North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts
2011/2012
Your feedback
We want our Quality Account to be a dialogue between North Somerset
community partnership and our patients, members of the public and other
stakeholders.
To let us know what you think of the account, or to tell us what you think we
should be prioritising, please contact us in one of the following ways:
By email: qualityaccounts@nsomersetcp-cic.nhs.uk
By post: Penny Smith, Lead Clinician
North Somerset Community Partnership
Castlewood
Tickenham Road
Clevedon
BS21 9AX
Contents
Introduction
About Us………………………………………… 8
Part 3: Quality Strategy and
Priorities 2012/13
Quality Strategy……………………………… 40
Part 1: Quality Statements
Delivering the Strategy……………………… 41
Statement On Quality From The Chair………… 10
Our Quality Priorities………………………… 42
Statement On Quality From The Chief Executive…11
Part 4: Statements
Part 2: Our Quality
Achievements And Performance Primary Care Trusts………………………………??
Awards & Recognition For North Somerset
Communities Partnership Staff……………… 14
Enabling Quality………………………………
Through Workforce Capability………………
By Improving Our Facilities…………………
By Changing Our Service Model…………
17
17
20
21
Patient Safety…………………………………
Reduction In Falls……………………………
Medication Safety…………………………
Pressure Area Reduction……………………
Venous Thrombo Embolism………………
Managing The Deteriorating Patient………
Catheter Associated Urinary Tract Infection…
Mrsa…………………………………………
C. Diff………………………………………
Npsa Alert Compliance……………………
22
23
24
25
26
27
28
29
30
31
Local Involvement Networks ………………………??
Overview and Scrutiny Committees ………………??
Statement of Directors’ Responsibilities…………??
Part 5: Appendices
Appendix 1: Local Audits…………………………??
Appendix 2: Non Relevant National Audits………??
Appendix 3: CQUIN Goals…………………………??
Personal Care
Patient Survey……………………………… 32
Same Sex Accomodation………………… 33
Patient Environment Action Team………… 33
Clinical Effectiveness
Clinical Audit…………………………………
Clinical Research……………………………
Quality Improvement and Innovation………
Data Quality…………………………………
34
35
35
35
Performance Against National Targets……… 36
Information Governance……………………… 37
Registration with the CQC…………………… 37
Staff Survey…………………………………… 38
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
Introduction: About Us
North Somerset
Community Partnership
“Your Local Health Service”
About Us
This is the first North Somerset Community Partnership (NSCP) Quality Account.
October 1st 2011 marked an important step for us as we became a Social
Enterprise. Considerable planning led up to this important day and marked an
important step in demonstrating our commitment to delivering safe, clean and high
quality care and services to the population of North Somerset.
In the broadest sense, a
Social Enterprise is a business
whose objectives are primarily
social, and whose profits
are reinvested back into its
services or the community.
With no financial commitments
to shareholders or owners,
Social Enterprises are free to
use their surplus income to
invest in their operations to
make them as efficient and
effective as possible.
Social Enterprises come
in many shapes and sizes,
from small communityowned village shops to large
organisations delivering public
services; from individual social
entrepreneurs to multi-million
pound global organisations.
Social Enterprises are
distinctive from traditional
charities or voluntary
organisations in that they
generate the majority, if not
all of their income through the
trading of goods or services
rather than through donations.
The Social Enterprise model offers advantages for patients
and service users such as:
• The ability to involve patients, staff and service users in
designing the services they provide and tailored to the local
population
• The ability to benefit the whole community as well as the people
who would traditionally use their services.
• Offering the opportunity to deliver services in ways that are
flexible, non-bureaucratic and responsive.
• Staff having a stake in the organisation which experience has
shown means they are committed to the aims and values of the
organisation
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
Introduction: About Us
North Somerset covers an
area over 145 square miles.
It serves a very diverse
population ranging from
communities in the wealthy
suburbs on the outskirts of
Bristol, to rural villages and
the communities of popular
seaside towns. North Somerset
Community Partnership
shares its boundaries with
North Somerset Council and
works with a diversity of health
care providers. Community
Services are delivered from a
range of localities, including
Clevedon Community
Hospital, Weston General
Hospital, and a number of
community bases including
GP practices as shown. We
provide a total of 25 services
in our core area, including
community nursing and
therapies, children’s services
and learning disabilities. We
deliver a number of specialist
services including diabetes
nurses and a service that
works across Bristol and South
Gloucestershire supporting
patients with Lymphoedema
(swelling caused by impairment
to the lymph system). We also
have a community hospital in
Clevedon where we have 18
beds and are able to provide
rehabilitation and respite. A
range of outpatient services
are also delivered on that
site including a community
endoscopy service.
Changing Population
In 2009, the Office for National
Statistics estimated the
population of North Somerset
was 209,100 living in both
towns and rural locations.
The proportion of 0-15 year
olds (18.1%) is slightly lower
than the national average
(18.7%). The working age
population in North Somerset
(58%) is lower than the
national average. Older people
(over 60 for women and 65
for men) make up 23.8% of
North Somerset’s population
compared to 19.5% nationally.
Between 1999 and 2009, the
population of North Somerset
grew by 12%, with most
growth seen in the over 65
age group. In this period the
over 85’s grew by 32%. Most
North Somerset
Community Partnership
“Your Local Health Service”
of the population growth is
due to people moving to North
Somerset from elsewhere in
the UK. The number of births
has been increasing and at a
faster rate than the national
average.
By 2033, the population of
North Somerset is projected
to increase by 40%, with the
biggest growth expected in the
over 65’s, however increases
are also expected in children
and those of working age. By
2026, 13,400 homes are due
to be built, two thirds of these
in Weston-super-Mare and
Weston villages.
from 1.4% in 2001 to 3.7%
in 2007, below the national
average of 11.8%. There is a
substantial Gypsy, Roma and
Traveller population within
North Somerset.
North Somerset has the 11th
largest range of inequality in
the country.
The proportion of black and
ethnic minority groups (ethnic
groups other than white) in
North Somerset has increased
Quality Accounts 2011/12
9
Part 1
Quality Statements
Quality Statement from The Chair
Quality Statement from the Chief Executive
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
10
Part 1: Quality Statements
Statement on Quality
from Delyth Lloyd Evans, Chair
This Quality Account reinforces North Somerset Community Partnership’s
approach and commitment to embedding quality at the very heart of all we do.
I am pleased that it has been developed by engaging our front line staff and
encompassing the views of stakeholders and partners. It serves to reflect on our
significant achievements and provides cohesion about what quality means for
the services we provide to improve the health and wellbeing for the population of
North Somerset.
Members of the public,
patients and others will be able
to use the report to understand
new clinical developments and
plans for further enhancement
of services in the future. We
have been at the forefront
of providing some exciting
clinical innovations in particular
through the introduction of
community wards. This has
meant more patients are being
cared for outside of hospital by
an integrated team of nurses
and therapists with strong
links with social services.
North Somerset Community
Partnership staff have also
been recognised for their
North Somerset
Community Partnership
“Your Local Health Service”
significant contribution to the
Quality Improvement Patient
Safety Programme to enhance
clinical care for patients.
Within North Somerset
Community Partnership we
are committed to providing an
integrated approach to all our
services working in partnership
with our stakeholders across
North Somerset. To maximise
the impact of our workforce,
we have also invested in
developing the capabilities and
competences of all our staff.
We will continue to improve
clinical quality, where there
is a culture of continuous
improvement based on
partnership with staff, patients
and other stakeholders. As
a Social Enterprise we have
already made significant
progress and over the next
year have clear plans of what
we are trying to accomplish
with identified measurable
benefits.
I would like to extend my
appreciation to all staff within
North Somerset Community
Partnership for their passion,
hard work and commitment to
innovation and improvement in
services for the population of
North Somerset.
Quality Accounts 2011/12
11
Part 1: Quality Statements
Statement on Quality
from Penny Brown, Chief Executive Officer
I am delighted to present this first Quality Account from North Somerset
Community Partnership, our newly formed Social Enterprise following our
separation from North Somerset Primary Care Trust in October 2011. It builds on
the Quality Account published last year, and really demonstrates our commitment
to providing services of the highest quality for the population of North Somerset.
This account aims to provide
an honest picture of the quality
standards we have achieved
over the past year, it reviews
our achievements against our
quality aims for 2011/12 and
outlines our priorities for quality
improvement for 2012/13.
It is set out in three parts:
Part 1 is an introduction to
the account and confirms the
accuracy of the information
contained within it.
Part 2 describes how North
Somerset Community
Partnership addressed our
Quality agenda in 2011/12,
combining hard data with
wider descriptions of our
quality achievements, including
feedback from service users,
Quality Accounts 2011/12
and reviews progress against
our plans for 2011/12.
Part 3 outlines our priorities
for quality improvement for
2012/13 which will endeavour
to refresh and build upon
our previous achievements
in a more streamlined and
structured way.
Part 4 demonstrates how
we have communicated with
external organisations
Our overarching aim as an
organisation is to improve
health and wellbeing for the
population of North Somerset
through providing quality
services centred on individual
and community health need.
We have a firm commitment to
partnership working in order
to provide seamless services
for the population and over the
last year have been actively
engaged on care pathway
work with our local Acute Trust
which is Weston Area Health
Trust and North Somerset
Council.
We have delivered our
organisational change
programme and now deliver
our services from seven
multidisciplinary community
teams linking closely with
Social care. These teams have
brought together community
nursing and therapy services
and offer joined up care for
the patient by offering services
by the Right Person ( health
or social care professional
as appropriate) at the Right
North Somerset
Community Partnership
“Your Local Health Service”
12
Part 1: Quality Statements
Time ( in order to prevent
an unnecessary hospital
admission in the Right Place
(as near to home as possible).
We have had very positive
feedback from the people who
have used our services.
We recognise the links
between quality services and
the quality of our staff, and
the benefits of ensuring that
all our staff are appropriately
trained. We have invested in
five Professional Education
Facilitators to train our front
line staff in order that the
capabilities and competences
of our workforce are
maximised. We are further
developing our education and
training strategy to link with
our workforce plan which
ensures we are as efficient and
cost effective as possible.
Our commitment to high
quality, safety and value has
been paramount and we are
using our newly installed
information system RIO
as our clinical information
system as well as providing
activity detail. We are already
seeing the gains of having
a full understanding of all
practitioners involved in the
care of our patients, which is
enabling us to develop a key
worker approach.
We are particularly proud
of our involvement in the
Quality and Patient Safety
Improvement Programme
(QIPSI) and the Quality
Account provides the detail
of progress within the work
streams. It has been noted
by the South West Strategic
Health Authority that as a
community organisation we
have led the way with quality
improvements for our patients.
We have benefited from this
programme by working with
and learning from some of the
best organisations in the NHS
and internationally.
As a stand alone organisation
we are committed to finding
better and improved ways
to deliver services more
effectively, working in
partnership to meet the
financial challenges facing all
organisations. Quality remains
our absolute priority, and we
are working in partnership to
develop system wide care
pathways to deliver ever more
seamless care.
As a new organisation we have given consideration to our purpose, values and
aims which are defined as:
To improve the health and wellbeing of people
living in North Somerset by:
1. Providing a growing, sustainable range of local
healthcare services
2. Providing safe, effective and personal care
3. Helping people and families to be better at looking after
their own health
4. Supporting people to stay in their own homes and
avoid stays in hospitals whenever possible
through
5. Having a well trained workforce and being a good
employer
6. Working in partnership with our community to promote
good health
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
13
Part 2
Quality Achievments and Performance.
Last year we set ourselves three key priorities:
Maintain and improve the experience of our patients
To maintain and improve patient safety
To maintain and improve the effectiveness of our services
These priorities are threaded through the achievements set within this section.
Awards & Recognition For North Somerset Communities Partnership Staff
Enabling Quality
Patient Safety
Personal Care
Clinical Effectiveness
Performance Against National Targets
Information Governance
Registration with the CQC
Staff Survey
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
Part 2: Quality Achievements and Performance
14
Awards and recognition for North Somerset
Community Partnership staff
As part of our Quality Account we wanted to inform you of some of the awards
and recognition that our staff have been involved with over the past year. This
demonstrates our commitment and passion to continually strive to improve the
quality of care and the outcomes for our patients across North Somerset.
North Somerset Community
Partnership, Quality and
Patient Safety Improvement
Programme, the team that has
made the most progress in
the South West-a programme
that started in 2011 but we
hope will be never ending!
The team took part in the
Strategic Health Authority
(SHA) Celebration Event DVD
which was shown at an event
at the University of the West of
England in February 2012.
The Professional Educational
Lead was asked to speak
at the Health Innovation
Education Cluster which
comprised an audience of
700 people. Her topic was
the training needs analysis
that had been piloted for
Skills for Health. A training
needs analysis is an analysis
of the training, learning and
development needs of the
staff, volunteers and trustees
in an organisation
North Somerset
Community Partnership
“Your Local Health Service”
A generic support worker
from the Falls Prevention
and Management Service
spoke at an event hosted by
British Telecom at the London
Auditorium in August 2011
on the benefits of using a
‘Toughbook’ which is mobile
information technology,
to support working in the
community setting. She saw
some of the benefits as:• recording information at the
same time as completing a
care activity
• immediate ability to discuss
with the patient any open
referrals
• avoidance of duplication
• increased ‘quality time’ with
the patient
• improved assessment where
problems can be identified
and actioned immediately
• reduced need for future visits
• The Musculo-skeletal
Interface Team was chosen
as one of two teams out of 17
entries to take part in an NHS
South West Research project
‘no decision about me, without
me’ - implementing shared
decision making in the NHS.
This means that the team will
be working with internationally
renowned trainers and
researchers to test and
evaluate the decision making
quality that will be transferred
across all health conditions
and can be used to inform
improvement programmes for
frontline clinicians.
Praise was given to the Rapid
Response and Rehabilitation
team by a senior clinician
associated with care of
the dying, from outside the
organisation. She wanted it
noted that this team were
exceptional with responding
immediately to a crisis,
especially out of hours, when
the hospice team needed a
few hours to get to a patient.
This cooperation meant that
patients were able to stay in
their own home rather than
being taken to a hospital.
Quality Accounts 2011/12
15
Part 2: Quality Achievements and Performance
We were commended by the
SHA for our flu campaign
which ensured that we had
provided the opportunity
for our staff to receive a flu
vaccination. There was a
significant increase in the
levels we achieved this year in
the uptake of the vaccination
rising from 24.8% last year to
67.2%, placing us as second
overall in the region
The Department of Podiatric
Medicine received their
certificate of accreditation
from the Society of
Chiropodists and Podiatrists
for both clinic and domiciliary
services in January 2012.
The Head of Infection
Control has been working
in conjunction with Weston
Area Health Trust on a project
to reduce the number of
catheter associated urinary
tract infections (CAUTI) in
both the community and the
hospital. To date the project
has seen a 70% reduction
in patients with CAUTI being
admitted from the community
to the hospital. This work was
presented at the Infection
Prevention Society National
Conference in September
Quality Accounts 2011/12
2011 and internationally at the
‘All for None’ conference in
Minnesota in October 2011.
Community nurses presented
posters at the November
Wounds UK conference in
Harrogate. They each wrote
a case study charting the
management and progress of
a patient with a wound that
was complex and difficult to
heal. One of the case studies
monitored the progress over
four months of a distressing
and painful wound caused
by poor arterial circulation.
The case study demonstrated
how high quality care resulted
in significant improvement
in both the wound and the
patient’s quality of life. The
poster also included a patient
testimonial stating how much
the treatment had improved
their quality of life
In September 2011 NHS
North Somerset and NSCP
passed the second stage of
the UNICEF Baby Friendly
initiative accreditation process,
which assesses the quality
and standards that are in place
for delivering breastfeeding
care to pregnant women and
new mothers. The assessors
commended the high level of
knowledge and skill amongst
health visiting staff, which help
increase breastfeeding rates
and consequently the health
outcomes of children in North
Somerset
North Somerset Community
Partnership were finalists
in four categories of the
General Practice awards in
December 2011 in London.
The categories were Nursing
Team of the Year, Innovators of
the Year, Clinical Team of the
Year for both Respiratory and
Long Term Conditions
The Quality and Patient
Safety Improvement Team
were nominated by the SHA
safe care leads for their work
with the programme in two
categories. The categories
were ‘Whole Health Economy
Engagement’ as in two of
the work streams we had
demonstrated real team
collaboration across the whole
health community. The other
category was ‘Participation in
the Programme’ which was an
award for the team who had
demonstrated outstanding
engagement, for example,
in conference calls, learning
sessions, measurement
and contribution to regional
meetings.
North Somerset
Community Partnership
“Your Local Health Service”
Part 2: Quality Achievements and Performance
16
Each year NHS North Somerset host a staff awards ceremony at the Annual
Public meeting. During this year various community services won 5 awards and
demonstrated some of the excellent work which teams and individuals have
undertaken in the past year.
Housekeeping Team - the
housekeeping team at
Clevedon Hospital won
their award for the excellent
services they provide which
contribute to the quality of
the patient experience in the
hospital.
Community Team - Clevedon
Community Team won for their
implementation of Community
Wards and Teams. They
were recognised for the high
quality of the care delivered
whilst undergoing significant
organisational change
North Somerset
Community Partnership
“Your Local Health Service”
Most innovative individual - a
member of the podiatry team
won in recognition of the
work he had undertaken to
introduce a nail surgery pack
leading to the reduction in
post surgery nail infections.
An outstanding achievement
award was given to a
Specialist Practitioner for the
commitment and passion she
has shown for the work that
she does to improve both
health and life outcomes for
children and young people.
The Children’s Centre won
a best partner award for
the work they have done in
supporting breast feeding
and infant feeding in North
Somerset.
The award for the most
successful service
improvement initiative was
won by the End of Life
Facilitators for the work
they have done on raising
awareness and the choices
that people have when they
are at the end of their life.
Quality Accounts 2011/12
17
Part 2: Quality Achievements and Performance
Enabling Quality
Through Workforce Capability
Over the past year we have invested in service improvement and staff training
by significantly increasing and developing our service improvement team and a
professional development team. Both teams are working with front line staff to
ensure that we are improving the way we provide our services and that people
have the appropriate clinical skills to deliver high quality care.
The service improvement team
has increased from one to four
members and some of the
achievements include:• Developing a capacity and
acuity tool to ensure that our
staffing levels are matched
to the demands of each
service
• Working with staff in the
Community hospital to
reduce the length of stay and
develop the rehabilitation
patient pathways as well
as extending the range of
services provided within the
Minor Injuries Unit (MIU)
• Establishing an ‘ideas
factory’ so that great ideas
for service improvement
from frontline staff can be
supported and implemented.
Their approach is rooted in
working directly with teams
so that staff are fully involved
and have the opportunity
to develop their skills by
working with the Service
Improvement Managers. This
concept built on the formal
LEAN training that was
conducted during 2010/11.
Developing our workforce:
Over the last year we have invested in a number of leadership
development opportunities.
• Aspiring top leaders
• Emerging Leaders
• Level 2 award in team leading
• Level 3 diploma in first line management
In addition the following are also available:
• Coaching
• Occupational Health Services are available to NSCP staff;
• Counselling Service available to all NSCP staff;
• Policies in place to support staff and wellbeing;
• Individual Coaching and Mentorship
Quality Accounts 2011/12
Above: Some of the Band 7 and 8s on our Clinical
Leadership Programme
North Somerset
Community Partnership
“Your Local Health Service”
18
Part 2: Quality Achievements and Performance
Workforce Balanced Scorecard:
During 2011 - 2012, we reported on the following:
* Gender, age and ethnicity profiles for workforce
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
19
Part 2: Quality Achievements and Performance
Appraisals
For 2011 to 2012 North Somerset Community Partnership set a target of 100% for
performance appraisals for all permanent staff. By February 2012 we had achieved
64% of completed appraisals. The data below highlights these figures:
As we have not been
successful in reaching our
target we have explored
the reasons for this. We
concluded that our current
appraisal documentation was
cumbersome and not easy
to use. We are committed
to ensuring that all our staff
receive an annual appraisal
and are developing new
documentation which is easier
to use and relevant to our staff
groups. We will prioritise this
for the year ahead.
Mandatory Training
Sickness and Absence Levels
In 2011/12 we aimed to reduce ongoing sickness and absence rates to a target of
4.5%
Reporting, training and
support for managers in
the application of the policy
and the new processes has
resulted in a significantly
Quality Accounts 2011/12
reduced sickness absence
figure by March 2012.
For 2012/13: We will continue
to build on the progress we
have made so far and strive
to achieve our stretch target
of 3.7% for sickness absence
and 100% for staff appraisal.
North Somerset
Community Partnership
“Your Local Health Service”
Part 2: Quality Achievements and Performance
20
By Improving Our Facilities
As part of the ongoing
programme to improve the
facilities for our staff, NSCP
have made some significant
changes during the past year
One of our priorities has been
to improve accommodation for
staff across North Somerset.
One of the many advantages
of being a standalone
organisation is that we are
able to rapidly progress with
plans to re-locate members
of our Specialist Public Health
Nursing teams, currently
based at Worle Health Centre.
The first of these moves took
place in December 2011 with
several teams moving to a
dedicated office in Drove
Road, Weston-super-Mare.
January 2012 saw one of the
North Somerset
Community Partnership
“Your Local Health Service”
community ward teams based
at Worle Health centre relocated to the newly built St
Georges Health Centre.
More recently we moved the
Health Visitor/School Nurse
and Young Persons project
team from their old base at the
For All Healthy Living Centre,
Weston-super-Mare to a
newly refurbished office within
Badger House. This move has
not only improved the teams
working environment, but
allows for future expansion of
the team.
March 2012 was a very busy
period, with the completion
of the Worle Health Centre
refurbishment project. This
project was the catalyst for
another 3 team moves. The
first of these came about when
some of the Health Visitors
and School Nurses moved
from Worle Health Centre to
their new home at Partnership
House in Worle, this move saw
the team co-located with the
integrated learning disabilities
team.
Pier View Community Ward
team then occupied the office
left behind by the team moving
to Partnership House and
finally we saw some of our
Rapid Response colleagues
move from Castlewood,
Clevedon to Worle Health
Centre
All these moves ensure our
teams are evenly spread
across the region to provide
better support to the
community.
Quality Accounts 2011/12
21
Part 2: Quality Achievements and Performance
By Changing our Service Model
Set up of Community Teams and Wards
Each year in North Somerset,
there are 9,700 unplanned
hospital admissions, 6,000
of which are patients over
the age of 60, many staying
up to 3 nights. The average
cost in 2011/12 of a medical
admission with a length of
more than one night is £2000.
During their stay, patients
often undergo a series of
investigations but require no
high level clinical intervention
because in the past there were
insufficient community based
health services available to
meet their acute needs.
We have developed 7
multidisciplinary teams,
linked to small clusters of
GP practices, to help reduce
the number of unnecessary
admissions, allowing patients
to be cared for in their own
homes.
Within each community teams
is a 'virtual' community ward
providing specialist acute
clinical care for patients at
high risk of admission to
hospital. Patients admitted
to a community ward will be
cared for at home, visited
up to 4 times per day by a
group of multi disciplinary
professionals with extended
clinical assessment,
examination and prescribing
skills.
Aim: Reduce unnecessary admissions to hospital
How much: 7 Community Teams / Wards impacting by November 2012
Project status: Commenced November 2010
Progress: Phase 2 implementation commencing April 2012
Key Milestones
Improvements Identified Include:
• 7 multidisciplinary community teams and
wards operational by November 2011
• Improved patient and carer experience
• Patients who would normally have been
admitted to hospital now cared for at
home by the most appropriate health care
professional
• 24 hour health and social care available
including short term packages of social care
as required
• Close working with GPs, social care,
ambulance service and acute hospitals
• Capacity to care for up to 35 acutely ill and
high risk patients
• Daily Board Rounds to discuss ward patients
• Care closer to home
• Reduced hospital admissions thereby lower
the risk of infection and falls
• 13% reduction in emergency medical
admissions
• £700,000 saving on hospital costs
• Improved integration of health and social care
including Ambulance services
• Better understanding of the needs of the local
population
• Less duplication of services (right person, right
time, right place)
• Access to a wide range of specialist services
including Mental Health, Speech and
Language and Intravenous Therapy
• Access to short stay Safe Haven beds in the
Community Hospital or independent sector
nursing homes should they be required
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
Part 2: Quality Achievements and Performance
22
Patient Safety Projects
Over the last year we have prioritised a number of Quality Improvement Projects
these are outlined below:
Quality and Patient Safety
Improvement Programme
(QIPSI)
We aim to be, and are at
the the forefront of quality
improvement knowledge and
learning. With this in mind
we have been taking part in
the South West Quality and
Patient Safety Improvement
Programme which focuses on
increasing the quality of care
received by our patients.
The aim of this initiative sits
well with our new Quality
Strategy. We know that
avoidable harm occurs within
healthcare settings, so we are
dedicated to building a culture
where all staff work together
toward zero tolerance to
avoidable harm.
Case Study: Jo Keen
programme in
and Safety Patient Improvement
I became involved in the Quality
y recognition
work stream aiming to improve earl
November 2011. I am part of the
ient.
and rescue of the deteriorating pat
clinical
been designing and testing a new
Part of this exciting journey has
n, ensuring a
ratio
erio
det
staff to early signs of
observation chart, which alerts the
of preventing
aim
rall
ove
quick response with the
in full use
is
form
The
.
hospital admissions
in the
but
l
pita
hos
ity
at our Commun
its use
ting
pilo
still
are
community we
work
the
ing’
ead
‘spr
at
but looking
wider.
Working on this programme has
been both an inspiring and positive
lth
experience. The Institute for Hea
d
vide
pro
has
)
Improvement (IHI
us with useful tools that will be
transferable to other areas of
improvement and we look forward
to continuing the great work we
have started.
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
23
Part 2: Quality Achievements and Performance
Achievments: Reduction in Falls
Scrutiny of patient stories illustrates the anxiety and distress that in patient falls
cause for both patients and their families. Clevedon community hospital is working
on a project to reduce their number of falls.
What: To reduce serious harms from falls
How much by: 50%
By when: 2013
Outcome:
Work stream in place
Progress : On track
Improvements achieved
We set an organisational aim to increase
awareness of falls within the hospital and to flag
those patients most at risk by introducing quick
risk assessment tools, colour coded walking
aids and report falls on handover ‘hot sheet’.
All patients admitted to the hospital have a
falls risk assessment undertaken on admission;
this helps us identify those who are at higher
risk of falling. If patients fall into this category
they have a further extended assessment to
determine what were the extra trigger factors for
their falls.
Further Improvements
identified:
Colour coded
walking aids:Green - Independent to walk
unsupervised
Yellow -To walk with supervision
Red - To walk with assistance
(1 red tag with 1 person,
2 red tags with 2
people)
Blue - Additional support
required at night time
Black- Patients to transfer only
We will develop this work further within the
community teams and care homes
Introduction of ‘intentional rounding’ (comfort
rounds) which involves reviewing patients at
regular intervals, especially those at higher
risk, based on key safety issues, for example,
changing their position, toileting, offering a drink,
asking about any pain they may have.
Ensure the patients who are deemed as higher
risk of falls when they are discharged home are
referred to the Falls Service.
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
Part 2: Quality Achievements and Performance
24
Medication safety
We are continually reviewing the ways we work to make sure that medicines are used in the safest
and most effective way for patients within our services. We aim to introduce more ways of working
that reduce the chance of harm with medicines and ensure there are reliable processes for using
medicines.
What: 95% of patients have medication reconciliation
within 24 hours of admission
How much:95%
By when: By 2013
Outcome: Work stream in place
Progress: On track
Improvements achieved
• The guidance for staff on how medicines are
used within all services has been reviewed
and updated
• We have set up systems to make sure we are
‘getting medicines right’ for patients when
they are admitted to the Community hospital.
This helps to make sure that there are no
unintentional changes to patients medicines
when they move from home into hospital.
• All medication errors are investigated and
plans put in place to prevent them happening
again.
• New systems have been introduced so
that housebound patients on warfarin
(anticoagulation therapy) can have a quicker,
less painful blood test
• Further training for nurses has been provided
to enable some patients to have infections
treated at home, rather than having to go into
hospital
• A Medicines Management Group has been
set up to make sure that there is a standard
approach across the organisation that looks
at all areas where medicines are used
• We have set up systems to monitor how
controlled drugs are used within our services
North Somerset
Community Partnership
“Your Local Health Service”
Further Improvements
identified
• We plan to review the paperwork that staff are
using to make it easier and quicker to record
when medicines are used
• We are reviewing how medicines in the
Community hospital are stored and given
to patients to make sure that the correct
medicines are given to the right patients.
• We are reviewing how medicines in the
Community hospital are given to patients and
looking to introduce systems to allow suitable
patients to manage their own medicines
whilst they are inpatients. Alongside this, we
will also be reviewing how patients receive
information about their medicines
• We will be spreading the systems for ‘getting
medicines right’ into community teams, so
that patients in their own homes also benefit
from these improvements.
Quality Accounts 2011/12
25
Part 2: Quality Achievements and Performance
Pressure Area Reduction
Pressure ulcers are areas of localised damage to the skin and underlying tissue caused by
pressure, shear or friction, or a combination of these. Although some pressure sores are
unavoidable, it is clear that many can be avoided.
What: Reduce pressure ulcers in the hospital and
community
How much: 30% reduction in community
By when: 2013
Outcome: work stream in place
Progress: Behind schedule-due to increased awareness
reporting figures are high, this will be a major
priority for 2012/13
The Tissue Viability Service is
leading care of and prevention
of pressure ulcers within
North Somerset Community
Partnership.
An audit of pressure ulcers
identified that:• Reporting was insufficient
• Whilst care for the more
complex ulcers was good,
the care for category 1&2
ulcers was not so good
• Nutritional assessment was
lacking
• There was also a need to
carry out root cause analysis
to capitalise the learning
What improvements did we
make?
• Developed a steering group
• Introduced a robust
reporting system to capture
all our pressure ulcers
• Introduced a training
programme to enable staff
to prevent harm.
• Developed simple visual
cards for community nurses
to give to patients that
are at risk of developing
pressure ulcers. These cards
give simple prompts to the
patient/carer on pressure
Quality Accounts 2011/12
Action for identified High Risk
P = Pressure Points
Inspect the areas of skin that are near to the bone as
often as your nurse suggests which will be at least
three times a week.
R = Red –Report it
Report at once any painful areas and new red marks
that do not disappear after 20 – 30 minutes.
O = Oral Intake
It is important to eat a balanced diet and drink plenty
of fluids. Seek advice PROMPTLY if this is not
possible.
M = Moisture
Keep the skin clean and dry. Use barrier cream if
needed.
P = Posture
Be aware of your posture. If your position is causing
pain on the areas of skin close to your bones seek
assistance. Poor posture can contribute to the
development of pressures ulcers.
T = Take pressure off
Change position 2-4 hourly. If you are unable to do
this pressure-relieving aids may be needed. Please
contact your nurse.
PRESSURE needs PROMPT
action
Identified as at high risk
Pressure Points
Red – Report it
Oral Intake
Moisture
Posture
TAKE PRESSURE
OFF
Pressure ulcers are serious wounds and skin can quickly
break down.
Seek advice PROMPTLY if unsure
Contact Number…………….
ulcer prevention according
to the level of risk
• Developed standard
guidelines for the nursing
record which direct the
nurses in the best practice
• Produced a pressure ulcer
policy
• Updated the pressure ulcer
guidelines
• Introduced a competency
framework for assessing
pressure ulcer prevention
and management nursing
skills
• Developed a patient
education leaflets on the
© S Humphreys, North Somerset Community Partnership 2011
prevention of pressure ulcers
and looking after your skin
What next?
• A public health campaign
- We are developing a
pressure ulcer awareness
card for individuals at risk
of pressure ulceration with
the backing of the Queens
Nursing Institute and the
Burdett Trust for Nursing.
• Rolling out a programme of
training and assessment of
competency in wound and
pressure ulcer management
to all trained nurses.
North Somerset
Community Partnership
“Your Local Health Service”
26
Part 2: Quality Achievements and Performance
Venous Thrombo-embolism
Venous Thrombo-embolism (VTE) is a term that covers both deep vein thrombosis and its
possible consequence: pulmonary embolism (PE). A deep vein thrombosis (DVT) is a blood clot
that develops in the deep veins of the leg and if the blood clot becomes mobile in the blood
stream it can travel to the lungs and cause a potentially fatal blockage (PE). In 2005, the House
of Commons Health Committee reported that an estimated 25,000 people die from preventable
hospital-acquired VTE in the UK every year. The risk of hospital-acquired VTE can be greatly
reduced by risk assessing patients and prescribing them appropriate prophylaxis (preventative
measures).
What:
95% of patients have a documented risk
assessment for venous thrombo-embolism and
those at risk will be prescribed medication to
prevent blood clotting.
How much: 95%
By when: By 2013
Outcome Work: Stream in place
Progress On track
Improvements achieved
• Monthly reporting on compliance with VTE
risk assessments.
• Introduction of training to ensure staff
understand how to complete the risk
assessment
Further Improvements
identified
• Following discussion with GPs it was decided
to insert the risk assessment tool into the
drug chart and the GP will work with the VTE
nurse to achieve this
• Explore the opportunities for conducting
VTE risk assessments on patients in the
Community wards
• Collaborative working with Partner providers
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
27
Part 2: Quality Achievements and Performance
Managing The Deteriorating Patient
Early recognition and management of a patient who is becoming unwell is vital for safe care.
With more acutely ill patients being managed in the community it is essential we have systems to
escalate if they deteriorate.
Improvements achieved
This work stream has developed an early
warning observation tool for use in the patients
own home. The team have trained staff in
the use of the observation tool. The Strategic
Health Authority (SHA) has noted this work
as innovative in its approach. The work was
featured in the DVD that was used at the SHA
‘Celebration Event’ at the University of the
West of England in February 2012.
Quality Accounts 2011/12
Further improvements
identified:
• Spread to all community wards and Clevedon
Community Hospital
• Roll out of the relevant measure to
understand our levels of implementation
• Include in the training programme for clinical
assessment of patients
North Somerset
Community Partnership
“Your Local Health Service”
Part 2: Quality Achievements and Performance
28
Catheter Associated Urinary Tract Infection
Cather Associated Urinary Tract Infection is one of the most common types of care acquired
infection. By reducing the number of people with catheters in place we aim to reduce this type of
infection.
What: Reduction of Catheter Associated Urinary
Tract Infections (CAUTI)
How much: 50%
By when: By 2013
Outcome: Work stream in place
Progress: On track
Improvements achieved
We have been working in collaboration with
Weston Area Health Trust (WAHT) on this
project and has seen a significant reduction
in CAUTI in patients being admitted from
the community into the hospital. The project
involved a joint evaluation of the anti-infection
release NF silicone catheter which releases
nitofurazone, a non-systemic antibacterial
agent into the urethral tract. A small working
group was established with staff across acute
and community boundaries to drive the change
in clinical practice and oversee measurement.
After initial roll out in the acute setting, roll
out within the community started in WestonSuper-Mare and 74 community patients have
so far had the new Release NF catheters.
Provisional results suggest a 70% reduction
in hospital admissions due to community
acquired infections and no infection has been
identified in those having the catheter.
Further improvements
identified
The work to continue and spread across North
Somerset from the Weston area, and to involve
the care home settings.
This project demonstrates excellent working
across both primary and secondary care. This
work is now being shared with colleagues
across the South West.
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
29
Part 2: Quality Achievements and Performance
Meticillin Resistant Staphylococcus Aureus (MRSA)
MRSA is a well known health care associated infection. It is estimated that 3% of people carry
MRSA harmlessly on their skin but for hospital or community patients the risk of infection may
be increased due to wounds, or invasive treatments which make them more vulnerable. Serious
MRSA infection may result in MRSA blood stream infections (bacteraemia).
What: To sustain a reduction in preventable MRSA
blood stream infections (bacteraemia)
How much: Target for 2011/12 for Clevedon hospital was 0
By when: March 2012
Outcome:0
Progress: Target achieved
Improvements achieved
• We have sustained a low infection rate at the
community hospital
• We have exceeded three years at the
Community hospital without an MRSA
bacteraemia
• We screen all our admissions for MRSA
• We conduct root cause analysis on all cases
of MRSA notified to the hospital
Quality Accounts 2011/12
Further improvements
identified
• All patients will be nursed in single rooms
in the new Community hospital in Clevedon
(CCH)
• We will encourage local ownership of
infection data. All staff at the hospital will be
aware of the number of infections acquired
in their areas and will know what their local
reduction targets are and their performance
against these.
North Somerset
Community Partnership
“Your Local Health Service”
30
Part 2: Quality Achievements and Performance
Clostridium difficile (C. diff)
Clostridium difficile is a common cause of healthcare associated diarrhoea. It is a bacteria that ia
harmlessly present in the bowel of about 3% of healthy adults, and up to 30% of elderly patients.
When certain antibiotics disturb the balance of bacteria in the gut, Clostridium difficile can multiply
rapidly and produce toxins which cause diarrhoea and illness
What: To sustain a reduction in preventable
Clostridium difficile infections
How much: Target for 2011/12 was 2 cases
attributed to CCH
By when: March 2012
Outcome: Target achieved
Improvements achieved
• Medicines Management have conducted
an antibiotic prescribing audit for all GP
practices across North Somerset, the results
of which are fed back to the practices
• Any patient with symptoms of diarrhoea are
isolated immediately
• All patients who have a diagnosis of C diff
undergo a root cause analysis to ensure that
the case is not attributable to any practice
within Clevedon Community Hospital
North Somerset
Community Partnership
“Your Local Health Service”
Further improvements
identified;• New Medicines Management Committee
being set up for NSCP
• We will continue to encourage local
ownership of infection data. All Clevedon
Hospital staff will be aware of the number of
infections acquired in their area and will know
what their local reduction targets are and their
performance against these.
Quality Accounts 2011/12
31
Part 2: Quality Achievements and Performance
NPSA Alert Compliance
Central Alerting System
The Central Alerting System (CAS) is designed to give healthcare organisations rapid access
to a variety of Patient Safety notices over such issues such as Medication and medical
devices. Since 1st April 2011 there have been 158 CAS alerts issued and previously these were
administered across the PCT. Since the creation of the Social Enterprise on the 1st October 2011
the company has created its own system for distribution and implementation. The CAS Liaison
Officer for the organisation, monitors the system and distributes Alerts within the prescribed
timescales. CAS ALERTS ISSUED FROM APRIL 2011 – MARCH 2012
Reference
Alert Title
Issue Date
Response
Deadline
Date
Compliance
achieved
Medical Device Alerts
MDA/2011/033
Optilube lubricating jelly supplied
as 150 x 5g sachets per box. Lot
25092010. NHS Supply Chain
code EXC027. Manufactured by
Optimum Medical Solutions
07.04.2011
Disseminated to
staff for information
but not used by
community teams
21.04.2011
20.04.2011
MDA/2011/037
Sterile urine drainage bags –
various volumes, tube lengths
and presentations. Manufactured
by Unomedical a/s (a Conva Tec
Company). Specific product codes
and lot numbers.
14.04.2011
Information
disseminated, batch
numbers checked
and bags disposed
of.
12.05.2011
20.04.2011
MDA/2011/068
Needle-free intravenous
connectors. All manufacturers. All
models
15.06.2011
May be used
in connection
IV infusions of
antibiotics in
Community.
Disseminated to
teams
13.07.2011
04.07.2011
MDA/2011/085
Transactive and Transportable
overhead hoists manufactured by
Waverley Glen. Supplied in the UK
by Freeway healthcare Ltd (now
Prism Medical UK) from June 2000
to August 2003 inclusive
27.07.2011
Equipment issued by
Social Services staff
may come across in
the community
27.10.2011
01.08.2011
MDA/2012/003
Catheter Valve manufactured by
Coloplast. Item number 380851
specific lot numbers
01.02.2012
Action not required
Action not
required
28.03.2012
MDA/2012/009
Level 1® Normothermic IV fluid
administration sets specific lots of
model numbers
01.03.2012
Action not required
Action not
required
29.03.2012
Integral side-stay mechanism
window restrictors with plastic
spacers
19.01.2012
Assessing relevance
31.07.2012
Reporting of defects and failures
and disseminating Estates and
Facilities Alerts
20.02.2012
Action completed
23.07.2012
Estates and Facilities
EFA/2012/001
DH
DH 2012/001
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
Part 2: Quality Achievements and Performance
32
Personal Care
Patient Survey
We value the views of our patients and use their comments to help us improve
the services we provide. Each year all of our services are required to undertake
a patient experience survey, where patients are selected at random and sent a
questionnaire to complete and return. The current criterion is that a minimum of
25% of patients currently on the caseload are contacted and asked their views.
Patient Feedback
What our patients
said in 2011/12
• Absolutely fantastic nurse in
charge!
• Thank you very much for
your prompt attention
• It is brilliant to have
somewhere to ask about
minor medical concerns
• First class service and
attention
•
I have been very well treated
– thanks
Our housebound patients
said they did not know when
the nurse was calling. This
sometimes impacted on the
carer who felt that they also
needed to wait in all day.
Following an Away Day, which
is a day for teams to get
together and discuss how they
can improve, they decided to
introduce calling cards which
gave the patient the date of
the visit and whether it would
be an am or pm appointment.
They are also given a direct
contact number for the team
that they are attached to, so if
there is an issue they can talk
to someone who works as part
of their team.
As part of our ongoing
commitment to Quality
Improvement we plan to
introduce the collection
of real time data during
2012/13 and we are currently
planning how we will do this.
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
33
Part 2: Quality Achievements and Performance
Same Sex accommodation
Every patient has the right to receive high quality care that is safe, effective and
respects their privacy and dignity. Clevedon Community Hospital is committed
to providing every patient with same sex accommodation because it helps to
safeguard their privacy and dignity when they are at their most vulnerable. Other
than in exceptional circumstances, patients admitted to the hospital can expect to
find the following standards for provision of Same Sex accommodation:The room where their bed is
will only have patients of the
same sex.
The toilet and bathroom will be
just for one gender, and will be
close to the bed area
Patients may share some
communal space, such as day
rooms or dining rooms.
In the occasional circumstance
when it is not possible to care
for patients in a same sex
accommodation, for example,
in the case of an emergency
or specialist care situation, the
clinical (medical) need will take
priority ver keeping the patient
apart from other patients of
the opposite sex. This is to
make sure patients receive
appropriate treatment as
quickly as possible and it will
only happen by exception.
A monthly return is completed
for this requirement to identify
any breaches. During this
reporting period no such
breaches have occurred.
Patient Environment Action Team (PEAT)
As required by the Community Contract we completed our PEAT assessment on
27th February 2012.
Unfortunately at the time of going to print the results had still to be published by PEAT, but based
on the continued hard work, by the staff at Clevedon Community Hospital, we expect to see
similar scores reflected in the results from this year’s assessment.
Site Name
Environment Score
Food Score
Privacy & Dignity
Score
Clevedon Hospital
TBA
TBA
TBA
Site Name
Environment Score
Food Score
Privacy & Dignity
Score
Clevedon Hospital
Good
Good
Good
Last Year’s scores were:
The hospital manager will continue to monitor quality to maintain high standards and ensure
further improvement.
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
34
Part 2: Quality Achievements and Performance
Participation in Clinical audits
What is clinical audit?
Clinical audit is:
“a quality improvement process that seeks to improve patient care and outcomes
through systematic review of care against explicit criteria and the implementation
of change”
Select
topic
8. Re-audit
7. Implement
change
Action
6. Make
recommendatio
ns
Planning
3.Define
methods
Audit
5. Analysis and
Reporting
2. Agree
standards of
best practice
4. Pilot
and data
collection
‘Principles for Best Practice in Clinical Audit’ (2002, NICE/CHI)
Clinical audit is an integral
part of clinical governance
and can be carried out by any
practitioner involved in the
care and treatment of patients.
Audits are described as
national and local in origin.
NSCP has reviewed the list of
national audits to be included
in the quality accounts for
applicability and of those
national audits 5 are partially
applicable to the services
we provide. Of these, we
submitted data to the national
diabetes audit, in conjunction
with University Hospitals
Bristol NHS Foundation Trust.
North Somerset
Community Partnership
“Your Local Health Service”
Outcomes from participation
in 2010-11 indicate a quality
of care better than the national
average. The majority of the
components in the audits
where participation did not
occur were primarily focused
on the acute care settings, and
are therefore not relevant.
In addition to the national
audits, specific local topics
were audited to evaluate the
care provided to patients,
providing assurance that
clinical services are meeting
the needs of the service users
in an efficient and effective
way. Following audits, services
are required to develop action
plans as part of the quality
improvement cycle.
As well as all areas being
required to undertake
a documentation audit,
Appendix 2 details the
national audits not relevant
and Appendix 3 details the
local audits undertaken across
NSCP.
In the future, 2012-13 will
hold a greater focus on
audit to allow us to better
demonstrate effective,
quality care.
Quality Accounts 2011/12
35
Part 2: Quality Achievements and Performance
Participation in Clinical research
North Somerset Community Partnership, in collaboration with Avon Primary Care
Research Collaborative participates in research projects. Those undertaken in
2011-12 are:
•Integrated working in
health and social care - A
comparative analysis of two
different referral systems
in community Care, carried
out by the Single Point of
Access team.
•Pilot randomised controlled
trial of home based reach
to grasp training for people
after stroke
•Developing and evaluating
a questionnaire to assess
incontinence
•FAST- First Aid & Safety
Parent Programme
Goals Agreed with the Commissioners
Use of the Quality Improvement & Innovation (CQUIN) payment
A proportion of NSCP income
in 2011/12 was dependant on
achieving the CQUIN goals
negotiated with NHS North
Somerset. Two of these were
mandatory and set nationally.
For 2011/12 the baseline
value of the CQUINs was
1.5% of the contract value
and would be paid upon
achievement of the CQUIN.
If any of the CQUINs had not
been achieved the money
would have been withheld.
NSCP have achieved 100%
of CQUINs monies to date.
Appendix 3 provides details of
the individual CQUINs and the
percentage of contract value
which each CQUIN attracted.
Further details of the agreed
goals for 2011/12 and the
following twelve month period
are available electronically
on request from the Lead
Clinician.
Data Quality
Excellent data quality is reliant on complete, accurate and timely information
to support both the delivery of core business objectives and the monitoring of
activity and performance. This enables information to be used to improve patient
care which is the key goal in North Somerset Community Partnership.
Use of effective measurement
systems and tools is essential
in improving quality and
meeting cost pressures.
We need to know what our
operating costs are and the
baseline measures for all areas
that we are trying to improve.
These include the following
which form the basis of our
service key performance
indicators:
- Patient and staff experience
and satisfaction
- Patient safety
- Quality of care
- Clinical outcomes
- Cost effectiveness
Quality Accounts 2011/12
- Prevention
- Population health
- Staff productivity
North Somerset Community
Partnership currently report
accurate and up to date
performance data to the
monthly contract review
meeting with commissioners
presented on a scorecard
which is populated by
our services. Our data is
reasonably robust but is
currently reported on Excel
spreadsheets compiled by
the clinical leads of services.
A lot of work has been done
to roll out a computerised
clinical systems for each of the
teams (largely Rio) and it will
be a focus of North Somerset
Community Partnership in
2012/2013 to extract at least
70% of performance data
from the clinical systems to
populate the scorecard which
should free up our clinicians
time to see patients. Standard
operating procedures for
data input into these clinical
systems have been produced
for each of our services
which should minimise risk of
input of inaccurate data and
increase the quality of the data
we will extract.
North Somerset
Community Partnership
“Your Local Health Service”
36
Part 2: Quality Achievements and Performance
Performance Against National targets 2010/11
Performance Against National Targets and Regulatory Requirements 2011/12
National Target
and Minimum
Standards
Target Description
Target 2011/12
2011/12*
2010/11
Infection Control Number of MRSA infections
0
0

2

Access to
Treatment
RTT waits – non admitted patients
treated in 18.3 weeks
95%
99%

99%

RTT waits – incomplete patient
waiting less than 18 weeks
95%
98%

97%

RTT waits – median time waited for 6.6 weeks
non admitted patients
3.9 weeks 
N/A

RTT waits – median time waited for 7.2 weeks
incomplete pathways
6.4 weeks 
N/A

Unplanned re-attendance rate
>5%
3%

7%
Total time spent in A&E (95th
percentile)
>4 hours
1hr 40 m

N/A
Left department without being
seen
>5%
0%

0%
Time to initial assessment (95th
percentile)
>15 minutes
0m

0m
Time to treatment in department
(median)
> 60 minutes
19 m

N/A
Target Description
Target 2011/12
2011/12*
100%
100%

Symptomatic Indwelling Catheter
Urinary Infections
2
TBC
 3
Implementation of the code of
practice for the prevention and
control of Health Care Infection
Fully Compliant
Fully
Compliant 
N/A
Clinical Quality/
effectiveness
All patients with long term
conditions to have a personalised
care plan
100%
100%
100%
Patient Safety
Implementation of National
Patient Safety Agency safe
practice guidance
Fully Compliant
Fully
Compliant 
N/A
Patient
Satisfaction
Compliments
338
394
Complaints
3
13
Access to A&E
Local Quality
Measures
Infection Control MRSA Screening Compliance
North Somerset
Community Partnership
“Your Local Health Service”
2010/11

100%


Quality Accounts 2011/12
37
Part 2: Quality Achievements and Performance
Information Governance
To reflect the changes to the organisation a new assessment model of the
Information Governance Toolkit (IGT) is due to be completed and submitted to
NHS North Somerset as assurance that we are meeting the requirements to
safeguard personal sensitive data. This will differ slightly to previous assessments
but will cover the areas below
• Information Governance
Management
• Confidentiality and Data
Protection Assurance
• Information security
assurance
• Clinical information
assurance
Our aim is to continue
achieving at least satisfactory
status within each of the
requirements to demonstrate
compliance as mandated
within the contractual
obligations set out by NHS
North Somerset. The IGT is an
ever evolving piece of work to
improve the control measures
to safeguard personal
sensitive data.
Registration with the Care Quality
Commission (CQC)
With the advent of moving into a Social Enterprise, North Somerset Community
Partnership was required to submit an application for registration prior to October
1st 2011.
Part of this process was
to undertake a compliance
review of all the services to
ensure they met the CQC’s
Essential Standards. This
was duly completed along
with the appointment of the
registered managers for
both locations. This entailed
interviews with CQC assessors
and a thorough review of the
assessment process. This
was completed on time and
enabled the company to be
registered without conditions,
in order to carry out the
following legally regulated
activities:
• Nursing care,
There are two registered
locations for the company
and these are:
• Castlewood - Head Quarters
for all Community Teams
• Clevedon Community
Hospital - 18 bedded
Community hospital
North Somerset
Community Partnership
has no conditions on its
registration.
The Care Quality
Commission did not take
enforcement action against
North Somerset Community
Partnership.
• Treatment of disease,
disorder or injury,
• Diagnostic and screening
procedures.
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
Part 2: Quality Achievements and Performance
38
Staff Survey
The 2010 staff survey demonstrated a high level of staff engagement with
the organisation being in the best 20% of PCTs for this indicator. Overall, the
staff survey results showed a significant improvement to those for 2009 and in
particular we scored well on our commitment to work/ life balance, the % of staff
receiving appraisals and the % of staff receiving training and development.
The staff survey results
reflected the investment
that had been made by the
organisation in engaging with
the wider leadership team to
improve communication, and
to create an environment in
which staff feel supported and
can contribute ideas.
However, the results also
showed that, a higher % of
staff felt under work pressure
and worked extra hours than
in other PCTs. In addition,
65% were satisfied with the
quality of work and patient
care that they are able to
deliver compared with an
average of 72% in similar
organisations.
The staff survey results were
shared widely and workshops
were run with a cross section
of staff groups to identify
ways which the issues raised
could be addressed. The
following actions have been
implemented:
North Somerset
Community Partnership
“Your Local Health Service”
• Work on understanding the
capacity and workload of
community teams – a pilot
version of a capacity tool
was developed and has
been further refined
• Investment in tough books/
lap tops to enable teams to
work more productively and
support the collection of
data through the electronic
patient record system
• Stress management and
resilience workshops
held with departmental
teams and open sessions
for staff from across the
organisation
• Health and well being
initiatives such as
supporting lunch time yoga
/meditation sessions
• Investment and publicity
about employee assistance
programmes
• Creation of an “ideas
factory” where staff can bid
for financial or time support
to implement ideas to
improve patient care or the
way teams work.
It is nevertheless recognised
that there has been a
significant amount of
organisational change over
the past year with many staff
adopting new ways of working
and moving to work in new
teams as the Community
Wards and Teams have been
rolled out. In addition, the
creation of a new organisation
outside of the NHS created
uncertainty for staff. There has
been open dialogue with staff
throughout this process with
many open meetings with the
Senior Leadership Team. In
addition, we have created a
staff council to further improve
communication between
senior managers and staff as
well as providing a vehicle
for staff to influence how the
organisation is run.
Quality Accounts 2011/12
39
Part 3
Our Quality Strategy and Priorities 2012/13
Quality Strategy
Delivering the Strategy
Our Quality Priorities
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
40
Part 3: Our Quality Strategy and Priorities 2012/13
Quality Strategy
In April 2012 we will launch our strategy for the next three years. We aim to be
the provider of choice for our patients with an excellent reputation for a personal,
safe and innovative service which is community and staff centred. As a new
organisation we will focus on getting our foundations right and specific projects
and targets that will drive continued and improved quality for our patients.
We will ensure our work will achieve improved outcomes for our patients and
ensure the care we give is reliable and evidence based.
ent
!
rem
Me
asu
nd
ard
s!
!
Sta
shi
p
der
Lea
Equality!
Integrity!
iv
pe
os
Pr
!
hip
ers
rtn
Pa
!
ility
es!
e!
tiv
va
pab
Ca
no
ct
Assurance and Compliance!
u
Val
e!
Sa
Value !
fe
!
In
Compassion!
ct
fe
&
al
on
rs
Ef
Pe
iv
e
!
Quality Strategy!
Aims!
Principles!
Enablers!
Delivering our strategy: Improvement methodology.
We will achieve change and practice development through the use of the ‘model for improvement’
based on the ‘plan do study act cycle’. This will ensure the changes we make are tested and work.
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
41
Part 3: Our Quality Strategy and Priorities 2012/13
Delivering the strategy:
Delivering the strategy:
Leadership
Performance and
Measurement
In 2012 to 2015 we will prioritise strong,
visible competent leadership. There will be
a focus on:
• Board development and coaching
• Implementing Director Walk-rounds
• Development of our Business Support
Managers and Clinical/ Professional
leaders
• Further defining our values
Delivering the strategy:
In 2012 -15 we will nurture a performance
culture to empower our staff and
customers by:
• Introducing service line reporting
bringing together quality, performance,
people and financial data
• Capitalise on information technology
platforms and new technologies
• Measure the right things including clinical
outcomes Maintain our systems for
statutory and regulatory compliance
Values
In 2012-15 we will continue to develop our
values by:
• Defining and acting upon our social
purpose and ethical base
• Delivering a clear accountability
framework including organisational,
professional and individual elements
• Respond to good and bad behaviours
• Promote respect and compassion
• Listen and respond to customers and
staff
Delivering the strategy:
Work environment
and equipment
In 2012-15 we will prioritise our work
environment and the equipment we need
to work safely by:
• Developing and accommodation strategy
• Improving control of medical and nonmedical equipment
Delivering the strategy:
Delivering the Strategy:
Capability
In 2012-15 we will focus on having the
right workforce, in the right place at the
right time with the right skills. We aim
to recruit, retain and develop capable,
competent staff. We will:
• Address our education and training
arrangements and improve appraisals
and use competency frameworks
• Plan our current and future workforce
• Spot and nurture our talented staff
• Expand our Health Visitor workforce
• Develop new skills
Quality Accounts 2011/12
Working in partnership
In 2012 -15 we will develop our
relationship with our community and build
on integrating our approach across health
and social care systems
• Developing our community forum and
voluntary sector links
• Working across the health system to
avoid unnecessary admissions and
support facilitated discharge
• Working actively with our Staff Council
and shareholders to shape our
organisation going forward
• Positively engaging with our customers
in a meaningful way again to shape and
evaluate our services and the value we
offer.
North Somerset
Community Partnership
“Your Local Health Service”
Part 3: Our Quality Strategy and Priorities 2012/13
42
Our Quality Priorities 2012/13
The specific projects selected for delivery in 2012/13 will contribute to our aim
to provide, safe, effective, personal and innovative care that is right for our
community.
Priority one
What:
We will reduce the
number of patients
who acquire
avoidable pressure
ulcers in our care
Why:
Pressure ulcers
cause pain, infection
increased length of
treatment. Some are
avoidable.
How much:
40% reduction in
preventable pressure
ulcers
How:
Implementation of
the SSKIN bundle
in community wards
and teams, Clevedon
Community Hospital
Lead Director: Helen Mee, Associate Director of Operations
Priority Two
What:
We will develop new
ways to capture our
patients experience
Why:
Understanding our
patient’s experience
will help us learn and
improve services
How much:
Five services will
identify and adopt
new methods
How:
We will scope
and test different
methods with our
patients, carers and
staff.
We will engage with
our Community
Forum to seek
their views on our
proposals
How much:
10 services will
identify and adopt
new methods
How:
We will use validated
outcome tools
and capture data
using the electronic
patient record
Lead Director: Penny Smith, Lead Clinician
Priority Three
What:
We will capture the
clinical outcome
measure service
level.
Why:
Clinical outcome
data can be used
to improve care,
benchmark services
and assure those
around us.
Lead Director: Penny Smith, Lead Clinician
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
43
Part 3: Our Quality Strategy and Priorities 2012/13
Priority Four
What:
We will improve the
standard of clinical
record keeping
Why:
The healthcare
record formalises
clinical assessment
and ongoing
evaluation, it also
aids communication
between carers.
How much:
20 services will
achieve 75% in
the revised record
keeping audit
How:
We will continue to
roll out the electronic
patient record,
review individual
practice through new
clinical supervision
arrangements
and implement
a standardised
communication tool.
Lead Directors: Thelma Howell, Associate Director of Operations for RIO
Penny Smith, Lead Clinician for clinical practice
Priority Five
What:
We will increase
the use of new
technologies to
improve quality
Why:
Improving the patient
and carer experience
by enabling
increased autonomy
in managing their
long term condition
How much:
30 patients in 2 GP
practices for a 3
month period
How:
Testing assistive
living device
(telehealth) in a proof
of concept pilot with 02 Health
Lead Directors: Helen Mee, Associate Director of Operations
Priority Six
What:
Dementia, we will
improve the care for
patients and their
carers
Why:
We believe care and
services that are
sensitive to their
needs and respect
their dignity
How much:
Full achievement
of dementia related
CQUINs
How:
Membership of the
commissioning
led group to
improve services,
collaborative
work with partner
providers,
identification of a
CQUIN lead
Lead Directors: Thelma Howell, Associate Director for Operations
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
Part 3: Our Quality Strategy and Priorities 2012/13
44
Priority Seven
What:
Continued
implementation
of the the Quality
Improvement Safety
Programme
Why:
The programme
builds improvement
capabilities within
the organisation and
addresses the most
frequently identified
causes of patient
harm
How much:
Achievement of
attainment level 2.5
(programme scoring
system)
How:
Implementation of
the project spread
plan for each work
stream.
How much:
Three foundation
modules
How:
Implementation
according to
Institute of
Improvement
and Innovation
programme
Lead Director: Penny Smith, Lead Clinician
Priority Eight
What:
We will implement
the community
productive series in
community teams
Why:
The community
productive series
will help standardise
practice and
measurement which
will release time to
care
Lead Director: Thelma Howell, Associate Director of Operations
Priority Nine
What:
We will contribute to
relevant mandatory
national audits and
national confidential
enquiries
Why:
Contribution will
help us improve
care, benchmark
services and
provide assurance
for ourselves and
others.
How much:
100% contribution
How:
Clinical audit
support for services,
identification of
clinical leads at
service level,
link contribution
to service level
reporting.
Lead Director: Penny Smith, Lead Clinician
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
45
Part 3: Our Quality Strategy and Priorities 2012/13
Statement from Primary Care Trust
North Somerset Community Partnership (NSCP)
NHS Bristol, North Somerset and South Gloucestershire Primary Care Trust
Cluster have reviewed the North Somerset Community Partnership Quality
Account report 2011/12 and believe that this provides a fair reflection of quality of
healthcare services provided and the majority of the mandatory elements required.
We have reviewed the data presented and are satisfied that this gives an overall accurate account
and analysis of the quality of services.
This is in line with the data supplied by North Somerset Community Partnership for 2011/12
which is reviewed as part of their performance under the contract during the year both as a Social
Enterprise, and as an NHS organisation before this.
All of the quality improvement and innovation (CQUIN) goals were achieved in 2011/12 apart
from the Dementia care standards which is due to the fabric and environment of the Clevedon
Community Hospital building.
The account identifies significant progress in relation to:
• The sustained reduction of HCAI particularly MRSA, bacteraemias and C Difficile
• High levels of compliance with Venous Thrombo Embolism (VTE) screening
• Commended involvement with the SHA Quality and Patient Safety Improvement Programme.
We will continue to work closely with North Somerset Community Partnership to implement a
more integrated approach to caring for patients across the three domains of Quality, Safety,
Clinical Effectiveness and Patient Experience.
This will include continuing to raise the profile for quality improvement and having a patient
outcome focus.
The ongoing engagement of clinicians close working with primary care will remain crucial in
monitoring standards and improving services for local people.
This Quality Account follows the Quality Accounts Toolkit framework.
Toolkit Appraisal Criteria
Part 1
Quality Accounts 2011/12
Comments
A statement on the Quality
Account from the Chief Executive
and the senior employee outlining
that to the best of that persons
knowledge the information in that
document is accurate
Compliant. Clear and concise
statement from the Chair and
Chief Executive.
North Somerset
Community Partnership
“Your Local Health Service”
Part 3: Our Quality Strategy and Priorities 2012/13
46
Statement from Local Involvement Networks
Awaiting content for this section
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
47
Part 3: Our Quality Strategy and Priorities 2012/13
Statement from Overview and Scrutiny
Panel
The Panel noted the NSCP Quality Account and the Quality Strategy and Priorities
for 2012/2015.
Members commented that the transfer to a Social Enterprise and its success within its first year
was a very positive achievement.
They noted the Specific Projects selected for delivery in 2012/2013 and requested that the Panel
be kept informed of progress in these areas, in particular Priority Two: “We will develop ways to
capture our patients’ experience.” There is a need to also understand the carer’s experience.
The Panel recognises the difficulties all health providers are experiencing with the ever changing
health landscape, at this time, and the impact of the changes and pressures on those staff.
The Panel will continue to scrutinise NSCP and act as a critical friend as and when necessary.
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
Part 3: Our Quality Strategy and Priorities 2012/13
48
Statement of Directors’ Responsibilities in
respect of the Quality Report
The directors are required under the Health Act 2009 and the National Health
introfinancial year.
The content of the Quality Report is consistent
with internal and external sources of
information including:
• Board minutes and papers for the period April
2011 to June 2012
• Papers relating to Quality reported to the
Board over the period April 2011 to June
2012
• Feedback from the commissioners during
2011/12
There are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Report,
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 Report
is robust and reliable, conforms to specified
and subject to appropriate scrutiny
• The [latest] national staff survey April 2011
• The (latest) CQC quality and risk profiles
The Directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board.
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
49
Part 3
Appendices
Appendix 1: Local Audits
Appendix 2: Non Relevant National Audits
Appendix 3: CQUIN Goals
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
50
Part 4: Appendices
Appendix 1
The following local audits were undertaken during 2011-12:
Service
Podiatry
Audit Tile
Community Diabetic Ulcer Audit
Hand Hygiene Audit
DNA
HPC audit
MSK
MSK Interface and Physiotherapy GP
Satisfaction Survey
An audit of the use and effectiveness of
corticosteroid injections used in North
Somerset musculoskeletal service
Osteoarthritis, General and knee - NICE
compliance
Lower Back Pain and neck - NICE compliance
Clinical Outcomes - Spine
Clinical Outcomes - Lower limb
Clinical Outcomes - Upper Limb
MRI - appropriateness of request by service
Bladder & Bowel Service
Audit of children‘s non attendance at health
appointments offered by Bladder and Bowel
Service, MSK Physiotherapy and Podiatry
during the period 1st Jan – 31st March 2011
Clevedon Hospital
Catering Audit
Diabetes - Paediatric
Getting to know others with diabetes
Clevedon Rehab Team
Falls tagging mobility aids
In Patient Group Exercise Programme
Weekend Working
Rehab and GP beds therapy input per
discipline per length of stay
Rapid Response & Rehab
Analysis of Clevedon Hospital Menus
Safeguarding Children
MIU Communication re-audit
A & E Communcation audit (BNSSG)
DNA outpatients appointment re-audit
Supervision Audit
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12
51
Part 4: Appendices
Appendix 2
National Clinical Audits not relevant to services provided by North Somerset
Community Partnership for inclusion in Quality Accounts
Peri and Neonatal
• Perinatal mortality (CEMACH)
• CABG and valvular surgery (Adult cardiac
surgery audit)
• Neonatal intensive and special care (NNAP)
Cardiovascular disease
Children
• Paediatric pneumonia (British Thoracic
Society)
• Paediatric asthma (British Thoracic Society)
• Familial hypercholesterolaemia (National
Clinical Audit of Mgt of FH)
• Acute Myocardial Infarction & other ACS
(MINAP)
• Paediatric fever (College of Emergency
Medicine)
• Pulmonary hypertension (Pulmonary
Hypertension Audit)
• Childhood epilepsy (RCPH National
Childhood Epilepsy Audit)
• Heart failure
• Paediatric intensive care (PICANet)
Renal disease
• Renal replacement therapy (Renal Registry)
• Paediatric cardiac surgery (NICOR
Congenital Heart Disease Audit)
• Renal transplantation (NHSBT UK Transplant
Registry)
Acute care
• Patient transport (National Kidney Care
Audit)
• Emergency use of oxygen (British Thoracic
Society)
• Renal colic (College of Emergency Medicine)
• Adult community acquired pneumonia
(British Thoracic Society)
Cancer
• Non invasive ventilation (NIV) - adults (British
Thoracic Society)
• Bowel cancer (National Bowel Cancer Audit
Programme)
• Pleural procedures (British Thoracic Society)
• Cardiac arrest (National Cardiac Arrest Audit)
• Vital signs in majors (College of Emergency
Medicine)
• Adult critical care (Case Mix Programme)
• Potential donor audit (NHS Blood &
Transplant)
• Acute stroke (SINAP)
Elective procedures
• Hip, knee and ankle replacements (National
Joint Registry)
• Elective surgery (National PROMs
Programme)
• Cardiothoracic transplantation (NHSBT UK
Transplant Registry)
• Liver transplantation (NHSBT UK Transplant
Registry)
• Coronary angioplasty (NICOR Adult cardiac
interventions audit)
• Peripheral vascular surgery (VSGBI Vascular
Surgery Database)
• Lung cancer (National Lung Cancer Audit)
• Head & neck cancer (DAHNO)
Trauma
• Hip fracture (National Hip Fracture Database)
• Severe trauma (Trauma Audit & Research
Network)
Psychological conditions
• Depression & anxiety (National Audit of
Psychological Therapies)
• Prescribing in mental health services (POMH)
• National Audit of Schizophrenia (NAS)
Long Term Conditions
• Ulcerative colitis & Crohn’s disease (National
IBD Audit)
Blood transfusion
• O neg blood use (National Comparative
Audit of Blood Transfusion) – this is not yet
being rolled out to community hospitals
• Platelet use (National Comparative Audit of
Blood Transfusion) – this is not yet being
rolled out to community hospitals
• Carotid interventions (Carotid Intervention
Audit)
Quality Accounts 2011/12
North Somerset
Community Partnership
“Your Local Health Service”
52
Part 4: Appendices
Appendix 3
Quality Improvement & Innovation (CQUIN) Goals 2011–12
Description of goal
Quality
Domain(s)
Reduce avoidable
death, disability and
chronic ill health from
Venous Thromboembolism (VTE) through
the application of
NICE guidance and in
accordance with local
implementation policy
Safety,
Prevention
Improve responsiveness
to the personal needs of
patients
Introduction of patient
outcome tools as per the
agreed Implementation
Plan
National or
Regional
indicator
Indicator name
Indicator
weighting
VTE risk assessment using
the national tool – on
admission / transfer and
repeated at 24 hours
National –
Adapted for
Community
Services
2.5 %
Patients receiving
appropriate VTE prophylaxis
No
2.5 %
Patient
Experience
Composite indicator on
responsiveness to personal
needs from the adult
inpatient survey to include
all services and Clevedon
Community Hospital
National –
Adapted for
Community
Services
5%
Effectiveness/
Patient
Experience
Number of services
using and reviewing impact
of an outcome tool
No
25%
Number of patients having
a MUST assessment
Number of patients having
a MUST assessment as a
percentage of the patients
in agreed services
No
20%
No
12.5%
Skilled and knowledgeable
workforce
Increase in the skills and
knowledge of CCH staff &
Community Nurses
No
12.5%
Self care
Number of patients with
diabetes with a self care
plan admitted to CCH and
Community Nurses
No
Number of services (using
and reviewing an outcome
tool) as a percentage of
the services agreed in the
Implementation Plan for
2011/12
Nutrition – ensuring
patients (in agreed
services) are assessed
using the Malnutrition
Universal Screening Tool
(MUST)
Effectiveness
Improved management
of patients in the
community with diabetes
Safety/
Experience
Improving management
of End of Life care
patients in Weston /
Worle (links with Weston
Hospice)
Effectiveness
Accurate record of patients
receiving End of Life care
No
10%
Improving care for
people with dementia
or mild cognitive
impairment while in
hospital
Safety /
Effectiveness /
Experience
Compliance with Level 1
dementia care standards
No
10%
North Somerset
Community Partnership
“Your Local Health Service”
Quality Accounts 2011/12