The Service User Forum has allowed service users to be involved in all aspects of our work. It ensures we
always think of service users so they are involved in all aspects of our work. It ensures we think of service user
needs first and consider the impact of any changes or developments upon them. It has resulted in service
users and staff working together as a team on a number of projects and having a voice on key meetings such
as the communications group and the board of trustees. In turn, it has enabled us to improve the quality of
care we provide and helps The Sussex Beacon deliver excellent services that have integrity.
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The Voice
The Sussex Beacon also supports the production of an e-newsletter
called ‘The Voice’, which is written by service users for service
users to give them a voice within the wider context of the
organisation’s sphere of influence. This quarterly publication is
now available on our website.
3.2 Who has been involved in setting the content of the Quality Account and
the priorities for 2011-12?
This is the first quality account produced by The Sussex Beacon and has been a learning experience for us all,
much of the content has been derived from the activity of managers, staff and service users and will provide us
with a framework from which to develop in the future. We shall endeavour to improve our quality
performance by forming a working party that consists of service users, staff and trustees to guide us and set
out future priorities.
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