Quality Account 2011-2012
Contents
Page
Part 1
Statement from SEQOL‟s Chief Executive
3
Statement of accuracy
4
Part 2
What is a Quality Account
5
About SEQOL
6
Looking forward
8
Part 3
Review of Quality
15
Statements from the Board
23
What others say about us
24
SEQOL Quality Account 2011/2012
Page 2 of 26
Part 1
Statement from the Chief
Executive
I am delighted to be presenting the first Quality
Account for SEQOL and to be sharing with you
our passion for quality.
Here at SEQOL we are committed to delivering integrated
quality services and putting people at the heart of all we
do. Being responsible for delivering both health services,
such as community nursing and podiatry, and social care
services, such as day services for adults with physical or learning disabilities, we
can take a very joined-up approach.
This means seeing everyone we care for as a person, with their own unique needs,
rather than simply looking at one area of need. We strive to provide the balance of
high quality support and care needed to live life as people want to –wherever in
your own home, and enjoying the dignity and respect you deserve. Most
importantly, we give genuine choice in the delivery of care.
Our employees, who before SEQOL was established in 2011, worked for Adult
Services at NHS Swindon and Swindon Borough Council, are integral to our ability
to serve you well. Their experience and skills and dedication to their work are
what help to deliver the care and support people need.
But they are also integral to SEQOL because most of them have a personal stake in
the organisation. SEQOL is a social enterprise (a Community Interest Company),
which means most of our employees own a share in the organisation. This means,
they have a real say in how SEQOL is run and how it works.
Staff are represented on our board and we meet regularly with frontline staff
throughout the organisation. This brings the work of our teams to life in the board
room and ensures our decision making remains focussed on delivering the best we
can for residents. As a result of this board members have agreed to undertake
quality visits with frontline members of staff as part of the patient safety
improvement programme.
We have a residents‟ champion on our board who provides a direct link back to the
community we serve and in 2012/13 we will be working with him to develop a
User‟s Forum to inform us of areas where our practice is very much appreciated
and other areas where practice can be improved.
Heather Mitchell
Chief Executive
SEQOL Quality Account 2011/2012
Page 3 of 26
Statement of Accuracy
Statement of Directors’ Responsibilities in respect of the Quality Account
The Directors are required under the Health Act 2009, National Health Service
(Quality Accounts) Regulations 2010 and National Health Service (Quality Account)
Amendment Regulation 2011 to prepare Quality Account for each financial year.
The Department of Health has issued guidance on the form and content of annual
Quality Accounts (which incorporate the above legal requirements).
In preparing the Quality Account, Directors are required to take steps to satisfy
themselves that:
the Quality Account presents a balanced picture of the organisations
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, is subject to appropriate scrutiny and review;
and the Quality Account has been prepared in accordance with Department
of Health guidance.
The Directors confirm to the best of their knowledge and belief they have
complied with the above requirements in preparing the Quality Account. By order
of the Board
Michelle Howard
Board Chair
SEQOL Quality Account 2011/2012
Heather Mitchell
Chief Executive
Page 4 of 26
Part 2
What is a Quality Account
A Quality Account is an annual report which all providers of healthcare services
must publish to inform the public of the quality of the services they provide. This
is set out in the Health Act 2009 and supporting regulations, some parts of the
Quality Account are mandatory.
The purpose of Quality Accounts is to enable:
 Service users and their carers to make well informed choices about their
providers of healthcare
 The public to hold providers to account for the quality of the services they
deliver
 Boards of NHS providers to report on the improvements made to their
services and set out their priorities for the following year.
The aim of Quality Account is to:
 look back on what we have achieved in the past 12 months and to look at
how we can focus on quality improvements for the coming year.
SEQOL Quality Account 2011/2012
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About SEQOL
The past 12 months have seen many
changes for the organisation; in April
2011 we were the provider arm of
Swindon PCT delivering adult health
and social care. We then became Care
and Support Partnership a separate
provider in shadow form and finally
launched as SEQOL in October 2011.
SEQOL is the trading name for Care
and Support Partnership Community
Interest Company.
SEQOL is a social enterprise
organisation; most of the people
working within SEQOL own a share in
the organisation. This means they
have a real say in how SEQOL is run
and how it works. Unlike a private
company any surplus funds which are
raised, will be reinvested into
improving outcomes for the
communities which we serve. SEQOL
generates its income from
commissioners of community services
such as the NHS, General
Practitioners and local authorities.
SEQOL provides integrated health and
social care services to adults in
Swindon and health care services to
adults in Shrivenham. It provides a
wide range of services such as
community nursing, rehabilitation,
podiatry and day care services for
adults with physical or learning
disabilities These services include
assessment, care management and
safeguarding adults services for
Swindon Borough Council as well as
NHS community services.
SEQOL also offers real opportunities
for people with a variety of
disabilities. Enterprise Works is a
supported employment service which
was first established in Swindon in
1964 and has continued to evolve
since. It provides opportunity, support
and training for disabled people in the
SEQOL Quality Account 2011/2012
community. It is a regional leader of
exemplary supported employment
services helping to remove barriers to
employment for 200 or more people
with disabilities or health conditions
each year. SEQOL Energy2work is a
unique and ground breaking project
that helps people who are
unemployed develop the skills that
employers need.
An important and positive aspect of
SEQOL is that it is an integrated
health and social care organisation.
This facilitates a „joined up‟ approach
to the care being delivered. SEQOL
views everyone as an individual with
unique needs, rather than simply
looking at one area of need, we strive
to provide a balance of high quality
provision whilst supporting and
facilitating people to make choices
about their care and to live their lives
how they want - in their own home
and enjoying the dignity and respect
they deserve.
Set out in this report are our priorities
for improving patient safety,
effectiveness and experience in
2012/13. As Care and Support
Partnership we had a proven record of
delivering the highest quality service,
supporting people to remain living
independently in the community for
longer. As SEQOL we are committed
to continue to develop strong
community teams. We have set
ourselves high standards and have
every intention of meeting these and
building on them in future years.
This report also reflects upon the
achievements we have made in
quality improvement activity in the
areas identified in the 2011/12
Quality Account. Improving the
quality of the care we give people is
important to us; it is a fundamental
Page 6 of 26
part of our business planning. The
Quality Safety and Performance Unit
sits within SEQOL‟s business unit and
leads, supports and promotes Practice
Governance (i.e. issues relating to
clinical and professional practice) in
order to assure the Board of the safe
and effective delivery of health and
care services. As an integrated
organisation SEQOL practice
governance incorporates both the
Care Quality Commission (CQC)
essential standards of quality and
safety and the social care outcomes
framework.
Rehabilitation in the Swindon Intermediate Care Centre
SEQOL Quality Account 2011/2012
Page 7 of 26
Looking forward
Quality improvement capacity
and capability
on customers/consumer
requirements.
Capacity:
Capability
In order to deliver quality
improvements within services it is
important to develop capacity and
capability. SEQOL as a new Social
Enterprise organisation is an
independent non NHS organisation.
Part of its business is to deliver
commissioned NHS services.
Throughout this report we have
referred to the South West Strategic
Health Authority Quality and Patient
Safety Improvement Programme
(QSPIP) which was established in
Autumn2010. This programme
facilitates health communities
working together to improve safety
and outcomes for patients by reducing
risks within key areas, SEQOL has
been actively participating in the
programme since it began.
SEQOL has four operational business
units: Urgent care, Intermediate
Care, Health and Well Being and
Promoting Independence, all
supported by Business Services. There
are 9 operational co-ordinators some
of whom work across more than one
business unit to maximise
efficiencies.
SEQOL is developing a matrix
management structure whereby
people with similar expertise and
abilities work within teams to deliver
different projects. Individuals may
report to more than one manager for
example a therapist may report to a
senior therapist functionally, and
also report to a project manager on
operational project issues.
Teams are called upon to co-ordinate,
co-operate and be flexible for the
matrix structure to work well. SEQOL
has chosen the matrix model as it
provides a structure for product
development and fast implementation
of new systems and processes that
will drive up efficiency, giving greater
accountability for performance to all
employees and will enhance the focus
SEQOL Quality Account 2011/2012
There are a number of risks identified
within QSPIP all of which we will
continue to address. However, our
main focus will be:
Pressure ulcers
A pressure ulcer is an area of
localised damage to the skin and
underlying tissue, which can range
from single layer to full thickness skin
and involving damage to the bone.
They are graded from 1 to 4 to
determine the severity of the
damage.
Pressure ulcers are caused by either
pressure (from the weight of the body
pressing down on the skin), shear
(which occurs when the layers of skin
are forced to slide over one another
or over deeper tissues e.g. sliding
down a bed), friction (rubbing the
skin) or a combination of any of
these.
Page 8 of 26
VTE
Venous Thromboembolism (VTE) is a
collective medical term for two
conditions:
Deep Vein Thrombosis (DVT): a blood
clot inside a deep vein – most
commonly a deep vein in the leg that
blocks the flow of blood.
Pulmonary Embolism (PE): a
potentially fatal complication where
the blood clot breaks loose and
travels to the lungs.
Falls
A fall is defined as “An unexpected
event when the person 'falls' to the
ground from any level, this also
includes falling on the stairs and onto
a piece of furniture with or without a
loss of consciousness” (National
Institute for Clinical Excellence 2004)
Catheter-associated urinary tract
infections
A catheter-associated urinary tract
infection (CAUTI) occurs when germs
(usually bacteria) enter the urinary
tract through the urinary catheter and
cause infection. CAUTIs have been
associated with increased morbidity,
mortality, healthcare costs, and
length of stay. The risk of CAUTI can
be reduced by ensuring that catheters
are used only when needed and
removed as soon as possible; that
catheters are placed using proper
aseptic technique; and that the
closed sterile drainage system is
maintained.
SEQOL Quality Account 2011/2012
Improving patient safety and quality is
through focusing on clinical and
professional practice. The programme
is aimed at reducing mortality rates
and serious adverse events, in both
local communities and across the
wider health community.
It is estimated that more than
200,000 people each year suffer
complications caused by pressure
ulcers, falls, urinary catheter
infections and blood clots (venous
thromboembolism or VTE). The cost
to the NHS is considerable, as is the
cost to each individual.
All harms are related as the scenario
below shows:
„A patient is not eating well or taking
enough fluids, which is making them
dizzy when they stand and at risk of
falling. Their catheter is not draining
well because they’re not drinking
enough water and they are at risk of
developing an infection. Lack of food
is making them lethargic and less
motivated to move so they’re at risk
of VTE and because they’re spending
more time in bed pressure ulcers
could develop’.
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Safety and Effectiveness
How these priorities are managed within SEQOL:
Work streams have been established for each priority area, these consist of small
multi-disciplinary teams which are clinically led and focused.
These teams lead the developments in specific service areas. A Plan Do Study Act
(PDSA) model has been used to initiate small tests of change which are linked to
quality improvements in the chosen outcome measures. Across SEQOL, pilot sites
have been identified to test change using the PDSA approach to establish effective
practice before implementing more widely. These priorities and the work being
undertaken link closely with quality performance indicators which have been
agreed with NHS Swindon: commissioners of SEQOL services and also with the Care
Quality Commission (CQC) Essential Standards of Quality and Safety.
Priorities for
improvement
Aims
Pressure Ulcers (PU)
Reduce grade 3 and 4 pressure ulcers – by 30%
Venous
Thromboembolism
(VTE)
95% of patients to have a documented risk assessment
for VTE
Fall
Reduce serious injury from Falls – 50%
Catheter Associated
Urinary Tract
infections
Reduce catheter associated urinary tract infections by 50%
95% of patients assessed to be at risk of VTE to receive
appropriate prophylaxis
(CAUTI)
Dementia screening
All patients in SwICC 75 years and over to have
dementia screening within 72 hours of admission.
With a reduction to 48 hours by March 2013.
Progress will be made towards implementation of
dementia screening within the virtual ward from
January 2013. The virtual ward is where patients
receive expert clinical care for complex health
conditions which are managed outside hospital and
usually in the patient‟s own home.
SEQOL Quality Account 2011/2012
Page 10 of 26
Priorities for
improvement
Aims
Of those screened numbers referred to the mental
health services will be recorded and reported to
commissioners.
Nutrition and
hydration
„Malnutrition Universal Screening Tool‟ („MUST‟) used
for nutritional screening.
(secondary driver to
delivering harmfree
care)
Weight monitoring as appropriate to the care setting
Development of „protected mealtimes‟ and the „red
tray‟ system
Applied to both Care Homes as well as Swindon
Intermediate Care Centre (SwICC) and community
services
Maintain Service Level Agreement for Community
Dietetic Service
Learning from
complaints
SEQOL is committed to making experiences count by
placing a high priority on the local resolution of
complaints in a manner that is fair to all parties involved.
From 1st October 2011 to 31st March 2012 were 58
complaints.
Actions to address priorities
•
•
•
•
•
•
•
Undertake monthly tests of change
Report on Institute of Health and Innovation (IHI) website
Review and report successes, barriers and breakthroughs
Use the IHI Faculty assessment of SEQOL‟s work stream data and progress
to inform on-going change
Conduct team development sessions
Participate in learning conference calls
Continue to build communication strategies such as posters for updates,
agenda items at team meetings to include Quality, Safety and
Performance unit and attendance at other meetings e.g. SEQOL board
SEQOL Quality Account 2011/2012
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How are we going to monitor and
measure the progress we are
making?
The Safety Thermometer is the
agreed measuring, monitoring, and
reporting tool to be used by SEQOL to
report on the 4 key areas that
demonstrate harm free care (i.e.
pressure ulcers, venous
thromboembolism, falls and catheter
associated urinary tract infections). It
is the tool that has been agreed with
commissioners to report quality care
that will release funding to SEQOL.
The Commissioning for Quality and
Innovation (CQUIN) payment
framework enables commissioners to
reward excellence by linking a
proportion of providers‟ income to the
achievement of local quality
improvement goals.
The Safety Thermometer will be the
over-arching umbrella tool that
reports on a SEQOL wide basis on
harm free care in these four key
areas. In order to report harm free
care from the patient‟s perspective
we need to think differently about
the total number of people receiving
our services without incident or harm,
and express this as a positive
percentage. This is different to
reporting the number of incidents or
harm occurring, although we will still
need to report this in order to
understand the level of harm free
care. A sampling strategy will be
used to demonstrate harm free care
from a range of SEQOL services.
The number of incidents in relation to
the four key areas will be reported
using the Sentinel risk management
SEQOL Quality Account 2011/2012
system. This is a web-based system
used by SEQOL to report all incidents.
Risk management is about having
systems in place to understand,
monitor and reduce the risks to
patients, including learning the
lessons
from
mistakes. Monthly
reporting will enable the leadership
team to identify services or teams in
which there is a higher rate or
number of incidents, where local
action and reporting using the Quality
and Patient Safety Improvement
programme will then be initiated.
The Quality and Patient Safety
Improvement programme work will
focus on identified areas of care for
improvement at a local level using the
established Plan, Do, Study, Act cycle
of quality improvement. We will
continue to use Sentinel, or other
appropriate measurement, to monitor
the effects of our
improvements. Teams will be
supported to develop action plans for
improvement until it is demonstrated
that the improvement has been
sustained. We will therefore be
focusing the Quality and Patient
Safety Improvement programme on
services and teams identified through
the Safety Thermometer
reporting. (Teams already involved in
the Quality and Patient Safety
Improvement programme will be able
to continue using the IHI database to
monitor their on-going work.
Participation in National Audits
A national clinical audit is either a
project funded by the Healthcare
Quality Improvement Partnership who
Page 12 of 26
manage the National Clinical Audit
and Patients Outcome Programme
(NCAPOP) or separately funded. These
audit projects meet the following
criteria:
National coverage (achieved or
intended)
main focus is improving the
quality of clinical practice
evaluates practice against
clinical criteria/guidelines
and/or collects outcomes data
applies the complete audit
cycle and/or monitors
clinical/patient outcomes data
in an on-going way as part of a
programme of driving change
is prospective - i.e. does not
include retrospective reviews
of adverse outcomes such as
confidential enquiries
includes patients in their
governance and takes data
from patients themselves.
The purpose of national clinical audits
is to engage healthcare professionals
in systematic evaluation of their
clinical practice against standards and
to support and encourage
improvement in the quality of
treatment and care. SEQOL intends to
expand participation in national
clinical audits over the forthcoming
year and use the results to help
improve services.
The reports from these audits can
reassure people that SEQOL provides
safe and effective services and that
any deficiencies are being rectified.
Furthermore, people who are using or
considering using SEQOL‟s services
will be able to see practice and
performance against other
organisations and allow them to
SEQOL Quality Account 2011/2012
question the quality of care and
exercise choice.
The best audits have the involvement
of the people who have experienced
or are experiencing the practice
and/or service being audited. Many
national audits now include feedback
from people within the audit design
such as whether they were treated
with dignity and humanity, how
quickly they were seen and treated,
and their quality of life. In reality,
people who experience the stress of
any illness are the true professionals
of their condition.
People’s Experience
SEQOL provides a range of integrated
health and social care services to
meet the needs of service users. In
order to improve the quality of the
care we provide we have many
systems and processes in place such
as: training for staff, a commitment
to safe recruiting, operational policies
and for procedures, guidelines and
good practice and management of
complaints. All of which we recognise
as being important. However in order
to improve quality of care we
recognise that the best way of finding
out how good the care is, is to ask the
people who are receiving it. We
asked some of our patients. We
engaged people in conversations to
attain an understanding of their
experiences.
We undertook a pilot study in August
2011, to look at engaging patients in
conversations; asking specific
Page 13 of 26
questions to help identify patient‟s
experience of their care whilst in
Swindon Intermediate Care Centre
(SwICC) and looking at the feasibility
of involving members of the Local
Involvement Network with any future
patient conversation studies.
Feel involved in my care
planning
Staff listen to you
The pilot was successful which has
encouraged us to have further
„patient conversations‟ in
intermediate care. We have reviewed
the responses to the questions and
have shared them with staff on the
wards. The recommendations from
the conversations will inform and
support changes to how we deliver
care. The patient conversations will
be embedded across services and
form part of the framework of
SEQOL‟s peoples experience strategy.
Staff treat you with
respect
Staff speak to you the
way they should
What patients in SwICC told us
Food is tasty, there is
enough food, and portions
are big
Reasonable selection
Have had physio and been
given a Zimmer frame and a
toilet rail to help me when I
get home
Have been given some
exercises
Generally hot
There is enough to drink –
patients are pushed to drink
there is always a jug of
water available
SEQOL Quality Account 2011/2012
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Part 3
Review of Quality
There are three important quality
improvement areas for all service
users: Safety, Experience and
Effectiveness and these will be
addressed within our Quality Account.
Safety is about taking steps to ensure
the safety of everyone who comes
into contact with SEQOL services. It
encompasses a range of processes to
be in place which includes assessing
how patients may be harmed;
preventing or managing risks;
reporting incidents; looking at the
root cause of incidents so we can
learn what may have gone wrong and
how we can avoid the same or similar
incidents happening again.
Effectiveness is about the right
person, doing the right thing, at the
right time, in the right place, with
the right result. This encompasses our
teams having the competencies and
skills for the jobs they do, that their
practice is evidence based, and that
we provide effective services when
and where they are needed.
Experience is about people benefiting
from safe quality care, treatment and
support. Making sure people‟s privacy,
dignity and independence are
respected. Providing information so
people are empowered and feel
confident to make informed choices
about their care and learning from
complaints so that users‟ experiences
are improved.
SEQOL Quality Account 2011/2012
At SEQOL we acknowledge that
quality care is not achieved by
focusing only on one or two of these
areas; high quality care encompasses
all three aspects with equal
importance being placed on each and
with persistent focus. We will be
reviewing how we have done in the
past year 2011/12 in these three
quality areas and looking ahead to our
priorities for next year 2012/13.
Looking back – our achievements
2011-12
As stated in last year‟s Quality
Account, teams within SEQOL have
continued to be actively involved in
the South West Quality and Patient
Safety Improvement Programme. An
important part of this programme is
to link with existing groups working
on safety and quality topics, to build
on local expertise and further develop
areas of good work.
We continue to use the knowledge
gathered from attending the regional
training sessions, we focus on
enhancing current skills within teams.
Applying these skills whilst caring for
patients helps to consolidate the
learning and improve patient care.
The information below outlines
SEQOL‟s progress against the priorities
for 2011/12 as published by Care and
Support Partnership in last year‟s
Quality Account.
Page 15 of 26
Patient safety - Reduce acquired infection:
QUALITY MEASURE: Number of Methicillin-Resistant Staphylococcus Aureus (MRSA)
bacteraemia reported in Swindon Intermediate Care Centre (SwICC)
There have been no MRSA bacteraemia reported by SwICC during 2011-2012
maintaining the achievement of the previous year.
QUALITY MEASURE: Number of Clostridium difficile infections reported in SwICC
Two Clostridium difficile infections were reported by SwICC – one on Orchard ward
and one on Forest ward matching the achievement of last year.
QUALITY MEASURE: Number of Catheter associated urinary tract infections
Reducing the number of Catheter Associated Urinary Tract Infections is one of the
work streams of the Quality and Patient Safety Improvement programme. The
work has addressed the following key issues:
1. Establishing the number of people in the community who have long term
indwelling catheters, and are known to our services
2. Improving education in residential and nursing homes to reduce the rate of
catheterisation, where alternative treatment, care, or management can be
identified.
3. Establishing effective and accurate ways to monitor catheter associated
UTIs, in those people who have an indwelling urethral catheter. This work
has been focused in specific community nursing caseloads
The work carried out so far has resulted in a steady reduction in the number of
people with indwelling catheters, particularly in residential or nursing home
care. The number of people with catheters in the caseloads that we have studied
has remained more constant. Methods of monitoring infection rates in these
people are under continual review and development, using established
methodology recommended as part of the Quality and Patient Safety Improvement
programme.
Patient safety –Reduce avoidable harm
QUALITY MEASURE: Reduce the number of Grade 3 and Grade 4 pressure ulcers
From April 2011 to November 2011 we reported a total of 16 Grade 3 and 12 Grade
4 pressure sores. During the period December 2011 to the end of March 2012
SEQOL has not reported any Grade 3 or Grade 4 pressure sores. We believe the
Patient Improvement Programme work has led to better identification of the
seriousness of the sore and greater clarity about whether the sore is inherited or
acquired. SEQOL must report sores acquired during the provision of services and
we have had no Grade 3 or 4 sores to report since December 2012.
SEQOL Quality Account 2011/2012
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QUALITY MEASURE: Review of incident reporting
All incidents within SEQOL are recorded using the Sentinel on-line reporting
system. Incidents recorded this year are as follows:
Clinical incidents (harm caused) – 269
Clinical incidents (no harm) – 296
Equipment - 12
Staff sickness – 3
Other – 25
Security – 24
Patient absconded – 1
Staff accident (with injury) – 34
Staff accident (no injury) – 2
Vehicle – 7
Violence/Abuse/Harassment (with injury) – 8
Violence/Abuse/Harassment (no injury) - 36
Patient safety – Reduce avoidable harm (NPSA)
QUALITY MEASURE: Medication errors
All medication errors within SEQOL are recorded using the Sentinel on-line
reporting system. Medication errors recorded this year are as follows:
Wrong Dose – 15
Wrong drug – 4
Omitted drug – 5 medications
Patient allergic – 2
Wrong frequency – 14
Other - 28
QUALITY MEASURE: Recognition and rescue of the deteriorating patient
This is one of the work streams within (QSPIP). We are developing skills and
resources within our teams to support this quality improvement.
SEQOL Quality Account 2011/2012
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Effectiveness -Deliver effective evidence based care
QUALITY MEASURE: Compliance with Venous thromboembolism (VTE) guidance and
action plan
This is one of the QSPIP work streams. SEQOL have worked robustly towards
complying with this NICE guidance as good practice as the guidance currently is
applicable to acute areas.
There is an established community VTE group. We have formed close links with the
Great Western Hospital VTE nurse specialist who attends our meetings and a SEQOL
representative attends the hospital thromobopropylaxis meeting. This has helped
to ensure that policies and risk assessments are similar across the care pathway
and facilitate a sharing of learning across organisations.
For both SwICC and community teams SEQOL have developed specific procedures
including competencies to support staff delivering care.
SEQOL intend to continue to embed management of VTE within the community.
QUALITY MEASURE: Compliance with National Institute for Health and Clinical
Effectiveness (NICE) guidance
Compliance with NICE Guidance has occurred through participation in programmes
such as Quality and Patient Safety Improvement Programme; national and local
audit. In the forthcoming year, SEQOL will have developed a system to ensure
distribution of NICE Guidance and compliance through formal governance channels.
QUALITY MEASURE: Compliance with Central Alert System
SEQOL complies with the Central Alert System and has acted upon all relevant
alerts received within the required time scales.
Experience
QUALITY MEASURE: Patients treated with dignity and respect
There are two residential care homes within SEQOL: Fessey House and Whitbourne
House. A peer review observational audit was undertaken in April 2011 to assure
the quality of care given takes account of people‟s privacy and dignity and to
continually improve the quality of services.
In August 2011a patient experience pilot was undertaken using „patient
conversations‟ to discover people‟s experience of the care they are receiving
whilst in intermediate care. Following the success of the pilot further „patient
conversations‟ were undertaken in Feb 2012 this time in partnership with Swindon
Local Involvement Network.
During 2011-2012 SEQOL invited relevant people to share their experiences of
therapeutic exercise as part of a falls prevention service by means of a postal
questionnaire. This was part of a national exercise co-ordinated by the Royal
SEQOL Quality Account 2011/2012
Page 18 of 26
College of Physicians to complement the findings from the recent National Falls
and Bone Health report in older people 2010. SEQOL has recently received the
report of this patient and public involvement exercise and intends to review this in
the forthcoming year.
SEQOL supported and facilitated a programme to ascertain the experiences of
people who have Parkinson‟s disease. Experience Based Design tools from the NHS
Institute for Innovation and Improvement were used to identify key moments
where people came into contact with the service and where their subjective
experience was shaped. One key theme was that there was no dedicated
Parkinson‟s Disease nurse. The report was published during 2011 and reviewed by
both SEQOL and NHS Swindon (Commissioners). SEQOL intend to appoint a
specialist nurse for Parkinson‟s Disease in the coming year.
QUALITY MEASURE for Swindon Intermediate Care Centre:
Patient Environment Action Teams (PEAT)
PEAT is an annual assessment of inpatient healthcare sites in England. It is a
benchmarking tool to ensure improvements are made in the non-clinical aspects of
patient care. The scores demonstrate how well individual healthcare providers
believe they are performing in key areas including food, cleanliness, infection
control and patient environment (including bathroom areas, décor, lighting, floors
and patient areas).
Assessments are carried out by NHS staff such as nurses, doctors, catering and
domestic service managers. Patients, patient representatives and members of the
public are also part of this assessment process.
Results are determined on a 5-point scale of Excellent, Good, Acceptable, Poor
and Unacceptable
SEQOL maintained an EXCELLENT result.
Comply with governance and regulatory obligations
QUALITY MEASURE: Care Quality Commission registration
On 30th September 2011 Care and Support Partnership Community Interest
Company Ltd. trading as SEQOL registered with the Care Quality Commission (CQC)
to provide regulated activities. It is an offence to carry out a regulated activity
without being registered. CQC is the independent regulator of health and adult
social services in England.
Registration requires that essential standards of quality and safety are met, across
all regulated activities to ensure the quality of people‟s experience of the care
they receive.
SEQOL Quality Account 2011/2012
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CQC monitors compliance with the essential standards of quality and safety. The
focus is on outcomes rather than systems and processes and places the views and
experiences of people who use services at its centre.
CQC inspect most hospitals, care homes and home care agencies at least once a
year.
Since registration SEQOL has had two unannounced visits to review compliance.
In both areas, the services were deemed to be meeting all the essential standards
of quality and safety. To maintain this CQC suggested some improvements; in
response to their request, action plans were developed, implemented and the
outcomes shared with CQC.
QUALITY MEASURE: Staff survey (Relates to health staff only)
During Oct 2011, employees who had transferred to SEQOL from NHS Swindon took
part in the 9th mandatory National NHS Staff Survey. Response rates were 41%
(middle cluster).
The Board reviewed the survey findings in Jan 2012, but were mindful that the
survey only represented colleagues from health, and therefore took the decision
for a whole organisation SEQOL survey to be administered during 2012 to obtain a
more reliable collective view.
The organisation was however assured by clinically specific responses in relation
to:Numbers of staff accessing training in the past 12 months and keeping up to date
with developments (81%)
Numbers of staff who had received conflict resolution training (90%)
Numbers of staff who had received infection control training (97%)
Number of staff who have received training on handling confidential information
(96%)
QUALITY MEASURES: Vulnerable adults
SEQOL continues to meet its statutory duties regarding the safeguarding of
vulnerable adults including Deprivation of Liberty Safeguards and Best Interests
and expects all staff to understand what is required of them with regard to
alerting on issues of safeguarding adults and adult protection.
SEQOL Quality Account 2011/2012
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Participation in clinical audits
During 2011 – 2012 there were 2
national clinical audits but no
national confidential enquiries that
covered the NHS services that SEQOL
provide.
During that period SEQOL participated
in 50% national clinical audits which it
was eligible to participate in (i.e.
National Parkinson‟s Audit). There
were no national confidential
enquiries that covered services which
SEQOL provide.
The national clinical audits that
SEQOL was eligible to participate in
during 2011 – 2012 are as follows:
National Parkinson’s Audit
The national audit of services for
people with multiple sclerosis
“The national clinical audits that
SEQOL participated in, and for which
data collection was completed during
2011 – 2012, are listed below
alongside the number of registered
cases required by the terms of that
audit. There were no national
confidential enquiries that SEQOL was
eligible to participate in.
Audit Name
% of cases submitted
National Parkinson‟s Audit
Physiotherapy section
Occupational Therapy section
Speech & Language Therapy section
100%
90%
0%
The report of the national audit of falls and bone health in older people 2010
“Falling standards, broken promises” was reviewed by the provider in 2011 – 2012
and SEQOL intends to take the following actions to improve the quality of health
care provided:
Review relevant components of Swindon Integrated falls pathway
Review falls policy, protocol and procedure
Train staff on falls & bone health screening.
The reports of 2 local clinical audits were reviewed in 2011 -2012 and SEQOL
intends to take the following actions to improve the quality of healthcare
provided:
SEQOL Quality Account 2011/2012
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Local Audit Reviewed
Actions to Improve Quality
Privacy & Dignity in SEQOL
Care Homes
Health and Social Care
Records audit
Portable screens for use in an emergency
Revisit possibility of using a local Primary Care
Practice as the sole provider to one of the care
homes
Improve signage with regard to toilet
identification
Consideration to adding an audible alarm to an
outside door following a Health & Safety risk
assessment
Improving discharge communications between
hospital and care homes
Regular monthly audits of record keeping standards
were undertaken across the majority of services
which SEQOL provides. Over the year, there were
demonstrable improvements in all service areas.
Nevertheless, SEQOL accepts that improvement
needs to be sustained in the pursuit of excellence.
The end of year recommendations will be reviewed
as it is recognised that as a new organisation SEQOL
Community Interest Company will require a
different strategy to maintain improvements in
record keeping.
Participation in clinical research
“The number of patients receiving NHS services provided or sub-contracted by
SEQOL in 2011 – 2012 that were recruited during that period to participate in
research approved by a research ethics committee was zero”
Information Governance Toolkit attainment levels
“SEQOL Information Governance Assessment Report score overall score for 1st
October 2011 – 31st March 2012 was 36% and was graded Pink.
„The Connecting for Health Information Governance Toolkit requires all
organisations to perform at level 2 or above. During 2011/12 NHS Swindon and
SEQOL had part ownership for this assessment period. SEQOL made the decision to
submit the toolkit assessment at level 1, from 1st October 2011 to 31st March 2012;
the Information Governance Toolkit returned an automated rating as „Not
Satisfactory‟. SEQOL is developing an action plan for 2012/13 that will ensure
each of the 29 elements rate at level 2 or above.
SEQOL Quality Account 2011/2012
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Statements of assurance from
the Board
During 2011 – 2012 Care and Support Partnership Community Interest Company
trading as SEQOL has provided NHS services in accordance with the contract with
NHS Swindon.
SEQOL has reviewed the data available to them on the quality of care in all of
these NHS 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 SEQOL
for 2011 – 2012.
Use of CQUIN payment framework
A proportion of SEQOL income in 2011 – 2012 was conditional on achieving quality
improvement and innovation goals agreed between SEQOL and NHS Swindon for
the provision if NHS Services through the Commissioning for Quality and
Innovation payment framework (CQUIN). SEQOL received payment based on the
agreed CQUIN goals for 2011/12 which were as follows:
VTE - reducing avoidable death, disability and chronic ill health from
Venous thromboembolism (VTE).
Service user experience - improve responsiveness to personal needs of
patients.
Reduce emergency admissions for VHIUs (very high intensity users).
Supporting people to die in their place of choice.
Reducing acute hospital bed days through improved self-management.
Increasing community productivity to reduce urgent care activity with a
pro-active approach to care coordination via a Single Point of Access and
the introduction of virtual beds in the community.
SEQOL are pro-actively implementing the national CQUIN goals for 2012/13
as follows:
Reducing avoidable death, disability and chronic ill health from Venousthromboembolism (VTE).
Improving the responsiveness to the personal needs of patients.
SEQOL Quality Account 2011/2012
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Improving the collection of data in relation to pressure ulcers, falls,
urinary tract infection in those with a catheter and VTE.
Improving the awareness and diagnosis of dementia.
Local CQUIN goals will be published on the SEQOL website
http://www.seqol.org/once agreed with NHS Swindon.
Statement from the CQC
SEQOL is required to register with the Care Quality Commission and its current
registration status is „Registered‟ SEQOL has no current conditions on registration.
The Care Quality Commission has taken no enforcement action against SEQOL
during 2011/2012. SEQOL has not participated in any special reviews or
investigations by the CQC during the reporting time.
Statement from Swindon Local Involvement Network
For those reading the document on the internet, double columns can be
awkward. We would prefer to see the text in single columns throughout.
Swindon Local Involvement Network (LINk) steering group welcomes the
opportunity to comment on this interesting and useful draft SEQOL Quality
Account (QA). We are pleased to see the statement included in the published
document. Last year SEQOL‟s predecessor organisation failed to publish the LINk
statement in its 2010/11 QA.
Governance and organisation
SEQOL continues to demonstrate that its understanding of "social enterprise" is
insufficient. Page 2 (and similarly page 6) of the QA states:
"SEQOL is a social enterprise (a Community Interest Company), which means most
of our employees own a share in the organisation." Having employees owning a
share of an organisation is not a definition of a social enterprise, so "which
means that" is not accurate. Some private sector bodies, for example, have
employee share ownership. Most are neither social enterprises nor not for profit
distribution bodies. A Community Interest Company is a legal structure for a
corporate body not a description of a type of enterprise. There is reference to
staff being "represented" on the SEQOL board. Directors are not permitted by
law to be representatives of any particular group. All directors have a fiduciary
duty to the corporate body. It would be more accurate to state that there are
SEQOL employees on the board or even, perhaps, that there is a mechanism to
appoint employees to the SEQOL board or for employees to be involved in so
choosing such persons (if there is such a means).
It would be helpful to show the SEQOL organisational structure together with
details of the Board of Directors.
SEQOL Quality Account 2011/2012
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Service delivery
It is acknowledged that a QA is about health care services and the reporting
framework is somewhat prescribed. The chief executive‟s statement helpfully
sets out some information about the range of services provided by SEQOL. Much
of the performance report is, perhaps inevitably, devoted to the Intermediate
Care Centre, SwICC. There is no mention of the wheelchair service and little
about other community health services. As a consequence the QA gives a partial
view of SEQOL as an organisation. This is unfortunate because one of the
purposes of the QA is for “service users and their carers to make well informed
choices about their providers of healthcare”.
The QA states that “SEQOL generates its income from commissioners of
community services such as the NHS, General Practitioners and local
authorities.” The QA could perhaps also mention that it also sells some
services direct to its clientele – the footcare service being an example.
On page 11 “From 1 October 2011 to 31 March 2012 were 58 complaints”. Within
the context of the QA and its reporting framework, it would be helpful to know
the type and nature of the complaints to understand whether they were
applicable to many or all patients, and what action was or might be taken to
resolve them.
We do not think that (page 16) two Clostridium difficile infections were
reported by SwICC – one on Orchard ward and one on Forest ward is an
achievement which matches last year as such. The achievement could
possibly be the success in preventing an increase.
We think it would be reasonable to include a reference to the involvement of
(and funding from) Parkinson‟s UK in the following statement on page 19. We
take it that “the provider” is a reference to SEQOL? The QA says “….
SEQOL intend to appoint a specialist nurse for Parkinson‟s Disease in the coming
year. The report of the national audit of falls and bone health in older people
2010 “Falling standards, broken promises” was reviewed by the provider in 2011
– 2012 and SEQOL intends ……”
Page 22 Information Governance Toolkit attainment levels. SEQOL‟s
performance is below standard which should provide scope for improvement in
2012/13 and subsequently which we and Healthwatch Swindon will look
forward to hearing about.
And finally
It would be helpful to have web links where there are references to other
documents like “Care and Support Swindon, Quality Account 2010-2011” on
page 26
SEQOL Quality Account 2011/2012
Page 25 of 26
Statement from NHS Swindon
NHS Swindon has reviewed SEQOLs Quality Accounts report for 2011/12. The
Quality Accounts were reviewed by the Commissioning for Quality group which
includes Clinical Commissioning group representation. NHS Swindon can confirm
that, in their view, the Quality Accounts (QA) complies with the guidelines for
application for the organisations QA report.
Commissioners monitor performance and the quality of services routinely each
month with SEQOL. Commissioners can confirm that, to the best of our
knowledge, the Quality Accounts 2011/12 contains accurate information in relation
to the services provided.
As a new organisation SEQOL has set out their governance model that clearly
places patient safety, experience and effectiveness at the centre of their business.
In addition they have explored multiple sources ranging from patient feedback to
local intelligence collected via incident reporting and complaints to ensure they
have achieved their contractual quality requirements and to prioritise for 2012/13.
It is good to see the focus on capacity and capability through their operating
model and through the delivery of the outcomes set out in the CQUINs.
Overall, SEQOL has good plans to improve quality during 2012/13, and with the
impending transition from Primary Care Trusts to Clinical Commissioning Groups we
look forward to working together to ensure that quality of care and services
remains key.
Statement from Health Overview and Scrutiny (Swindon Borough Council)
The Health Overview & Scrutiny Committee is committed to having a good working
relationship with SEQOL and, based on the Committee‟s knowledge, endorses the
Quality Account for 2011/12.
The Committee is grateful for SEQOL‟s attendance and regular reporting at its
committee meetings and hopes that this continues during 2012/13.
The Committee supports the areas for Quality Improvement and looks forward to
continuing to work with SEQOL to provide Health and Social Care services for the
residents of Swindon. (13/06/2012)
Bibliography
„Harmfree‟ care Journal; www.harmfreecare.org
Care and Support Swindon, Quality Account 2010-2011
NHS Safety thermometer: http://www.ic.nhs.uk/services/nhs-safety-thermometer
SEQOL Quality Account 2011/2012
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