QUALITY ACCOUNT
2011 – 2012
SURREY COMMUNITY HEALTH
PROVIDER SERVICES
Provider ID 5P5 NHS Surrey is registered and therefore licensed to provide
services, by the Care Quality Commission
For more information, visit www.cqc.org.uk
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Contents
PART 1 ........................................................................................................................................... 3
Host Commissioner Statement .................................................................................................. 4
Highlights of some of our key improvement priorities delivered in 2011/12 which support
Safety Quality and User Experience .......................................................................................... 5
PART 2 ........................................................................................................................................... 7
Priorities for Improving Quality Safety and User Experience going forward in 2012/13 ............ 7
How our priority objective will be monitored, measured and reported in 2012/13 ..................... 9
STATUTORY SECTION ............................................................................................................... 10
Clinical Audit............................................................................................................................. 10
National Audit programme participation 2011/12 ..................................................................... 11
Research and Publications ...................................................................................................... 13
Inspections and National Service Reviews Care Quality Commission (CQC)......................... 13
Equality and Diversity Initiatives ............................................................................................... 16
Data Quality and actions to improve Data Quality ................................................................... 16
Quality Management Systems and Initiatives for Improving: capacity and support for staff .. 18
Safety ....................................................................................................................................... 18
Safeguarding ............................................................................................................................ 18
Workforce ................................................................................................................................. 18
Supporting High Quality Staff Education and Training............................................................. 19
Clinical Effectiveness ............................................................................................................... 19
Patient Outcomes ..................................................................................................................... 20
SERVICE REVIEWS .................................................................................................................... 20
PART 3 ......................................................................................................................................... 23
Review of our quality and performance in 2011/12.................................................................. 23
National Achievements ............................................................................................................ 23
Award Winning Clinical Services.............................................................................................. 23
Service Innovation .................................................................................................................... 23
APPENDIX 1 ................................................................................................................................ 26
Commissioning For Quality and Innovation (CQUIN) Targets 2011/12 ................................... 26
Patient Experience ................................................................................................................... 26
Clinical Incident Reporting ....................................................................................................... 27
High Impact Actions for Improving Patient Safety:................................................................... 30
Safety Thermometer and Safe Care Metrics ........................................................................... 30
Safety Alert Bulletins ................................................................................................................ 33
APPENDIX 2 ................................................................................................................................ 34
Who was involved in the development and review of the Second Quality Account ................ 34
APPENDIX 3 ................................................................................................................................ 35
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PART 1
In May 2011 during a time of significant organisational change,
we published our five year strategy1 to transform Surrey
Community Health into the leading provider of NHS funded
community services based on our reputation for quality and
value. Our strategy has allowed us to ensure that there was no
loss of focus on operational and clinical transformation.
We believe that the best way to lead and achieve change is through our five
year strategy which builds on last year’s success with financial and clinical
service transformation and sets out how we will:
 Better understand the strategic drivers of change in the NHS and how
we can use this knowledge to achieve our vision and deliver our
strategic goals.
 Work with patients, users, our clinicians and staff, partner organisations
and commissioners to innovate and improve integrated care and
ensure that financial systems support the concept of ‘money following the
patient’.
 Harness the latest medical technology to support our clinicians to deliver
quality and value.
We set out a number of quality aspirations for 2011/12 that would impact on
safety, user experience and for effectiveness of the services we provide. We are
proud that on reflection at the year-end we have achieved many changes; page
5 provides a summary of some of our key successes and part 3 provides
outcomes from some of our service line reviews and safety and quality data
which to the best of my knowledge this information is accurate.
In developing our second set of Quality Accounts, the executive team, clinicians
and staff have been able to reflect on and demonstrate their commitment to
continuous, evidence-based quality improvement and patient experience in
part 2.
The White Paper ‘Liberating the NHS- Equity and Excellence’, set strict
timescales for Primary Care Trusts to determine a suitable organisational home
for their provider services and transfer their responsibilities for commissioning to
GP consortia, before abolition in April 2013. Surrey Community Health
transferred to a new organisation Virgin Care Ltd on 1 April 2012.
1
Leading with Ambition, Delivering with Passion: May 2011
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Our focus going forward is to continue to progress transforming our services so
that our plans are consistent with the national agenda for quality, innovation
productivity and prevention (QIPP).
Alison Edgington, Chief Executive Officer, Surrey Community Health – 21 June 2012 Host Commissioner Statement
The host commissioning PCT, NHS Surrey have reviewed Surrey Community
Health Provider Services draft Quality Account document for 2011 – 2012 and
believes that this provides a fair reflection of the work of the provider and
includes the mandatory elements required. The priorities have been discussed
and will be further developed with input from commissioners including Clinical
Commissioning Groups.
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 Surrey Community Health during the year and reviewed as part
of their performance under the contract.
We continue to work with the organisation to ensure that data accuracy at all
levels remains a key priority, including the application of clinical coding.
The account identifies significant success in relation to:


Clear reference to staff and patient engagement
Successful delivery of TCS separation
We will continue to work with Surrey Community Health Provider Services to
raise the profile for quality improvement and regularly review the continuous
improvement cycle. The engagement of clinicians close working with primary
care will remain crucial in monitoring standards, and improving services for local
people. The staff are commended for their continued good work and emphasis
on quality of patient care.
Date: May 2012
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Highlights of some of our key improvement priorities delivered in 2011/12
which support Safety Quality and User Experience
Patient safety
Delivering essential standards for
quality and safety that everyone who
uses our services has a right to expect
Clinical Effectiveness
We published our clinical strategy to
develop and support the improvement
of clinical pathways and provide safe
care for people who use our service
User Experience
We wanted to make appropriate
changes based on user feedback so
we can provide the highest quality
care at all times
we are reporting :
 safe care metrics to demonstrate on-going improvements to
patient care
 our statutory training targets were met
 no MRSA bacteraemia cases acquired in our community
services
 the introduction of the ‘Green Bag’ – pharmacy initiative
 that we completed a full evidence review of clinical
equipment assets and buildings safety management
requirements, to provide on-going assurance of regulatory
compliance before registering as a new provider
organisation
we achieved our targets for CQUIN:
 for end of life care, heart failure, baby friendly initiatives
and pressure ulcers
we reviewed and made changes to some
services such as:
 Child Health service model for 0-19 years
 Wheelchair service
 Paediatric Therapy pathway & staffing
 Paediatric Audiology staffing and waiting times
we are developing:
 clinical pathways, for example, for frail elderly aimed at
keeping people at most risk out of hospital and introduce
the concept of virtual wards and shared point of access
 Heart Failure EQ project
we appointed:
 a clinical director for developmental paediatrics and nurse
consultant to support people with long term conditions
we participated:
 in all applicable national clinical audit programmes and
agreed actions to sustain improvements
working in partnership
 we updated our Children’s and Young People’s Health
Strategy
we piloted:
 a new way of collecting feedback on our services by
introducing ‘net promoter’
we initiated;
 a youth parliament
 launched and publicised an online survey as part of Men’s
Health week to find out how best to access men
we conducted :
 inpatient interviews with patients and careers to seek
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greater insight into how we can improve integration and
socialisation during an inpatient stay
 we used mystery shoppers in therapy services to test
quality and experience
we achieved:
 a successful role out of new syringe drivers across all
service lines to deliver medicines safely
we wish to say a big thank you to :
 the League of Friends, our volunteers and our Patient
Panel for helping us promote quality and enhance the
experience of our service users
Quality Management
we successfully re- registered with CQC:
Systems
 following a successful transition to Virgin Care Ltd and
Drawing on the NHS quality and safety
closured 2010/11 CQC action plans
standards, national and local targets,  registered with the Home Office for controlled drugs
we wanted to improve how we
we received :
measure safety quality and patient
 positive assurance from our internal auditors against our
experience
process for evidencing CQC compliance and early
warning systems
 good reports from CQC assessment and prison health
service quality indicators peer review
 a fair assessment of one of our community hospitals
following CQC’s inspection and closed actions required to
maintain compliance from last year
we introduced:
 an internal audit programme to help us monitor our
services and where improvements were identified, actions
were closely monitored by the executive team
 patient information leaflets linked to areas within High
Impact Actions (e.g. falls pressure damage )
we completed:
 all service line reviews and reduced the cost of clinical
service provision; by working in partnership with others to
reduce waste; by working smarter and investing in new
clinical technologies
we benchmark:
 our services by submitting national safety returns and
participating in the community hospital benchmark
we delivered :
 our target for full service roll out of the new RIO clinical
records system
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PART 2
Priorities for Improving Quality Safety and User Experience going forward
in 2012/13
Following the successful outcome of the national centrally led NHS reorganisation agenda, Surrey Community Health’s priorities for improvement in
2012-13 have not been planned in isolation but have been discussed and
agreed through discussions with our staff, our partners in health and social care,
service users and our commissioners and will focus on:
► delivering the commitment set out in our five year strategy Leading with
Ambition Delivering with Passion, to provide clinically effective healthcare in
people’s homes and close to where they live, driven by our clinical strategy
► actions following the review of how we delivered last year’s quality
improvement priorities, national and local targets including the outcomes
from benchmark reviews
► extending the use of patient focused outcomes
► continuing to take forward patient, service user and carer involvement and
acting on real time patient feedback, received at key locations, to improve
safety and experience
We have used workshops held, together with partners in social care, education,
early years and primary care, to agree priorities for developing children’s services.
We have held a number of quality events during the year across Surrey, to look at
how we will continue to improve services for adults. We consulted with our staff,
service users, and patient representatives to establish a balance of quality and
safety initiatives for the coming year.
We want to demonstrate our developments and strike the right balance of
commissioning for quality and innovation (CQUIN) schemes and our compliance
with the 16 essential standards for registration with the Care Quality Commission
over the next five years.
Priorities objectives and
rational for on-going
improvement in 2012/13
Safety - On-going programme for
the reduction of patient / user
safety risks
Considerable and valuable work
has taken place which has had a
Implementing and monitoring our priorities
during 2012/13
►we will continue to focus on safer smarter
metrics and the safety thermometer for the
reduction of common patient safety risks,
such as, falls in community hospitals,
community acquired infections, medication
errors and skin damage (pressure sores)
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►we have in place, a significant programme of
work and a clinical audit programme led and
monitored by the Safety Express Group, the
Medicines Management Patient Safety
Group and Safeguarding Governance
Group, to ensure this happens
►Executive ‘walk the floor’ and 80 road
shows are planned this year to listen and
learn from staff and users of our services
►our revised performance dashboard ensures
the board and public are kept well informed
of risks and our successes
►we will continue to monitor for example,
safer use Insulin e-learning uptake to meet
the Department of Health’s requirement to
reduce incidents associated with its use and
all medicines risks through our medicines
competency framework
►we will deliver continue to deliver our
Clinical Effectiveness –
clinical strategy and are jointly working with
Delivering quality and value
others on clinical pathways for frail elderly,
dementia, stroke and those of young people
Our aim is to ensure that all our
services consistently use validated ►we will use our clinical audit programme to
measure how well we meet clinical
patient reported outcomes to
standards supporting these pathways
demonstrate NHS quality
►we aim to develop more patient reported
standards and meet national
outcome measures into service line reports
targets
►key performance indicators will be relevant
Patient Experience and transparent to users and patients by
Through more involvement
involving them in new clinical pathway
Patient experience activity and
initiatives for example, dementia and stroke
how we monitor this has shown
care
improvement, especially over the
►rollout the net promoter pilot across more
last year. However, patient/user
services
involvement in service delivery and ►use our web site and mobile working to
design, across all services,
gather more real-time user feedback
requires further attention as a key
►engage more people from across the age
quality objective in delivering
spectrum to support us in service design and
patient focussed services
quality monitoring
Quality Management Systems - ►we have revised our business plan and
assurance framework and set our savings
To deliver clinically safe care
plan for the next five years
►we will deliver new federated models of
We are committed to linking our
significant impact on, for example,
reducing the number of falls. More
is yet to be achieved within the
whole healthcare system in
relation to pressure wounds,
medicines safety and acquired
infections resulting from invasive
procedure for example, following
the insertion of a catheter
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five year strategic vision, clinical
and QIPP plans and delivering
these through service operational
plans, managing risks and
delivering our budget targets so
that we can re-invest to continue
to improve services
Deliver our IT strategy
Improve access and diagnostics
Monitoring Regulatory compliance
To ensure we maintain the
essential standards for Quality and
Safety of all
clinical services working in partnership with
the Cluster Commissioning groups, acute
hospitals and social services
►we will monitor the success of our business
plan (2012/13 and beyond) by delivering the
community contract performance data and
learning outcomes from external reviews
►we are delivering our IT strategy with ongoing investment in; technology to enable
staff to have remote access to users and
patients to support them to manage their
own conditions at home
►we continue to invest in portable diagnostic
equipment to deliver safe and effective
clinical care to patients
►we will deliver Telehealth into prison
healthcare services
►progress against our strategy is scrutinised
by IT programme board
►will be monitored through a second year of
internal onsite inspections and the
introduction of an integrated electronic
management tool designed to embed local
safety and quality monitoring
How our priority objective will be monitored, measured and reported in
2012/13
We monitor all that we do through our existing clinical governance, risk, quality
and patient safety assurance processes. For example, we use our board
assurance framework and risk register to ensure that we deliver our operational
plan and services operate efficiently, effectively and safely. Our report cycle for
example includes quarterly matron, service managers and the healthcare
governance reports which provide a significant amount of information on safety
risks and quality initiatives. Our quality and performance dashboards, patient
experience and clinical audit outcome reports are reviewed by appropriate
committees, reported up to the board and areas identified for improvement are
actioned by service and clinical leads.
Key indicators to measure performance and service outcomes have been
agreed for 2012/13 across all service lines. These are inclusive of, but not
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limited to; demonstrating on-going regulatory compliance with the essential
standards of quality and safety and delivering and service innovation. Services
will continue to contribute to the national audit programme and participate in
benchmarking of services to measure standards and practice and support the
on-going development of clinical outcomes, quality and safety monitoring.
A revised internal audit programme will support us with the on-going review of
our system and process for safety, quality and innovation. Contract
performance, data quality, clinical audit, smarter nursing matrix and patient
reported outcomes remain high profile and will continue to be reported and
reviewed through our governance structures up to the board as a new
organisation.
STATUTORY SECTION
Clinical Audit
Last year, we acknowledged that a broader range of clinical audit activity was
required to seek opportunities for quality improvement in patient care and
experiences. A focus on health outcomes rather than the process of care
delivery was a major priority, together with ensuring that our clinical audit
programme developed in line with NHS Outcomes Framework 2011/12. Where
evidence of best practice has been published, in the form of National Institute of
Health and Clinical Excellence (NICE) Quality Standards and Clinical
Guidelines, evidence is being used to understand the degree of local safe and
clinically effective outcomes and of positive service user experience, on
discharge from community hospital and community services.
In line with the ‘Transforming Community Services programme for
demonstrating and measuring achievement’, community service indicators for
quality improvement have been incorporated into local clinical audit projects.
This is particularly for indicators 23 and 24, which concern assessment using a
validated tool, and measuring improvement using these validated tools.
Key highlights in 2011/12
► Over 40 different validated outcome indicators are routinely measured across
SCH to enable reflection and continuous quality improvement. These form
the basis of service specific clinical audits that measure clinical
effectiveness.
► A local speech and language therapist is currently auditing the use and value
of a dysphagia (swallowing) outcome measure by recording the clinical
effectiveness of the service provided, which is an area where a nationally
validated outcome measure is lacking.
► In-patient rehabilitation teams, intermediate care teams, stroke teams for
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early discharge and community rehabilitation teams all use validated
assessment tools to understand levels of on-going clinical effectiveness and
service user progress achieved whilst receiving SCH care.
► SCH participation in the first national audit of intermediate care is enabling us
to benchmark local service provision against the national average and range
achieved.
► Therapists within SW locality undertook an ‘Essence of Care’ audit that
included site visits to clinical settings, engagement of staff in discussion and
reflection on their actions to promote respect, and feedback from ninety three
patients concerning their experience of respect during therapy sessions.
► Our core clinical audit programme continues to help ensure safe care through
infection control site audits, hand hygiene observations, medicines
management and record keeping audits.
► An audit tracker tool has been introduced to improve the sharing of
knowledge about clinical audit activity undertaken across services and the
learning arising from it, reported through the clinical governance report cycle.
► SCH clinical audit projects that have incorporated nationally approved
outcome measures included:






The national ‘Enhancing Quality in Heart Failure’ project
Community nursing venous leg ulcer clinical audit
Community hospitals and community nursing pressure ulcer audit
Community hospitals urinary catheter audit
Community hospitals falls audit
National safety thermometer pilot safe care metrics
► Local ‘Quality Innovation, Productivity Prevention’ (QIPP) projects such as
leg ulcer and pressure ulcer reduction, continue to rely on clinical audit
evidence to demonstrate quality improvement.
► The medicines safety audit programme continues to be inclusive of
medication administration, prescribing, recording, safe storage and
competency assurance and compliance with all NPSA rapid response and
drug alerts.
National Audit programme participation 2011/12
The national clinical audits that SCH was eligible to participate in were:
 E-Diabetes – community nursing, children’s community nursing and
podiatry
 National falls & bone health audit follow up project involving patients who
have attended local exercise programmes following a fall
 Multiple sclerosis
 Depression & anxiety (National Audit of Psychological Therapies)
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 Bedside blood transfusion
 Paediatric epilepsy - (RCPH National Childhood Epilepsy Audit)
 Parkinson’s disease – involving nurses, doctors, physiotherapists,
occupational therapists, speech and language therapists and
intermediate care teams
Actions arising from these clinical audit report findings were raised in a report to
the governing committee and are being acted on at service level.
Our priority for the year ahead is to continue to commit to participation in all
national audits that we are eligible to undertake, and national benchmarking, as
feedback is valuable in understanding comparative strengths and weaknesses,
and in identifying where quality improvements may be introduced. These will
include:
 Stroke national audit programme (Royal College of Physicians)
 The national audit of dementia if it is extended to cover community
provider services
 National urgent care audit (Royal College of Paediatrics and Child Health
and Royal College of GPs) within walk in centres and minor injuries unit.
Other audit priorities for 2012/13
►A planned multi-professional audit of dementia care will take place within SCH
community hospitals during national dementia awareness week (May 2012)
and offers an important opportunity to benchmark local service against the raft
of nationally published guidance such as:
 Prime Minister’s challenge on dementia; delivering major improvements
in dementia care and research by 2015 (Dept of Health March 2012)
 NICE Quality Standard – Dementia (June 2010)
 Quality Outcomes for people with dementia: building on the work of the
National Dementia Strategy (Dept of Health 2010).
The outcome of the audit will provide a valuable baseline from which actions
for improvement will continue to help ensure high quality care for patients who
have dementia and their carers, and skills development within our ‘older
peoples’ services. We intend to introduce the national butterfly scheme over
the coming months. Our clinical services standards monitoring is being
enhanced this year to include the 15 step challenge tool and will provide
another comprehensive way to drive quality for patients and their carers and
families.
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►On-going audit of ‘Essence of Care’ benchmarks remains a priority closely
linked with dementia care, especially in terms of ensuring dignity and respect
within the ward environment and in effective communication.
►We will use validated Care Dependency models to ensure service staffing
levels are appropriate and continue to monitor this through the safety triangle
manager’s performance reports
Research and Publications
Our participation in research in 2011/12 continues to demonstrate our drive to
continuously improve the quality of services. In 2011/12:
The Jarvis Breast Screening and Diagnostic Centre was one of five breast
screening units in England to take part in the randomised trial of screening of
women from 47 to 73 years. Full role out is expected in 2016.
Research conducted by Dr I Kneebone and rehabilitation staff at the Godwin,
Bradley and Runfold rehabilitation units was accepted for publication in ‘Neurorehabilitation and Neural Repair’.
The study, “Sometimes we get it wrong but keep on trying” - coping with
communication problems by informal carers of stroke survivors with
aphasia, was accepted for publication in the communication disorders
journal ‘Aphasiology’.
NW Physiotherapists’ “Is a practice incremental shuttle walk test (ISWT) really
necessary”, was published by the Chronic Respiratory Disease Journal.
Inspections and National Service Reviews Care Quality Commission (CQC)
The following CQC inspection improvement action plans developed in the
2010/11 assessment year were closed in 2011/12
 Regulation 16: Ionising radiation regulations HMP High Down x- ray unit:
positive assurance was received in 2011 from the independent Regional
Radiation Protection Advisory Service site visit and inspection supported
the action to close by the Health and Safety Subcommittee.
 Regulation 23: the Governing Committee continued to monitor reports
against our targets set for statutory training and staff appraisals.
 Milford Community Hospital CQC improvement action plan was closed by
the Clinical Quality and Risk Subcommittee (CQ&R).
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Our process for on-going monitoring
 On-going assurance of provider services base line regulatory compliance
assessments were subject to an independent internal audit review in
year. The outcome of the internal auditor’s report stated ‘significant
assurance ‘against our on-going self-assessment process, against the
essential standards for quality and safety.
 The learning from onsite service spot checks, conducted by the
healthcare governance team and executive led unannounced day and
night visits to our community hospitals, were reported back to service
leads and through our committee structure.
 Actions taken in response to an unannounced Surrey LINKs visits to one
of our community hospitals, were reported as part of the annual cycle of
reports to the committee structure.
CQC unannounced assessments in 2011/12
The Care Quality Commission has not taken enforcement action against
SCH registered services as of 31 March 2012. Actions, to ensure full
compliance is maintained, were identified during 2011/12 inspections at:
Farnham Community Hospital:
The following action is being taken to ensure full compliance is maintained:
 An agreed multidisciplinary team standard for clinical records
documentation for use across all SCH community hospitals to ensure
compliance.
HMP High Down healthcare unit:
The following actions are being taken to ensure that full compliance is achieved:
 Resourcing additional dentists, and access for prisoners on licence to
general dental practices to reduce waiting times.
 Exploring the potential to provide specific minor oral dental treatment to
High Down prison following evaluation of a pilot scheme and improve
dental pain pathways for short term prison stays.
The report from HM chief inspector of prisons, reflects the excellence of the staff
of all disciplines who work together to look after a very needy and complex
group of people.
Internal Unannounced Compliance Visits Conducted in 2011/12
As part of the continuous quality review process the healthcare governance
team and SCH’s chief pharmacist conducted unannounced and announced
visits to community hospitals and other community service sites to support
services and identify actions for on-going improvement. These were conducted
in a similar style to CQC inspections and information gathered from these spot
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checks was reported back to the operational directors and senior managers.
Where actions for shared learning were identified, these were taken forward
through the locality clinical effectiveness and quality meetings.
External Reviews
Radiation Protection Advisory Service (Regulation 16) ionising radiation
regulations
 Special Care Community Dental service and the north west X-ray service
received their annual radiation protection, equipment performance and
maintenance reports.
ISO 9001:2008 - Quality Management System Certification
 The Jarvis breast screening centre remains complaint with ISO
9001:2008 - Quality Management System Certification and all equipment
was subject to an independent Regional Radiation Protection Service
assessment. Mobile unit Mammography Physics Routine Survey Report
and independent Regional Radiation Protection Service reports were
reviewed, integral to the transforming community services due diligence
process. Where reports identified action going forward in 2012,
monitoring is through the quarterly clinical quality meetings.
Surrey LINks enter and view visit to Milford Hospital
 A satisfactory response was provided back to the concern “it appeared
that the present system of handover between shifts might not allow
sufficient cover to respond to patient requests”. Staffing levels are
continuously monitored integral to the safety triangle initiative.
Internal auditor’s opinion
 SCH’s processes for continuously assessing compliance with the Care
Quality Commission’s essential standards of quality and safety: was
given ‘significant assurance’.
 Early warning indicators: a bench mark review of performance and early
warning indicators report, confirmed that our approach is well developed
and comprehensive when compared with other similar organisations.
 The audit of the provision, frequency and performance reporting of
assurance against statutory and mandatory training was given ‘significant
assurance’.
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Equality and Diversity Initiatives
 The organisation has a single equality scheme and action plan which sets
out our legal duties under the Equality Act 2010 and our approach and
actions towards meeting this duty. The Scheme was used to assist us in
developing our equality objectives for 2012/13.
 SCH responsibilities for registering with CQC, integral to the outcome of
transforming community services, required us to review and submit a
revised equality declaration based on our equalities strategy.
 The equality and diversity lead gives specialist guidance and direction to
the equality agenda within the organisation and provides regular reports
to the senior management team as well as an annual equality and
diversity report detailing the progress made against the protected
characteristics.
 SCH have representation at the health and social-care black and minority
ethnic (BME) network which was launched in October, it is an alliance of
NHS, ambulance, fire and other public services which have recognised
the need to jointly promote equality in austerity.
 SCH has a BME Disability Awareness Network which supports staff.
 Annual health needs assessments, for example of prison healthcare
needs and the joint strategic needs assessment for children, ensure our
services are reviewed and aligned to meet the health needs of those
groups.
 A communications toolkit has been produced to help staff to support
patients with communication needs including guidance on accessing
services such as Language line and British Sign Language (BSL).
 All our policies and strategies have and will continue to go through an
equalities impact assessment.
Data Quality and actions to improve Data Quality
Ethnicity
Capture of ethnicity data for patients has been identified as being an area where
as an organisation we need to make significant improvement. During May 2012
we are launching an awareness campaign to promote to staff and patients the
need to collect ethnicity. Posters, leaflets and reference cards will be used in
addition to e-Brief, the Schoop a communications publication. Monitoring of
improvement of recording valid ethnicity will be monitored.
Secondary user data submission
We submitted our admitted patient care returns during 2011/12 to the
Secondary Uses service for inclusion in the hospital episode statistics (HES)
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which are included in the latest published data. We are continuing to working
with the Southern Programme for IT and our RiO supplier to be able to extract
outpatient care data from the electronic RiO care record system.
NHS Number Validation
In order to complete the NHS number field on RiO the patient demographics
have to be synchronised with the national spine. It is not possible to enter an
NHS number on to RiO other than for use as a search facility. It is only possible
for records that have not been synchronised, to not have an NHS number. 0.8%
of records do not have an NHS number, 0.1% have open referrals and are being
investigated, the remaining 0.7% are records that were migrated onto RiO
without an NHS number and are under investigation.
Duplicates
The Data Quality team are checking all possible duplicate records on the clinical
records system (RiO) and use a report that is refreshed on a daily basis. The
majority of those found to be duplicates were created when records were
transferred from legacy systems and when found are merged immediately.
Where a patient appears to have a more than one NHS number these are
reported to the National Back Office who investigate and deal with promptly. It is
not possible to have two NHS numbers the same on RiO.
Information Governance Toolkit attainment level 2
The process involves the use of the National Connecting for Health Information
Governance Toolkit which provides an overall assessment of data systems,
standards and process. As the provider service of NHS Surrey we contributed to
the organisations submission and met our target for IG training. SCH undertook
a separate internal assessment in March against key elements of the toolkit and
are developing an action plan to support areas of improvement in 2012/13.
Clinical records audits
Service participation in clinical records audit is monitored at committee level.
The audit provided information about specific areas found by CQC as requiring
improvement and these remain high priority in terms of demonstrating effective
assessment and systematic reviews. A new audit tool has been developed and
is currently being tested for use with the RiO clinical records system.
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Quality Management Systems and Initiatives for Improving: capacity and
support for staff
Safety
 We provided appropriate management responses to the
recommendations made in the internal auditors’ reports and continue to
audit areas to assure on-going compliance.
 We launched the ‘safety triangle management tool’ into all our service
lines. This tool aim is to support managers in identifying potential risks
early on and work with staff to jointly review quality, risks, workforce and
culture indicators, it is a tool for action.
 A sponsored study day was held and sixty care homes were invited to
participate in this event to share best practice in the prevention and
treatment of pressure ulcers. .
 A medicines management competency framework developed by SCH’s
medicines management team was successfully launched as a new
initiative and helps nursing staff to embed safe medicine management
into the organisations culture.
Safeguarding
 The internal governance structure review for adult and children’s
safeguarding was completed. An executive director and senior
safeguarding lead oversee both adult and children’s safeguarding issues,
and are supported by the chief nurse and safeguarding teams. There is a
revised report framework to the overarching safeguarding meetings from
the specific working subgroups for children and for adults to support this
wider forum.
 The adult safeguarding self-assessment tool was completed and sent to
the Surrey Safeguarding Adults Board.
 A baseline review of the ADASS Adult Safeguarding proposed new
standards was completed and an action plan developed to monitor
progress against the implementation of the standards.
Workforce
 As an employer we signed up to the Mindful Employer Charter, which
looks at how we recruit and support staff with mental health issues and
builds on the wellbeing calendar.
 We provide educational workshops on a variety of topics relating to
emotional well-being for staff and carers.
 Our learning and development department are proactive in the
commissioning of training opportunities and the professional development
of staff.
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We re-instated the specialist practice district nurse qualification
programme (two years), part time.
We are a ‘shadow early implementer’ of the government’s ‘Health Visitor
Implementation Plan’ and have successfully recruited and encouraged
staff back into the workforce.
We led an event ‘Your future as a Health Visitor’ on behalf of other Surrey
& west Sussex healthcare providers to encourage and support potential
staff, members of the public and students wishing to become health
visitors.
We host the return to practice initiative on behalf of a number of Surrey
healthcare providers.
We host the health & social care joint training programme on behalf of
Surrey County Council.
Three new apprentices were recruited in a pilot scheme, by the learning
and development team. The aim of the project is to gain valuable
additions to our workforce while encouraging young people to pursue a
career in community healthcare.
Occupational health services offered all staff the opportunity to have a
free health MOT and advice on stopping smoking, alcohol, diet, physical
activity and mental wellbeing.
Supporting High Quality Staff Education and Training
 We successfully ran conferences for adult community nursing, sexual
health and safeguarding adults at risk and audit days, led by nursing and
therapy teams, which were designed as learning events and included a
range of external and internal speakers.
 We completed a full organisational wide training needs analysis to ensure
that we commission the right training for our staff in line with our clinical
strategy.
 An annual organisation and practice placement self-assessment audit
assured the University of Surrey and the NHS South of England of the
quality of learning environment - this was RAG rated ‘Green’ for 2011/12.
 We have an accredited vocational training centre with City and Guilds
and the National Examination Board for Dental Nursing, staff in the
Diabetic Retinopathy Screening Service successfully gained City and
Guilds Level 3 Diploma in Retinal Screening to enhance the team’s skills,
four trainee Dental Nurses obtained City and Guilds VRQ level 3.
Clinical Effectiveness
 “Virtual wards” take the best elements of hospital care (hence "Ward")
and applies them to patients living in their own homes. (Hence "Virtual").
The model of home-based coordinated care deployed recently in north
west Surrey offers promise in reducing hospital admissions in a relatively
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
low cost manner. The "virtual ward" programme provides multidisciplinary
case management services to people who have been identified, using a
predictive model, as high risk for future emergency hospitalisation. Virtual
wards use the systems, staffing and daily routine of a hospital ward to
deliver preventive care to patients in their own homes. Patients have so
far reported that they value the improved co-ordination of their care, while
staff report satisfaction in working on a virtual ward and the opportunity to
share problems and find solutions with colleagues who are caring for the
same patients.
Patient experience surveys will be evaluated over the coming year with a
target set at > 80% satisfaction as a measured patient reported outcome.
Patient Outcomes
 Patient experience surveys continue at various points of care including
discharge. Patient postcards were introduced to gain service user
feedback in specific audit projects such as pressure damage and venous
leg ulceration. This led to a better understanding of specific care and
information needs and in particular at the point of discharge from
community hospitals. The ‘net promoter score’ is being piloted in various
sites to capture the level of service user satisfaction.
 The recently published NICE Quality Standard, guidance and pathway
documents for improving patient experience provide the statements of
best practice to which all services aspire to.
SERVICE REVIEWS
During 2011/12 all our community service completed service lines reviews to
align with our five year strategy and have provided some highlights of changes
aimed at improving quality safety and experience.
End of Life Care Regional Innovation Project
 Based on success in year one, we secured additional funding from July
2011 to June 2012 to enhance our community service and work with
Marie Curie to extend night cover. This enabled the service to improve
the co-ordination and management of care requests.
 Patient feedback on quality of care and involvement in care and dignity
was scored as 98% and 100% respectively. Only 3 % of patients did not
achieve their preferred place of care at the end of their life.
 The model has made a significant difference to patient and carer
experiences and choice for place of care and demonstrates the benefit of
working in partnership.
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National breast screening
 Following the £4m investment in digital technology supporting the cancer
reform strategy, the staff at the Jarvis Breast Screening and Diagnostic
centre processed the last analogue (black and white x-ray ) film at the
end of March last year and launched five new state of the art digital vans
and four new diagnostic machines.
 The service again received a positive ISO 9001:2008 re- audit report
against the three year call and recall breast screening, assessment and
diagnostic service.
Special care dental services
 Registered successfully as an independent provider with the Care Quality
Commission for 2012, this required the service to reassess and produce
evidence against the 16 essential standards for quality and safety and
provide evidence to satisfy the independent assessment by the Radiation
Protection Advisory Service for Surrey.
Paediatric Audiology Services
Commissioned an independent review of the service and implemented the
following changes based on the findings of the review:
 Invested in audiology staff, increasing capacity in clinics by 50% which
reduced wait times to four weeks from the previous six months for new
referrals.
 Commissioned independent surveys of sites and selected three for
investment of £63K for refurbishment and purchasing new equipment.
Rapid Response: intravenous vascular (IV) services
 Supports early discharge of patients from the acute hospital in north west
Surrey. Staff work in partnership with community day & night nurse
services to maintain patients at home through the provision of a 24hr
service.
 Out of a hundred and sixty six patients who received the service, seven
patients required re-admission to an acute hospital, feedback from
patients has been very positive.
 The service produces an IV newsletter and provides on-going training to
staff.
Community Respiratory Service SW
 The respiratory service concentrated on admission avoidance, identifying
at risk patients diagnosed with chronic obstructive air way disease. These
patients are proactively helped and managed in their own homes with
support from, our community teams and their GPs.
 The service introduced a mental health professional to support patients
with anxiety and depression.
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
Last year one hundred and fifty six patients were admitted to the acute
hospital, this year only sixty one had to be admitted which shows a
significant improvement on the previous year.
Prison Healthcare
 An analgesic review clinic, led in partnership with the GP service was
piloted in one of Surrey’s prisons. The results over the first two months
show significant reduction in the prescribing of potent analgesics and
more appropriate treatments at each medical review. A second prison
introduced back care classes, run by a prison service training instructor
who was trained by our community physiotherapist.
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PART 3
Review of our quality and performance in 2011/12
During 2011/12 we collected, analysed and produced a range of business and
performance reports, providing information on how we achieved patient safety
and clinical quality improvements. This next section, though not exhaustive,
shows a range of achievements, innovations and key metrics/performance
indicators we monitored, and demonstrate quality safety and experience
improvements.
National Achievements
A leading clinical Paediatric Occupational Therapist presented work on
developing and implementing outcome measures to provide evidence of best
practice at the national conference held by the College of Occupational
Therapists.
Our Tissue Viability Nurse Specialists attended a national conference in Belgium
and presented a best practice poster.
Our stroke leads attended and presented at the Manchester conference.
Award Winning Clinical Services
Our health visiting teams successfully achieved UNICEF Baby Friendly Initiative
stage 1 and have recruited two health visitors as infant feeding advisors to lead
this important health initiative to promote breastfeeding for the first six months of
life. Another health visitor was awarded a commendation from Surrey Police
Investigation Commander for work linked to safeguarding children.
Prison healthcare service won the national heat for best practice regarding
prevention, health education (health promotion service) in the World Health
Organisation’s Health in prisons programme ‘Best Practice Award’s 2011’ and
went on to the European stage of the competition.
Service Innovation
Partnership working
Community Matrons participated in a nursing home project commissioned by the
Surrey Heath Commissioning Group, the projects aim was:
 To help nursing homes to manage their patients’ care to help reduce the
need for urgent interventions and acute hospital admissions.
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
We have a nurse prescriber in the team, this means that patients can be
prescribed antibiotics by this nurse, for example for chest infections,
cellulitis and urinary tract infections, thus saving GP visits and possible
admissions in to the acute hospital.
Improving Access
The Shared Point of Access (SPA) Scheme which was first piloted in the SW in
March 2009 is now available to all and based at Milford Hospital. The service is
operating seven days a week and is run by nurse co-ordinators and social
services whose aim is to support and advise on care options including respite.
Sustaining productive community service
This project has one hundred and eighty teams involved, positive outcomes
reported by service lines are:
 it is a measurable process
 promotes consistent service delivery
 enables planning cross Surrey wide services
Supporting people to manage their own risks aimed at preventing a fall
Watch your step was the theme for this year’s Age UK’s Falls Awareness week.
Staff gave informal tutorials and provided information on falls, bones and
muscles in older people to staff and ran sessions for patients and their relatives
in assisted accommodation.
 The aim was to increase awareness of how vision impairment can lead to
an increase risk of falls and how to help older people manage risks
associated with falls by checking equipment, teaching exercises and
sampling footwear.
Raising young people’s awareness
The ‘Go Check Yourself’ Sexual Health Improvement Team ran promotional
road shows at eleven colleges across Surrey during the weeks surrounding
Valentine's Day, the aim was to:
 counter myths such as; ‘you cannot get pregnant the first time you
have sex’, ‘only girls get Chlamydia’ and ‘Chlamydia is caught from
toilet seats’.
 'Big Buster', a booth was used where people can step inside and talk
honestly about their worries, fears or questions surrounding sex and
sexual health.
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Helping patients and carers to manage their medicines
We are an early adopter in a new initiative led by the Department of Health
which strives to keep patients safe when they transfer between care providers.
 we provide and encourage patients to use a green, easy identifiable,
reusable bag with the right dosage information on it.
 self-medicating is encouraged for patients whilst on the ward as this gets
them used to their, often new, medicine regime and also gives the nurses
the opportunity to see how they are coping.
Supporting people to manage their own mental wellbeing
Psychological intervention from the Beacon Assessment & Therapy Unit team
has significantly reduced patient symptoms of anxiety and depression as
evidenced in the PHQ-9 and GAD-7 psychological tools evaluation.
Enhancing quality of life
We have specialist staff providing Lymphoedema management. This focusses
on enhancing quality of life through proactive management of limb swelling to
maximise comfort, help preserve limb function and movement, minimise the
potential for complications and enhance personal esteem and confidence.
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APPENDIX 1
Commissioning For Quality and Innovation (CQUIN) Targets 2011/12
A proportion of Surrey Community Health’s income in 2011/12 (1.5%) was
conditional on achieving quality improvement and innovation goals agreed
between Surrey Community Health and any person or body they entered into a
contract, agreement or arrangement with, for the provision of NHS services,
through the ‘Commissioning for Quality and Innovation payment framework’.
As a result of successfully achieving the following quality improvement targets
agreed by NHS Surrey Commissioners and which complement our priorities for
improving quality, we met most of our contract requirements in 2011/12.
Table 1 CQUIN Targets for the Community Contract
Target
End of life care
(Experience)
Pressure damage
(Safety, Experience Effectiveness)
Baby Friendly Initiative
Smoking
Measure / rational
98% / preferred place of care at end
of life
monthly reporting of category 2 and
above pressure ulcers
Level 1 / achieved
Did not achieve target, it is a target for
improvement in 2012/13
Further details of the agreed goals for [2011-12] and for the following 12 month
period are available at (www.institute.nhs.uk)
Patient Experience
We want to provide services to all those who use our services in a way that we
would like for ourselves or our families. SCH is reviewing its Patient and Public
Involvement (PPI) strategy which provides more detail as to specific PPI
objectives. During 2011/12 a number of changes were made to the approach to
dealing with complaints focusing on a patient-centred approach. More
complainants were offered and accepted opportunities to meet with us and
discuss their concerns. Our annual complaints report reflects the outcomes and
changes made as a result of listening to our service users, patients and carers.
Net promoter scheme
We began a pilot of the ‘Net Promoter ‘scheme which enables patients to rate
the service they have received, from poor to excellent. This acts as a daily
‘snapshot’ survey and has been piloted at our Community Hospitals in the north
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west locality as well as our breast screening and podiatry services. This will be
rolled out to all our outpatients’ services during 2012.
Patient panel
Our patient panel continue their excellent work and this year have focussed, in
particular, on a leaflet review for services. They have reviewed over one
hundred and thirty pieces of information that we provide for patients and carers
and service users, making amendments and suggestions which have resulted in
the information being more accessible to all. Each document is ‘lighthouse’
marked as an indicator of their approval.
Dignity in Action
As part of the national ‘Dignity in Action Day’, we pledged our commitment to
making sure every patient is treated with compassion and dignity by signing up
more than seventy staff members to become ‘Dignity Champions’‘ including
health care assistants, nurses, all of the executive team, porters and hotel
services staff. We also launched the 15 Steps Challenge. This involves dignity
champions visiting different sites outside of their usual working environment and
looking at areas such as how welcoming a ward is, the welcome they receive,
how staff work together and what they notice about quality and safety of care.
Clinical Incident Reporting
We aim to ensure that all potential or actual harm events when they have been
identified are reported, investigated and learning is shared across the
organisation.
Monthly numbers of clinically related incidents reported during 2011/12
compared to 2010/11 are shown in Figure A1.
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Annual Comparison
The total number of incidents reported for 2011/12 was 2257
The total number of incidents reported for 2010/11 was 2045
Monthly severity ratings of clinically related incidents are show below
Figure A2 ‐ Severities of clinical incidents during 2011/12
(National Patient Safety Agency severity descriptors)
160
Major injury / illness leading
to permanent or long‐term
harm
140
120
100
Moderate injury / illness
requiring professional
intervention
80
60
Minor injury / illness
requiring minor intervention
40
20
March 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sept 11
Aug 11
July 11
June 11
April 11
May 11
0
None/Near Miss
% of incidents in each severity class
Benchmarking taken from the National Learning and Reported System
(NPSA NRLS) report for the first six months of 2011/12
SCH showed lower levels of clinical incidents resulting in moderate/ minor injury
to patients/users of our services as with other organisations in the NPSA NLRS
cluster. (Figure A3)
Figure A3- Benchmarked severity data for clinical
incidents (NPSA NLRS benchmarking data)
70
60
50
40
All Organisations in cluster (AprSept.2011 NLRS data)
30
SCH (Apr -Sept. 2011 NLRS data)
20
10
0
N.B. Full year data for 2011/12 is yet to be published by the NPSA NLRS.
- 28 -
Key observations:
 Our analysis shows an increase in the overall numbers of clinical
incidents reported during 2011/12 when compared to 2010/11.
 We reported lower frequencies of clinical incidents resulting in minor or
moderate harm to patients when compared to other organisations within
the NPSA NLRS cluster during April-September 2011/12.
 We have a slightly higher proportion of no injury/near-miss incidents
when compared to other organisations within the cluster.
 Compared with similar community provider benchmark figures the
organisation is viewed as having a positive reporting culture.
Key Priorities for 2012/13
Will continue to be driven by safe care metrics initiatives and mitigation of risks
Medicine Incidents
Total numbers of medicines related incidents reported during 2011/12 compared
to 2010/11 are shown blow
Percentage of Prescribing and Administration incidents
70%
60%
Percentage
50%
Administration 2010/11
40%
Administration 2011/12
Prescribing 2010/11
30%
Prescribing 2011/12
20%
10%
0%
Q1
Q2
Q3
Q4
Quarter
Note: Following separation of the former East locality of SCH to form another
organisation from 1st October 2011, reports from quarter Q3 2011/12 onwards
do not include incidents for First Community Health and Care (FCH&C).
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Key Observations
 Although administration incidents continue to be the most frequently
reported type of incident, when expressed as a percentage of all, the
proportion of administration incidents is dropping. This is a positive effect
of mandatory medicines administration training being delivered across
the organisation.
 Trend shows a recent reduction in the proportion of administration
incidents when compared with the total number of all medicines incident
and a slight increase in the reporting of incidents relating to record
keeping or documentation and dispensing or supply which could be due
to a raised awareness of other types of medicines incidents.
Key Priority in 2012/13
Following the development of the Medicines Management organisational
standards for the Medicines Safety, an audit has been developed for use to
benchmark medicines safety stands across service to provide us with assurance
that the safe use and handling of medicines is standard across all services.
High Impact Actions for Improving Patient Safety:
Safety Thermometer and Safe Care Metrics
Since September 2010 we have been involved in piloting the national safety
thermometer and have used safe care metrics to measure and report levels of
patient harm. Over the next year we will be using these tools every month for all
clinical teams and wards to measure and learn from:
 the number of incidences and severity of falls
 the number of patients with and the severity of skin damage
(pressure ulcers)
 the number of patients who are risk assessed for nutritional needs using
the Malnutrition Universal Screening Tool
 the number of patients who have an indwelling urinary catheter and a
urinary tract infection
 the number of patients who have had a venous thromboembolism (a
blood clot), a risk assessment and prophylaxis
 the number of medication errors
 the number of patient complaints
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Mitigating the risk of inpatient falls
We recognise that falls may occur as a hazard of independence and
rehabilitation progress.
We aim to prevent serious injuries to patients as a result of falls and to
significantly reduce the overall number of inpatient falls that occur but do not
result in any injury, without compromising patient dignity, independence and
rehabilitation. The Falls Action Group has been proactive and achieved a
reduction in the overall numbers this year compared with last year (Figure A4)
no. patient falls incidents
Figure A4 - Patient Falls Incidents 2011/12 vs 2010/11
120
100
80
2011/12
60
2010/11
40
20
0
Mitigating the risk of patient pressure damage
We recognise that the majority of skin damage from pressure is avoidable. We
aim to prevent the risk of pressure ulcers developing or deteriorating for those
who are receiving our care.
Up until September 2011 pressure ulcers were reported as an incident whether
they developed under the care of SCH or not. Over the last six months (Oct
2011 - March 2012) a total of one hundred and ninety pressure ulcers (category
2 and above) were reported through our incident reporting system. This is
comparable to the first six months of the year (April to Sept 2011).
However, due to our new skin care bundle and incident reporting forms we are
now able to determine that only 25% of these pressure ulcers developed
following admission to SCH. Some of these 25% were unavoidable but this new
information has helped us to drive up the emphasis on preventing pressure
damage. As a result, systems have been put in place to review all pressure
ulcers that develop under the care of SCH and to share learning and ensure any
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identified actions are taken.
Key Observations
 Safety express group focused on pressure ulcers and we implemented a
Surrey wide pressure ulcer pathway.
 The reporting process of pressure ulcer damage has improved and we
now have a greater understanding of the severity of pressure damage.
 We expanded our pressure ulcer incident form to include Serious Incident
report components to avoid duplication and improve record Quality.
 We implemented a Rout Cause Analysis (RCA) tool to review the reasons
for and the factors contributing to pressure ulcer damage to support
learning and ensure actions are implemented.
 We undertook a pressure ulcer prevalence audit for the third year in a row
and used findings to make improvements to care processes.
 We developed and implemented a community SKIN Care Bundle which
includes the five areas of best practice and improves the consistency of
pressure ulcer risk assessment and monitoring of condition.
 We held pressure ulcer workshops and training updates to share best
practice and to promote the prevention of pressure ulcer damage.
 We distributed our ‘how to prevent pressure damage’ information leaflet
to patients and carers.
Key Actions for 2012/13
 Undertake the safety thermometer survey each month for 100% of teams
and wards by March 2013 and continue to report safe care metrics.
 Present our work at a South Coast SHA ‘Energising for Excellence’
conference.
 Ensure all patients at risk of pressure damage are risk assessed for
nutritional needs using the Malnutrition Universal Screening Tool (MUST)
and distribute our newly developed ‘how to improve your nutrition leaflet’
Mitigating the risk of Venous Thromboembolism (VTE)
We aim to ensure that all people admitted to our community hospitals should
have been risk assessed for VTE and where clinically indicated are prescribed
prophylaxis to reduce the risk of a blood clot developing.
Over the last year we have used the Safety Thermometer Survey to monitor the
number of patients in our community hospitals with risk assessments. This has
increased during the period April 2011 to March 2012 to 100%.
This year will continue to use the Safety Thermometer Survey to monitor the
number of patients in our community hospitals with a VTE risk assessment.
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Urinary catheter infections
We aim to ensure that we know of patients who have an indwelling urinary
catheter and a urinary tract infection through the monthly safety
thermometer survey.
Last year we developed and distributed a patient information leaflet ‘how to care
for your catheter’ which highlights the indications of infection and the steps
to take.
This year we will continue to use the Safety Thermometer Survey to monitor the
number of all patients with an indwelling urinary catheter and a urinary tract
infection. We will improve the use of our electronic record system to enable
team leaders to have a live catheter register so that we can audit practice and
take appropriate steps to improve care processes.
Mitigating the risk of community acquired infections
Key observations:
 We reported no community acquired MRSA bacterimia infections
 We reported 100% preadmission MRSA screens
 We reported no isolation omissions
 47 ‘infection protection society audit report’ site visits have been
completed and the average overall score for 2011/12 was 93.5% (up
2.9% from last year)
 Within the specific area of safe practice in sharps disposal, an average of
94.3% was achieved and from 396 staff included in safe sharps
management and disposal, 99% was achieved.
 Hand hygiene audits results from direct observation of clinician hand
hygiene were completed for 520 staff where an average of 97% for hand
hygiene was achieved.
Safety Alert Bulletins
Our internal alert process was the subject of an internal auditors’ review,
improvements following this review were inclusive of the introduction of a sifting
process and risk based spot audits which supported us in achieving
improvements to service responses.
One hundred and eighty seven alerts were issued during 2011/12 of these, one
National Patient Safety Alert (NPSA: Reducing the harm caused by misplaced
nasogastric feeding tubes) remained open beyond the deadline. This was due to
the complexity of having to produce appropriate guidance for Children’s
Community Nursing in liaison with five acute hospitals to ensure a standardised
practice across service boundaries.
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APPENDIX 2
Who was involved in the development and review of the Second Quality
Account
NHS Surrey statement has been included
We used service user feedback
We involved:
Our service leads in the service review section
Our Data Quality department
Our HR and Learning and Development leads
Our Equality lead
Our Safeguarding team
Our internal auditors who provided us with assurance reports on which we relied
on during the year to support our compliance declarations and which supported
us to identify areas for improvement going forward as a new independent
provider of NHS funded care
We invited statements from Surrey LINks and the Health Overview and Scrutiny
Committee
The HOSC's comment is as below:
The Health Overview & Scrutiny Committee is pleased to be invited to comment
on the Trust’s Care Quality Account for 2011/12. At present the Health Overview
& Scrutiny Committee does not have a robust process in place for commenting
on a trust’s Care Quality Accounts; however, this is under review.
The main priority for Health Overview & Scrutiny Members is to seek
assurances that any planned changes to the way health services are
commissioned and delivered in the future will not have a detrimental impact on
the health of people living in Surrey.
In May, the Committee set its priorities and work programme for the next year.
We look forward to working with the Trust on any areas of scrutiny in which you
may be asked to be involved.
--------------------------------Scrutiny Officer
Adult Social Care Select Committee and Health Scrutiny Committee
Surrey County Council Democratic Services
- 34 -
APPENDIX 3
GLOSSARY OF TERMS
Term
Explanation
Acute trust
A trust is an NHS organisation responsible for
providing a group of healthcare services. An
acute trust provides hospital services (but not
mental health hospital services, which are
provided by a mental health trust).
Care Quality Commission
The Care Quality Commission (CQC) replaced
the Healthcare Commission, Mental Health Act
Commission and the Commission for Social
Care Inspection in April 2009. The CQC is the
independent regulator of health and social
care in England. It regulates health and adult
social care services, whether provided by the
NHS, local authorities, private companies or
voluntary organisations. Visit: www.cqc.org.uk
Clinical audit
Clinical audit is a quality improvement tool that
compares current care with evidence based
practice, to identify areas that have the
potential to be improved, for consistently safe,
clinically effective care and positive service
user experience.
Commissioning for Quality and Innovation
(CQUIN) payment framework.
Visit:
www.dh.gov.uk/en/Publicationsandstatistics/P
ublications/PublicationsPolicyAndGuidance/D
H_091443
Community services
Health services provided in the community, for
example health visiting, school nursing
community nursing, special dental services,
physiotherapy, podiatry (foot care).
Digital mammography
This means taking a deep picture of beast
tissue using x-ray machine and sending the
picture onto a screen (monitor).
Healthcare
Healthcare includes all forms of healthcare
provided for individuals, whether relating to
physical or mental health, and includes
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procedures of medical or surgical care.
Institute for Health and Clinical Excellence
The National Institute for Health and Clinical
Excellence is an independent organisation
responsible for providing national guidance on
promoting good health and preventing and
treating ill health. Visit: www.nice.org.uk
Net Promoter Score
This is a new way of collecting user
experience at the time of their care. A green
disc is given to the service user or their carer
and they have the opportunity to drop it into a
series of boxes which best reflects how they
felt about the service. At the end of each day
the discs are added up and an over all score is
give to that service in a report.
NHS Outcomes Framework 2011/12
Is the document which sets out the outcomes
and indicators that will be used to hold all
providers of health care to account and
provides the financial planning and business
rules that support the delivery of NHS
priorities.
Overview and scrutiny committees
Since January 2003, every local authority with
responsibilities for social services (150 in all)
has had the power to scrutinise local health
services. Overview and scrutiny committees
take on the role of scrutiny of the NHS – not
just major changes but the on-going operation
and planning of services. They bring
democratic accountability into healthcare
decisions and make the NHS more publicly
accountable and responsive to local
communities.
Patient reported outcome
These are self-reports from patients which tell
us if they felt satisfied in terms of treatment
and services given
Telecare ‘ Telehealth’ technologies
Is the delivery of health-related services and
information via telecommunications
technologies such as video links special
phones, and it covers preventive, promotive
and curative aspects of patient treatment.
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