Locala Community Partnerships
Quality Account
2011 - 2012
www.locala.org.uk
Contents
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Section One:
4
1.1
Foreword from the Chief Executive
4
1.2
Statement of Quality Assurance from the
Chief Executive and Chair
5
Section Two:
6
2.1
6
Priorities for improvement
2.11How will we monitor, measure and
report these priorities?
7
2.2
Statements relating to the quality of services provided
9
2.2.1 Review of services
9
2.2.2 Participation in clinical audits
10
2.2.3 Participation in clinical research
11
2.2.4 Use of the CQUIN payment framework
11
2.2.5 Statements from Care Quality Commission
11
2.2.6 Data quality
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Quality Account 2011/12
Section Three:
16
3.1Complaints
17
3.2
Claims and litigation
19
3.3
Local patient surveys
19
3.4
Patient opinion
19
3.5
Incident reporting and monitoring
20
3.6
Serious untoward incidents
20
3.7
Serious case reviews
20
3.8
Contract quality areas
21
3.9
Reducing mixed gender accommodation
23
3.10 Compliance with NICE guidance
23
3.11 NICE quality standards
24
3.12 Healthcare Associated Infections
24
3.13 Hand hygiene
24
3.14 Methicillin-resistant Staphylococcus Aureus (MRSA)
24
3.15 Screening patients for MRSA
24
3.16 Clostridium Difficile
24
3.17Norovirus
25
3.18 PEAT (Patient Environment Action Team)
25
3.19 Compliance with national target for 18 weeks
from referral to treatment
25
Section Four:
26
4.1
Appendix 1
26
4.1.1 CQUIN compliance information
26
Section Five:
30
5.1
Statements from our Stakeholders
30
5.1.1 Kirklees Local Involvement Network
30
5.1.2 Kirklees Wellbeing and Communities Scrutiny Panel
30
5.1.3 NHS Kirklees
30
5.1.4 NHS Greater Huddersfield Clinical Commissioning Group
31
5.1.5 NHS North Kirklees Clinical Commissioning Group
31
5.2
How to provide feedback on this account
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Section one
1.1 Foreword from the Chief Executive
Welcome to Locala Community Partnerships’ first annual Quality Account. It’s been
a momentous year for us – on 1 October 2011 we started life as Locala, a community
based, co-operative organisation providing NHS services to the people of West
Yorkshire, having previously been known as Kirklees Community Healthcare Services,
part of NHS Kirklees. One of the reasons we became Locala was to ensure we could
put quality at the forefront of everything we do. This document will demonstrate
our commitment to quality and our drive to improve. Our passion is to provide care
and support to the people we serve, through highly trained and well-motivated
colleagues.
We provide a wide range of services – from nursing in the home, to acute therapies
to specialised dentistry. All our colleagues in each of our services know that safety
comes first every time. Our Board has ensured that we have robust and thorough
procedures in place so that we learn quickly from mistakes, and that we continually
review our clinical practice to make sure we are performing to our best and providing
high quality services for the people of Kirklees.
I am particularly pleased that we have:
• Proven the impact of the Community Matron service on admission avoidance
and the effective care of patients with chronic health conditions
• Improved our measurement and performance for nursery nurses within the
Healthy Child programme
• Set up Community Care teams - our ground-breaking new service to people
with long term conditions where we put in place integrated health and social
care teams to deliver seamless services.
The coming year brings us new opportunities and challenges. Our focus will be on
putting in place the foundations of a strong and quality-driven organisation. This
means we are investing in new technology, improved clinical equipment and, most
importantly, our colleagues. We are determined to build a strong business, based on
a mutual ethic which utilises the best possible technology to deliver the best quality
care possible.
I look forward to reporting on quality improvement in future years.
Robert Flack
Chief Executive of Locala Community Partnerships Community Interest Company
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1.2 Statement of Quality Assurance from Chief Executive and Chair
The Board of Locala Community Partnerships CIC endorses this Quality Account which
puts improving quality and safety at the forefront of our work. We are committed to
providing care which makes a genuine difference to people’s lives and to our staff
who are driven by the desire to improve their services. The Board is excited that our
company has active involvement and direction from both staff and members of the
community. The Board has listened, and will continue to listen to their experiences
and respond by helping the organisation develop around the needs of the individual
and the community it serves.
This Quality Account has been reviewed by the Board, and to the best of our
knowledge, accurately reflects both an overview of the quality of the services
provided by Kirklees Community Healthcare Services and Locala during 2011/12 and
our priorities for quality improvements during the next year.
In preparing the Quality Account, Directors are required to take steps to satisfy
themselves that:
• the Quality Account presents a balanced picture of the organisation’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 reported in the Quality
Account is robust and reliable, conforms to specified data quality standards
and prescribed definitions, and 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.
The information provided in this report
is, to the best of our knowledge accurate
and a reasonable reflection of our
commitment to quality in 2011-2012.
Robert Flack
Managing Director
Mark Sanders, OBE
Chair
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Section two
2.1 Priorities for improvement
In this section of our report, we intend to focus on the future and 2012-13 in
particular. It should be noted that this section of the report has not been planned
in isolation but that the priorities discussed below have been agreed through
discussion with our staff and commissioners.
We believe that it is important that our priorities complement the Commissioning
for Quality and Innovation (CQUIN) scheme, our compliance with the 16 essential
standards for registration with the Care Quality Commission, and demonstrate our
development over time. We have agreed that we will focus on a small number of
important priorities during the next year and aim for significant improvement.
Table 1 – 2012/13 priorities
Lead Responsibility
Priority 1:
Category
Aim
Clinical effectiveness
To reduce the length of time
from diagnosis to healing of
true venous leg ulcers.
To reduce the length of
healing of true venous leg
ulcers to 12 weeks.
Patient safety
To reduce the number
of patients developing a
pressure ulcer whilst in the
care of Locala.
To reduce the incidence of
pressure ulcers by 50%
Patient safety
To reduce the number
of falls experienced
by patients within
intermediate care in-patient
rehabilitation units.
To reduce the number of
patient falls attributable
to vulnerability through
medical conditions.
Patient experience
To ensure patients within
the community nursing
service receive a response
appropriate to their
needs within a specified
timeframe
To ensure that 80%
of patients within the
community nursing service
receive a response from a
health care professional
within a specified time
frame
Patient experience
To increase the number of
comments on patient opinion
website that show a positive
experience of our services.
50% of comments on
patient opinion website
show a positive experience
of our services.
Sponsor:
Executive Director of Clinical
and Operational Services
Objective
Responsible manager:
Heads of Operations
Priority 2:
Sponsor:
Executive Director of Clinical
and Operational Services
Responsible manager:
Heads of Operations
Priority 3:
Sponsor:
Executive Director of Clinical
and Operational Services
Responsible manager:
Heads of Operations
Priority 4:
Sponsor:
Executive Director of Clinical
and Operational Services
Responsible manager:
Heads of Operations
Priority 5:
Sponsor:
Executive Director of Clinical
and Operational Services
Responsible manager:
Heads of Operations
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2.1.1 How will we monitor, measure and report these priorities?
Each priority is being sponsored by an Executive Director. The Performance Committee will monitor each priority and report
to Locala Board on progress.
The reports to the Board from the Performance Committee will be made by the Executive Director of Clinical and Operational Services.
Priority 1:
Priority 2:
Situation
Current healing rates for Venous Leg Ulcers within a 12 week
time frame fall well below that reported, where existing best
practice models are employed. A lack of focus on optimum
delivery of care can, and does, result in extended healing
times; an increased risk of clinical infection; a deterioration
of underlying pathological structures; increased clinical time
delivery; patient isolation and increased service costs.
Situation
This priority continues from 2011/2012. Locala Community
Partnerships treats the development of pressure ulcers very
seriously as this delays mobilisation for patients and can result
in deteriorating health and quality of life. We are working
with partner organisations to ensure that patients receive
the highest quality care in a timely manner and receive
the appropriate equipment to support that care. We have
established a Pressure Ulcer panel to help us to understand
why pressure ulcers have developed, to share learning across
the organisation, and to support service improvements.
To reduce the length of time from diagnosis to healing of
true venous leg ulcers.
Why is there a problem?
There is inconsistency across our community nursing teams
with respect to the number of skilled practitioners, levels of
relevant knowledge, and focussed optimum care delivery,
resulting in a variation in the length of time of healing rates.
Initiatives to be implemented in 2012-13
• Training for front line colleagues.
• A rolling programme of continual professional development
• Detailed, timely assessments undertaken by community
nurses and health care assistants
• Investment in skills and equipment
• Establishment of two centres of excellence (north and south)
• Patient education programmes
• Robust reporting procedures
To reduce the incidence of pressure ulcers caused whilst in
the care of Locala Community Partnerships by 50%
Why is there a problem?
Due to data issues, we were unable to be confident regarding
the number of pressure ulcers that were attributable to Locala
services. Our performance colleagues have worked alongside
our front line colleagues to improve this and we are confident
that we will be able to demonstrate improvements this year.
Initiatives to be implemented in 2012-2013
• Robust systems for assessing a patient’s skin on admission to
Locala care in order to have a baseline when the skin deteriorates
• Work with Kirklees Integrated Community Equipment Service
and local acute partners to develop a whole system approach.
• Through the Pressure Ulcer panel approach, support and
monitor service improvements
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Priority 3:
Priority 4:
Situation
We have a relatively high number of falls within the intermediate
care bed bases compared to other non-rehabilitation units. The
prevention of falls must be individualised, as each patient is
affected differently by the interplay within a range of risk factors.
Situation
Locala Community Partnerships has developed a single point
of access for community nursing which specifies the response
time required within a time frame, according to priority.
To reduce the number of falls experienced by patients
within intermediate care in-patient rehabilitation units
Why is there a problem?
Rehabilitation by its very nature will involve the risk of falls. If
we reduce all risks we will increase the length of stay on the
unit and potentially increase the number of clients admitted
to 24-hour care. Patient’s safety has to be balanced with
independence, rehabilitation, privacy and dignity - a patient
who is not allowed to walk alone will very quickly become a
patient who is unable to walk alone.
Initiatives to be implemented in 2012-13
• Each patient to have an individual Falls Care Plan with clear
plan of action/exercise programme for falls prevention.
• Increased signage around the ward,(floor signage to indicate
which direction the patient needs to follow)
• Identification and monitoring of trends in patient safety
incidents to prioritise areas for action.
To ensure that 80% of patients within the community
nursing service receive a response from a health care
professional within a specified time frame
Why is there a problem?
There have been challenges in developing the systems to
ensure that patients’ priorities are identified when care is ongoing and their needs change
Initiatives to be implemented in 2012-13
• To develop a robust method of ensuring that each patient
is given the right priority level at the point of referral (or
referral for a new problem)
• To collect information to assure that the patient’s need has
been met according to the grade of priority
• To monitor the number of calls waiting to be answered
at the Single Point of Access as this is an indication of the
quality of response this service is providing.
• Falls prevention check list for all patients admitted to the unit.
(12 categories).The check list is displayed by every bedside.
• The purchase of two additional ‘Carroll Beds-Falls beds’. Correct
usage of these beds for those deemed high risk.
• All patients will be discharged home with a Patient Information
Leaflet re preventing falls.
Priority 5:
To increase the number of comments on the Patient Opinion website that show a positive experience of our services.
Situation
There is currently no national patient survey for community
services. Although many of our services have developed
individual questionnaires, these have been limited in scope.
The use of the national Patient Opinion will enable patients/
carers and service users to provide open comments on the
services they have received with the facility for the organisation
to provide prompt public feedback.
Why is there a problem?
Locala Community Partnerships recognises the importance of
involving patients and carers in the care we provide and using
their experience of services, good and bad, to inform services
delivery. Whilst such feedback is currently collected, the approach
can be fragmented across services and a more co-ordinated
approach is required. We are also keen to demonstrate the impact
patient’s stories and experiences have in shaping services.
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Initiatives to be implemented in 2012-13
• Linking of all services to the Patient Opinion website
• Training for front-line colleagues on the use of Patient Opinion
• Use of Patient Opinion organisational response facility by
the Locala Governance team
• Monitoring of comments placed on Patient Opinion website
with reports to Standards Committee on performance
Each of these initiatives will be supported by strong Executive
leadership and work with our main education providers to
ensure that our staff are able to develop additional skills
and competences. Training and education are important
contributors to the quality and culture of our organisation.
2.2 Statements relating to the quality of services provided
2.2.1 Review of Services
During 2011-2012 Locala Community Partnerships provided a range of services across Kirklees. On 31 March 2012, we were
providing care for over 420,437 people across Kirklees.
The organisation is led by a Chief Executive and services have been structured to reflect the changing local landscape following the
introduction of the Health and Social Care Act and the introduction of Clinical Commissioning Groups (CCGs). We have two CCGs in Kirklees:
• Greater Huddersfield Consortium (South)
• North Kirklees Healthcare Alliance (North)
We have two Heads of Operations, each being aligned to one of these commissioning groups. They are responsible for the
delivery of the following services:
Accessible homes team
Intermediate care services
Breastfeeding initiative counsellor
Jubilee rehabilitation centre
Broughton House GP practice
Kirklees Integrated Community Equipment service
District Nurses
Looked after children
Children’s community nursing
MacMillan nurse specialists for care homes
Children’s Immunisation team
Maple ward
Chlamydia screening
Moorfields primary care centre
Community child health
Occupational Therapy
Community Dental Service (Calderdale and Kirklees)
PodiatryMusculoskeletal service
Community Diabetes service
Primary care gynaecological service
Community Matrons
Pupil referral service
Community rehabilitation service
Respiratory Service
Continence service
School Nursing
Contraception and Sexual Health
Smoking cessation service
Coronary heart disease service
Speech and Language Therapy
Day surgery
Vasectomy service
Drug and Alcohol Action team
Walk in centre, Dewsbury District Hospital
Family nurse partnership
Whitehouse GP practice
Health Checks
Youth offending team
Health Visiting
Senior managers regularly spend time within clinical services to review issues with staff and consider governance concerns.
Our clinical services are supported by a number of central functions including Finance, Human Resources, Business Support,
Medicines Management, Safeguarding, Integrated Governance and Training.
We have reviewed all the data available to us on the quality of care in 100% of these services.
The income generated by the NHS services reviewed in 2011-2012 represents 100% per cent of the total income generated from
the provision of NHS services by the organisation this year.
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2.2.2 Participation in clinical audits
Clinical audit is supported by the Integrated Governance team. All local clinical audit proposals are received by the Audit
and Effectiveness Committee and quality appraised. Completed clinical audit reports are quality assured and action plans
for quality improvement received through this committee.
Twenty-eight local clinical audit proposals were received by the Audit and Effectiveness Committee for the period 2011-2012 with
20 clinical audit reports being received to date. Action plans have been received and applied within services.
The Diabetes Service undertook an audit with patients who were on Continuous Subcutaneous Insulin Infusion (CSII therapy).
Following CSII therapy all the patients were happier with the treatment and had less unacceptable high and low blood glucose
levels. They found the treatment more convenient and flexible. Their diabetes knowledge had also improved. They were much
more likely to recommend and continue with CSII.
Furthermore, patients reported an improvement in their symptoms of hypoglycaemia, and had reduced disabling hypoglycaemia
requiring medical assistance.
Prior to CSII four patients had been admitted to hospital one or more times due to diabetes but following CSII this was reduced to one.
During 2011-2012, three national clinical audits and confidential enquiries covered NHS services that Locala Community
Partnerships provides. Services participated in two of the audits as shown below. Although invited to participate, it was apparent
when the audit details were considered, that the Heart Failure audit was not applicable to the Locala service.
Number of cases submitted
Percentage of registered
cases required
National Adult Diabetes Audit
28
100%
National Paediatric Diabetes Audit
67
100%
Heart Failure Audit
0
-
The reports of one national clinical audit was reviewed by us in 2011-2012 and Locala Community Partnerships intends to take
the following actions to improve the quality of healthcare provided:
National clinical audit
Actions
National Sentinel Audit for Stroke
• To Identify and target population with HbA1c above 9.5%
• To give intensive education and support to those identified
• To ensure child or young person is initially followed up by telephone and
subsequently in a nurse led clinic or home visit
• To repeat HbA1c on a 4 monthly basis
External reviews
Our systems are subject to periodic review by the West Yorkshire Audit Consortium. During 2011-2012, the Audit Consortium
provided us with specific developmental support on establishing our systems for the new organisational form. Joint work
between the Locala Governance team and the Audit Consortium has strengthened service evidence for Care Quality Commission
compliance. It is intended that this will be subject to formal review during the next year.
A review was undertaken on the organisation’s Information Governance toolkit evidence which was awarded a ‘Significant
Assurance’ grading.
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2.2.3 Participation in clinical
research
During the past year, we have
concentrated on developing the
framework within which we can
examine our compliance with evidence
based practice through clinical
audit and benchmarking against
NICE guidance. Discussions with
the local health economy Research
Ethics Committees are continuing
to determine a mechanism by which
Locala Community Partnerships, as a
social enterprise, can be involved.
We are committed to participating in
clinical research to improve the quality
of care we offer and to contributing
to wider health improvement. Such
involvement will enable our clinical staff
to stay abreast of the latest possible
treatment possibilities, and participate
actively in research leads to bring about
successful patient outcomes.
2.2.4 Use of the CQUIN payment framework
A proportion of Locala Community Partnerships’ income in 2011-2012 was
conditional on achieving quality improvement and innovation goals agreed
between the organisation and NHS Kirklees through the Commissioning for Quality
and Innovation (CQUIN) payment framework.
Our achievement against CQUIN targets is shown in Appendix 1.
2.2.5 Statements from CQC
Locala Community Partnerships is required to register with the Care Quality
Commission. The organisation is registered and licensed to provide services. This
means that it has been agreed that our services meet the essential standards of
quality and safety. These standards are available electronically at www.cqc.org.uk.
The Care Quality Commission has not taken enforcement action against Locala
Community Partnerships during 2011-2012.
The Care Quality Commission undertook an unannounced inspection to Holme Valley
Memorial Hospital on 21 November 2011 as part of its routine schedule of planned
reviews, and monitored our compliance against five of the Essential Standards. A
minor concern was raised regarding the completion of ‘Do not resuscitate’ forms for
patients transferred to Maple Ward from acute hospital trusts. Subsequently, our
systems have been strengthened and monitoring shows that these forms are now
fully completed. Observations during the inspection, and feedback from patients,
showed that the dignity and privacy of patients was fully achieved.
Our Head of Integrated Governance meets with the Care Quality Commission’s link
manager on a quarterly basis to maintain a regular dialogue.
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Participation in Special Reviews
Locala Community Partnerships has participated in special reviews by the Care Quality Commission relating to the following
areas during 2010-11:
Integrated inspection of Safeguarding and Looked After Children’s Services in Kirklees
The inspection was conducted alongside the Ofsted-led programme of children’s services inspections which focus on
safeguarding and the care of looked after children within a specified local authority. In response to the recommendations made
by the inspection team, Locala Community Partnerships has undertaken the actions detailed below:
Safeguarding
Recommendations
A detailed Implementation plan to be developed with clear
time lines to ensure that the following actions are in place:
• Recruit 6 wte Health Visitors by end of March 2012
• The post natal visit is delivered by Health Visitors to include
the Universal Needs Assessment and registration with
Children’s Centre
• The three-month visit is delivered by Health Visitors to include
postnatal depression assessment and weaning discussion
• Delivery of a one year contact by Community Nursery
Nurse with a follow up by Health Visitor if required
Actions to 31 March 2012
Implementation plan for Health Visitor developments
Additional five 5wte Health Visitors recruited
Monthly updates reported to the Health Visitor
implementation group meeting
Included as performance measures on the Health Visitor
dashboard
Locala contract monitoring and a standing agenda item on
Locala Contract Quality Board
• Delivery of a two-year assessment by Health Visiting Team
To ensure all children with identified health needs have a
health care plan completed by, or effectively supported by, a
suitably qualified experienced health professional
Health plans in place where appropriate. Assistance required
from commissioners to ensure GP’s, Consultants, Nurse
Consultants and Practice Nurses are supplying care plans to
children and young people in their care at initial discharge
and on-going review meetings.
Audit school health care plans to ensure that needs are met in a
timely manner, by most appropriate professional involved and
identify lead/key professional to ensure that plans are in place
and reviewed annually by Team Leader/Governance team
Report from the audit presented to the Contracting Quality
Board for Locala. SystmOne reports will identify children with
and without medical needs and care plans on Health Visitor
and School Nurse caseloads.
The child will be on the caseload of the school nurse
responsible for that school.
Numbers of children in each school on caseload of the School
Nurse and the number of children who have a care plan in place.
• The health plan is revised at the start of each autumn term.
Annual report to identify that all plans have been reviewed.
• Change in need identified, health plan is updated sooner.
Standing agenda item on Supporting families Team Leader
meeting.
• Roll out of best practice following pilot in the north of the
district to include:
• Integrated working to ensure that the school nursing
service, health visiting service and education staff are
identifying any needs prior to commencement in nursery.
• Referral to health professional and care plan in place.
• Nursery entry questionnaire, supported by both education
and school nursing staff.
• Review by the Supporting Families service, either Health
Visitor or school nurse dependent on age
• Engagement of health professionals involved –
Consultants, Community Paediatricians, GPs and Specialist
Nurses- strategy development January 2012
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Standing agenda item on Locala Contracting Quality Board
Pilot still in progress, implementation and Kirklees wide roll
out not yet feasible
Looked After Children (LAC)
Recommendations
Actions to 31 March 2012
• Audit the existing Looked After Children caseload to
identify age, current numbers registered with a dentist,
placements in and external to Kirklees.
Audit completed.
Establish a regular update and review process for this
indicator.
Information to be input onto Care First 6 and SystmOne so
that reports can be produced.
LAC Nurses/Health Visitors/School nurses should make sure
that children and young people are registered with a dentist at
six month/annual review and that they have attended for an
appointment during that period.
Taken to Children’s Forum, Health Visitor/School Nurse to input
data onto SystmOne. Guidance how to do this to be produced.
Work with Local Authority colleagues to ensure social workers
are identifying dental and health checks as a key area with
foster carers and care homes
Work undertaken with the social work teams, foster carers
and their Supervising Social Workers, Independent Reviewing
Officers and Residential Units to ensure that all those involved in
children’s care are addressing dental care - attendance at Team/
Unit Meetings, Residential Managers Group/ Under- and Over-8s
Foster Carers Group, Training/Induction for New Starters.
2.2.6 Data Quality
We accept responsibility for providing good quality information to support
effective patient care. We participate in NHS Kirklees information governance
processes and are supported by the Executive Director of Clinical and Operational
Services who is currently our designated Caldicott Guardian.
Most of our services now use electronic records through SystmOne which provides
a single clinical information system and reduces the number of times a patient is
required to provide personal data. We have adopted mobile technology which
enables the clinical professional to have access to records whilst providing care,
whatever the location, and saves the clinician having to return to base. This equipment
also includes an alarm system to enhance staff safety. The project has been subject to
strict governance arrangements to ensure that patient information is secure.
During 2012-2013, Locala Community Partnerships will be taking the following
actions to improve data quality:
• Implement the mandatory data set for community services to ensure consistency
of data collection within all clinical services.
• Achieve the Data Quality Priorities as set out in the contract for community
services with NHS Kirklees.
• Ensure the appropriate use of SystmOne functionality to support the accurate
recording of patient activities.
• Develop Data Quality measures that will support the collection and reporting of
information to evidence clinical / patient outcomes.
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NHS Number
Clinical records audit
At the end of March 2011, 99.6% of clinical records included the patient’s NHS
number and 99.6% included the patient’s GP.
Previous record keeping audits have followed
a similar methodological format in terms
of comparing a selection of clinical records
against an audit tool developed to reflect
professional guidelines. The main focus has
been to establish whether records comply
with professional body standards. Whilst
recognising the importance of this approach,
the 2011 audit took a different focus.
The following graph shows the age breakdown of our patients. It should be noted that,
because all children in Kirklees are registered with a Health Visitor or School Nurse, the
caseload statistics for the Supporting Families service has been shown separately.
Locala - age bands
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Age
Band
0-5
Age
Band
6-10
Age
Band
11-15
Age
Band
16-20
Age
Band
21-25
Age
Band
26-30
Age
Band
31-35
Age
Band
36-40
Age
Band
41-45
Age
Band
46-50
Age
Band
51-55
Supporting Families (Health Visiting and School Nursing)
Age
Band
56-60
Age
Band
61-65
Age
Band
66-70
Age
Band
71-75
Age
Band
76-80
Age
Band
81-85
Age
Band
86-90
Age
Age
Age
Age
Band Band Band Band
91-95 96-100 101-105 106-110
Nursing and Therapy Services
We have been working to increase the number of patient records that include the
ethnic background as stated by the patient. This has increased from 17.7% in April
2010 to 71.6% in March 2012. The breakdown is shown in the graph below:
Locala - ethnicity coding
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
British
or Mixed
British
Irish
Other
White and White and White and
Other
Indian
White
Black
Black
Asian
Mixed
or British
Background Caribbean African
Background Indian
Pakistani Bangladeshi Other
Caribbean
or British or British
Asian
Pakistani Bangladeshi Background
African
Other
Chinese
Black
Background
Other
Not
Stated
Not
Recorded
As one of its strategic objectives, Locala
wants to ensure that ‘high quality patient
care and service delivery is constantly
evidenced within the electronic clinical
record’ and by carrying out an audit of
the electronic clinical records developed
and used by its various services, Locala’s
intention was to be able to identify
any current weaknesses and make
recommendations to clinicians and
service managers as to how high quality
patient care and service delivery can be
best evidenced within the electronic
clinical recording system in use.
This audit highlighted areas for
improvement as well as elements of
best practice across the organisation
and produced recommendations as to
how all records should be structured
and maintained in the future. A
detailed action plan was produced
and gave detailed instruction in terms
of how these recommendations
should be implemented and included
accountabilities to guarantee quality is
ensured. Ultimately it is intended that by
improving the quality of documentation
and all the key functions of clinical record
keeping, this will positively impact on
patient care and patient outcomes for
those receiving treatment within Locala
Community Partnership.
Information Governance Toolkit attainment levels
Information quality and records management is assessed using the Connecting for
Health Information Governance Toolkit which provides an overall assessment of data
systems, standards and processes. The toolkit is completed by the Head of Integrated
Governance on behalf of Locala Community Partnerships’ Information Governance
committee and is validated by the Directors before submission.
Our Information Governance Assessment Report score for 2011-2012 was 61%
and was graded Red. As a new organisation, we were able to demonstrate that we
have implemented appropriate information security measures but had not been in
existence for long enough to have evidence of monitoring our compliance with the
standards. We have implemented an action plan to manage the issues identified.
14
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Quality Account 2011/12
Clinical coding error rate
Clinical coding is a process that translates
the medical language of patients’ records
into an internationally recognised code
describing the diagnosis and treatment
of a patient.
Kirklees Community Healthcare Services
was not subject to the Payment by
Results clinical coding audit during 20102011 by the Audit Commission.
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Locala Community Partnerships
15
Section Three
Review of Quality Performance
In 2011, as Kirklees Community Healthcare Services, we produced our first Quality Account in which we identified a
number of quality priorities that we intended to take forward. Our progress to date is shown below. It should be noted that,
because of data collection issues, priorities 2, 3, and 4 have been taken forward into our quality initiatives for 2012-2013.
Priority
Priority 1
Priority 2
Priority 3
Priority 4
Priority 5
16
Category
Aim
Objective
% Outcome
To increase the number
of patients supported
to remain at home for at
least 90 days to 85% of
all patients discharged
from intermediate care
units following a stay in
hospital
75%
To reduce the incidence
of pressure ulcers by 50%
Not able to report due to
the inability to split the
baseline into acquired
and not acquired in
community
To reduce the number
of falls experienced
by patients within
intermediate care
inpatient rehabilitation
units
To reduce the number of
patient falls by 50%
There is likely to be an
increase in the number
of falls rather than a
reduction. There were
89 clinical incident
forms completed in the
financial year 2010-11
and there has been 86
completed between April
and January of 2011-12.
Patient experience
To ensure patients within
the community nursing
service receive a response
appropriate to their
needs within a specified
timeframe
To ensure that 80%
of patients within the
community nursing
service receive a response
from a health care
professional within a
specified time frame
68%
Patient experience
To improve outcomes
relating to child
development and
behaviour through the
targeted intervention
of community nursery
nurses
To ensure that a
minimum of 50% of
targeted interventions
by a community nursery
nurse result in positive
outcomes for parents and
children
59%
positive outcome
Clinical
effectiveness
To support patients to
remain at home following
discharge from hospital
Patient safety
To reduce the number
of patients developing a
pressure ulcer whilst in
the care of KCHS
Patient safety
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Quality Account 2011/12
3.1Complaints
All staff work hard to get things right, but sometimes things do go wrong and if
people are not happy with the level of service received they are encouraged to let us
know so that we can better understand and improve our services.
During the year, 45 complaints were received relating to our services.
Complaints are handled according to Locala Community Partnership’s complaints
procedure. We aim to resolve complaints at service level by the service manager. This
enables the service manager to resolve the concern quickly for the patient and in turn
they will use the learning from the complaint to develop or change the service. The
Chief Executive takes a personal interest in patients’ concerns and replies to formal
complaints.
Complaints are reviewed in detail with an Executive Director at least quarterly
through a Complaints Closure Panel, at which recommendations for further actions
are made. After an individual review with the service managers our complaints are
reported to our commissioners through the contract monitoring process.
We aim to acknowledge formal complaints within two working days. The appropriate
service manager will investigate the issues raised by the complainant and contact
them as part of our local resolution. At the end of the investigation a written
response is sent to the complainant by the Chief Executive. We aim to complete our
investigations within 25 working days. When this is not possible the complainant is
kept fully informed of how our investigation is progressing. At the conclusion of the
complaint investigation the service manager may make recommendations for service
improvements and the implementation of an action plan is monitored.
Quality Account 2011/12
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Locala Community Partnerships
17
The table below shows the number of complaints by service:
Year 2010-11
complaints
Year 2011-12
complaints
Community Rehabilitation team
1
0
Continence
3
2
Contraception and Sexual Health (CaSH)
1
0
Dental
2
5
Dermatology
1
0
District Nursing
5
12
Health Visiting
3
3
Home Laundry
1
0
Intermediate care
1
0
KICES
0
1
Multi-agency hospital discharge
1
1
Musculo-skeletal service North
1
3
Parking
0
2
Podiatry
1
10
Speech and Language Therapy
0
1
School Nursing
0
2
Single Point of Access
1
0
Walk in Centre
0
1
Westmoor
0
1
The Whitehouse Centre
0
1
22
45
Year 2010-11
complaints
Year 2011-12
complaints
Admissions, discharge and transfer arrangements
2
4
Appointments delay / cancellation (outpatient)
2
8
Attitude of staff
2
13
All aspects of clinical treatment
5
17
Communication / information to patients (written and oral)
4
1
PCT commissioning (including waiting lists)
5
2
Personal records (including medical and / or complaints)
1
0
Other
1
0
22
45
Service
Total
Reasons for the complaint
Written complaints received, by subject of complaint
(using Department of Health categories)
Total
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Quality Account 2011/12
Learning from complaints
The number of complaints received regarding the category ‘Attitude of Staff’ is a priority concern for Locala. During quarter three,
Locala implemented Service Reviews whereby the service managers review and feedback on the successes and improvements
of their services. At these reviews complaints and learning from complaints are an integral part and form part of the services’
development.
It is crucial that the organisation learns from all issues raised and ensures changes in practice to further the provision of high
quality services. The following describes some of these changes that have occurred:
1 Review of end of life care by the Facilitator of End of Life Care to improve health and social services communication with
families whilst caring for terminally ill patients
2 Community Podiatry has encouraged patients to become involved in the development of patient information leaflets.
3 Dental Services has rewritten the ‘first’ patient appointment letter to include a more detailed explanation of what the
patient can expect when attending their first appointment.
Any complainant who remains unhappy after their complaint has been investigated is provided with the opportunity to meet with
the service manager and relevant clinical staff in a further attempt to resolve the issues. All complainants are informed of their right
to refer their unresolved complaint to the Health Service Ombudsman. During 2011-12 no complaints were referred in this way
3.2 Claims and litigation
During this period we had seven claims registered with the NHS Litigation Authority
dating from 2008 to 2010; of these claims, only three remain active as four have been
withdrawn.
3.3 Local patient surveys
A regional survey of the Colposcopy Service at Holme Valley Memorial Hospital
found that 92% of the patients reported the service to be excellent, with the
remaining 8% reporting it as good.
A District Nursing service survey between April and August 2011 found that 100% of
patients reported being treated with dignity and respect; and all patients felt that the
service they had received was good:
“All the staff are totally supportive to my mother and me and my sister who are her only
carers. Nothing is too much trouble for the nurses to explain treatment and give morale
and support us.”
“Wonderful friendly and gentle care and the regular treatment has built me up and got
me out of my downward feelings of depression, mind and body, and it has made me
well. I cannot think how the nurses could possible do more than they did for me.”
3.4 Patient Opinion
Patient engagement is extremely important to us in shaping the services we provide.
Patient Opinion is a social enterprise organisation that offers the opportunity for patients
to share their experiences with others and to gain support from each other. People can
submit stories via the internet, postal system or telephone calls with the opportunity
for organisations to respond. We have begun to roll information on these feedback
mechanisms across our services.
Quality Account 2011/12
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Locala Community Partnerships
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3.5 Incident reporting and monitoring
The National Patient Safety Agency (NPSA) suggests that high levels of incident
reporting should be viewed as positive. Those organisations that report
incidents are more likely to have systems and processes in place to learn from
incidents.
In 2010/11 effort was made to raise the profile of Patient Safety Incident reporting which
resulted in a 100% increase in the incidents being reported. The number of patient safety
incidents reported during the past year has stabilised suggesting that we now have an
accurate reflection of what is occurring within Locala.
There have been no serious untoward
incidents within Locala Community
Partnerships’ services during 20112012. Managers and staff have provided
support and information for a number
of investigations within neighbouring
organisations.
However, reporting is only part of the challenge and learning from incidents is of
paramount importance. In house Root Cause Analysis training has been provided and
patient safety incidents, actions and learning points continue to be quality assured
centrally. Trends and themes are identified and shared with professionals within and
external to Locala.
3.7 Serious Case
Reviews
We are aware that the increasingly diverse nature of care being delivered in the community
by a variety of health professionals means that patient safety is even more important. We
will continue to ensure that patient safety is paramount and that our incident reporting
and monitoring systems and processes are constantly reviewed to meet the ever changing
demands in community healthcare provision.
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3.6 Serious Untoward
Incidents
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Quality Account 2011/12
There have been no additional serious
case reviews related to children and
adults this year. We continue to be
represented at both the Children’s and
Adult’s Local Safeguarding Boards and
actively participate in the learning
from previous case reviews.
3.8 Contract quality areas
Our contract to provide care includes a number of quality requirements. These are shown in the table below, and include our
achievements in 2010-11, the targets that were set for 2011-12 and our actual performance as measured on 31 March 2012.
In addition, there are a number of nationally specified targets with which we are required to comply and a number of Never
Events which are serious, largely preventable patient safety incidents that should not occur if the available preventative measures
have been implemented. Our compliance is shown right:
2010-11
Actual
2011-12
Target
2011-12
Actual
Community acquired MRSA bacteraemia
3
<2
0
Failure to have a Delivering Same Sex Accommodation Plan or missing a
milestone in the Plan
0
Requirements
continue to be
met
0
Proportion of children who complete recommended immunisations by 12
Months
97%
95%
96.9%
Proportion of children who complete recommended immunisations by 24
Months
93.8%
95%
97.3%
Proportion of children who complete recommended immunisations by 5 Years
91.9%
95%
93.9%
Four week smoking quitters (Specialist Service) Actual
100%
No target
100%
Target 453
End of year
trajectory
550
550
Quality Requirement
Four week smoking quitters (Specialist Service) Trajectory
End of year
trajectory 607
Percentage able to see a doctor fairly quickly
Access to Primary Care - (from the results of the National Patient Survey)
Broughton House = 83%
Whitehouse: 84%
Childhood Obesity Measurement Coverage - Reception Year
91%
No target
92%
Childhood Obesity Measurement Coverage- Year 6
87%
No target
92%
Experience of Patients
Good
No target
Good
Home Loans 94.42%
Joint
Contingency 60.36%
Equipment delivered within 7 days of client being assessed
as requiring equipment
Continuing
Care - 94.78%
Contingency 60.36%
Home Loans –
88.08%
100%
Joint
Contingency
– 62.8%
Continuing
Care – 95.9%
Continuing
Care - 94.78%
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Locala Community Partnerships
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Waiting time at surgery
Area Code
Frequency of seeing
preferred doctor
Able to see a
doctor fairly
quickly
Area
less
than
5mins
5-15
mins
16-30
mins
more
than
30mins
Always
A lot
of the
time
Some
of the
time
Yes
B85622
Broughton House Surgery
2%
55%
28%
9%
35%
25%
30%
83%
B85659
The Whitehouse Centre
9%
33%
21%
16%
29%
28%
37%
84%
5N2
Kirklees PCT
10%
52%
17%
5%
54%
22%
20%
80%
N/A
England (as a whole)
10%
52%
19%
6%
52%
21%
22%
79%
In addition, there are a number of nationally specified targets with which we are required to comply and a number of Never
Events which are serious, largely preventable patient safety incidents that should not occur if the available preventative measures
have been implemented. Our compliance is shown below:
2010-11
Actual
2011-12
Target
2011-12
Actual
100%
95%
98%
3
<7
4
100%
98%
99.99%
0
0
0
2010-11
Actual
2011-12
Target
2011-12
Actual
Wrong site surgery
0
0
0
Retained instrument post-operation
0
0
0
Misplaced naso-or orogastric tube not detected prior to use
0
0
0
Nationally Specified Event
Percentage of Service Users seen within 18 weeks across all speciality groups
for admitted and non-admitted pathways
Rates of Clostridium Difficile acquired in the community
4 hour maximum wait in A&E from arrival to admission, transfer or discharge
Breach of the Same Sex Accommodation Requirements
Never Event
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3.9 Reducing mixed gender
accommodation
Locala Community Partnerships has declared full compliance
with the national target for single sex accommodation.
Within the 20 bedded ward at Holme Valley Memorial
Hospital, 15 beds are provided in 5 x 3 bedded wards, and
there are 5 single rooms. The accommodation can be used by
either men or women as all these rooms have en-suite toilet
and shower facilities.
The ward moved into its present accommodation in August 2009.
The ward area was specifically designed for the client group.
As part of the rehabilitation process, all patients are fully
dressed through the day.
Because all admissions are planned, there is no situation in
which single sex accommodation requirements would be
breached. The layout of the ward allows patients to move
rooms as their condition improves which enables both male
and female admissions to be managed. Maple ward would be
able to accept a husband and wife admission but they would
be either within two single rooms or in two separate bed bays.
However, the admission of two sisters or brothers could be
facilitated within one bed bay.
The combination of environment and care processes fully
supports the patients’ dignity and privacy. This is also
monitored through a discharge questionnaire. Analysis of
returns consistently demonstrates that patients and their carers
are appreciative of the environment and care provided.
3.10 Compliance with NICE guidance
There were 96 pieces of NICE guidance published in
2011-12, of which 16 were deemed applicable to Locala
services and distributed accordingly. All services provided
assurance of compliance.
However, from 2012, the way in which Locala handles NICE
guidance will change ensuring an even more robust process for
the implementation, monitoring and auditing of NICE guidance.
• NICE guidance will be formally received every two months
by the Audit and Effectiveness (A&E) Committee. This will
then be distributed to appropriate Service Managers and
minuted in the A&E Committee minutes.
• In future, rather than “compliance” being obtained,
“reassurance” from Service Managers that the guidance
is being discussed with clinicians in team meetings and
applied if clinically indicated will be the Locala way to
address NICE guidance.
• These team discussions must be recorded in the minutes
of team meetings. When teams identify barriers to
implementing the guidance, it must be included in the
team’s KORS (Key Opportunities and Risks) at the Service
Review meetings. Action plans from service reviews will then
inform future actions.
• Where services are not able to apply the guidance (for
example cost issues, not currently commissioned to provide
an aspect of a service etc) a NICE self -assessment tool must
be completed and forwarded back to Governance for review
at the subsequent Audit and Effectiveness Committee.
• Exception reports will then be provided to Commissioners
after each Audit and Effectiveness Committee.
Quality Account 2011/12
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Locala Community Partnerships
23
3.11 NICE Quality
Standards
3.13 Hand Hygiene
Studies show that infection rates can be reduced by 10-50% when healthcare
staff regularly clean their hands. The introduction of alcohol hand rub has
been important in improving hand hygiene compliance in healthcare and is
recommended for routine use in the clinical environment when hands are not
visibly soiled. Alcohol hand gel at the point of care is critical in increasing the
likelihood that staff will clean their hands at the appropriate times. All staff are
provided with community hand hygiene packs for home visits.
The standards are sets of specific
statements that act as markers of
high quality, cost effective patient
care, covering the treatment and
prevention of different diseases
and conditions. They are developed
from the best available evidence
in partnership with NHS and social
care professionals and service users,
and address the three dimensions of
quality: clinical effectiveness, patient
safety and patient experience.
The National Patient Safety Agency (NPSA) developed the ‘clean your hands’ campaign
which was extended to community services in 2008. All staff are required to provide
clinical care ‘bare below the elbows’. This has been included in our Clinical Dress Code
policy. Audit tools which measure compliance with hand hygiene requirements include
the ‘bare below the elbows’ requirement. During the past year, staff compliance across
all our services with these standards has been 99%.
Of the 13 standards published during
2011-2012, we have determined that five
have some relevance to the services we
provide. The relevant services are actively
considering our compliance against
these standards. During 2012-2013, we
will be working with our commissioners
and colleagues from other organisations
to ensure that we are able to provide
evidence that our patients are receiving
high quality care.
3.12 Health Care
Associated Infections
Effective infection prevention and
control is essential to ensure the
safety of patients in our care, through
avoiding Healthcare Associated
Infections (HCAIs), as well as providing
excellent patient experience. We
are proud of our infection control
achievements, some of which are set
out below:
In addition, in 2009-2010 we introduced a monitoring tool for use by staff undertaking
catheter care. This has been further enhanced by the introduction of electronic care
plans for urinary catheter insertion and continuing catheter care and catheter training
for all clinical staff. Compliance with these standards for the last year has been 99%. A
simple guide for catheter hygiene has also been developed for carers, home care and
care home staff for patients in their own homes which have to be signed and dated
daily by the carer.
Where compliance against these standards has not been demonstrated, additional training
is provided with close monitoring until compliance has been consistently achieved.
A patient held catheter passport is currently being developed across the health
economy to improve urinary catheter management.
3.14 Methicillin-resistant Staphylococcus Aureus
(MRSA)
We were set a target by NHS Kirklees of no more than two cases of MRSA during
2011-12. No patients receiving care from Locala Community Partnerships were
diagnosed with an MRSA bacteraemia during the year.
3.15 Screening patients for MRSA
Mandatory screening of all patients admitted to intermediate care beds and
patients undergoing podiatric surgery was introduced in 2009 in line with
Department of Health policy. During 2011-12, of the 101 patients screened in
day surgery, only one was positive; 236 patients were screened on Maple Ward
of whom four were positive for MRSA. Performance against this standard is
monitored on a monthly basis with a consistent 100% compliance.
3.16 Clostridium Difficile
Incidence of Clostridium Difficile is also monitored closely. We were given a
target of no more than seven cases. During the year, three patients have been
diagnosed as having Clostridium Difficile whilst in the care of our services. In
each case, an in-depth review has been undertaken and recommendations for
improvement implemented.
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Quality Account 2011/12
3.17Norovirus
There have been no outbreaks of diarrhoea and vomiting in the ward at Holme Valley Memorial Hospital during 2011-12
and the ward has remained open for admissions throughout the year. (An outbreak is defined as two or more connected
patients with the same symptoms).
3.18 PEAT (Patient Environment Action Team)
PEAT is an annual assessment of inpatient healthcare sites in England with more than 10 beds. The assessment was
started in 2000 and has been managed by the National Patient Safety Agency (NPSA) since 2006. It is a benchmarking tool
to ensure improvements are made in the non-clinical aspects of a patient’s healthcare experience. It highlights areas for
improvement and shares best practice across the NHS.
The annual assessment took place at Holme Valley Memorial Hospital in January 2012. The team included a non-executive director
and a representative from the hospital’s League of Friends. Scores from all organisations are submitted to the National Patient
Safety Agency and are available on the NPSA website: www.nrls.npsa.nhs.uk/patient-safety-data/peat
Results
Year
Environment
Food
Privacy and dignity
2012 (provisional)
Good
Good
Excellent
2011
Good
Good
Excellent
2010
Good
Excellent
Good
2009
Good
Excellent
Excellent
3.19 Compliance with National Target for 18
weeks from referral to treatment
The 2004 NHS Improvement plan set out the concept that no-one would have
to wait longer than 18 weeks from GP referral to treatment. This target applies
to services that provide assessment and treatment but which may need to refer
onwards to a consultant led service.
Over the year, 100% of the relevant services were compliant with this approach.
Across these services, the average waiting time was three weeks.
Quality Account 2011/12
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Locala Community Partnerships
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Section four: Appendix 1
Quality
priority
Long Term
Conditions
End of Life
Care
Vulnerable
children
26
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
People with a Long Term
Condition have a single
personalised care plan
57%
78%
91%
97%
90%
100% of Patients identified as
being End of Life are on the
End of Life Care Register
100%
100%
100%
100%
100%
Percentage of patients that
died whilst on a Liverpool Care
Pathway or equivalent
29%
25%
22%
28%
>/= 30%
Percentage of patients who
died on an end of life pathway
with an advanced care plan
8%
7%
6%
12%
>/= 50%
Percentage of patients that
died on an end of life pathway
with an identified preferred
place of death
39%
40%
45%
56%
80%
Percentage of patients on
an end of life pathway who
achieved preferred place of
death
55%
68%
68%
81%
90%
Percentage of patients who
have had carer support offered
Not
collected
3%
13%
32%
85%
CAFs for 0-5 year olds are
initiated by health professional
79%
53%
71%
35%
85%
CAFs for 6-11 year olds are
initiated by health professional
24%
43%
52%
6%
44%
CAFs for 12-18 year olds are
initiated by health professional
21%
35%
20%
20%
41%
CAFs for 0-5 year olds led by
health professional
64%
72%
71%
33%
45%
CAFs for 6-11 year olds led by
health professional
27%
52%
57%
11%
41%
CAFs for 12-18 year olds led by
health professional
21%
21%
21%
16%
41%
Percentage of CAFs initiated
and the GP informed
100%
100%
100%
100%
100%
Aim
Improving
and sharing
personalised
care plans
for patients
with long
conditions
Improving
the quality of
palliative care
Increase the
use of the
Common
Assessment
Framework
(CAF) for
vulnerable
children
Objectives
Locala Community Partnerships
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Quality Account 2011/12
(2011/12)
(2011/12)
(2011/12)
(2011/12)
Target
Quality
priority
Aim
Child
protection
supervision
Maintain high
levels of Child
Protection
Supervision
given to
staff that
have regular
contact with
children,
young people
and parents.
Nutrition
Pressure
ulcers on
community
wards
Pressure
ulcers in nonward areas
Achieving
best practice
standards
as set out in
Essence of
Care
Improvement
in pressure
ulcer
prevention
and
management
in line with
Essence of
Care
Reduction in
the number
of pressure
ulcers
requiring care
within the
community
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Staff who are eligible for child
protection supervision have
child protection supervision
within each quarter
97%
93%
93%
99%
95%
Admitted patients who
underwent nutritional
screening within 24 hours of
admission
100%
100%
100%
100%
100%
Percentage of patients
managed in accordance with
Essence of Care over 65yrs
100%
100%
100%
100%
100%
100% of patients with a grade
III pressure ulcer or above
have had a root cause analysis
investigation
None
100%
None
None
100%
No patients acquiring a
pressure ulcer within 10 days
of admission to the ward
None
None
None
None
<5%
< 19 patients with one or more
pressure ulcers, with the highest
ulcer having NICE Trigger Grading
III in quarter four.(Cumulative
figure for the quarter)
51
37
33
41
<19
<5 patients with one or more
pressure ulcers, with the highest
ulcer having NICE Trigger Grading
IV in quarter four. (Cumulative
figure for the quarter)
16
15
14
16
</= 5
21%
16%
64%
95%
100%
Objectives
100% of root cause analysis
investigations undertaken for
patients with NICE Grade III
pressure ulcers and above.
(2011/12)
(2011/12)
Quality Account 2011/12
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(2011/12)
(2011/12)
Target
Locala Community Partnerships
27
Quality
priority
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
80%
76%
72%
70%
70% reduction in the incidence
of all grades of pressure ulcers
by 31st March 2012
314
323
360
269
-
> 3%
> 11%
< 25%
100% reduction in community
acquired pressure ulcers of
grade 3 and 4.
17
13
37
23
24%
reduction
54%
increase
38%
reduction
reduction
100%
100%
100%
100%
Aim
Objectives
100% of all patients to have
had a Waterlow Pressure Ulcer
risk Assessment
Incidence
of pressure
ulcers
Reduce the
incidence
of all grades
of Pressure
Ulcers
100% of incident forms to be
completed for Grade III & VI
28
(2011/12)
100%
(2011/12)
Chronic
wound
infections
To reduce
the risk and
incidence
of chronic
wound
infections
leading
to wound
related MRSA
bacteraemia
infections
A reduction in the number of
admissions related to chronic
wounds
Patient
experience
surveys
Improve the
responsiveness
to personal
needs of
patients
Increased positive scores
across six questions by
September 2012
92%
92%
Early
assessment
of dementia
Early
assessment
and diagnosis
of dementia
to improve
the quality
of care for
patients with
dementia
59% of all patients on
community services caseload
aged 65 yrs or over have
received a dementia assessment
by Quarter 4 2010-11
54%
64%
(2011/12)
(2011/12)
Target
100%
70%
reduction
100%
patients with a chronic wound - No admissions
Locala Community Partnerships
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Quality Account 2011/12
17
179
284
363
no target
97%
98%
Positive
increase
Aspiration
100%
69%
72%
59%
Quality
priority
Aim
Discharge
care
planning
Maintaining
more people at
home through
movement
towards
a multidisciplinary
approach to
discharge
planning with
patients and
carers fully
involved and
informed along
the process.
Single Point
of Access/
Rapid
Response
Trained health
professional
response
within 1 hour
will lead to
improved
quality of
care for and
outcomes for
patients in
crisis
Objectives
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Average
LOS 30
days
Average
LOS 27
days
Average
LOS 28
days
Average
LOS 24
days
(2011/12)
20% reduction in length of
stay (LOS) through effective
discharge/care planning by
Quarter 4 2010-11
Quarter 4 2010-11
baseline = 28 days
>7%
4
(2011/12)
3.5%
reduction
6
(2011/12)
0%
4
(2011/12)
14%
reduction
9
re-admission
re-admission
re-admission
re-admission
0%
reduction
50%
increase
0%
reduction
125%
increase
20% reduction in readmissions Quarter 4 2010-11
Quarter 4 2010-11
baseline = 4 re-admissions
Patients in crisis receive a
response from a trained health
professional within 1 hour in
Quarter 3 & 4 2010-11
92%
89%
Quality Account 2011/12
94%
|
96%
Target
Reduction
of 10% by
quarter 3
20% by
quarter 4
100%
with a
tolerance
of 10%
Locala Community Partnerships
29
Section five: Statements
5.1 Statements from our Stakeholders
5.1.1 Kirklees Local
Involvement Network
5.1.3 NHS Kirklees
Kirklees LINK would like to compliment
the reporting of information in the Locala
Community Partnerships Quality Account
2011-2012. The Kirklees LINK would
like to see service user experience and
participatory involvement as a core priority
and the publishing of equality impact
assessments for the complaints procedure.
It is also encouraging to note that data
information on ethnicity coding is being
updated for the service user population.
NHS Kirklees, operating as the lead commissioner for planning and purchasing
healthcare services from Locala, welcomes the opportunity to receive and comment
on the very first Locala Community Partnership quality account for 2011/12.
The account is a comprehensive and detailed assessment of the provider’s approach
to quality, and highlights the organisations ongoing commitment to delivering safe
effective patient care. The published account is a well produced and accessible
document that details their assessment of quality in 2011/12 and clearly highlights
Locala’s priorities for quality improvement for 2012/13.
To the best of our knowledge, through contract monitoring and Clinical Quality Board
arrangements the information provided is accurate. It describes the work the Locala
has undertaken to address its key priorities, acknowledging where aspirations have
not been met, and improvement has been less than anticipated.
The Quality Account describes the proactive work Locala has undertaken to address the
key quality priorities and we are pleased to note the progress and improvements made,
particularly around outcomes of targeted intervention of the Community Nursery
Nurses and the single personalised care plan for people with long term conditions.
5.1.2 Kirklees Wellbeing and
Communities Scrutiny Panel
(No comment received)
We also note that in some areas, whilst there have been some improvements,
targets have not been met due to data collection issues. These priorities have been
continued within the 2012/13 improvement priorities and therefore progress will be
monitored through the Clinical Quality Board.
The commissioners note the inclusion of the financial achievement of the 2011/12
CQuINs scheme but would like to see this section extended to include an overview of
the 2012/13 scheme.
Ensuring a clear focus on quality outcome measures (both clinical and patient
reported) within the Quality Account has been a clear challenge for Locala, and
whilst, as Commissioners, we welcome the progress that Locala has made during
2011/2 in developing an overall outcome focused approach, we look forward to
working closely during 2012/13 to further develop this key aspect of understanding
the quality of care provision particularly around the district nursing service.
We note that Locala is able to report on the number of complaints and aims to
investigate complaints within specific timeframes, resolving at service level where
possible. An area for development identified from the review of the Quality Account
would be to define and evidence how the investigation process is used to implement
lessons learnt and risk reduction programmes.
We are supportive of the approach Locala has taken to identify its key priorities for
2012/13, building on areas identified in previous years. The approach indicates the
continued commitment of key leaders to improving the quality and safety of services.
As commissioners we will continue to work with the Locala to improve the quality of
services for the local community, and intend to regularly monitor and hold the Locala
to account to deliver their key priorities.
30
Locala Community Partnerships
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Quality Account 2011/12
5.1.4 NHS Greater Huddersfield Clinical Commissioning Group
This has been an evolutionary year for Locala. I have been impressed with the way
their community based staff have been wholeheartedly committed to the delivery
of quality care to patients when all around them was changing. This fledgling
organisation is continually striving to improve its services and we look forward to
working with them in shaping the future healthcare system in Kirklees going forward.
5.1.5 NHS North Kirklees Clinical Commissioning Group
Overall a very positive start for Locala and encouraging performance in many areas
shown. Welcome the focus on quality and patient experience. Covers a range of
local and national areas showing increasing performance and achievement. Specific
comments on:
5.2 How to provide
feedback on this Quality
Account
If you would like to request a copy of
this document in an alternative format
or other language or have any queries
about its content, please contact the
Customer Liaison Team:
Tel: 01924 351531
Email: gwen.ruddlesdin@locala-cic.nhs.uk
This report is also available at locala.org.uk
Priority 4 - I would have thought the aim would be to ensure 100% achievement
Priority 5 - I would think the aim should be to achieve a much higher positive
patient experience than 50 % stated though not sure what figure represents a good
benchmark
Page 14 - what is the target % to be achieved and timescale for improvement re data/
IG governance
Page 18 - re: complaints, I note a significant increase in both podiatry and district
nursing - would be good to comment further on these as to why and what types of
complaints there have been and whether trends been identified and actions taken to
address them. Also note increased number re staff attitude and wondered why and
what’s being done to address this.
Page 26 - re: end of life care, note lack of significant improvement in some areas re
Liverpool care pathway and end of life planning whilst seeing improvement in other
aspects - some comment on reasons for this and action plan to address would be good
Page 28 - note comments on dementia screening being 59% - comments on plan to
increase and action on positive findings/referral process would be useful
Page 29 - unless I am reading figures wrong there has been an increase in readmission
rates rather than the aim of reduction - comments on this would be appropriate.
Quality Account 2011/12
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Locala Community Partnerships
31
June 2012 GD4859