Derbyshire Community Health
Services NHS Trust
Quality Account
2011/12
Contents
Opening comments from
Chief Executive Tracy Allen
5
A statement from the Chief Executive Tracy
Allen and the Chair Andrew Fry
6
Introduction by the Director of Quality/Chief
Nurse and the Medical Director
8
Monitoring progress
8
Overview of 2011/12
8
Looking forwards
Quality Improvement Priorities for 2012/13 10
Review of Quality Improvements
for 2011/12
13
Achievements, Awards and Accolades
14
Evidence of improvement in patient safety 17
Infection prevention and control
18
The Deep Clean Team
18
Infection Prevention Champions and Hand
Hygiene (IP&C)
18
High Impact Actions Falls and Bone Health
19
Babington Rehabilitation Centre –
Launch of the New Falls Programme
19
High Impact Actions - Tissue Viability
20
High Impact Actions - Catheter Acquired
Tract Infections (CAUTI)
21
Venous Thromboembolism (VTE)
22
Safety Express
23
Rapid Implementation of National
Patient Safety Alert on Syringe Drivers
24
Safeguarding
24/25
Evidence of clinical effectiveness
improvements
26
Breast Feeding Success
27
Stroke
28
Discharge Planning
29
Dementia Care
29
Mortality Audit
30
Care of the Acutely Ill Patient
31
Leicestershire County and Rutland
Out-patient, Diagnostic and Day Surgery 32
Hinckley and District Hospital
32
Loughborough Hospital
32
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DCHS QUALITY ACCOUNT 2011/12
Coalville Hospital
33
Making a difference - a focus upon
children and young people
33
Sexual Health Promotion Service
34
Specialist Children Services - Answering
Awkward Questions
34
Speech and Language Therapy
35
Clinical Audit
35
Information Governance
38
Research and Knowledge Services 38
Clinical Records
39
Evidence of improvements for
patient experience
40
Patient and Public Involvement (PPI)
41
Privacy and dignity
42
Patient experience
43
Carers
44
Listening and learning through complaints 44
Nutrition and Hydration
45
Supporting our End of Life patients
and families
46
Addressing Spirituality [Riverside] Art Work 46
Tea Party
47
Improving the patient environment
47
Ilkeston Hospital
47
Patient Leaflet
47
Quality Focus - Occupational therapy
outcomes
47
What others say about us
48
CQC update for Quality Account 2011/12 48
NHSLA - National Health Service
Litigation Authority
48
Health Ombudsman outcomes in 2011/12 48
Coroner’s Inquests
49
Never Events
49
Serious Incidents
49
Patients/carers
49
What our Staff say
49
Declaration and Statements
50
Glossary
52
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DCHS QUALITY ACCOUNT 2011/12
3
A statement from the Chief
Executive Tracy Allen and
the Chair Andrew Fry
4
DCHS QUALITY ACCOUNT 2011/12
Opening comments
from Chief Executive
Tracy Allen
On behalf of our Trust I am pleased
to present this Quality Account which
sets out our hard work, achievements
and areas of improvement for 2011/12
and our priorities for 2012/13. We place
great emphasis on the positive culture
and values of our Trust, the DCHS Way,
investing and believing in our staff to
deliver a high quality service. I believe
that the DCHS Way and being proud
of how we work will help us to improve
and meet the challenges ahead of
us. The scale and complexity of this
challenge is very great for our Trust as
an integral part of the health and social
community. This community is actively
involved in listening to local people
and working together to deliver a better
service as part of the new systems laid
out in the Health and Social Care Act.
Our success has been acknowledged
in many ways over the last few years
winning regional and national awards
for our services. Our journey to become
a Foundation Trust has helped us to
improve our quality and performance
systems. These have been tested by
expert external scrutiny.
In 2012/13 we plan to become one of
the new community Foundation Trusts
in England. We really look forward
to engaging and working with our
membership and governors helping us
to be a well run, financially stable Trust
that has quality at it’s heart.
DCHS QUALITY ACCOUNT 2011/12
5
Statement of Directors’
Responsibilities in respect
of the Quality Account
In preparing the Quality Account we confirm that:
• The Quality Account presents a balanced picture of the Trust’s performance over the period covered
• The performance information reported in the Quality Account is reliable and accurate
• There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account and these controls are subject to review to confirm that they are working effectively in practice
• The data underpinning the measures of
performance reporting in the Quality
Account is robust and reliable, conforms
to specified data quality standards and
prescribed definitions, is subject to
appropriate scrutiny and review; and
the Quality Account has been prepared
in accordance with Department of Health
guidance.
The directors confirm to the best of their knowledge and
belief they have complied with the above requirements
in preparing the Quality Account.
By order of the Board
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DCHS QUALITY ACCOUNT 2011/12
“In our Trust we have defined our way of working
as the DCHS Way. This places quality as a golden
thread that runs through DCHS whether it is
about services, people or business matters.”
DCHS QUALITY ACCOUNT 2011/12
7
Introduction by the Director of Quality/Chief
Nurse and Medical Director
8
At Derbyshire Community Health Services
NHS Trust (DCHS) we regard our annual
Quality Account as an extremely important
public report. We take great care to listen to the
views and feedback from the readers of this
report to continuously improve it. The purpose
of this report is to help patients, their family and
carers (as well as the wider public) hold us to
account in relation to the quality of the services
we provide. It shows how well we did in the
last year to improve the quality of services,
identifies what we could do better and sets out
our plans for the forth-coming year.
or business matters. DCHS responds to the
financial pressures first and foremost through
Quality Improvement techniques to help raise
standards of care and offer better value for
money to our public.
In our Trust we have defined our way of
working as the DCHS Way. This places
quality as a golden thread that runs through
DCHS whether it is about services, people
We welcome your feedback in relation to this
report and our quality priorities for the year
ahead.
Monitoring progress
Overview of 2011/12
We were set a greater challenge for 2011/12
building on the very high standards and
success of 2010/11 where we achieved
17 out of our 18 “CQUIN” targets. CQUIN
(Commissioning for Quality and Innovation
payment framework) is the national contract
method for incentivising improvements against
specific topics or service areas. A proportion of
DCHS income in 2011/12 was conditional on
achieving quality improvement and innovation
goals as part of our contract. An example
of how a focus area for quality improvement
is translated into CQUINs includes the High
Impact Action areas published by the Chief
Nursing Officer. These relate to the CQUIN
targets for falls, pressure ulcer, catheter
acquired infection reductions needed and
additionally venous thrombo embolism (VTE)
assessments. In order for the Trust to receive
full payment for the services it offers we must
meet these targets. The contract for 2011/12
contained higher expectations for delivering
quality as well as new specific, more detailed
and stretching CQUINS. There were 11 in total
with 6 national / regional targets and 5 local
targets agreed between our commissioners
and ourselves.
We successfully met or exceeded the following
CQUIN improvement targets:
• Patient Experience
• Engagement with Carers
• Care Planning
• Preventing readmissions to acute hospitals services
• Equitable access to specialist services for patients with Learning disabilities
• Assessing and preventing Venous
Thromboembolism (VTE)
• Reduction of urinary catheter acquired infections
• Breast feeding sustainment rates.
DCHS QUALITY ACCOUNT 2011/12
This year, in addition to our wide range
of established services we have taken on
the hosting of Planned Care Services for
Leicestershire County and Rutland and also
were awarded the contract for their community
Dental Services. This Quality Account includes
information on all of our services.
During 2011/12 our total income for providing
clinical services was £170m, of which £2.3m
was dedicated to the delivery of CQUINs
across our services. Of this we achieved 87%
of the financial value. Further details of the
agreed goals for 2011/12 and for the following
12 month period are available electronically.
It was noted by the commissioners that whilst
we have made significant improvement we
narrowly missed some targets:
• Reducing Falls
• Stroke Community Care
• Pressure ulcer (evidence of re-assessment)
• Dementia indicator for OPMH (older people
mental health) - reassessment of medications.
We have set ourselves new plans for the
coming year, with clear actions to maintain the
good performance of the targets we achieved
as well as meet the improvements for the ones
we narrowly missed. These will be monitored
in our contract for 2012/13.
In addition to the CQUIN quality targets
already mentioned there are other quality
standards and targets in place which are
set by the government and monitored by
our commissioners and external regulatory
bodies (such as the Care Quality Commission
– CQC). Our Board of Directors has overall
responsibility to ensure that these are
delivered and during the past year we made a
number of changes within our governance and
assurance structures to ensure that these were
being met.
Our Quality Strategy provides a framework for
the delivery of quality services within DCHS
and within this we have defined quality as:
• The delivery of services which are focused upon patient safety and reducing risk which may cause harm
• The delivery of services which are effective in the context of clinical outcomes and patient related outcomes
• The delivery of services which are considered by our patients, service users, their carers and families as being a positive or good patient experience.
This forms part of our Quality Governance
Framework which incorporates our strategy
(Integrated Business Plan), the capabilities and
culture within the organisation, our processes
and structures (which support delivery) and
how we measure success.
DCHS QUALITY ACCOUNT 2011/12
9
Looking forward
Quality Improvement
Priorities for 2012/13
As the NHS prepares itself to meet the
demands of the new Health and Social Care
Act, working in partnership with our patients
and their carers, other service providers,
statutory agencies and the voluntary and
community sector, will be key. This will be
particularly important as we redesign our
services to meet the needs of our local
communities in view of the challenging
economic and demographic climate. The
delivery of quality services, by quality people
within a quality business during this time is our
priority.
DCHS have identified key quality aims as part
of our Quality Strategy and Annual Plan. These
are:
• Keeping patients safe whilst in our care
• To get the basics right
• To put patients at the centre of care delivery.
Monitoring the delivery of these and our
other quality targets are through our quality
governance systems, with the Board of
Directors having overall responsibility.
These assurance systems include validated
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DCHS QUALITY ACCOUNT 2011/12
evidence and data from our performance
monitoring systems as well as our other quality
and safety processes such as service quality
and safety visits which span from frontline
care to the Board Room. (In addition, we have
developed a Safety and Quality Early Warning
System (SQEWI) which combines quality,
safety, patient feedback and staff performance
measures to strengthen our process and
help us to identify where we need to improve.
This will enable us to act sooner and reduce
avoidable harm to patients.
Safety Express (which is a quality improvement
tool as part of a national Safe Care
programme) continues to be the way in which
we will improve patient safety and quality of
care. We are also aware from those who use
our services that they wish to be listened to
and involved in their care, treated with fairness,
dignity and respect and treated by staff who
demonstrate compassion.
In 2011/12 NHS Midlands and East launched
its Ambitions Programme with its 5
priorities. Two ambitions to emphasise
in our next years objectives include
the Patient Revolution and
Eliminating Avoidable
Pressure Ulceration.
We have a new set of improvement measures
for 2012/13 that we have agreed with our
commissioners, these are fewer in number
but have more national direction and regional
overview. This is to help to inform collective
improvements and for benchmarking one
organisation against another.
Clinical improvements remain a high focus
and will be performance monitored against
improving targets as part of our contract. The
high impact action areas remain as part of this
set with the rollout of the safety thermometer
(which enables us to measure the impact of
care) into community services as a driver to
bring about reduction of harm to patients.
Patient experience and patient engagement
are high profile with significant work expected
to demonstrate how we seek out and act
upon the views of the service users, their
families and their carers in all that we provide
and undertake in meeting their health care
needs. This programme of work is known as
‘the Patient Revolution’ and is being taken
forward under the umbrella of our new Patient
Experience and Involvement Strategy. Patients
who use our service will get to know this as the
“Family & Friends test” asking how likely they
would recommend our services.
2012/13 Contracted Quality
Improvement (including CQUIN)
The priorities agreed in our contract for this
year has a more national emphasis. This is to
help national and local benchmarking of good
practice and performance. It is understandable
that many of these targets have an acute
hospital focus. As a Community Trust we
provide a range of hospital and community
services and work closely with our local
commissioners to see how best we can deliver
improvements in these areas.
DCHS QUALITY ACCOUNT 2011/12
11
Our CQUIN priorities for improvement as we
move forward into the future are set out as
follows:
National
• Reducing avoidable deaths, disability
and chronic ill health from venous-
thromboembolism (VTE)
• Patient experience - Improve responsiveness to personal needs of patients
• Dementia - Improve diagnosis of dementia, using risk assessment, in hospital settings
• NHS Safety Thermometer - Improve the
safe care of patients with regard to pressure ulcers, falls, urinary catheter care and VTE prevention.
Regional
• Patient Revolution - one of the 5 ambitions of NHS Midlands and East SHA. Measuring and improving the experience of patients using our services.
Local
• Support for residents of care homes - Improve partnership support with care homes
• Nutrition - Reduce malnutrition in the frail elderly population
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DCHS QUALITY ACCOUNT 2011/12
• Intermediate care support for patients in a domiciliary setting
• Make every contact count - promoting key health and well being messages to all.
These are mirrored by the regional ambitions
for Health Care Delivery for the SHA regional
cluster and pick up the national direction on
priorities for health improvements.
Delivering Same-Sex Accommodation
Declaration of compliance
DCHS has met the requirement to Eliminate
Mixed Sex Accommodation and have not
reported any breaches in 2011/12. Our
programme for environmental improvements
has continued throughout the year and these
have included both eliminating mixed sex
accommodation issues and meeting infection
prevention and control standards. All premises
have been assessed to determine they are ‘fit
for purpose’.
Review of quality
improvements for 2011/12
This section describes in more detail our successes
during the last year. We are also keen to present
examples of where we could better, to ensure we give
an open and balanced account. To help understand
this information we have presented this in the following
sections:
Achievements Awards and Accolades
Patient Safety (trying to prevent patients from being
harmed)
Clinical Effectiveness (making sure our treatment and
care works well)
Patient Experience (listening to what people think and
feel about our services)
DCHS QUALITY ACCOUNT 2011/12
13
Achievements, Awards and Accolades
St Oswald’s
our newest
hospital was
formally
opened by
HRH Prince
Edward in
May of this
year
Care Home Support Team
This pilot project won a national award from
the Health Service Journal (HSJ) for “Liberating
Ideas”. It demonstrated that supporting patients
in care homes helped to reduce falls and
hospital admissions by 60% among frail elderly
patients. The team worked with 29 care homes.
This service has helped to improve residents’
sense of wellbeing and confidence, reducing
the fear of falls and accidents. The learning
from this initiative has been shared across our
Trust and many others, and we are using this
learning to further facilitate work in supporting
care homes.
National Guidance
Queens Nurse Awards
Gill McKay, Health Visitor, and Caroline Hannan
Professional Lead, have both been awarded
the prestigious title of Queen’s Nurse (QN)
at awards ceremonies given by The Queen’s
Nursing Institute (QNI), in London. They are
representatives of a small cohort of 35 nurses
recognised this year for excellence in practice.
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DCHS QUALITY ACCOUNT 2011/12
The Derbyshire Sexual Health Promotion
Service peer education is to be included as
an example of best practice in guidelines
being produced by the National Chlamydia
Programme. Locally it is called the ‘Well Sexy
Programme’ and is a peer support outreach
service for young people between 15-25 yrs.
DCHS has very high levels of uptake compared
to some parts of the country.
NHS Microsoft Award
We received the NHS Microsoft Office Skills Training (MOST) Centre of Excellence award. This
demonstrates a high level of commitment from our Trust to the training and certification of our staff.
There are 187 MOST centres across England and we are the eighth centre to achieve the Centre
of Excellence award.
Safety Express
We won a national award for the
role we have played in developing
the ‘Safety Express’ programme, a
national campaign to providing safe
care for NHS patients.
Infection Prevention and Control
(IP&C) Team
A board game developed by our IP&C Team
won a NHS East Midlands Patient Safety
Innovation Award for making learning about
safety more fun. Judges were so impressed
that they have awarded the team £1,000 to
develop the game further.
DCHS QUALITY ACCOUNT 2011/12
15
These next pages are to provide contextual
information of the range of activities
undertaken to meet quality improvements
Each of the core subect areas that reflect the
quality improvement indicators are grouped
together into the following colours:
Evidence of improvements
in patient safety
Evidence of clinical
effectiveness improvements
Evidence of improvements
for patient experience
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DCHS QUALITY ACCOUNT 2011/12
Evidence of
improvements in
patient safety
DCHS QUALITY ACCOUNT 2011/12
17
PATIENT SAFETY
Infection prevention and
control
Target: to continue to reduce healthcare
associated infections.
What we achieved:
• Hand Hygiene more than 97% compliance with a World Health Organisation Advanced Category status
• No MRSA / MSSA Bacteraemia (no superbug infections in patients bloodstream)
• Clostridium Difficle (a potentially severe bowel infection): halved our last years rates of infection with 12 recorded cases.
What next:
Our annual performance for Clostridium Difficile
infections is not published through the national
Health Protection Agency (HPA) system which
focuses on Acute Trusts. Our own calculations
based on the HPA system demonstrates that
we have comparable performance. Despite
these very good results, in this last year we
had an episode on one ward of increased
Clostridium infection affecting three patients.
We have learned by investigating this incident
how the management of these could have
been better. We have now supported staff to
improve and maintain standards.
Our target is to continue to reduce rates of
healthcare associated infections (HCAI).
The Deep Clean Team
Deep cleaning is an annual requirement and is
incorporated into a rolling programme over and
above the daily cleaning routine. This team,
introduced in 2010, is now embedded and has
an identified programme of cleaning for areas
deemed to be requiring specialist cleaning
interventions and helps us to be able to reopen
wards much more rapidly. In 2011/12 the team
worked hard providing specialist support in
Noro Virus (“winter vomiting bug”) outbreaks.
Again we have learned what works well and
what we need to do better. This includes
improving communications both across our
teams and the public (especially visitors).
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DCHS QUALITY ACCOUNT 2011/12
Simon Goldsmith IP&C
Champion Programme
Facilitator.
DCHS is clearly able to demonstrate a
commitment to creating a patient focused clean
and safe environment having established this
rapid intervention specialist team approach.
This links to our PEAT (Patient Environment
Assessment Team) inspections.
Infection Prevention Champions and
Hand Hygiene (IP&C)
These Champions continue to play a key role
to ensure all staff adhere to clinical policy
and professional standards and to challenge
any member of staff demonstrating poor IPC
practices providing support and information.
The Champion’s groundwork in hand hygiene
compliance has seen high compliance rates
of just over 97%. We still have more to do to
reach the Trust target of 100%. This helps
patient safety by reducing the risk of health
care associated infections and helps patients
feel more secure and positive about their care.
In December 2011 we made an assessment
of Hand Hygiene provision across our 12
community hospitals and Ashgreen Learning
Disabilities Centre using the World Health
Organisations online assessment tool. DCHS
scored 465 out of a possible 500 which places
us firmly in the advanced category, an indicator
of good practice.
High impact actions
These are national improvements set for all
nurses by the Chief Nursing Officer of England
High Impact Actions - Falls and Bone
Health
Target: to reduce harm from falls
What we achieved:
A raised awareness of falls prevention actions
and a reduction of serious harm from falls.
What next:
Our target is that at least 96% of our in-patients
do not fall whilst in our care and that serious
harm does not happen as the result of a fall.
DCHS remains committed to providing high
quality, evidence based treatment and care
for people who are at risk of or have fallen,
to improve their bone health and reduce the
harm from these falls. Our falls strategy and
interventions help patients in our care e.g. in
one of our hospitals as well as in their own
homes.
Many service improvement initiatives and
developments have been put in place and will
continue to be developed and implemented this
year:
• Launch of “Safety Express” initiative across
all in-patient services. This includes the
“clinical rounding” process which has supported all staff to continually monitor and act on falls risk
• Development of Preventing Harms, (including
falls), ‘Board Game’. This is a tool that
promotes whole team thinking and planning to keep patients safe
• Monthly auditing of ‘4 harm’ incidents and
sharing these results at local team level so front line staff can learn and plan
• Continual review of falls prevention and
management policies and associated protocols and clinical tools
• Identification and training of falls champions
for all DCHS patient facing services. The
falls champion is the local resource for teams
to use to support them to turn local and
national policy and protocols into every day
falls prevention and management actions
and practice
• Development of new accessible training materials to raise awareness for all DCHS
staff in their individual roles and responsibilities.
DCHS worked with commissioners and acute
trust partners to develop and implement
an integrated care pathway for falls across
Derbyshire. This ensures high quality, evidence
based falls care is standard across the county
and gets people to the right services at the
right time. This pathway includes a ‘Single
Point of Access’ to falls services for GPs and
other referrers, a falls prevention advice and
information service, and new arrangements
with ambulance services who attend people
who have fallen but do not need to go to
hospital, and a ‘falls recovery’ service for
people who live in managed accommodation
who fall but again do not need to go to hospital.
This has resulted in a reduction of unnecessary
admissions to our hospitals.
Babington Rehabilitation Centre –
Launch of the New Falls Programme
The Falls Programme is provided for patients
in the Amber Valley area aged 65 and over who
have had a fall or are at risk of falling. These
patients benefit from an experienced multidisciplinary team input from physiotherapists,
occupational therapists, nurses, pharmacists
and rehabilitation support workers. After an
initial assessment, suitable patients attend
a seven week programme and at the end of
this period, benefit from improved balance
and co-ordination, increased awareness of
falls prevention, identification of falls risk
factors, increased confidence and self-esteem,
promotion of independence, peer group
discussions as well as social interaction. On
evaluation of the programme those patients
who have attended this programme have a
significant reduction in further falls, supporting
our work in reducing falls and harm from falls.
DCHS QUALITY ACCOUNT 2011/12
19
High Impact Actions - Tissue Viability
Target:
To improve reporting, monitoring and assessing
all grades of pressure ulcers, and a reduction
of in-patients that develop a new pressure
ulcer whilst in our care (Safety Express).
What we achieved:
Our reporting increased across the
organisation and all pressure ulcers were
investigated (using root cause analysis). Our
inpatient areas achieved an improvement from
83%-89% of in-patients who were assessed
within 6 hours of admission, documented and
reassessment increased from 26%-79% for
those who did not develop a new pressure
ulcer whilst in our care.
What next:
We are aiming to meet the Strategic Health
Authority (SHA) Ambition 1 which is to
eliminate all avoidable Grade 2, 3 and 4
pressure ulcers by December 2012.
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DCHS QUALITY ACCOUNT 2011/12
Pressure ulcers are areas of damaged skin
which can lead to ulceration and infection.
People who are immobile or unwell are more
likely to get these. Our Tissue Viability team
will be working closely with staff across the
organisation, other providers of care and
patients in order to meet this challenging
ambition.
• Our improvement work is focused upon evidence based practice and learning from elsewhere in order to make the necessary reduction in patients developing pressure ulcers. This includes raising awareness of patients and staff, improving staff training, improving our data collection and monitoring systems and focussing on prevention. This will be enhanced by working within the SHA Ambition programme of work.
Well planned interventions and care planning
with patients and carers can ensure that no
further deterioration of the skin occurs. To
support this we have developed a Patient
Information Leaflet and Self Care Advice Sheet
for patients and carers about how they can
help to improve or prevent pressure ulcers
developing.
High Impact Actions - Catheter
Acquired Tract Infections (CAUTI)
Target:
To reduce the numbers of in-patients with an
indwelling urinary catheter and the number of
catheter acquired infections.
What we achieved:
A reduction of the numbers of in-patients with
an inappropriate catheter whilst in our care
from 19.9% to 11.9% and a reduction in the
number of those patients who had an CAUTI
from 7.1% to zero.
What next:
To work with our acute hospital provider
partners to continue to monitor appropriate
use of catheters, extend our improvement
work across our community services and to
continue to reduce catheter acquired infections.
Catheters are used to help treat patients with
problems of passing urine. Medical evidence
tells us that these urinary catheters should only
be used where absolutely necessary because
they can cause or worsen urinary infections. To
support the improvements a Specialist Nurse
was appointed to provide clinical support to our
Community Hospitals. The nurse visited every
hospital in-patient area regularly to monitor
and assess the use of catheterisation, provide
training and to promote best practice.
A detailed audit was undertaken to establish
a baseline for improvement and the re-audit
demonstrated improvement in reducing the
numbers of patients with a catheter while in our
care and the number of those patients who did
not have an infection.
A new DVD training resource for staff has been
developed that will enable anyone involved
with catheter care to increase their knowledge.
Any catheter acquired urinary infection that
develops within our care is recorded and
reported as a clinical incident which will enable
us to monitor the situation, identify any trends
and deal with these immediately.
Important next steps in improving continence
and catheter care include working with different
professionals to develop a better system to
explain and communicate care plans when
patients move from different care settings.
DCHS QUALITY ACCOUNT 2011/12
21
Venous Thromboembolism (VTE)
Target:
>75% assessment rate for patients at risk of
VTE.
What we achieved:
Average 89% assessment rate.
What this means:
By assessing and treating patients at risk of
VTE it reduces the chance of harm and in
2011/12 we did not have a recorded in-patient
death from VTE.
VTE is the collective name for conditions where
a blood clot forms in the body, usually in the
deep veins in the leg. This is known as a Deep
Vein Thrombosis (DVT). These thromboses
can sometimes travel from the legs to the lungs
where it is called a pulmonary embolism (PE).
These blood clots are more likely to form when
patients are ill and can’t walk easily during
or following surgery or when they have other
acute medical illnesses. These conditions
can cause serious health problems and can
occasionally be fatal.
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DCHS QUALITY ACCOUNT 2011/12
• For the last two years DCHS has had in place a programme to assess and provide prophylaxis (preventative treatment) where appropriate, to all of our in-patients and day case patients
• For the year 2011/12 we were set a CQUIN target by our commissioners of 75% of these groups of patients to have been assessed
• We measure the results through specialist data collection systems and by doing audits
in the wards and theatres, and we have exceeded this target with an average score of 89% consistently since June 2011
• For the new year starting April 2012 we will be expected to achieve a 90% assessment rate for these groups of patients.
The assessments are carried out by an
appropriately trained nurse or doctor and
if preventative treatment is found to be
necessary it is given by a small injection under
the skin for a period of days. We also measure
whether there have been any ill effects arising
from the use of the treatment medication or
whether we have had any untoward incidents
or deaths arising from these conditions. During
2011/12 we have had no deaths arising from
DVT or PE within our community hospital
in-patients.
Safety Express
Target:
To embed the safety thermometer
measurement tool onto all our wards to reduce
harm in our hospitals.
What we achieved:
Introduction of the tool on all wards.
Monthly real time data is now provided that
informs us for early interventions
Monitoring and reporting of all catheter
acquired infections, and the appropriateness of
catheter use.
What Next:
To implement this tool within our community
nursing services (in addition to the community
hospital setting) and to embed Safety Express
(Quality and Patient Safety improvement
programme) across our services.
Safety of our patients and staff is our highest
priority and to further this DCHS signed up
to the Department of Health Safety Express
Programme which was developed from
an initiative called the Patient Safety First
Campaign. The effectiveness of Safety
Express is measured using the Safety
Thermometer tool.
The vision nationally is to reduce harm from
four main areas:
• Pressure Ulcers
• Falls
• Catheter acquired urinary tract infections
• Venous Thromboembolism
As part of this national pilot we have introduced
the safety thermometer tool to our hospitals
wards. Initially as a pilot on 2 wards, this was
then rolled out to all wards in all our hospitals.
The implementation of the ‘Thermometer’
as part of the Safety Express programme is
significantly strengthening how we collect
and report data. This system supports other
essential quality systems including DATIX
incident and reporting. We now capture all
grades of Pressure Ulcers and all Catheter
Acquired Infections that happen within our
care. Whilst there are few serious incidents, we
feel we can learn from these. Our audit plan is
being revised to align itself to the programme,
providing us with richer data.
We have been able to influence the
national agenda in terms of the way that the
programme is developing and how it impacts
locally. Our input at a national level has been
acknowledged in receiving a National Award for
our contribution to the programme. We have • Raised awareness with our staff delivering presentations and Q&A session
• Worked collaboratively with our regional SHA developing posters and leaflets for staff and the public. A DVD is in production
• Introduced Safety Rounds to our community
hospitals, and have developed a Safety Round tool suitable for the community setting
• Development of a learning resource ‘Safety Express’ board game which will be used for staff training.
DCHS QUALITY ACCOUNT 2011/12
23
Rapid Implementation of National Patient
Safety Alert on Syringe Drivers
Target:
To comply with a new national equipment
safety standard.
• Better monitoring of use and equipment
• Safer, more effective service, more positive patient satisfaction.
What we achieved:
Syringe Drivers are used predominantly in our
Trust to deliver medicines as a continuous
injection under the skin to reduce pain and
distress of patients often approaching the end
of their lives. By controlling these distressing
symptoms in a safe way we help improve
patients’ care and their experience.
• removal of old / non compliant devices across the Trust
• replacement with new syringe drivers
• supported RCN accredited training.
What this means:
• Reduced safety risk factors
• Reduced error and data retrieval problems from devices
Safeguarding
What we achieved:
• New appointments of named nurses
• Better organisation and leadership of our safeguarding teams
• Closer working with partner organisations including Social Services
• Delivered more training to staff about safeguarding.
together within one Safeguarding Unit at
Babington Hospital. With the increase in
staff the team have raised awareness and
improved support across the organisation.
The Safeguarding Adults Team has strong
links with the Health Community and partner
agencies and has staff co-located with the
police in the Central Referral Unit. This
enables a consistent approach to safeguarding
across all agencies and provides a timely
and appropriate response to safeguarding
concerns.
We plan to further the developments with the
appointment of a Head of Safeguarding and
drive up standards through benchmarking and
audit.
Safeguarding Children
Adults
Our Trust is involved with many people who
might be frail, elderly and or vulnerable to harm
and abuse. This is why we have continued our
investment and improvements to this specialist
team. We appointed two new Named Nurses
and brought the Adults and Children’s teams
24
DCHS QUALITY ACCOUNT 2011/12
Safeguarding children remains a high local
and national priority. After the death of Peter
Connelly – ‘Baby P’ it has been evident that
the number of children at risk or referred to
specialist services and social care
nationally has risen. This increase
is reflected in Derbyshire.
During 2011, DCHS Safeguarding Children
Service has continued to provide its core
function of providing expert supervision, advice
and training to health staff.
In 2011/12 The Safeguarding Children Service
delivered specialist training to 2581 members
of staff, an increase from 2010 when 1215 staff
received similar training.
Our team of Lead Named Nurse and Locality
Named Nurses work across our services
and with other agencies (such as the Local
Authority, Multi-Agency Teams (MAT), etc.
providing the health expertise in safeguarding
matters.
We also continue to embed into practice
learning from Serious Case Reviews and
monitoring the impact of this is a joint priority
for safeguarding services across Derbyshire in
the coming year.
The Named Nurses are involved in any
Serious Case Reviews of suspected abuse.
This includes scrutinising health records,
individual professional practice, communication
systems and programmes in order to identify
any concerns and develop an action plan.
These reviews help all the agencies involved
understand how staff and systems performed
and possible areas for improvement. As part
of our policy of being open we publish these
reviews and actions for improvement where
possible. Learning from Serious Case reviews
is also translated in our training programme for
staff on both a local and a multi agency basis.
Key developments in 2012/13
• To further improve electronic reporting and recording systems
• Further improvements in joint working with social services
• Review and implement the Munro Report
of Safeguarding and the ‘Think Family’ strategy
• Take forward and implement actions following the Ofsted review of Children’s
Services in Derbyshire (undertaken in 2011/12).
DCHS QUALITY ACCOUNT 2011/12
25
Evidence of clinical
effectiveness
improvements
26
DCHS QUALITY ACCOUNT 2011/12
Evidence of clinical effectiveness
improvements
Breast feeding success
Target:
To demonstrate we have supported 83% of our
mothers to sustain breast feeding beyond 6
weeks.
What we achieved:
We successfully demonstrated supporting 84%
of mothers exceeding our target.
What next:
Continue to maintain this level of support to our
new mothers.
• Achieved Baby Friendly Stage 21 accreditation, an international benchmark of quality. We received a commendation for the quality of evidence submitted
• Developed and launched a breastfeeding public information website with live links to local information
• Employed and trained some local breast feeding mothers to act as peer supporters within their own local community
• Targeted work with low uptake breastfeeding communities using our new peer supporters to help mothers succeed
• Established breastfeeding champions who work in partnership with wider services led by our health visitors.
This year we set ourselves the target of
achieving 84% of the mothers who started
breast feeding and supporting them to carry on
breastfeeding their baby beyond the age of
6 weeks which we have succeeded. Working
with our wider partners will help us to maintain
this level and encourage more mothers to try
breastfeeding at the point of birth. We know
that breast feeding gives the best long term
health outcomes for our next generation.
DCHS QUALITY ACCOUNT 2011/12
27
Stroke
Target:
To assess all patients with new strokes
and provide individual planned therapy
programmes.
What we achieved:
87% received their complete planned therapy
programme.
Assessment of wellbeing and recovery are the
areas we need to improve upon as we did not
do this as well as expected.
What next:
Achieve further improvement to the
comprehensive assessment for new stroke
patients received into our care.
‘Stroke has a major impact on individual
lives and on the whole nation’s health
and economy. Strokes are a blood clot or
bleed in the brain which can leave lasting
damage, affecting mobility, cognition,
sight or communication. After stroke,
individual recovery can be enhanced
through specialist therapy and wider social
support.’
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DCHS QUALITY ACCOUNT 2011/12
The National Strategy for Stroke,
December 2007
We remain committed to working with our
acute Trust partners to provide high quality,
evidence based stroke care and rehabilitation,
in line with national standards.
Many service improvement initiatives and
developments have been put in place in
2010/11 and will continue to be developed and
implemented next year including:
• Identified Lead stroke clinicians
• Multi-disciplinary stroke clinical reference groups
• Developing standard outcome measures for stroke which will allow real evaluation of how effective the care provided by all teams is
• Collaborative Stroke Discharge Service with the Chesterfield Royal Hospital
• The Derbyshire Stroke Co-ordination and
Support Service and Single Point of Access (SPA) continues to develop providing access for stroke survivors, their families and carers, to advice and information about stroke and holistic long term support to stroke
survivors.
Discharge Planning
Target:
100% of our patients to have a planned
discharge date in place.
What we achieved:
All patients had a planned discharge date in
place and all planned dates were met.
What Next:
To sustain this approach and to reduce the
length of time patients need to stay in our
hospitals.
Our Community Hospitals implemented several
strategies to support well-organised, safe care
through appropriate planning with the patient
and their relatives/carers from admission to
discharge.
The implementation of the “JONAH” discharge
planning database underpins the DCHS
Discharge Planning process, providing a
Multidisciplinary approach to delivering
individualised patient care. Using this process
has made sure all our patients have well
managed and planned discharges which
Dementia Care
Target:
To reduce the use of inappropriate
antipsychotic medication (causing excess
sedation) in patients in our care and
involvement of carers.
What we achieved:
80% had medication reviewed, 89% had a
carer identified, 87% documented discussion
with carer recorded, and reduction achieved for
a small number of patients.
What Next:
More work is planned to further reduce these
medicines in partnership with consultants, GP’s
and families.
enables them to be discharged on time and
not have to stay longer in hospital.
Discharge Summary-launched
August 2011
An electronic Discharge Summary was
introduced to provide the patient’s GP with the
most up-to-date information within 24 hours
of discharge. The summary provides the GP
with an overview of the care provided during
the patient’s admission and key information
such as medication changes or any after care
arrangements. This is sent to the GP within 24
hours of the patient’s discharge.
Admission, Discharge and Transfer
Policy- launched October 2011
DCHS revised their Admission Policy to include
new developments and to add emphasis
to the Discharge and Transfer processes
encompassing the whole patient pathway
following feedback from our patients.
The Admission, Discharge and Transfer policy
aims to define the purpose of in-patient care at
our Community Hospitals and how to access
these services.
This year we worked together with our
consultants to reduce the use of anti psychotic
medication for our dementia patients and utilise
more behavioural therapeutic interventions.
This work is continued on the back of the
environmental work we began in 2010 for
“Enhancing the Healing Environment” and
completed in 2011/12 . Both Spencer ward at
Buxton and Riverside ward at Newholme have
completed the environmental changes we
talked about in the 2012/11 Quality Account.
There has been a significant reduction in
medication intervention needed with the
patients in our care as the nurses utilise more
therapeutic measures providing significant
benefits to both patients and carers (see page
47).
DCHS QUALITY ACCOUNT 2011/12
29
Mortality Audit
Many people especially older patients, with
disability and long term conditions, fear that by
being admitted to hospital they may die. Public
inquiries, national reports and head line media
stories have quite rightly raised concerns.
Since April 2010, we have collected and
analysed data on all the deaths that have
occurred on the wards in our community
hospitals. This allows us to know who has died,
from what cause and if their care met specific
standards at that time.
Nationally there is a system for acute hospital
Trusts called the Summary Hospital Mortality
Indicator. This wasn’t designed for and doesn’t
apply to our Trust but we have been committed
to develop a local scheme. We are now in a
position to be able to look back and compare
our results over time and see whether we are
improving against our own local four summary
indicators.
1.The majority of deaths (>90%) in our community hospitals will be expected
This means we require our staff to identify patients who are dying from a natural process (where active treatment is no longer working)
2. Almost all (>90%) of expected deaths will be
on the End of Life (EoL) pathway.
This pathway is a system of care (nationally designed on best practice) to offer and monitor high quality palliative care (e.g. to reduce symptoms of pain and distress)
3.Of patients expected to die 80% will have their preferred place of death recorded
Many people would want to die in places they feel safe and comfortable. Best practice is to ask patients (and their families if they are unable) where this preferred place is.
4.Deaths directly attributed to adverse events
Even in the best hospitals some patients can die from adverse events such as a fall or from infections. Learning lessons from public enquires means that we have a minimal tolerance to these adverse events. By auditing them we can investigate and change practice where necessary.
Local Indicators
What we achieved
Standard 1
Expected deaths
>90%
Standard 2
>90% expected
deaths on EOL
pathway
Standard 3
Preferred place
recorded 80%
Standard 4
Minimal tolerance
of deaths from
adverse events
2010-2011
2010/2011
89%
65%
55%
0%
2011/2012*
Quarters 1-3
95%
80%
62%
0%
Quarter 4
94%
88%
63%
0%
*At the time of writing this account the full annual mortality report is being prepared
and validated. We have presented the results for this year with cumulative (and
averaged) first three quarters and last quarter (January- April) separately.
30
DCHS QUALITY ACCOUNT 2011/12
What we learned
• Standards 1 and 4 have met or exceed our high expectations
• Standards 2 and 3 show steady improvement is taking place in the number of patients appropriately placed on the end of life care pathway and in the number of patients having their preferred place of death recorded
• Standard 3 Establishing the Preferred Place of death is a challenge as there is a high prevalence of dementia in these patient groups which means often the patients don’t have the mental capacity to understand and explain their preference. This year we will
look into this area in more detail. This indicator might change in description and expectation.
What we do with these results
These are reported to the Trust Board. This
system for a specialist community provider, is
an innovation which most comparable Trusts
currently do not do. This information together
with other clinical outcome data (such as
Venous Thrombo Embolic Prevention) helps
us to understand whether we offer safe and
effective services.
This system drives and fuels wider Quality
Improvement objectives to improve:
• Communication between staff and patients (and their families)
• Assurance that our figures remain consistent and there are no unexpected increases or
decreases in expected deaths by ward
(driving positive leadership through local accountability)
• The numbers of patients who have their resuscitation status discussed and recorded appropriately
• Determine whether any deaths have occurred as a direct result of an adverse event on our premises so investigation and learning can be achieved
• Assurance that we are adhering to best practice in end of life care and providing safe
and high quality end of life care to our patients
• Focus staff and Trust resources into priority areas which patients and public want and need.
We have set very high standards for ourselves.
We feel this is very important because this
time in peoples’ lives is the most stressful and
our staff should aspire to the very best of care.
We are very encouraged by these results and
will continue to liaise with staff to maintain and
improve them further, and to support them in
this often challenging and sensitive area of
work.
Care of the Acutely Ill Patient
Embedding Best Practice and
Training:
• The new Care of the Acutely Ill Patient (CAIP) course is informative, interactive and hands-on. It is designed to give registered nurses and in-hospital health care assistants the essential skills and knowledge they
need to recognise and manage a deteriorating patient whilst waiting for help.
• Patient Safety Monitoring and Reporting
• By using robust and reliable early warning
systems and standard ways of communicating concerns about a patient that is deteriorating we are treating our patients more effectively.
DCHS QUALITY ACCOUNT 2011/12
31
Leicestershire County and Rutland
Out-patient, Diagnostic and Day
Surgery (LCRODDS)
LCRODDS identified the need for a flexible,
future proof, robust Digital Dictation workflow
system to be implemented Trust-wide. The
implementation of the Winscribe Digital
Dictation system made sure letters were
typed up rapidly to meet the 18 week target.
Benefits include improvements in efficiency,
visibility and management of work across sites,
provided the ability to transfer dictations from
author to secretary from any site and reduced
typing backlogs to achieve the two week
turnaround time. It also made sure prioritisation
monitoring and reporting of workloads,
improved and secure and instant transfer of
dictations via the hospital network, with no loss
of tapes or accidental deletion of dictations,
has occurred. This has stopped patient data
and confidentiality breaches.
Hinckley and District Hospital
Hinckley District Hospital has invested
£445,000 in new endoscopy equipment to
help with the early diagnosis and treatment of
patients. The new imaging equipment is the
most advanced technology available with a
miniature digital camera and newly developed
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DCHS QUALITY ACCOUNT 2011/12
wireless technology. Barrie Rathbone,
Consultant Physician and Gastroenterologist,
said: “Good quality imaging is a prerequisite
for the diagnosis and management of digestive
diseases. The state of-the-art equipment
will allow high quality endoscopy facilities at
Hinckley, helping to provide the best possible
service for patients.”
Loughborough Hospital
Loughborough Hospital was presented with
a new piece of equipment in 2010/11 which
is helping to ensure patients are in the best
possible condition to undergo their minor
operations.
The new Hemocue - a special device that
measures haemoglobin in the blood – was
presented to the hospital’s outpatients
department by the Rotary Club of
Loughborough Beacon. This will help us to
do a simple pin prick blood test on the day
when patients come in for procedures. The
Hemocue, is now being used routinely as part
of the pre-operative care for patients coming
into the hospital’s outpatients department
for day case procedures and will help
to make services safer and
improve patients experience.
Coalville Hospital
The new Phlebotomy appointment system
has transformed the department making it
more accessible and flexible for service users.
Patients can obtain advice and information
from the receptionist by telephone, particularly
special requirements when needed prior to a
blood test.
Patients have the option of using the phone
at reception or can call from home to improve
efficiency and reduce waiting time. April 2011
saw the launch of the first ‘drop-in’ afternoon
which allows patients to use the service at their
own convenience without having to book an
appointment.
The phlebotomists are trained in neonatal
and paediatric blood taking ensuring that
the service can be used by both adults
and children. The phlebotomists also have
teaching certificates which enables in-house
training for other NHS professionals and
provides continuation of care for both inpatients and service users.
Making a Difference – a focus upon
children and young people.
During this year we have been undertaking
work to improve children and young people’s
services.
There is a national priority to improve services
for the early years of a child’s life. This
has included a focus upon integrating the
provision of health care with other services
such as Children’s Centres and taking a more
preventative and interactive approach to
service delivery. We have also increased the
number of Health Visitors (specially qualified
nurses with an additional public health
qualification).
Derbyshire is a national early implementer site
for the delivery and improvement of the new
National Healthy Child Programme, (which
increases the interactions with families at key
stages in a child’s development).
As a result of this work there has been an
increase the number of children we have
seen at key stages of their development and
in particular for those ages 3-4 months old
and aged two years. Although it is too early to
monitor the impact of this we have received
some very positive comments from the families
involved who have responded well to this
increased level of service provision.
We have also been part of another national
development called the Family Nurse
Partnership (FNP). As a result of this we have
increased the number of specially trained
nurses and health visitors working with young
first time mothers from early pregnancy until
the child’s second birthday. Although it is too
early to see the benefits of the FNP we know
from national evidence that improved outcomes
for the children and families can be expected.
This work will continue through 2012/13 and
outcomes measured in accordance with
national programme requirements.
DCHS QUALITY ACCOUNT 2011/12
33
Sexual Health Promotion Service
Following on from the successful work
programme to increase the uptake in
chlamydia screening in 2009/10 the sexual
health promotion service undertook a new
piece of work. The focus of the Well Sexy
peer education outreach programme was to
increase awareness of sexual health issues.
This initiative targets young people primarily
aged between 15 and 25 in social settings such
as pubs and nightclubs, in educational settings
such as schools and colleges and at other
young people’s events such as music festivals.
The regular sustained programme that has
been delivered has involved the dissemination
of targeted health promotion messages
through themed campaigns, stalls and road
shows, along with the distribution of free safer
sex packs and signposting information. This
has been conducted throughout the year with
great success. They continue to be a key
player in the delivery of the National Chlamydia
Screening programme.
Specialist Children Services Answering Awkward Questions
During 2011/12 our school nursing service
undertook a piece of innovative work to
improve services for young people. Recent
34
DCHS QUALITY ACCOUNT 2011/12
research shows that children and young people
want to talk to their parents and carers about
sex and relationships.
Children are surrounded by sexual images and
information and they naturally will need help in
understanding these issues. By answering their
awkward questions from an early age, they can
be given confidence to make safe and healthy
choices as they grow up reducing the chance
of unplanned teenage pregnancy, unhealthy
relationships and other risks later in life.
Following a survey which took place in
Bolsover, the service identified parent concerns
and as a result, can now provide help and
guidance to answer children’s questions.
Books are available to be borrowed from
primary schools to share with a child, school
nurses and teachers are able to help with
questions and two specific websites feature
useful advice. Further leaflets and a website
forum are planned by the service for future
development.
Speech and Language Therapy
Key achievements this year:
Working with Young Offenders
2nd Annual Trust Clinical Audit Day/Raising
Awareness and Skills
New Trust Strategy and Policy
Investment in quality and clinical audit staff in
services
Delivering continuous clinical quality
improvements
Reporting improving levels of assurance,
validated by independent Auditors
A service model for young offenders with
speech, language and communication needs
(SLCN) was developed to detect unrecognised
communication difficulties. This community
based model encompasses universal elements
including raising staff awareness and training,
advice for staff working with such service
users together with specialist assessment and
access to speech and language interventions.
The model is to be transferred and adapted to
integrate with youth offending services. The
patient benefits from early recognition of and
empowerment to manage their communication
difficulties. It is hoped it will also lead to a
reduction of mental health problems later
in life by earlier detection of undiagnosed
communication difficulties. This then provides
enhanced opportunities to participate in
educational and recreational activities. The
proposed model of service is included in the
Integrated Pathway for SLCN. This is a tool
jointly designed in partnership with Derbyshire
County Council and North Derbyshire Speech
and Language Therapy Service. It is to support
the commissioning of both new and continuing
services to improve outcomes for children
with SLCN as identified in national and local
strategies.
Clinical Audit
Clinical audit is a service improvement tool
that measures how well we are doing against a
standard (e.g. NICE Guidance), helps us target
improvement on the basis of these results, and
then measures how well we have improved
after implementing the improvement plan.
As part of the Trust’s work to meet NHS
Litigation Authority standards for clinical audit
we have put in a lot of work to produce a
new Clinical Audit Strategy and Policy. The
policy sets up a mechanism for ensuring each
audit is checked before it starts and then
tracked to completion, including evidence of
a contribution to service improvement. This
will be implemented in full in 2012/13, and a
system to support this is under development.
The appointment of additional quality and
clinical audit support staff in the Integrated
Community Based Services and Health,
Wellbeing & Inclusion Divisions has been
a welcome development, supporting the
Annual Clinical Audit Service Plans and in
some instances helping clinical staff with data
collection for some audits.
In 2011/12 we built on the progress of 2010/11
and each service was asked to complete an
Annual Plan of Clinical Audits they expected to
undertake in year. The table below provides a
list of audits identified to be undertaken to meet
the PCT commissioners expectations, national
audits we are expected to deliver, and any
other audits that are of high importance.
DCHS QUALITY ACCOUNT 2011/12
35
36
2011-12 Priority Programme
Compliance to Standards
Stroke Community Care
Derbyshire CQUIN 2011/12, NICE Stroke
Quality Standard
Safety Express Audit
Derbyshire CQUIN 2011/12, DH initiative,
NHSLA
Content of Care Plans
Derbyshire CQUIN 2011/12
Preventing Readmission
Derbyshire CQUIN 2011/12
Learning Disabilities - Access to Appointment
Audit
Derbyshire CQUIN 2011/12
NICE Dementia Standards Audit
Derbyshire CQUIN 2011/12, NICE Dementia
Standard
Children’s Service - Midwifery Handover Audit
Derbyshire Quality Schedule 2011/12
Learning Disability - Physical Healthcare Audit
Derbyshire Quality Schedule 2011/12
Learning Disability - Dual Diagnosis Audit
Derbyshire Quality Schedule 2011/12
Adult End of Life - Inpatient Pathway Audit
Derbyshire Quality Schedule 2011/12
Adult End of Life - Needs and Preferences
Audit
Derbyshire Quality Schedule 2011/12
Antimicrobial Audit MIU and Theatres
L&R Quality Schedule 2011/12, Health &
Social Care Act, CQC, NHSLA
Safeguarding Children and Vulnerable Adults
L&R Quality Schedule 2011/12, Good Practice
for Safeguarding Children and Vulnerable
Adults
Care and Control of Medicines Policy
L&R Quality Schedule 2011/12, Care and
Control of Medicines Policy in Community
Hospitals
Controlled Drugs
L&R Quality Schedule 2011/12, Controlled
Drugs Legislation
Safer Surgery Programme
L&R Quality Schedule 2011/12, WHO Surgical
Safety Checklist
Clinical Records Audit
L&R Quality Schedule 2011/12 NHSLA, CQC
Clinical Records Audit
NHSLA, CQC
C Difficile Audit
Health & Social Care Act, CQC, NHSLA
MRSA Audit
Health & Social Care Act, CQC, NHSLA
Antimicrobial Audit Community Hospitals
Health & Social Care Act, CQC, NHSLA
PEAT Audit
Health & Social Care Act, CQC, NHSLA
Treatment Card Audit
Monitoring of DCHS Medicines Code, CQC,
NHSLA
Insulin Prescribing Audit
NPSA Alert, CQC, NHSLA
Pharmacy Interventions Audit
DCHS Medication Safety Team (MOST), CQC,
NHSLA
Mortality
Shipman Report, Francis Report, CQC, NHSLA
Wheelchair Audit
Incident
WHO Safe Surgical Checklist
NPSA
National Falls Patient Experience Audit
NCAPOP, NHSLA
National Integrated Care Audit
NCAPOP, NHSLA
DCHS QUALITY ACCOUNT 2011/12
Please see glossary for an explanation of the
multiple abbreviations used. We participated
in two specific national audits this year which
are relevant to our Trust – see below. Many
national audits in the NCAPOP programme
are not suitable for our community Trust,
but in future it is expected that new national
audits will include more that we will be able to
participate in. Next year the Clinical Audit Team
working in collaboration with the Research
Team will produce a new programme of four
half day training modules in basic audit,
evaluation and research skills for clinical staff.
Falls Exercise Programme
The national feedback to providers included:
• Review the provision of exercise programmes within the organisation to ensure they are evidence-based exercise for falls – we have completed this and comply to the Otago* system
• Ensure staff delivering exercise programmes are appropriately trained in delivering specific evidence based exercise interventions for reducing falls in older people - all our current staff are trained
• Ensure staff routinely explain to patients the benefits of exercise and why they are being
referred for an exercise programme
• Ensure patients are given an opportunity to express any concerns they may have about being referred and/or taking part in an exercise programme. We continue to audit these recommendations and relate them to the outcomes of the programmes and the patient experience of the service they received.
National Intermediate Care Audit
This national audit started in 2011/12. We have submitted our data and at the time of publication
we have not received any feedback.
*Note – The Otago Exercise Programme (OEP) is an individually tailored exercise programme
that is delivered in the patient’s home by a trained nurse or physiotherapist. It has been shown to
reduce falls by 35%.
DCHS QUALITY ACCOUNT 2011/12
37
Information Governance
Percentage of valid NHS Numbers and
Registered GP Practice codes for DCHS data
submitted to the Secondary Uses Service
(SUS) in 2011/12 (April 2011 to March 2012)
for inclusion in the Hospital Episode Statistics
(HES). This information is sourced from
the NHS Information Centre’s Data Quality
Dashboard:
• Admitted patient care: 100% Valid NHS Numbers and 100% Registered GP Practice
codes
Research and Knowledge Services
In 2011/12 we welcomed the transfer of these
teams into our new Trust from the PCT. They
continue to provide some services to the PCT
and primary care. The aims of the research
strategy for DCHS supports the participation in
and the effective use of research and service
evaluation to provide better community health
care services for the people of Derbyshire. Our
Trust complies with national requirements to
promote and conduct research, set goals for
research within our organisation and to report
on our achievement to the Board in an annual
report.
We present a small fraction of their work as
examples of what was done:
• Access to Derbyshire community hospitals and clinics
• Using financial incentives for smoking cessation in pregnancy
38
DCHS QUALITY ACCOUNT 2011/12
• Outpatient care: 99.9% valid NHS Numbers
and 100% valid Registered GP Practice codes
• Accident & Emergency (MIU) care: 99.4%
valid NHS Numbers and 100% valid
Registered GP Practice codes.
Information Governance Toolkit submission for
2011/12 – DCHS scored an overall percentage
of 71% and received a ‘satisfactory’ (green)
rating.
• Financial incentives for smoking cessation
in pregnancy: A pilot behaviour change intervention study
• Food health needs assessment - cooking
skills and food purchase by recently
bereaved elderly men
• Evaluation of Tier 3 Weight Reduction
Service Pilot (PCT/DCHS)
• Complex health and social care needs
• Principles to be used in making decisions
about changes in health and social care services
• Evaluation of Health Promoting Workforce
Project
• Single Point of Access and the Chesterfield
Winter Pressures Pilot
• Parents of children with additional needs
views of services provided by Health Visitors
• Young Carers views of services provided
by School Nurses.
Clinical Records
Target:
Increase the numbers of services engaged in
records audit and demonstrate improvement in
the worst performing services.
What we Achieved:
An increase in services engaging in this audit
and showed significant improvements in our
worst performing areas.
What next:
Clinical documentation and record keeping
standards remain a priority in our Trust. Root
Cause Analysis into specific serious incidents
showed that poor standards of record keeping
were contributory factors. Our Board will be
reviewing the expectations and driving further
improvement in 2012/13. This is part of our
commitment to get the basics right reflecting
our new quality strategy.
This year’s clinical records audit was
conducted in September and the results show
that we have maintained the improvement from
last year, but have only made a further 1%
improvement this year. The number of services
included in the audit increased from 29 to 37
this year as planned, including several services
that have not participated before, though some
of these services are now reported separately
where they were part of a larger group last
year. The results by each of the standards are
shown in the table.
The Research Team also supported and
evaluated the DCHS Foundation Trust public
consultation. This report to the Board helped
the Trust listen to and really understand the
expectations of local people and partner
organisations.
Comparison of Clinical Records Audit Results by Standard for 2010 and 2011
DCHS QUALITY ACCOUNT 2011/12
39
Evidence of
improvements for
patient experience
40
DCHS QUALITY ACCOUNT 2011/12
Evidence of improvements for patient
experience
The experience of our patients, relatives and
carers who use our services in Derbyshire and
Leicestershire and Rutland is of paramount
importance.
focus us upon placing our patients at the
centre of everything we do and enabling us to
make a difference together.
Patient and Public Involvement (PPI)
We understand the value, the benefits and
positive outcomes, both financial and non
financial, of involving patients and public in
the planning and development of our health
services.
Target:
Increase our patient and public involvement
activity involving our PPI champions across the
organisation further embedding PPI into our
infrastructure.
During 2011/12 our relationship with Local
Involvement Networks (LINks) and the
Improvement and Scrutiny Committee (ISC)
has strengthened. We have also reviewed our
internal systems and how we engage with our
public and patients.
Extend our engagement and involvement with
the public in all we undertake.
Our aim is to build upon this as the health
system changes and as new organisations
and structures emerge such as Healthwatch,
Clinical Commissioning Organisations etc.
Working with our commissioners, partners
and our public will be key, especially as DCHS
becomes a Community Foundation Trust and
we will be held to account by our Council of
Governors as well as our local populations.
We have identified that our work in relation
to patient engagement and involvement
needs to take on a whole new dimension
over the coming year. In order to do this we
have developed a Patient Experience and
Involvement Strategy. The aim of this is to
What we achieved:
45 champions identified and we provided a
range of evidence to our commissioners about
the improvements.
Examples of this include work in relation
to improving nutrition and hydration for our
patients, focus groups in relation to specific
service changes, the development of patient
diaries within our diagnostic and treatment
centre, initiatives in relation to dignity and an
increase in service users and carers being
involved in service changes.
What next:
During 2012/13 we will implement our Patient
Experience and Involvement Strategy with
a clear focus upon delivering the ‘Patient
Revolution’ and implementation of the “Family
and Friends Test.”
DCHS QUALITY ACCOUNT 2011/12
41
Privacy and Dignity
Target:
To ensure that from being admitted to hospital,
right through treatment, going home or
transferring to other care services there are the
same standards in place - with good outcomes
and positive experiences.
What we achieved:
Throughout DCHS staff continue to undertake
the Essence of Care benchmark on Privacy
and Dignity and Communication. We have
achieved good standards in compliance and
we have received positive feedback form our
patients.
We have also ‘signed up’ as a partner in a
joint initiative with Derbyshire County Council’s
Adult Care Service and Chesterfield Royal
Hospital to work together to help ensure
services deliver even better outcomes for
vulnerable local people of all ages by using the
Dignity in Care standards.
What next:
Privacy and Dignity remains a high priority
for DCHS. The hospital wards within DCHS
are now working towards the bronze award
for Dignity and Respect Challenge. This is in
conjunction with other Derbyshire Agencies
and is to align ourselves with our social care
providers who have been undertaking this
work as a bench mark of good practice. This
work will be completed during 2012/13 to
meet the wider social /health care best practice
benchmarking for CQC.
42
is not the best place for them or in agreeing
packages of care to support this where the
patient so desires.
• The 3 Derbyshire care organisations believe that by focussing the attention of all staff onto the Dignity in Care standards they will be able to strengthen joint working and further improve the experience local people have when being admitted to or discharged from hospital.
The joint programme will begin with
development work involving Derbyshire Adult
Care community social work teams working
together with:
• Chesterfield Royal Hospital wards
• DCHS Admission, Discharge and Transfer team and Spire and Derwent Wards at Walton Hospital.
The programme will be extended to include
all DCHS Community Hospital ward teams.
The aim is that all relevant teams will achieve
the bronze, silver and gold Dignity in Care
standard for their joint services through an
independent evaluation.
Dignity in Care Campaign-Raising the
Standard
Dignity Action Day was the 1 February 2012.
All the wards within DCHS participated to
celebrate the day with their patients. Events
organised included musical events, film shows,
display of major events celebrated since the
Queen’s Coronation, displays around dignity
and nutrition, war time posters, Pat dogs,
manicures and pamper sessions, tea parties
and education groups around falls.
Hotel services provided a lunch to patients with
a 40’s theme which was also available in all
hospital restaurants.
In November Derbyshire launched its joint
DCHS, Chesterfield Royal Hospital (CRHFT)
and Derbyshire Adult Care initiative to help
their services deliver even better outcomes
for local people. The campaign focuses
particularly on improvements to the way
hospital and community health teams work
together with adult social care teams, to plan
for discharge and care after their time in
hospital. Part of this work involves helping
patients to understand when returning home
By supporting Dignity Action Day the staff :
• Raised awareness of the importance of Dignity in Care
• Provided someone with an extra special day
• Reminded society that everyone has a role to play in respecting the dignity of those in your community
• Were part of a national celebration and demonstrate solidarity for Dignity in Care.
Web link: www.dignityincare.org.uk
DCHS QUALITY ACCOUNT 2011/12
Patient Experience
Target:
To improve the patient experience evidence
base and demonstrate positive change in light
of action taken from feedback.
What we achieved:
A systematic approach to undertaking a
patient questionnaire across our services.
Development of service plans in order to act
upon patient feedback.
What Next:
A comprehensive action plan has been
developed to support the delivery our Patient
Experience and Involvement Strategy. We
will strengthen our processes to evidence the
impact upon how we deliver services form our
patient and service user feedback.
The patient feedback questionnaire
has been cascaded to all services and
departments. Questions cover issues such
as Communication, Privacy and Dignity,
Cleanliness and Nutrition with an overall
question about rating of care received. As
we are such a large organisation a service
level approach was taken. Planned Care
Services were the first service groups targeted.
This covers Physiotherapy, Podiatry and
Occupational Therapy. Their results show that
96% of patients would recommend the services
to others and 79% rated the level of care as
Excellent. Action plans of these findings are
displayed in the service departments and
wards entitled “You said We did.” These
results are reported to our commissioners as
part of our Quality Assurance scheme. We
will continue to analyse and act upon service
change plans during 2012/13.
During the year we enhanced this approach
with a short postcard size questionnaire within
our minor injuries units which asked what we
did well, what we could do better and if there
were any additional comments. This form of
feedback provided immediate feedback from
patients and resulted in faster changes within
the service area. We have responded by
enhancing the skills of our MIU nurses with a
paediatric competency training programme,
improved our triaging process allowing us to
better allocate the staff to the patients and
improved our way of keeping patients informed
of waiting times. Following these changes
we have seen a reduction in our complaints
relating to children, sexual health emergency
care and wait times.
DCHS QUALITY ACCOUNT 2011/12
43
Carers
Target:
Supporting carers and ensuring their voices
are heard, and their opinions sought and acted
upon.
What we achieved:
A Carer champion has been identified for each
ward, to support carers when they attend the
ward and ensure they register with their GP as
a carer. DCHS has worked with the voluntary
sector Derbyshire Links to produce a patient
/ carer questionnaire for use across all our
hospital sites.
What next:
Implementing action plans in order to address
areas for improvement across our inpatient
sites.
Joint working was undertaken to ensure carers
recognise the need to register with their GP as
a carer. Carers are issued with the leaflet “Do
you care for someone” when appropriate as
they visit the wards. Evidence fed back to us
from our commissioners is that there has been
a significant rise in the numbers of carers now
registered.
Work was undertaken to establish a carers
group within community hospitals for education
on falls prevention once patients returned
home. The feedback from this project was
that it raised understanding of what they can
do to help reduce falls in their own home and
encourage mobility safely.
44
DCHS QUALITY ACCOUNT 2011/12
Riverside Ward at Newholme Hospital now
hold a weekly carers forum on the ward.
This supports carers (of current and previous
patients), providing advice and information in
recognition of the important role that carers
have and the need for ongoing support.
Listening and Learning through
complaints
In 2011/12 we received 6,300 compliments
and 441 complaints of which 221 required
further investigation. This is compared with 418
complaints received in 2010/11. This shows
no increase when the new activity from the
services hosted on behalf of Leicestershire and
Rutland PCT is accounted for.
As a result of the feedback we have received
through our complaints process we have
made a number of changes. Examples include
improving our operational processes when
patients transfer from DCHS to other hospitals,
inviting patients and their relatives to share
their experiences with the staff involved in
order to help staff understand what it felt like
from a patient or relatives perspective, and
sharing patient stories (both positive and
negative) within services and at our Quality
Services Committee and Board meetings.
We have also undertaken focused work with
our reception staff to develop standards of
care. As a result of our work in relation to
Safety Express we have made changes to the
ward environment such as smaller water jugs
and in infection prevention and control we have
improved the information for patients who need
to be nursed separately to other patients due
to an infection.
Nutrition and Hydration
PEAT (Patient Environment Action Team) is self
assessed annually and the scores demonstrate
how well individual healthcare providers
believe they are performing in key areas
including food, cleanliness, infection control
and patient environment (including bathroom
areas, décor, lighting, floors and patient areas).
Our patients can expect “excellent” food and a
high standard of privacy and dignity
when receiving treatment across all of our
community hospitals according to the latest
PEAT Assessments 2011.
SITE NAME
Ash Green
Babington Hospital
Bolsover Hospital
Buxton Hospital
Cavendish Hospital
Clay Cross Hospital
Heanor Memorial Hospital
Ilkeston Community Hospital
Newholme Hospital
Ripley Hospital
St Oswald’s Hospital
Whitworth Hospital
Walton Hospital
Sites are each given scores from one
(unacceptable) to five (excellent) and the
assessments are carried out by our Matrons,
Locality Managers, Infection Prevention &
Control Nurses and representatives from
the Estates Department. Patient and Public
Involvement (PPI) representatives are also
part of this assessment process. The National
Patient Safety Agency confirmed our results.
We scored excellent on all sites for food as part
of PEAT assessment.
FOOD SCORE 2010
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Audit cancelled ward closed
Excellent
Excellent
Excellent
FOOD SCORE 2011
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
These scores are displayed on all our hospital sites for the public to see the outcome of the
assessment.
DCHS QUALITY ACCOUNT 2011/12
45
Supporting our End of Life patients
and families
Our organisation remains committed to
providing quality End of Life Care to patients
and their families. To clarify “End of Life Care”
is identified as being the last year of a person’s
life and is inclusive of all patients with any
disease.
In February of this year DCHS held its first
End of Life Care Conference. Over 250 staff
came together from different organisations to
discuss and highlight the achievements made
so far and identify future needs to continue to
“transform” and improve the End of Life Care
that patients and families receive.
Following on from the very successful
DCHS End of Life Conference there was
the Excellence in End of Life Care Awards.
This attracted nominations from within our
organisation and ones we work in partnership
to. The joint winners of the award gave
excellent examples of individuals and teams
“going the extra mile” to give the best possible
care and choice to patients and their families.
Throughout 2011 we have looked at improving
our communication and information and to
further support this a new End of Life website
has been created that professionals and the
public can access through our DCHS webpage.
46
DCHS QUALITY ACCOUNT 2011/12
We continue to keep our staff trained and
updated through a wide range of training
opportunities. This year has seen some staff
appointed as End of Life Care “Champions”
who act as ambassadors to promote best
practice within their individual areas.
We are, and will remain committed to delivering
the best possible End of Life Care experience
to the people of Derbyshire.
Older People Mental Health (OPMH)
initiatives
Addressing Spirituality (Riverside)
Art Work
Working in partnership with the local clergy
who attend the ward at Newholme Hospital,
the team have embarked upon significant work
in addressing and meeting the spiritual needs
of the patients in their care. This has been
recognised and applauded and as a result the
team were asked to give a presentation to the
Diocesan Conference in Derby this year. They
have received very positive feedback on the
attention and care they have taken in meeting
the spiritual needs of our OPMH patients. This
has further informed the clergy of how our
teams are considerate of faith to our patients
approaching end of life while their links to
every day life are disappearing.
Tea Party
Riverside ward at Newholme Hospital is one
of our OPMH wards. The team have already
undertaken national recognised changes to
the environment and care approaches to the
patients as we reported in last year’s quality
account. Following on from this they continue
to be very innovative in their approaches to
enhancing the care and outcomes for the
patients during their stay. They have introduced
a café once a week with tea and cakes
much as we would all remember from our
younger days that have promoted increased
conversations with their families and carers
providing purpose and enjoyment to the time
they spend together while in our care.
Improving the patient environment
Enhancing the Healing environment is a
national initiative which focuses upon the
therapeutic benefits gained from improving
the environments in which we care for our
patients. The approach involves ward staff,
patients and relatives (supported by the Trust
Board and other services) identifying how the
clinical areas may be improved to deliver direct
benefits to the well-being of patients. As part
of this programme we were able to open a
safe outdoor area on our older peoples mental
health ward (Spencer Ward) in Buxton and
redesigned patient areas on Riverside ward
at Newholme Hospital. Early indications are
that there has been a positive impact upon
how patients are reacting with less falls and
increased opportunities for focused therapeutic
healing. Learning from this work has been
shared with others on a national basis.
Ilkeston Hospital - sensory garden
A newly created courtyard and sensory garden
at Ilkeston Community Hospital providing
a peaceful haven for elderly patients has
been opened by the Lord Lieutenant of
Derbyshire, William Tucker. The courtyard and
sensory garden has transformed a previously
nondescript and unused concrete area into a
calm and colourful purpose designed space,
with features such as raised flower-beds,
easy wheelchair access, handrails and even
surfaces underfoot, so patients with reduced
mobility can enjoy it safely. The transformation
has been completed with more than £11,000
funding support from the hospital’s League
of Friends and with help from students from
Broomfield Hall, part of Derby College, to carry
out the planting.
Patient Leaflet – Planning Your
Discharge From Hospital - launched
December 2011
Working closely with our partnership
organisations including Derbyshire Adult
Care, Derby City Adult Care, Chesterfield
Royal and Royal Derby Hospitals we have
jointly developed a leaflet for Patients and
their Families, “Planning Your Discharge from
Hospital.”
The leaflet briefly explains what patient’s
can expect if they are admitted to hospital
including the support they will receive to plan
their discharge. This has helped us work more
closely with patients, their carers, and their
families, in patients understanding what will
happen and planning early for discharge, which
helps to reduce readmissions and reduce
complaints about lack of information.
DCHS will continue to support patients to
receive the right care, in the right place, at the
right time.
Quality Focus – Changing the Way
we Identify Occupational Therapy
Outcomes
The Specialist Neurology Occupational
Therapy Service promotes or restores
independence in meaningful occupation by
addressing motor, cognitive and perceptual
dysfunction, as well as participation in
meaningful life roles and tasks. The
Occupational Therapy role in rehabilitation is
well recognised and documented in national
strategy and frameworks for stroke and longterm neurological conditions.
The benefits of this intervention are vast but
are based within the terms – enablement,
independence and quality of life. The focus
is to help people live their lives with their
condition and not just exist with it, bearing in
mind that no two patients will have the same
view about what is important and of value
to their life. We find a way to show what
really matters to a patient and improve their
quality of life without necessarily seeing major
improvements in their condition.
DCHS QUALITY ACCOUNT 2011/12
47
WHAT OTHERS SAY ABOUT US
Care Quality Commission (CQC)
update for Quality Account 2011/12
National Health Service
Litigation Authority (NHSLA)
DCHS NHS Trust successfully achieved
registration, without conditions, with the
Care Quality Commission in April 2011. The
organisation is now registered to provide the
following regulated activities;
• Treatment of disease, disorder or injury
• Assessment or medical treatment for persons detained under the 1983 Mental Health Act
• Surgical Procedures
• Diagnostic and Screening procedures
• Transport services
• Nursing care
• Termination of pregnancies.
DCHS were assessed against the NHSLA
Level 1 Risk Management Standards on 22nd
February 2012, and successfully passed the
assessment achieving a score of 50 out of 50
for the documentation.
These regulated activities are undertaken at 22
locations across Derbyshire and Leicestershire
including both hospitals based and community
based services.
Following our internal investigations into a
complaint if a complainant remains unsatisfied
with the outcome and wishes to take the issue
further, it is referred to the ombudsman for an
independent review.
The Care Quality Commission is the
independent regulatory body for health and
social care in England. The role of the CQC
is to ensure that care provided by hospitals,
dentists, ambulances, care home and services
in people’s own homes and elsewhere meets
government standards of quality and safety.
CQC inspectors make unannounced visits, to
ensure that they see the hospital as a patient
or visitor would see it. They focus on certain
areas of practice to form a ‘snap shot’ of the
trusts activities related to certain areas of care.
48
DCHS QUALITY ACCOUNT 2011/12
The organisation will now be working towards
Level 2 of the NHSLA Risk Management
Standards which means collecting twelve
months worth of evidence for the processes
of the 50 policies assessed at Level 1. The
evidence collection process will cover the wide
range of services that are provided by DCHS.
Health Ombudsman outcomes in
2011/12
12 cases went to the Ombudsman for
resolution.
Of the 12 cases referred only one was upheld
and following this a satisfactory remuneration
was agreed and paid promptly.
As this was our first year operating as an
NHS Trust we have no comparative data
for the previous year, this data is positive
in comparison to other NHS provider
organisations.
Coroner’s Inquests
During 2011/12, eight Coroner’s Inquests were
held and concluded.
There were no Rule 43 letters for the Trust as
a result of the above Inquests. (Rule 43 of the
Coroner’s Rules allows for a Coroner to report,
to the appropriate agency, circumstances in
which further deaths could occur if remedial
action is not taken).
Never Events
further improve clinical record keeping. One
serious incident where there was an increased
incident of Clostridium Difficile infection (3
cases) on one ward highlighted the importance
of strengthening and maintaining clinical
leadership and professional standards. The
learning from these incidents are captured
in service improvement action plans and are
monitored.
Patients/carers –
“I always chose to go to Ilkeston hospital if
it’s an option. I like the convenience to where
I live, and the generous parking bays for
disabled patients. It is a high incentive for me
to use my local hospital especially when I can
see the same consultant”
The NHS has a published list of clinical errors
called Never Events. These are very serious
errors that should not happen.
“My GP used the choose and book system
with me he printed the details and I booked
it myself at home which really worked for me
very efficient”
Our Trust has never had a Never Event.
“I have been to the local hospital before and
had a good experience as it is local it is very
convenient and I could fit it in with my work
pattern”
Serious Incidents
Patient Safety is a priority for DCHS, however
it is important to ensure that effective systems
are in place for reporting, monitoring,
investigating and improving following any
incident.
Data is recorded and reported by the National
Patient Safety Agency and is based upon
the rate of incident per 1,000 bed days
(comparative data against 19 other primary
care organisation with inpatient provision)
(March 2012 report).
When compared with the above organisations
DCHS is within the middle 50% of reporters
with a reporting rate of 32.5% against a median
of 30.8%.
Data for DCHS (1/4/11 – 30/9/11) shows
that our rate of Serious Incidents which
have resulted in severe harm or death is
0.4% against a rate of 0.7% in comparative
organisations.
Our Trust governance structure supports
a systematic analysis and learning from
serious incidents. Two serious incidents
relating to pressure ulceration and a serious
case review identified that there is a need to
“All the staff were courteous and polite at
all times explaining everything as they went
along”
“The hospital was the cleanest I have ever
been in and smelt like a hospital should do”
Response to the patient reference group“May I compliment DCHS from reception
to nurses and specialist , the service was
faultless and I can compare this to other
hospitals I have been patients at and can
clearly state that this was the best experience
by far.”
What our Staff say
As part of the national staff survey our staff
are asked the ‘net promoter’ question – i.e.
whether they would recommend our services
to family or friends. This is seen as one of the
indicators of the quality of service provided.
Our results for 2011/12 showed us that 76.5%
of our staff either agreed or strongly agreed
with this statement compared to 59% (average
amongst other trusts working with the Picker
Institute who collate this information).
DCHS QUALITY ACCOUNT 2011/12
49
DECLARATION AND STATEMENTS
Derbyshire County Council Improvement and Scrutiny Committee-People
Comment on Derbyshire Community Health Services NHS Trust Quality Account 2011/12
The Improvement and Scrutiny Committee
welcomes the opportunity to comment on
Derbyshire Community Health Services’
(the Trust) Quality Account for 2011/12. The
Committee has undertaken some work with the
Trust during the reporting period, most notably
around securing improvements for patients
and the public on the issue of nutrition and
hydration.
The Committee, in its involvement with the
Trust, have been impressed by the quality
of services it provides and its enthusiasm
and commitment to securing further quality
improvements that will benefit patients, staff,
and the service as a whole.
The Committee look forward to seeing
progress against the areas for improvement
identified by the Trust for this year.
Cllr Gill Farrington
Chair Improvement & Scrutiny Young People
Derbyshire LINk response to Derbyshire Community Health Services Quality
Accounts 2011/12
Derbyshire Community Health Services
(DCHS) NHS Trust has produced a
comprehensive document and what is
encouraging to Derbyshire LINk is that success
and failure (sometimes by a narrow margin) is
recognised equally and is seen as part of the
priorities for improvement in 2012/13.
Through our own engagement activities,
comments collated regarding the services
provided by DCHS are fed back through their
involvement as a Derbyshire LINk Stakeholder.
These comments are provided by way of a
formal and confidential report, on a bi-monthly
basis.
It is interesting to read of the emphasis given
to Infection Prevention and Control, through
the Champions initiative along with the
Safety Express and the Named Nurses for
Safeguarding Adults.
DCHS are receptive towards receiving this
intelligence, which is gained independently
from the Derbyshire public, and is considered
by DCHS in the planning, development and
delivery of their services.
Discharge planning is an important aspect
of patient care and one that Derbyshire LINk
has extensively investigated and reported
on. DCHS clearly have recognised this as an
area for development and clearly demonstrate
their ongoing commitment to improving patient
experience.
DCHS undoubtedly are responsible for
delivering a wide variety of health services and
Derbyshire LINk is pleased to have developed
an open communication channel with them in
order that the patients’ voice is heard.
The Speech and Language service
model, especially with young offenders, is
constructive. We are sometimes not aware
that we speak a different ‘language’ to young
people especially where restricted language
codes are involved.
Of particular interest to Derbyshire LINk are the
examples of Patient and Public Involvement
(PPI) work that DCHS have undertaken.
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DCHS QUALITY ACCOUNT 2011/12
Internal and external views sought as part of
consultation process Front line care council (FLCC) this is our staff
group from across all our services who act as
a consultation and listening group. They were
part of the consultation process for the writing
and production of this document.
The views of our Readers panel were
sought through our PPI team as part of
the consultation process along with some
independent readers who are part of our LAY
representatives.
Commissioners
General Comments
North Derbyshire Clinical Commissioning
Group (CCG) is the lead commissioner for
Derbyshire Community Health Services NHS
Trust (DCHS). The CCG is responsible for
commissioning the services from this provider
for NHS Derbyshire County and NHS Derby
City. The CCG believes that Derbyshire
Community Health Services NHS Trust has
produced a comprehensive quality account
which broadly reflects the information received
by NHS Derbyshire County through its contract
monitoring arrangements.
Measuring & Improving Performance
The CCG has well-established mechanisms in
place for checking service quality as part of its
contract monitoring arrangements. The CCG
has agreed with DCHS to monitor quality in a
wide range of areas, most of which are detailed
in this quality account.
As stated within the account a number of
quality measures that attract an incentive
payment were agreed for the year 2011/12
covering areas such as stroke care, dementia
care, falls, reducing pressure ulcers,
breastfeeding sustainment rates, care plans
and patient experience.
All of these schemes relating to the incentive
payments are detailed in the account. Through
review of the Trust performance in these areas
the CCG noted whilst some of the CQUIN
targets had not been achieved significant
progress in relation to the improvement of the
quality of services provided had been made.
It is noteworthy that DCHS is committed
to sustained improvement in the quality of
the services they deliver. Evidence of this
statement is shown within the strengthened
clinical governance processes and structures
which have been implemented within DCHS
during 2011/12, alongside the nationally
recognised work in relation to quality
improvements and innovation such as Safety
Express, HSJ award for Care Homes Support
Team and regional recognition for the Infection
Prevention and control team.
delivers to patients. This has ensured that
no patient is placed on a ward with mixed sex
accommodation and facilities and signage has
been improved.
Additional Comments
Quality Accounts are intended to help the
general public understand how their local
health services are performing and with that in
mind they should be written in plain English.
DCHS have produced a comprehensive, well
written Quality Account. It is easy to read and
is visually appealing.
The Quality Account demonstrates a high level
of commitment to quality in the broadest sense
and is commended.
Statement from NHS Leicester,
Leicestershire County and Rutland
The Derbyshire Community Health Services
Quality Account provides information covering
all areas of quality and reflects the work
implemented to improve care through the
CQUIN and quality indicators. We support
their objectives for improving quality for 201213 and would suggest that future Quality
Accounts are more outcome focused.
Caroline Trevithick
Chief Nurse and Quality Lead
West Leicestershire CCG
Carmel O’Brien
Chief Nurse and Quality Officer
East Leicestershire and Rutland CCG
The other area for which DCHS requires
praise is in the focus it has placed on
improving the environment of the services it
DCHS QUALITY ACCOUNT 2011/12
51
GLOSSARY
52
Abbreviation
or term
What it
stands for
What it means
A4C
Agenda for
Change
The national framework that determines pay and terms and
conditions for NHS staff
A&E
Accident and
Emergency
Hospital departments that assess and treat people with serious
injuries and those in need of emergency treatment
Acute Care
Specific care for diseases or illnesses that progress quickly,
feature severe symptoms and have a brief duration
AGM
Annual General
Meeting
This is a public meeting were we present our performance over
the year
AHP
Allied Health
Professional
A term used to describe a range of clinical professions (not
doctors or nurses) such as physiotherapists, podiatrists,
pharmacists etc.
APO
Autonomous
Provider
Organisation
The term used to describe the provider arm of a PCT which
is still legally part of the PCT but is managed as a separate
‘business unit’
BMA
British Medical
Association
Professional association that represents UK doctors and acts
as an independent trade union, scientific and educational body,
and publisher
BME
Black and
Minority Ethnic
This is a recognised description of people from different racial
and other minority groups
Caldicott
Guardians
Senior staff in the NHS and Social Services appointed to
protect patient information
CAF
Common
Assessment
Framework
A multi-agency assessment tool used to identify and support
children with additional needs
C.difficile
Clostridium
Difficile
A healthcare associated intestinal infection that mostly affects
elderly patients with other underlying diseases
CFT
Community
Foundation
Trust
This is a community trust that has been accepted by Monitor
to become a Foundation Trust
CMO
Chief Medical
Officer
The Government’s principal medical adviser and the
professional head of all medical staff in England
CNO
Chief Nursing
Officer
Responsible for delivering the Government’s strategy for
nursing, and leading all of England’s nurses, midwives, health
visitors and allied health professionals
Community
Matrons
Case managers with advanced clinical skills and expertise in
dealing with patients with complex long term conditions and
high intensity needs
DCHS QUALITY ACCOUNT 2011/12
Abbreviation
or term
What it
stands for
What it means
Children’s
Centres
Local facilities designed to help families with young children
Children’s
Trusts
Trusts that identify what needs to be improved in a local
area for children and young people, and then plan services
around those needs. Chaired by Local Authority Directors of
Children’s Services
CQC
Care Quality
Commission
The regulator of the quality of NHS and social care services
CQUIN
(scheme)
Commissioning
for Quality and
Innovation
A set of nationally and locally defined quality indicators agreed
between a provider and its commissioner. Performance
against the indicators is monitored through the contract and
a proportion of contract income is dependent on reaching the
required level of performance
DCC
Derbyshire
County Council
DCHS
Derbyshire
Community
Health Services
NHS Trust
We separated from the PCT and became our own Trust on 1st
April 2011
DHIS
Derbyshire
Health
Informatics
Service
A shared service, hosted by DCHS from October 2009,
that provides IM&T services to NHS organisations across
Derbyshire
DNA
Did Not Attend
The term used to describe an appointment or operation where
the patient failed to turn-up without prior cancellation.
Can be an indicator of quality issues within the service and is
also an efficient issue as capacity has been wasted
DNACPR
Do Not Attempt
CardioPulmonary
Resuscitation
Cardio-Pulmonary Resuscitation is the medical treatment that
attempts to restart a patient’s heart and breathing
DSCB
Derbyshire
Safeguarding
Children Board
The multi-agency board, chaired by the County Council, that
takes overall responsibility for safeguarding and promoting the
well-being of children and young people across Derbyshire
DTOCs
Delayed
Transfer of
Care
A nationally defined measure of patients still in hospital who
are ready to transfer home or into residential/nursing care
DCHS QUALITY ACCOUNT 2011/12
53
Abbreviation
or term
What it
stands for
What it means
ESR (system)
Electronic Staff
Record
A national human resources system which is used by
many NHS organisations to manage its staff records.
EoL
End of Life Care
Care for all adult patients nearing the end of their lives
EPP
Expert Patient
Programme
Programme designed to teach good self care and self
management skills to people with long-term conditions
FOI
Freedom of
Information Act
Government act which gives a general right of access to
all types of recorded information held by public authorities
HCAI
Healthcare
associated infection
An infection (e.g. MRSA, Clostridium Difficile) that a patient
has caught as a result of their healthcare treatment
IBP
Integrated Business
Plan
The term used by Monitor (the regulator for Foundation
Trusts) to describe a 3-5 year strategy and plan for an
organisation
Intermediate Care
Integrated services for older people that promote faster
recovery from illness, prevent unnecessary hospital
admissions and maximise independent living
KSF
Knowledge and
Skills Framework
The NHS KSF process involves managers working with
individual members of staff to plan their training and
development
LAA
Local Area
Agreement
Three year agreement that sets out the priorities for a
local area in certain policy fields as agreed between
government, local authority and other partners
LINk
Local Involvement
Network
Local Involvement Networks were established in England
and Wales as the new, independent way for all residents
to get involved in having more say in social care, medical
care and mental health services in Derbyshire
LMWH
Low Molecular
Weight Heparin
Drug treatment given by injection to prevent / treat Venous
Thrombo Embolic Disease
LTC
Long Term
Conditions
Conditions such as diabetes, asthma and arthritis that
cannot currently be cured but whose progress can
be managed and influenced by medication and other
therapies
MIU
Minor Injury Unit
A walk-in unit in a community setting that provides
treatment for minor injuries and illnesses.
The regulator of Foundation Trusts. Operates the
Foundation Trust application and authorisation process.
Monitor
MRSA
54
Methicillin Resistant
Staphylococcus
Aureus
DCHS QUALITY ACCOUNT 2011/12
Bacteria that can cause infection in a range of tissues
such as wounds, ulcers, abscesses or bloodstream
Abbreviation
or term
NCAPOP
NHSLA
NICE
NPSA
NSF
OPMH
PALS
PPI
QIPP
RTT
SHA
SHMI
SLA
TCS
What it
stands for
National Clinical
Audit and Patient
Outcomes
Programme
NHS Litigation
Authority
National Institute
for Health and
Clinical Excellence
National Patient
Safety Agency
National Service
Framework
Older Peoples
Mental Health
Patient Advice
and Liaison
Services
What it means
This is a closely linked set of centrally-funded national clinical
audit projects that collect data on compliance with evidence
based standards, and provide local trusts with benchmarked
reports on compliance and performance
An NHS ‘insurance scheme’ that organisations buy into to
manage the financial risks of litigation
The organisation that reviews new drugs and technologies and
either gives the NHS a mandatory ruling about what should be
funded on the NHS or gives advice that is optional
The body responsible for collating and sharing information
about patient safety risks across the NHS
A national set of defined best practice relating to a condition or
group of patients that commissioners and providers should be
working towards
This is a specialised service which supports elderly people with
mental health issues such as depression or dementia
Services that provide information, advice and support to help
patients, families and their carers
Involving the public in shaping a care system’s development
Patient and Public
and keeping patients well informed of clinical processes and
Involvement
decisions
Quality,
Innovation,
A new phrase/national programme to describe the priorities
Productivity and
that NHS organisations should be focused on
Prevention
The measure of how long a patient has waited from being
Referral to
referred by their GP to a specialist to receiving whatever
Treatment Time
treatment is required
There is a national requirement for patients to be treated within
18 weeks of referral
The ‘intermediate tier’ of the NHS that performance manages
Strategic Health
and coordinates NHS organisations on behalf of the
Authority
Department of Health
There are 10 across England and we are in the East Midlands
SHA
Summary
This is a system where health providers can demonstrate how
Hospital Mortality safe and efficient their services are and describe how and
Indicator
when people have died
Service Level
The term used for non-legally enforceable ‘contracts’ between
Agreement
NHS organisations
Transforming
The national programme launched by the Department of
Community
Health to drive up quality and value in community services
Services
It consists of different strands of national policy relating to
quality, innovation, commissioning and organisational forms.
People with disabilities or mental conditions who are unable to
Vulnerable Adults take care of themselves or protect themselves against harm or
exploitation from others
DCHS QUALITY ACCOUNT 2011/12
55
Derbyshire Community Health Services NHS Trust
Quality Account
2011/12
56
DCHS QUALITY ACCOUNT 2011/12