QUALITY ACCOUNT 2011-12
Quality Account 2011/12
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QUALITY ACCOUNT 2011-12
Sussex Community Trust Quality Account
Quick Reference Guide
Part 1: A Statement on Quality from the Chief
Executive
This section is shown in green and starts on
Page 3.
Part 2: Our priorities for improvement, telling you
how we did against our priorities for last year and
letting you know what our priority goals are for
2012/13.
This section is shown in blue and starts on
Page 4.
Glossary
Throughout the text you will find words in italics,
these words are listed and explained in the
glossary on Page 45.
Feedback form
We hope you enjoy reading our Quality Account.
We’d really like to know what you think of it.
Please use the feedback form on Page 49 to send
us your comments.
Also in Part 2 is our Statement of Assurance from
our Board of Directors, shown on Page 7 of the
blue section.
Finally in Part 2 is our review of our services for
2011/12.
This includes legally required
information on Clinical Audit, Clinical Research,
Use of the Commissioning for Quality and
Innovation (CQUIN) Payment Framework, Care
Quality Commission (CQC), Data Information and
the Information Governance Toolkit. This section,
also shown in blue, starts on Page 7.
Practice Example
You will also find boxes like this in all sections of the Quality
Account. These contain real life examples of how we have
improved quality in the three areas of patient safety, clinical
effectiveness and patient experience throughout 2011/12.
Part 3: Our review of overall quality performance
for the year 2011/12, which includes a number of
priority areas for quality. These are: Patient
Safety, Clinical Effectiveness and Patient
Experience.
This section is show in orange and starts on Page
15.
In this section we also outline who was involved in
putting together the Quality Account, starting on
Page 35, and on Page 36 we include the
responses to our Quality Account from the
Primary Care Trust (PCT), Local Involvement
Networks (LINks) and the Health and Adult Social
Care Select Committee (HASC) / Health Overview
Scrutiny Committee (HOSC).
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QUALITY ACCOUNT 2011-12
Part 1 - A Statement on Quality from the Chief
Executive
•
Welcome to our Quality Account 2011/12
•
At the heart of all we do is our commitment to
provide safe and effective community healthcare
services that meet your needs and expectations.
•
Our Quality Account provides you with details of
how far we have fulfilled this commitment. In this
way, I hope you’ll see it as part of our open and
honest dialogue about our strengths and
weaknesses.
This is our second Quality Account, and in it we:
•
•
•
Measure our progress against the quality
priorities we set for ourselves 12 months ago
in our first Quality Account
Outline our quality improvement priorities for
the year ahead
Describe what we’ll do to achieve, measure
and report on our performance against these
improvement priorities
•
We want to improve the percentage of serious
incidents that we report to NHS Sussex on
time, recognising that we didn’t hit the target
in 2011/12
We will ensure that all inpatients in our care
receive an assessment to identify their risk of
venous thromboembolism and of falling, and
are managed in line with their assessment
We will reduce the number of patients in our
care that suffer preventable pressure damage
or a healthcare acquired infection
We will improve the quality of care by
continuing to have patient feedback
mechanisms in all clinical teams, with locally
monitored action plans based on what the
feedback says
To the best of my knowledge the information
contained in this Quality Account is accurate. We
also want you to be confident that our Quality
Account is accurate, balanced and fair, so we
have asked our partners to comment on how far
we have achieved this and we include their
feedback at the back of the report.
I want our Quality Account to raise the profile of
what quality means. As you read it you’ll see
some of the significant progress we made over
the year. I’d especially like to highlight how we:
I’d welcome your comments on what you read and
on any other aspect of our work. In particular,
please feel free to challenge us if you think we
don’t measure up to the standards we set
ourselves. Feel free to email me on
clodagh.warde-robinson@nhs.net.
•
With best wishes
•
•
•
•
Developed our patient safety assurance
framework to give the board of directors
regular and detailed insight into our
performance across a range of areas,
including infection control, patient safety &
experience and workforce
Confirmed our strategy for improving patient
experience.
Overhauled the ways we manage serious
incidents and are promoting an open culture
that encourages staff to feel able to report
such incidents
Completed a wide-ranging review of a series
of policies, procedures and ways of working to
help us focus even more carefully on the
quality and safety of our work
Implemented the productive series, a
nationally recognised improvement
programme that helps us make small changes
that can deliver big benefits in terms of clinical
effectiveness and patient care
Clodagh Warde-Robinson
Deputy Chief Executive
(on behalf of Andy Painton)
In this year’s Quality Account you’ll see as well
the priorities we have set for the year 2012/13.
Foremost among these are:
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QUALITY ACCOUNT 2011-12
Part 2(a) Priorities for Improvement in 2012/13
Patient Safety
Framework
9
Governance
Review
Programme
9
In the National Health Service, quality is viewed
as having 3 elements:
•
•
•
Patient Safety – we need to make sure we
work to the highest clinical standards to
reduce, avoid and stop avoidable harm to
patients wherever possible
Clinical Effectiveness – we should improve
our understanding of treatment options and
success rate from different treatments for
different
conditions
including
clinical
measures,
possible
complications
of
treatments and measures of clinical
improvement
Patient Experience – we want to know what
patients think about our services and respond
to their views to improve the quality of what
we do in the services we provide.
The priorities we had for 2011/12 were framed
around these 3 elements of quality. Please see
the table below for the progress against these
priorities:
Patient Safety
Priority for
Improvement
Launch
Management
and Reporting of
Incidents Policy
(including
Serious
Incidents)
Increase the
quality of
Serious Incident
(SI) reporting so:
Achieved?
9 = Yes
X = No
▲=
Nearly
9
All SIs
completed on
time
X
SI Quarterly
Report to Board
9
Improved
system for
sharing learning
▲
Clinical Effectiveness
Priority for
Improvement
Community
Metrics
Achieved?
9
Outcome
More detailed
and timely reports
on incidents to
support services
in improving
patient safety.
The Board
receive regular
reports on SIs
and systems for
sharing learning
now include a
Quality Focus
newsletter. We
have more work
to do on
improving
timelines and
quality of our
reports and using
learning. Please
see page 18.
Patient Safety
Framework is in
place and the
Board receives a
monthly report.
This supports
work on areas
where quality
needs to be
improved.
All 20 projects
have been
completed
leading to a
variety of
improvements in
the quality of
patient care.
Please see page
16.
9
Productive
Series
Implementation
Outcome
The Trust submits
an operational
report to the
Board each
month that
includes:
community
metrics; patient
experience/quality
of care; financial
information and
staff support /
public
engagement.
The 2 year
programme is
now in place.
Please see page
27 for detailed
achievements.
Patient Experience
Priority for
Improvement
Patient
Experience
Strategy
Achieved?
9
Outcome
The strategy is in
place and has an
implementation
plan.
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QUALITY ACCOUNT 2011-12
Pilot new ways
of gathering
patient
experience
Collate and
evaluate
patient
experience
work
9
9
Achieved as part
of the 2010/11
CQUIN.
A database is in
place to record
the patient
experience
activity in all
clinical services.
The priorities for 2012/13 are also organised
around these three elements. For each priority
we have described:
• Why we chose this priority
• The measures we will use to assess whether
we are making progress
• The expected outcome(s) which will result
from improved performance.
Clinical Effectiveness
Venous Thromboembolism (VTE)
Why is it a priority?
DH - The Operating Framework for the NHS in
England 2012-13.
DH: Prevention of Venous Thromboembolism
(VTE) in Hospitalised Patients
DH: Venous thromboembolism (VTE) risk
assessment
National Institute for Health & Clinical Excellence
(NICE): VTE prevention quality standard
Improvement Measure
A new SCT-wide policy to be implemented.
Risk assessments will be undertaken for 100%
inpatients.
Patient Safety
Expected Outcome
Improved quality of care by assessing the risk of
patients acquiring VTE and taking appropriate
action to mitigate the risk to patients.
Serious Incident Reporting
Pressure Damage
Why is it a priority?
This priority was not achieved in the 2011/12
Quality Account.
Serious Incident Reporting and Learning
Framework (SIRL).
Improvement Measure
Percentage of Serious Incidents reported and
submitted within the required timeframe. This will
be monitored by the Serious Incident Review
Group (SIRG).
Why is it a priority?
Highest category of serious incident and it is a
priority for the Trust to improve quality in this area.
NICE: Pressure ulcers – prevention and treatment
Clinical Guideline.
Royal College of Nursing: Pressure Ulcer
Assessment and Prevention.
Improvement Measure
A pressure damage strategy is in place (see page
24 for more information). Progress against this
strategy will be monitored by the Pressure
Damage Prevention Group. Progress will be
measured
by
the
percentage
of
the
implementation plan completed.
Expected Outcome
Timely completion of Root Cause Analysis
facilitates learning from SIs and improvement in
the quality of care provided.
Healthcare Acquired infections
Why is it a priority?
Reducing Healthcare Associated Infections in
Hospitals in England.
Department of Health (DH) New objectives set to
reduce MRSA and C Difficile.
DH - The Operating Framework for the NHS in
England 2012-13.
Improvement Measure
Reduction in figures for C-Difficile infections.
Reduction in figures for MRSA infections.
Expected Outcome
Improved quality of care by eradicating all
avoidable Healthcare Acquired Infections (HCAI).
Expected Outcome
Improved quality of care by reducing the number
of preventable pressure damage acquired in our
care.
Medicines
Why is it a priority?
Second highest category of incident and it is a
priority for the Trust to improve quality in this area.
National Prescribing Centre: Reducing medication
errors.
DH: Building a safer NHS for patients: Improving
Medication Safety.
Improvement Measure
An action plan for medicines is shown on page 18
of the Quality Account. Achievements against this
plan will be monitored by the Medicines
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QUALITY ACCOUNT 2011-12
Management Committee. Progress
measured
by
the
percentage
implementation plan completed.
will be
of
the
Expected Outcome
Improved quality of care by reducing the harm
caused by preventable medication errors.
Falls and Fractures
Why is it a priority?
Third highest category of Serious Incident and it is
a priority for the Trust to improve quality in this
area.
Royal College of Physicians’ FallSafe care
bundle.
National Patient Safety Agency (NPSA)
Recommendations ‘Essential care after an
inpatient fall’.
Age UK: Breaking Through: Building Better Falls
and Fracture Services in England.
DH: Prevention package for older people
resources.
Improvement Measure
Monthly report to the Board on the number of
inpatients receiving a falls risk assessment within
the required timeframe. Falls risk assessment for
100% of in patients.
Expected Outcome
Improved quality of care by reducing the harm
caused by preventable falls.
Nutrition and Dietetics
Why is it a priority?
NPSA: Nutrition fact sheets.
DH: Improving nutritional care.
NICE: Nutrition support in adults: Oral nutrition
support, enteral tube feeding and parenteral
nutrition.
Improvement Measure
MUST assessment to be completed for 100% of
inpatients within 48 hours of admission.
MUST assessment to be completed for 100% of
community patients within 1 month.
Expected Outcome
Improved quality of care by maximising the
nutrition of inpatients through the use of nutritional
assessment and appropriate care planning.
Catheter / Urinary Tract Infections
Why is it a priority?
Catheter Care: RCN Guidance for Nurses.
NICE Guidance: Infection control, prevention of
healthcare-associated infection in primary and
community care.
DH: High Impact Intervention urinary catheter care
bundle.
Improvement Measure
Increased percentage of prevented emergency
admissions to hospital with catheter problems. To
see a further percentage reduction in emergency
admissions.
Expected Outcome
Improved quality of care through increasing the
skills of community nurses so that catheter
problems can be addressed at an early stage in
the community thus avoiding emergency
admissions and more timely intervention for
patients.
Patient Experience
Patient Experience Strategy
Why is it a priority?
The Health Service Ombudsmen’s report
‘Listening and Learning’.
DH - The Operating Framework for the NHS in
England 2012-13.
Improvement Measure
An implementation plan is in place for the Patient
Experience Strategy; this will be monitored by the
Patient Experience Steering Group. Progress will
be measured by the percentage of the
implementation plan completed.
Expected Outcome
Improved quality of care through having a variety
of ways to gain feedback from our patients and
act on this feedback to improve care.
Patient Surveys and Feedback
Why is it a priority?
The Health Service Ombudsmen’s report
‘Listening and Learning’.
DH - The Operating Framework for the NHS in
England 2012-13.
Improvement Measure
Maintain rate of 100% of all clinical teams
undertaking patient experience surveys/feedback.
Use of the 5 key questions from the CQC national
inpatient surveys across bedded units in the Trust.
Expected Outcome
Improved quality of care by having working
feedback mechanisms in all clinical teams with
locally monitored action plans.
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QUALITY ACCOUNT 2011-12
Volunteers
Why is it a priority?
‘Volunteering in the NHS’ guidance – Volunteering
England.
DH: Volunteers across the NHS: Improving the
patient experience and creating a patient-led
service.
Improvement Measure
A Volunteer Strategy is in place, progress against
this strategy will be monitored by the Volunteer
Services Steering Group. Progress will be
measured by the percentage of the
implementation plan completed.
Expected Outcome
Improved quality of care through having a group
of well supported volunteers working alongside
SCT services in a variety of settings.
Part 2(a)i Statement of Assurance from the
Board of Directors
The Executive Directors are required under the
Health Act 2009 and the NHS (Quality Accounts)
Regulations 2010 to prepare Quality Accounts for
each financial year.
In preparing the Quality Account, Executive
Directors are required to satisfy themselves that:
• The content of the Quality Account meets the
requirements set out in the Quality Accounts
Toolkit 2010/11
• The content of the Quality Account is
consistent with internal and external sources
of information including:
o Board minutes and papers for the period
April 2011 to March 2012
o Papers relating to Quality reported to the
Board over the period April 2011 to March
2012
o The Trust’s complaints report published
under regulation 18 of the Local Authority
Social Services and NHS Complaints
Regulations 2009
o The national staff survey September 2011
o CQC Quality and Risk profiles for the year
2011/12.
• The Quality Account presents a balanced
picture of SCT performance over 2011/12
• The performance information reported in the
Quality Accounts is reliable and accurate.
patient safety, Clinical Effectiveness and patient
experience on a monthly basis.
Stakeholders were consulted and involved in
overseeing the information contained in the
Quality Account in a variety of ways, for example:
•
•
•
Public Board Meetings
Non-Executive Directors involvement in Trust
Committees
Patient representation on Trust groups.
The collection and reporting of the information
given in our Quality Account is subject to internal
audit by South Coast Audit.
The Executive Directors confirm to the best of
their knowledge and belief they have complied
with the above requirements in preparing the
Quality Account.
Part 2(b) Statements Relating to Quality of
Service
Review of Services
During 2011/12 we provided, either directly or in
partnership via sub-contracts, 60 NHS services.
The data available on the quality of care in all
these 60 NHS services has been reviewed. This
data is provided to our commissioners where
required as part of our contract and is reviewed
monthly at a joint meeting between Sussex
Community Trust (SCT) and our respective
groups of commissioners. In addition the data is
reviewed monthly internally.
During 2012/13 we will be comparing the data for
a number of our services against similar
organisations in addition to benchmarking against
National standards where available and relevant.
The income generated by the NHS services
reviewed in 2011/12 represents 79 per cent of the
total income generated from the provision of NHS
services by SCT for 2011/12.
AAA Screening (Abdominal Aortic Aneurism)
From April 2012 the AAA screening Programme will cover
both West & East Sussex. In some community locations all
day services have been established, which are more cost
effective.
To ensure our Quality Account is fair, each month
the Board reviews performance against key
indicators.
The Executive Directors and the
Quality and Safety Committee (a non-Executive
Director lead committee) review information on
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QUALITY ACCOUNT 2011-12
•
•
•
Parkinson’s disease (National Parkinson’s
Audit)
Adult asthma (British Thoracic Society)
Bronchiectasis (British Thoracic Society).
The Trust was unable to participate in a number of
the national audits listed above due to the restructure of operations services. In 2012/13 the
Trust will launch a revised audit policy and will
work to increase participation in national audits.
Our Spending
Our 2011/12 income totalled £184m. Most of this
income is from Primary Care Trusts (PCTs) - NHS
West Sussex (£116m), NHS Brighton and Hove
(£28m) and other PCTs (£4m). We also receive
£13m of income from Local Authorities for the
provision of children’s services and our other
income totals £23m, which includes dental, audit
and estates rental income.
Our income plan for 2012/13 is £178m. This £6m
annual reduction demonstrates the value for
money that we deliver to our commissioners by
improving our efficiency as well as the target set
by NHS Sussex and the West Sussex Clinical
Commissioning Groups to further reduce our
expenditure this year.
Participation in Clinical Audits
National Clinical Audits
During 2011-2012, seven national Clinical Audits
and no national confidential enquiries covered
NHS services that SCT provides.
During that period SCT participated in 29% of
national Clinical Audits of which the Trust was
eligible to participate in, and 3 further national
audits which were not listed.
The national Clinical Audits and national
confidential enquiries that SCT was eligible to
participate in during 2011-2012 are as follows:
•
•
•
•
Childhood epilepsy (RCPH National
Childhood Epilepsy Audit)
Diabetes (RCPH National Paediatric Diabetes
Audit)
Diabetes (National Adult Diabetes Audit)
Chronic pain (National Pain Audit)
The national Clinical Audits and national
confidential enquiries that SCT participated in,
and for which data collection was completed
during 2011/12, are listed below. Data for the
number of cases submitted to each audit or
enquiry as a percentage of the number of
registered cases required by the terms of that
audit or enquiry was not available at the time of
production of this report.
Participation
% Case
Submitted
Childhood epilepsy
(RCPH National
Childhood Epilepsy
Audit)
9
n/a
Diabetes (RCPH
National Paediatric
Diabetes Audit)
8
-
Diabetes (National
Adult Diabetes
Audit)
8
-
Chronic pain
(National Pain Audit)
8
-
Parkinson’s disease
(National
Parkinson’s Audit)
9
n/a
Adult asthma (British
Thoracic Society)
8
-
Bronchiectasis
(British Thoracic
Society)
8
-
National Audit
SCT participated in three other National Audits
which are listed below:
• National Falls and Bone Health Audit (2yearly)
• National Audit of Services for People with
Multiple Sclerosis 2011
• Depression and anxiety (National Audit of
Psychological Therapies).
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QUALITY ACCOUNT 2011-12
The reports of 3 national Clinical Audits were
reviewed by SCT in 2011/12 and SCT intends to
take the following actions to improve the quality of
healthcare provided (listed by audit title):
National Audit of Services for People with Multiple
Sclerosis (MS) 2011
•
National Falls and Bone Health Audit (2-yearly)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Identify with the PCT whether there is a
pharmacist with the specific remit for bone
health
Identify a consultant with a staffing
commitment to ‘Falls’ identified in their job
plan
Recommend to the commissioners that a
fracture liaison service should be jointly
funded across primary and secondary
healthcare
Offer training to care home staff regarding
falls and osteoporosis screening
Recommend to the commissioners that
provision of evidence based exercise
programmes are negotiated with the council
for funding and delivery and supported by the
osteoporosis and falls prevention service
Offer falls and osteoporosis screening to staff
working in inpatient settings within the Trust
Review and integrate the falls prevention
policies from the legacy organisations into the
health and safety policy for SCT
Fracture Risk Assessment Tool (FRAX) to be
integrated into the multifactorial falls risk
assessment on patients age 40-90. Training
to be offered to clinicians, and further
discussion regarding implementation to be
carried out
Discussion to be had with Consultant for
elderly medicine regarding routine ECG
Falls Prevention Service to review pathways
with eye hospital and opticians regarding
referral for vision assessment
Falls
Prevention
Service
to
explore
standardised Cognitive Tests within Service
Governance meetings
Falls Prevention service to have a rolling
training programme established for all health
and social care staff across Brighton and
Hove and West Sussex and to include care
home staff
Slips Trips and Falls Prevention procedure
needs to be launched following review and
integration into SCT
Re-audit of Falls Prevention policy within
inpatient
settings
6
months
after
implementation.
•
•
•
•
•
•
Consider developing a plan to initiate a five
year project, with protected staff with the
responsibility to re-organise services, to
achieve compliance with the standards put
forward by the National Service Framework
for long-term Conditions and NICE CG8 on
the management of people with multiple
sclerosis
MS team working with all clinical staff to raise
awareness about routinely asking people with
multiple sclerosis if they have pain and, if so
whether it is adequately controlled
MS team working with all clinical staff to
review the process for assessing the need for
equipment for people with multiple sclerosis
and responsibility around that.
All patients needing additional service
provision to be referred and service short-fall
to be drawn to the attention of commissioners
Review the national MS audit report and their
own performance at board level to improve
the standards of care provided by them to
people with MS
Look at ways in which it can involve people
with MS in the design and provision of
services within the Trust that are used by
people with MS
Foster links with other relevant organisations
within and beyond the NHS i.e. Social Care,
patient organisations through the ongoing
provision of the MS team.
National Audit of Psychological Therapies for
Anxiety and Depression 2011
•
The Trust has reviewed the findings and
recommendations from the national report
published in November 2011. There are no
significant actions or improvements required
by the Trust services at this time.
Time to Talk
Time to Talk (psychological therapies in primary care) is
part of the national Improving Access to Psychological
Therapies programme
Key achievements in 2011/12:
Recovery rate is 54% ( target > 50%)
Return to work rate is 9.5% ( target >5%)
High patient satisfaction - 97% of patients would
recommend the service to family / friends.
Time to Talk will offer Cognitive Behaviour Therapy to help
patients feel better and therefore self manage their
conditions more effectively. These 10 week courses will be
available across West Sussex during 2012/13.
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QUALITY ACCOUNT 2011-12
Local Clinical Audits
Audit: Audit of Medical Devices
The reports of 25 local Clinical Audits undertaken
by SCT staff were reviewed in 2011-12 (some
audits focussed on a specific service or service
type, for others all services participated). The
following examples demonstrate the variety of
actions we intend to take to improve the quality of
healthcare provided (listed by audit title):
•
Audit: Faecal Incontinence in Children and Young
People, 2007 / Constipation in Children and
Young People, 2010
• Improve patient access to professional advice
• Improve written information about Continence
Supplies
• Produce standard assessment tool for
continence needs
• Ensure care planning is shared with patient
and parent/carer
• Provide education and training for care
deliverers including update of training pack for
staff running Enuretic Clinics
• Continue to undertake patient experience
surveys
• Ensure comprehensive information available
to parents, carers and professionals.
•
Infection Control Environmental Audits
Essential Steps Hand Hygiene Observations
Essential Steps Catheter Insertions and Ongoing
Care
Essential Steps Clostridium Difficile
• Programme underway to provide compliant
hand wash basins in clinical areas
• Ensure correct decontamination of equipment
in line with SCT Decontamination Guidelines
• Improve assurance of equipment cleaning via
label or book system
• Improve the clinical environment to allow ease
of cleaning i.e. re-decoration/ removal of
carpets
• Improve compliance with hand hygiene
technique and 'bare below the elbows'
• Reduction of risks relating to Catheter
Associated Urinary Tract Infection (CAUTI)
• Improved compliance to SCT Clostridium
Difficile Guidelines
• Closer involvement of clinicians with Audit
and Essential Steps programme
• Environmental audit results now incorporated
into Estates Capital building programme.
•
•
•
•
•
Increased knowledge of the need to separate
dirty and clean devices
Improved processes of cleaning and labelling
medical devices
Greater understanding of maintenance and
servicing requirements
Improvements in the development of generic
risk assessments
Improvements in local recording of training,
maintenance and servicing and the use of
manufacturer instructions
Greater joint working with the infection control
leads and decontamination lead undertaking
joint environmental audits.
Audit: Productive Ward Audits
•
•
•
•
•
•
•
•
Development of local standards to reflect the
Trust policies and improve local practice and
consistency
Introduction of protected meal times
Introduction of patient hand wipes for use
prior to meals
Reduction in delays between the meal trolley
being ready and staff being able to start the
meal service
Introduction of daily observations for all
patients as a minimum
Improvements to the quality of the recordings
of the observations taken
Introduction of training for all staff to raise
awareness of why observations are taken,
what they mean and how to act on them if
concerned
Development of a competency assessed
programme for all staff undertaking or
reviewing patient observations
Improvements in the quality of recording
medication administration on the prescription
charts.
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QUALITY ACCOUNT 2011-12
Audit: Antimicrobial prescribing re-audit – adult
inpatients
Improvements compared to last years’ audit
include:
• Increase in the number of antimicrobial
prescriptions with the duration, indication and
patients’ allergy/sensitivities recorded
• Recommendations for further improvements
made in particular with regards to Education
and Training of prescribers and nurses.
Audit: Audit of completed Thromboembolism
(VTE) risk assessment forms for newly admitted
adult inpatients
• 75% of all newly admitted inpatients had a
VTE risk assessment form completed across
all adult inpatient units
• Further recommendations for improvements
were made.
Audit: South Coast Audit Medicines Management
Audit
• Improved storage of medicines
• Continued compliance with recommendations
will be followed up by the Medicines
Management Team in 2012/13.
Audit: Audit of Allergy/Sensitivity Recording (Adult
Inpatient Units)
• Demonstrated that all 15 adult inpatient wards
audited (except 2 wards) achieved 100% of
inpatients with allergy/sensitivity completed
• Will be carried out within community nursing
in 2012/13.
Audit: Health Records
Thirty-one health records audits were undertaken
by SCT services in 2011/12. Action plans include:
• Sticky labels with ‘Sussex Community Trust’
on will be made available for folders
• Community teams to meet and discuss layout
to ensure uniformity across all 4 teams
• Community teams to discuss whether each
folder is to have a Trust abbreviation list or to
allow no abbreviations in notes
• Community team members to be aware of the
importance of clear documentation and that
all documentation must comply with Trust
policy
• New initial assessment forms have been
developed
• Liaison with all staff individually and item at
staff meeting to remind staff to write clearly
and/or print as necessary.
Participation in Clinical Research
The number of patients receiving NHS services,
provided or sub-contracted by SCT in 2011/12,
recruited during that period to participate in
research approved by a research ethics
committee was 196 from 12 studies.
Health Improvement
Senior operational groups have been established jointly
with Public Health in West Sussex and County Council
(WSCC) colleagues. These groups link services who have
joint health outcomes for children. An outcome of this
group has been a quality improvement project called
"Healthy Children and Family Centres" - this identifies 9
health outcomes and locally brings together partners from
across services and communities to look how together they
can be improved. This is being rolled out across West
Sussex and is jointly supported by SCT and WSCC.
Seven of the studies were National Institute for
Health Research (NIHR) Portfolio studies, of
which 3 involved adult patients and 4 involved
children’s patients. Portfolio studies involving
adults focused on venous leg ulcer care and
pressure ulcer care with the Tissue Viability
Team, diabetes with the Community Diabetes
Specialist Nursing Service, renal / urogenital with
the
Continence
Advisory
Service
and
rheumatology with the Occupational Therapy
Service. Portfolio studies involving children
focused on eating and drinking and the postural
management while sleeping of children with
cerebral palsy.
Children’s Community Nursing, Continuing Care at
Home and Health Led Short Breaks West Sussex
Children’s Community Nursing will be taking part in a
national research project led by the Social Policy Research
Unit at the University of York and funded by the NIHR. The
research is on transforming community health services for
children and young people. West Sussex is one of the 3
pilot sites. In addition the service has set up a Quality,
Standards, Innovation and Evidence Forum and are
working to agreed priorities.
The 5 non portfolio studies also involved both
adults and children. Studies with adults focused
on palliative care with the Midhurst Macmillan
Specialist
Palliative
Care
Service
and
musculoskeletal with the Osteoporosis Specialist
Nurse. Studies with children focused on epilepsy
with the Child Development Service, the
exploration of the experience of sleep in children
with cerebral palsy with Chailey Heritage Clinical
Services and speech perception assessments
with deaf/hearing impaired patients with the
Speech and Language Service.
Page 11 of 50
QUALITY ACCOUNT 2011-12
Use of the Commissioning for Quality and
Innovation (CQUIN) Payment Framework
Statements from the Care Quality Commission
(CQC)
A proportion of Trust income in 2011/12 was
conditional on achieving quality improvement and
innovation goals to improve outcomes for people
who use our services. Goals were agreed
between SCT and our commissioners, through the
CQUIN payment framework. The agreed CQUIN
payment was 1.5% of the contract value.
SCT is required to register with the Care Quality
Commission and its current registration status is
‘registered with no conditions’.
The goals included:
• Improving services for patients with heart
failure
• Ensuring we capture and use information from
patients about their experience of using our
services
• Reducing the number of emergency
admissions to hospital by using our
community services effectively to keep
patients well enough to stay at home
• Reducing the length of stay in our community
beds
• Using appropriate technology and processes
to ensure that GPs receive accurate,
complete and timely information about any of
their patients being discharged from our
community beds
• Training our community staff in methods of
talking with their patients to help them lead
healthier lives and achieve better health
outcomes.
We achieved the majority of the goals, however
we still have further work to do on some areas:
• the number of emergency admissions to
hospitals reduced by 5 percentage points
against a target of 10
• the target for reduced length of stay was
achieved in 10 inpatient units against a target
of 14
• A small proportion of faxed discharge
summaries did not include all the required
information.
Further details of the agreed goals for 2011/12
and for the following 12 month period are
available electronically at:
http://www.institute.nhs.uk/world_class_Commissi
oning/PCT_portal/CQUIN.html
The Care Quality Commission has not taken
enforcement action against SCT during the
reporting period (1st April 2011 to 31st March
2012).
The Trust has not participated in any special
reviews or investigations by the CQC during the
reporting period.
Between 1st April 2011 and 31st March 2012, two
Review of Compliance reports were published for
Trust locations registered with the CQC. Both
locations
were
subject
to
unannounced
inspections within a CQC Planned Review
programme.
Both locations inspected were
assessed as compliant with all 16 CQC Core
Outcomes.
The Trust also undertakes proactive internal
‘Assurance Reviews’ to self-assess its service
user, visitor and staff safety, Clinical Effectiveness
and service user experience against the CQC
Outcomes, identifying areas for improvement and
ensuring follow-up remedial actions are
completed.
Horsham Hospital
“The internal assurance review was, although nervewracking to begin with, a non-threatening process which
was excellent practice for an actual review by the CQC.
Although it takes a whole day it does give you the time
and space to reassess everything and review processes
and practices that you wouldn’t normally have time for on
a day to day basis, such as opening every cupboard and
checking the contents. Some of the findings were
actioned on the day, such as updating the logo on
paperwork that still had the legacy organisation’s details
on. The report that followed gave me some extra
authority to get the storage system in the equipment
room sorted out, which I had been trying to do for some
time. The patients also really enjoyed the experience,
and they were delighted to be able to report directly to
the ‘hierarchy’ about how pleased they were with the
level of care they had been receiving on the ward.”
Data Quality
Review of actions put in place for 2011/12:
• Procurement of a new community and child
health system - local procurement did not go
ahead as SCT is participating in the
procurement of a system under the Southern
Programme for IT
Page 12 of 50
QUALITY ACCOUNT 2011-12
•
•
•
•
A new Trust-wide business intelligence
system ‘Scholar’ (Sussex Community On-Line
Analysis and Reporting) was launched with a
small-scale roll-out during 2011/12. From
April 2012 Scholar will be released to Trust
staff more widely
A Scholar user group with membership from
across the Trust will be meeting monthly
throughout 2012/13 to support further
development of the system
A unified Performance Analysis Team was
formed in July 2011
The integrated risk management system
‘Safeguard’ has been further developed to
reflect the restructuring of the organisation.
In 2012/13 SCT will be taking the following actions
to improve data quality:
•
•
•
•
•
Implementation
of
the
Performance
Management Framework. This will include:
an integrated board report with finance, staff
records, governance and clinical systems,
supported by more detailed information
available to service managers through
Scholar.
A task and finish group with
membership across the Trust will meet
monthly to oversee the development of this
reporting.
Data quality and compliance measures will be
presented to the board and at service level in
the new reports for regular review. These
measures will include: percentage of patients
with a valid NHS Number recorded,
percentage of patient activity with a valid GP
practice, percentage of patient activity with a
valid postcode, percentage of admissions
entered on the system within 24 hours,
percentage of community contacts or
appointments entered on the system within 5
days
Introduction of new data collection methods
using the Trust Intranet for services that are
not able to record the data directly onto the
clinical system
Review and reconfiguration of community
service IT systems, in preparation for
Community Information Dataset (CIDS)
Further development of the Trust Data
Warehouse to provide a central repository for
corporate and clinical information, enabling
more efficient performance and data quality
reporting.
NHS Number and General Medical Practice
Code Validity
SCT submitted records during 2011/12 to the
Secondary Uses Service (SUS) for inclusion in the
Hospital Episode Statistics which are included in
the latest published data.
The percentage of records in the published data
which included the patient’s valid NHS number
was:
•
•
•
99.9% for admitted patient care
99.0% for outpatient care
99.2% for accident and emergency care.
The percentage of records in the published data
which included the patient’s valid General Medical
Practice Code was:
•
•
•
99.7% for admitted patient care
99.7% for out patient care
100% for accident and emergency care.
There is ongoing development work to ensure that
submissions include all services that should be
reflected in these datasets.
Information Governance Toolkit Attainment
Levels
The SCT Information Governance Assessment
Report overall score for 2011/12 was 59%, and
was rated “Not Satisfactory”, equivalent to the
previously used colour definition of ‘Amber’. The
score for 2010/11 was 54%.
An action plan has been drawn up to address the
areas requiring further work. A new Senior
Information Risk Owner and several new
Information Asset Owners have been appointed.
All will receive training for their role and will meet
regularly to ensure progression of action plans.
Targeted work will also take place regarding the
requirement for all staff to undertake annual
information governance training and to ensure
that the requirements relating to data quality,
benchmarking and validation are addressed.
Page 13 of 50
QUALITY ACCOUNT 2011-12
Clinical Coding Error Rate
SCT was not subject to the Payment by Results
Clinical Coding audit during 2011/12 by the Audit
Commission.
Page 14 of 50
QUALITY ACCOUNT 2011-12
Part 3(a) Review of Quality Performance
SERVICE USER, STAFF AND VISITOR SAFETY
Serious Incidents and Incident Reporting
Incident
Type
Action
Pressure
Damage
The majority of pressure damage is
detected in our community patients
and reflects both patients who are
new to the service and where the
wound has progressed whilst under
our care. A Pressure Damage
Prevention Strategy and Policy have
been developed and these are being
proactively managed by a dedicated
group to ensure best practice is
shared.
Medication
The Trust proactively looks to
identify both prescribing and
administration errors to safeguard
our patients. These incidents are
reported to and actively reviewed by
the Medicines Management
Committee. Further details on
medicines management can be
found in the Medication section on
page 20.
Falls
The Trust has a dedicated
Intermediate Care &
Osteoporosis/Falls Prevention
Service, which is supported by a
Falls Prevention Group. The Trust
has developed and is introducing a
‘Falls Bundle’ to reflect the Royal
College of Physicians’ FallSafe care
bundle.
The Trust has developed a new incident reporting
system ‘Safeguard’ to enable all staff to easily
report electronically any incident or near miss they
might have witnessed. This has improved the
frequency of incidents being reported and the
ability of the Trust to provide a rapid response to a
situation.
The following provides an overview of the Trust’s
reporting activity during 2011/12:
Incident Reporting Frequency 2011/12 (patients)
100
90
80
70
60
50
40
30
20
10
0
450
400
350
300
250
200
.
150
100
50
0
Total Incident s
2010 Tot al
NPSA benchmark/ bed-days
SCT Rate - / bed-days
A total of 4453 incidents were reported via
Safeguard in 2011/12. The Trust monitors its
reporting against the benchmark provided by the
National Patient Safety Agency (NPSA) through
their National Reporting and Learning System
(NRLS). This benchmark represents the number
of incidents reported per 1,000 bed days. Whilst
for 2011/12 the Trust reported on average fewer
patient safety incidents than the benchmark
figure, the overall trend shows an increase in
incident reporting.
The top 3 most frequently reported types of
incident are detailed in the chart below. The Trust
has developed work streams to undertake
targeted actions directed in these areas.
250
Serious Incidents (SIs)
The requirement to report any incident which
might be deemed as being ‘serious’ as defined by
the NPSA’s Serious Incidents Requiring
Investigation framework is clearly stated in the
Trust’s ‘Incident Management and Reporting
(including Serious Incidents)’ policy.
In 2011/12 the Trust reported 56 SIs. Whilst this
is a significant increase on the previous year, we
are pleased that this reflects a more positive
reporting culture.
200
150
100
50
Falls
Pressure Damage
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
0
Medication
Page 15 of 50
QUALITY ACCOUNT 2011-12
Serious Incidents by Type 2011/12
12
10
8
6
4
2
0
M edical Device Failure
M is-Int erpret Result s
Pressure Ulcer
Child Prot ect ion
Unexpect ed Deat h
Failure t o M onit or
C Dif f
Slip, Trip, Fall
Pot ent ial HR Issue
2010 Tot al
M edicat ion
Dat a Prot ect ion
Clinical Treat ment
Syringe Driver Incident
D&V Out break
Suicide
Pressure damage (grade 3 or 4) is the most
frequently reported type of SI accounting for 48%
of those reported in 2011/12 - the Trust reports
grade 3 or 4 pressure damage as SIs regardless
of whether SCT is the primary care provider.
The second highest type of reported SIs is ‘Slip,
Trip and Fall’ and accounts for 10.7% of all SIs,
and the third highest is medication incidents.
The Trust has developed a number of key staff
within the organisation who have been trained by
the NPSA in their approved investigation methods
to identify the root causes of all SIs. These Lead
Investigators are to be supplemented in the near
future by dedicated Patient Safety Leads.
The findings of these investigations are reviewed
by a Serious Incident Review Group, chaired by
the Medical Director, to ensure their consistency
and that the causes of the incidents are known
and that the learning is shared.
An Intranet page, ‘Learning from Incidents’, has
been developed to provide all staff with
information on the underlying root causes
identified through these reviews together with a
periodic ‘Quality Focus’ newsletter for distribution
to all Trust staff.
Patient Safety Framework
The Patient Safety Framework was produced and
implemented in 2011/12 and reflects a suite of
Metrics that are reported to the Board monthly as
part of the Patient Safety and Experience report.
Data displayed on the Patient Safety and
Experience report has been extracted as part of a
set of Metrics designed and set up via the
Community Metrics Project. These Metrics will
form the basis for Quality, Safety and Experience
within the Trust. The majority of these Metrics
have not identified targets as over the next 12
months we will be monitoring and reporting on
the data and will be looking to set
thresholds/targets at the end of the first year
when we identify baselines. We will then be able
to monitor year on year trends. A new
performance framework is being developed for
2012/13 which will include stretch targets to
reduce levels of harm to patients and improve the
quality of care and patient experience.
Governance Review Programme
The Governance Review Programme 2011/12
brought together 20 projects initiated in response
to the external governance reviews of SCT’s
legacy organisations West Sussex Health and
South Downs Health. The reviews used the
Manchester
Patient
Safety
Assessment
Framework (MAPSAF) as a tool. Each project
plan had an Executive Director Lead and progress
against the programme was monitored through
monthly meetings of a Programme Board.
At final review 99% of the tasks within the
programme were complete and outcomes
included:
•
•
Trust Board meeting briefing letter to all staff
and new staff magazine launched
Monthly Serious Incident (SI) data provided to
the Board through Patient Safety Indicators.
An Annual SI report on themes and trends is
also provided to the Board and the Wider
Executive Directors Management Team
Page 16 of 50
QUALITY ACCOUNT 2011-12
•
•
•
(EDMT) meeting receives a monthly report on
SIs and the SI Tracker
New staff induction arrangements are in place
and induction compliance published
Urinary catheter care bundle and DH high
impact intervention for urinary catheter
insertion and ongoing management has been
rolled out to relevant clinical areas and is
being audited on an ongoing monthly basis
A programme of regular internal Assurance
Reviews is now being carried out across the
Trust.
In order to promote embedding of the
achievements from the 2012/12 programme, close
down meetings for each plan have identified
where each task will be taken forward in 2012/13
and how this will be monitored.
Healthcare Acquired Infections
In 2011/12 two patients were reported as having a
Methicillin-Resistant
Staphylococcus
Aureus
(MRSA) bloodstream infection (BSI), one from a
bedded unit and one from a virtual ward. This is in
line with the projected trajectory of two cases and
is an improvement on the three cases reported in
2010/11. A further community acquired MRSA BSI
is currently under investigation for March 2012 but
it is unknown at this stage whether this will be
attributed to SCT.
Graph 1: SCT MRSA bloodstream infection (BSI) cumulative cases against trajectory
In 2011/12 eleven patients were reported as having a Clostridium Difficile infection in SCT bedded units. This
is below the projected trajectory of fifteen cases and is also an improvement on the eighteen cases reported
in 2010/11. Two further cases were also investigated during 2011/12 but not attributed to SCT. Work is
ongoing towards improving antimicrobial prescribing across the Trust aiming to reduce figures further in
2012/13.
Graph 2: SCT Clostridium Difficile infection (C.Diff) cumulative cases against trajectory
Page 17 of 50
QUALITY ACCOUNT 2011-12
Central Alert System
The Central Alerts System (CAS) has been
designed to rapidly disseminate important safety
and device alerts to nominated leads in NHS
trusts in a consistent and streamlined way for
onward transmission to those who need to take
action. Alerts originate from the following
organisations:
• Medicines
and
Healthcare
products
Regulatory Agency (MHRA)
• National Patient Safety Agency (NPSA)
• Department of Health Estates and Facilities
Division (DHEF)
• Department of Health (DH)
• Local Alerts.
when a patient safety incident occurs, when a
patient makes a formal/informal complaint, or in
the case of a lawsuit, claim or litigation.
Openness about what happened and discussing
patient safety incidents promptly, fully, and
compassionately can help patients cope better
with any after effects. Openness when things go
wrong is fundamental to the partnership between
patients, and/or their carers and those who
provide their care.
Any alert applicable to the Trust will have a
detailed action plan and an identified lead to
progress work. During 2011/12 101 alerts were
received of which:
• 93% of alerts were acknowledged within two
days
• 98% of alerts had action underway within
prescribed time scales.
The alert response process is currently under
review to identify why the Trust did not achieve
100%, and improvements actions will be identified
to ensure that the Trust hits full compliance in the
year 2012/13.
Never Events
The Department of Health has identified a range
of 25 patient safety incidents which are largely
preventable and should not occur if the relevant
preventative measures are put in place. These
are known as “Never Events”. These 25 incident
types were introduced in February 2011 to replace
the 8 previously identified. Any occurrence of a
never event must be reported as a serious
incident.
The Trust did not report any Never Event
incidents during the period 2011/12.
Being Open
The Trust has a ‘Being Open’ policy to ensure
transparent communication, which is based
primarily on the National Patient Safety Agency’s
framework, ‘Being Open: communicating patient
safety incidents with patients, their families and
carers’. Open and effective communication with
patients begins at the start of their care and
should continue throughout their time within the
healthcare system. This should be no different
IMPROVING CLINICAL EFFECTIVENESS
Venous Thromboembolism (VTE)
In 2010 NICE launched guidance to prevent
Venous Thromboembolism (VTE) in hospitals.
Although not a high risk for most of our community
hospitals we have followed the national guidance
and are developing a policy that will ensure all
patients are risk assessed for developing VTE in
all our bedded units.
Page 18 of 50
QUALITY ACCOUNT 2011-12
Medication
Medicines are the most common treatment
intervention and almost all services across the
Trust are involved in the use of medicines. The
Trust’s Medicines Management Team is working
together with clinical services and external
partners to increase patient safety in relation to
medicines. The main focus continues to be to
work towards standardisation of medicines
management processes across the Trust as this is
the most effective and productive way of
improving quality.
Standardisation of Medicines Management
Documentation
Completed 2011/12
Planned for 2012/13
Community Nursing Instruction Charts
Previously there were over
6 different designs of
medication instruction
charts used within
community nursing. Trustwide community nursing
medication instruction
charts were developed and
approved by the Trust.
Phased implementation
started on the 9th of
January 2012.
Implementation of
the Trust-wide
community nursing
instruction charts
to be completed by
the 29th of June
2012.
Adult Inpatient Drug Chart
Currently different drug
charts are used across the
adult inpatient units. Best
practice would be to have a
Trust-wide drug chart
across the adult inpatient
units supporting the
standardisation of
medicines management
processes. Work on this
started on the 12th of
November 2011.
Produce a Trustwide adult
inpatient drug
chart to be ready
for use by 14th
February 2013.
Patient’s Medication Record Card
This is a card held by the
patient and contains a
record of all their medicines
including the reason for
taking them. The card was
developed with input from
pharmacy staff, nurses and
patient representatives
from the Trust’s Patient /
Introduce the
Medication Record
Card and the
guidance for its
use to all clinical
areas by 1st June
2012.
Provide supporting
Carer Database. In addition training to relevant
written guidance has been
registered
issued to help registered
healthcare
nurses, pharmacists and
professionals by
pharmacy technicians
1st June 2012.
discuss medicines with
patients and help complete
this Medication Record
Card.
Audits: The following medicines management
audits were completed during 2011/12. All have
an action plan in place to make further
improvements.
Completed 2011/12
Planned for 2012/13
• Antimicrobial
• To follow-up on
prescribing audit (adult
these action plans
inpatients)
• To complete the
• Refrigerator storage of
medicines
medicines (adult
management
inpatients)
audit programme
for 2012/13.
• Training in standard
operating procedure for
controlled drugs (adult
inpatient units)
• Omitted doses –
baseline audit (all adult
inpatients)
• Completed Venous
Thromboembolism
(VTE) risk assessment
forms for newly
admitted adult
inpatients
• South Coast Audit:
Medicines
Management Audit
• Collaborative baseline
audit of intravenous
therapy in the
community setting
(coordinated by East &
South East England
Specialist Pharmacy
Services across
several trusts).
Medicines Management Reviews of adult
inpatient services
Completed 2011/12
•
Medicines
management
reviews were
undertaken of nine
of the Trust’s adult
inpatient units.
Planned for 2012/13
These actions have been
translated into workstreams:
• Development of a Trustwide adult inpatient drug
chart (see above)
Page 19 of 50
QUALITY ACCOUNT 2011-12
•
These reviews
involved looking at
medicines
management
processes such as
medicines
prescribing,
administration and
supply including
medicines storage
and handling
Each medicines
management
review was
followed up by a
report. A total of
197 actions were
identified to
support the
improvement of
practice and to
increase patient
safety.
• Use of patients’ own
drugs (one-stopdispensing) scheme
within all adult inpatient
services
• Training of nurses to
support them further in
their role on:
• The process for
checking patients’
own drugs on
admission and on
discharge
• Process and completion
of Patient’s Medication
Record Chart (see
above)
• To follow-up on these
action plans
• Continue with the
Medicines Management
Review programme.
Safe and secure handling of medicines
assessments
Completed 2011/12
Planned for 2012/13
•
Seven
assessments of
clinics within the
Trust were
assessed to ensure
compliance with
the Trust’s
Medicines Policy
A total of 53
actions for
improvements were
identified.
•
A total of 34 Trustwide Safe and
Secure Handling of
Medicines
workshops for
registered
healthcare
professionals were
delivered across
the Trust. This
ensures staff are
aware of the
Medicines Policy
and requirements
around medicines.
•
•
•
•
Continue with the
Safe and Secure
Handling of Medicines
assessment
programme of clinics
To follow-up on these
action plans
Continue to deliver
these Trust-wide Safe
and Secure Handling
of Medicines
workshops across the
Trust.
Competency assessment for medicines
administration
•
The hospital
matrons initiated in
2011/12 a
competency
assessment for
administration of
medicines for all
nurses working
within the adult
inpatient units.
Newsletters
Completed 2011/12
The “Learning from
Incidents” newsletters
are circulated to all
staff via the Trust’s
weekly
communication. The
newsletter is a one
page easy to read
briefing. The purpose
is to share learning
from reviewing
reported medication
incidents from within
the Trust or from
relevant medication
incidents highlighted
nationally.
A total of 13
newsletters were
produced in 2011/12.
Eight Medicines
Management
newsletters were
circulated to clinicians
in 2011/12 to provide
them with updates
related to medicines.
•
To extend the
competency
assessment for
medicines
administration to
community nursing.
Planned for 2012/13
Continue to produce the
Learning from Incident
newsletter to ensure
learning from medication
incidents are shared
across the Trust.
Continue to produce the
Medicines Management
Newsletter to provide
updates to clinicians
regarding medicines.
Falls and Fractures
In 2011/12 the Osteoporosis and Falls Prevention
Service in Brighton and Hove, and the Falls
Prevention Services across West Sussex have
continued to develop services within the
community to ensure patients receive evidence
based interventions for falls and fracture
prevention.
The SCT Falls Policy has been modified and
updated to include recommendations and risk
assessments to be used across inpatient and
community settings, in line with recommendations
Page 20 of 50
QUALITY ACCOUNT 2011-12
from the NPSA and other current best practice
guidelines. An audit of the policy will be
undertaken across the Trust in 2012/13 to ensure
the guidelines are being met and risk
assessments are being used.
reduce the number of falls within care homes. The
training will be rolled out across other areas in
Sussex in 2012/13 with the aim of reducing the
number of patients admitted to hospital from care
homes due to falls and fractures.
A specialist training programme has been
developed for staff within SCT working in both the
community and within community hospitals and
rehabilitation units. The training has been
designed to:
•
•
•
Ensure continuity across the Trust in the
management of patients at risk of falls and
fractures
Promote best practice in line with national
recommendations
Ensure appropriate risk assessments and
evidence based interventions are completed
in all settings.
This training will continue to occur quarterly for
2012/13.
The Osteoporosis and Falls Prevention Service
has worked closely with Brighton and Hove Albion
Football Club to establish the Standing Tall
Exercise Class within the community. This has
been invaluable in providing the opportunity for
patients discharged from the NHS to continue
evidence based exercises within a community
setting. These classes have been very successful
and there are hopes to offer more classes in
different venues across the city in 2012/13.
The Falls Prevention Service within Chichester
has worked closely with local council and
Community Nurses to establish a successful
training programme for senior staff within care
homes. The training has increased care home
staff knowledge on falls and fracture prevention
and ensured staff are able to complete risk
assessments and appropriate care plans to
The graph below shows the number of falls in inpatient units, resulting in an injury, over the course of the
year 2011/12:
Page 21 of 50
QUALITY ACCOUNT 2011-12
Nutrition and Dietetics
SCT’s compliance with these standards in the
West Sussex area throughout has risen from 95%
of admissions with a risk assessment being
undertaken within 48 hours in June 2010, to 99%
in March 2011. We have also seen an
improvement in the follow up actions to the risk
assessment being detailed in a care plan from
91% in June 2010 to 97% in March 2011. Please
see below (please note the data below is based
on sample testing):
In recognition of the importance of good nutrition
and hydration all patients in our bedded units and
those being cared for by our community nursing
teams have a nutritional assessment. All inpatient
units are required to undertake a Malnutrition
Universal Screening Tool (MUST) assessment on
all patients within 48 hours of admission. The
MUST tool leads to recommended actions which
form part of the individual plan of care.
Chart 1: % Patients with nutritional assessment within 48 hrs (Inpatients) - 2011/12
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Key:
2011/12 target achieved
below 2011/12 target
ar
ch
M
Fe
br
ua
ry
ry
Ja
nu
a
De
ce
m
be
r
be
r
No
ve
m
O
ct
ob
er
be
r
t
Se
pt
em
Au
gu
s
Ju
ly
Ju
ne
ay
M
Ap
ril
0%
2010/11 CQUIN target
Chart 2: % Patients with nutritional assessment within 1 month (Community Virtual Wards) - 2011/12
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
April
Key:
May
June
2011/12 target achieved
July
August
September
below 2011/12 target
October
November
December
January
February
March
2010/11 CQUIN target
Page 22 of 50
QUALITY ACCOUNT 2011-12
The Matrons have an ongoing commitment to
improving patient experience and quality of care.
A review of incidents was undertaken in February
this year, followed by a benchmarking exercise of
the patient experience issues from ” The Francis
Report” (Independent investigation into care
provided by Mid Staffordshire NHS Foundation
Trust Jan 2005 – March 2009) and “Care and
Compassion?” Report of the health Service
Ombudsman on ten investigations into NHS care
of older people (Feb 2011).
In response to issues raised in these reports
regarding nutrition and dietetics services have
introduced a number of initiatives and solutions to
improve nutrition and hydration care for patients.
For example:
9 Introduction of red trays for patients who
require assistance with or monitoring of
nutritional intake
9 Introduction of red jug lids for patients who
require monitoring of fluid intake
9 Review of nutrition standards and compliance
with them
9 Implementation of the Productive Wards
Meals module
9 Use of the Patient Safety First audit tool for
fluid balance charts
9 Ensuring monthly mealtime audits using
Protected Mealtime Observation Tool (covers
environment, patient experience and privacy
and dignity) to cover all 3 main meals in turn
9 Provision of feedback form for patients to
comment on individual meals
9 Production of a laminated chart showing how
much commonly used items such as cups and
glasses contain to facilitate accurate
completion of fluid charts
9 Matrons include nutrition and privacy, dignity
and respect in clinical rounds
9 Working with relatives of patients with
dementia to advance plan menus to ensure
preferences the patient might not be able to
communicate are respected.
Community Matrons
A trust wide Community Matron forum has been developed
to support with sharing best practice and team
development.
End of Life Care
This year has seen an emphasis on increasing the
number of people who die in their usual place of
residence and in particular their preferred place of
care. A number of initiatives are underway to
facilitate this including Gold Standard Framework
accreditation taking place for a number of care
homes who have signed up with the programme
being run by SCT End of Life care coordinators.
The Liverpool Care Pathway, a best practice
nationally approved pathway, is being used to
ensure all people involved are delivering the best
and most appropriate care to each person cared
for in the community at the end of life .
Table 1 and Graph 1 show the numbers and
percentages of people cared for by the Brighton
and Hove community Macmillan Team (MCT) who
died in their preferred place of care.
Apr
May
Jun Jul
Aug
Sep
Oct
Nov Dec
Jan
Feb
Mar Total
% Dying in PPC 62.2% 60.9% 51.4% 78.1% 70.6% 87.0% 65.8% 68.8% 73.8% 76.7% 61.5% 75.9% 69.5%
No dying in PPC
23
28
18
25
24
40
25
33
31
33
24
22
314
Total Deaths
37
46
35
32
34
46
38
48
42
43
39
29
452
% of Patients Dying in Preferred Place of Care
100.0%
75.0%
50.0%
25.0%
0.0%
Apr May Jun
Jul
Aug Sep Oct Nov Dec Jan Feb Mar
Brighton Macmillan Comm 62.2 60.9 51.4 78.1 70.6 87.0 65.8 68.8 73.8 76.7 61.5 75.9
%
%
%
%
%
%
%
%
%
%
%
%
Team
Table 2 and graph 2 show the percentages of
people cared for by the Midhurst Macmillan
Community Team (MCT) who died in their
preferred place of care.
% Dying in PPC
Apr
May
74% 74%
Jun Jul
Aug Sep
Oct
Nov Dec
Jan
Feb
Mar
92% 75%
74% 90% 75% 88% 73% 92% 75% 91%
% of Patients Dying in Preferred Place of Care
The Matrons have shared this work and are now
looking at what worked well in other units and how
they can be implemented in a standard way
across the bedded units. They are working on
standardising documentation including food and
fluid charts and will have this work complete by
the end of October 2012.
100%
75%
50%
25%
0%
Apr May Jun
Jul
Aug Sep
Oct Nov Dec Jan
Feb Mar
Midhurst Macmillan Unit 74% 74% 74% 90% 75% 88% 73% 92% 75% 91% 92% 75%
Page 23 of 50
QUALITY ACCOUNT 2011-12
Pressure Damage
These excellent results for Brighton and Hove and
Midhurst set the standard for the rest of the Trust.
Using advance care planning and achieving
preferred place of care has ensured there are
fewer inappropriate hospital admissions and
contributed to more patients dying in their usual
place of residence. The process of recording this
data will be extended to community nursing teams
over the next year. This will give the opportunity to
review the figures for achieving preferred place of
care for those people who may not have been
cared for by either of the MCT’s in SCT. The
overall aim is to provide optimal care by
discussing and agreeing where a person wishes
to be cared for and working with all those involved
to allow this to happen in a safe and dignified way.
During 2011/12 a strategy has been developed to
address any identified issues relating to pressure
damage management where improvements are
required. Some of the work is already complete
and has resulted in an updated Pressure Damage
Prevention and Treatment Policy being ratified.
Work is ongoing as part of a three year plan. Staff
have been advised to report all pressure damage
incidents of category 2, 3 or 4. Staff are also
advised to refer all patients with pressure damage
of category 3 and 4 to the Tissue Viability Team
for advice and support with their patient
management plan.
The Tissue Viability Specialist Nurses are
available to provide clinical advice and support to
any manager involved in investigating a Serious
Incident or Safeguarding Adults at Risk alert that
involves pressure damage.
The Tissue Viability Team have increased the
number of training sessions available for both
registered and unregistered nurses, with 41
training courses being run over the 2011/12
period.
Graph 1: Pressure Damage Developed Under SCT Care
Pressure Damage (Under SCT Care)
18
16
14
12
Grade 4
10
Grade 3
8
Grade 2
6
4
2
0
April 11 May 11 June 11 July 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12
Page 24 of 50
QUALITY ACCOUNT 2011-12
Graph 2: Pressure Damage Developed Outside SCT Care
Pressure Damage (From Outside SCT Care)
60
50
40
Grade 4
Grade 3
30
Grade 2
20
10
0
April
11
May
11
June July 11
11
Aug
11
Sep
11
Integrated Discharge Pathway from Surrey and Sussex
Healthcare to West Sussex
SCT have integrated their delivery of discharge liaison
into East Surrey Hospital with One Team. This is to ensure
7 day cover to ‘in reach’ and facilitate discharge to
community beds and community services. We have had
very positive feedback from the local acute trust and the
integration has led to improvement in patient care.
Safeguarding Adults at Risk
The SCT Safeguarding Adults at Risk (SAR) team
works in collaboration with other agencies to:
•
•
•
Ensure that those at risk, by nature of their
disease or frailty, receive appropriate care
Prevent people from harm through
investigating areas and issues of concerns
that have not been addressed through normal
reporting lines
Respond and investigate specific alerts from
appropriate Public Health Agencies and
Social Services referrals in Brighton & Hove
and West Sussex.
Safeguarding Adults at Risk within Sussex
Community Trust (SCT) has seen further
development throughout 2011/12. During this time
the team has established itself as a resource for
staff employed by SCT and continues to be a
point of referral for Health Investigating Officers by
West Sussex County Council (WSCC) and
Brighton & Hove City Council.
Oct 11 Nov 11
Dec
11
Jan 12
Feb
12
Mar 12
Over the past twelve months the Team have
worked in collaboration with the Trust’s
Governance Team to enhance the Trust’s SAR
activity. This activity is also shared via the South
of England Strategic Health Authority dashboard
and suggests that during this time SCT have
raised 40 safeguarding alerts across West Sussex
and Brighton & Hove.
During the reporting period SCT Trust provided 78
instances of Health Investigating Officer input into
safeguarding investigations for WSCC. Over 70%
of the 78 investigations were levels 3 & 4 and
25% were at level 2. The team has been involved
in a number of high profile level multi-agency SAR
investigations involving Health, Adult Services,
CQC, the Coroner’s Office, Police and the UK
Border Agency.
Future plans and priority areas for 2012/13 and
beyond:
•
•
Developing strategies aimed at improving the
numbers of staff who access SAR awareness
and update training
One of the outcomes that the recent West
Sussex Local Safeguarding Adults Board
(LSAB) identified was that SCT need to
propose key areas of adult safeguarding
development that the Local Safeguarding
Adults Board could work on across agencies
in 2012/13 – SCT is very keen to establish
some pressure damage protocols to support
both health and social care to determine if
Page 25 of 50
QUALITY ACCOUNT 2011-12
•
•
•
these wounds should be processed as clinical
incidences or whether they should be
processed as SAR
Establishing and embedding the Trust’s SAR
Committee to monitor clinical areas for
improvements in practise
Incorporating Prevent Strategy into relevant
practise areas
Establishing locality areas for the Teams’
SAR Practitioners. These are likely to be
aligned with existing WSCC Adult Services
boundaries. This would allow greater multiagency working with Adult Services Teams,
Independent
Chairs
and
community
healthcare teams.
many emergency admissions as possible into
Accident and Emergency (due to urinary catheter
related problems) by providing a comprehensive
urinary catheterisation education programme for
registered community clinicians. The service
provides clinical support and guidance to
community clinicians to enable individuals to be
managed at home.
The Trust-wide Continence Service works closely
with all community services and secondary care to
reduce the number of patients with, and time that
they have, an indwelling urinary catheter. By
minimising the length of time individuals need to
have a urinary catheter in-situ the risk of urinary
tract infections is reduced.
In 2011/12, as part of the service commitment to
reduce the number of urinary catheters, a urinary
catheterisation pathway document has been
developed for Trust-wide use. This prompts
clinicians each time they carry out a urinary
catheterisation or re-catheterisation to assess
whether the individual needs or continues to need
a urinary catheter. Individuals that no longer
require a urinary catheter undergo a planned trial
period without catheter.
Catheter Care / Urinary Tract Infections
The Trust-wide Continence Service has provided
urinary catheterisation and catheterisation update
study days throughout 2011/12 - these were open
to both Trust and external registered clinicians.
During 2011/12 the Brighton and Hove
Continence Team has continued to prevent as
Graph 1: emergency admissions to BSUH (Brighton & Hove area) for catheter problems. (For the
purpose of this report we have omitted any patients over which we have no control e.g. nursing home
patients, out of area patients).
Page 26 of 50
QUALITY ACCOUNT 2011-12
In 2012/13 the service aims to work with all the
community teams in West Sussex to give them
support to assess all individuals who have an
indwelling urinary catheter. The assessment will
be to ensure that they require this intervention,
plus a localised database will be compiled of all
individuals that have an indwelling urinary
catheter so that the service can monitor the
number of indwelling urinary catheters in the
community.
patient areas with such MDT working to lift care
for all.
The Trust-wide service aims to continue to try to
prevent emergency admissions into accident and
emergency for urinary catheter problems by
having in place a comprehensive education
programme for all healthcare professionals for the
forthcoming year.
This 2011/12 winter saw very high levels of
attendance at local acute hospitals with rates
being up by 20% in some weeks. For example in
the February 2012 half term this was the case
across the whole of Sussex, mainly due to
respiratory illness. In the Worthing and Chichester
areas the acute hospitals set a target of no more
than 5% of delays in patients coming into our care
and we achieved figures below 3%. So this was a
success in providing care planning to the benefit
of patients in these areas.
Health Children Programme West Sussex
The percentage of eligible children receiving health review
has increased. For Looked After Children In West Sussex
Immunisation uptake is 97% against a national rate of 79%
and dental checks completed within past year in West
Sussex is 92% and nationally 82.4%. Children's Continence
team have completed all outstanding reassessments and
families have been offered support to assist their children in
attaining continence. In School Nursing the enuresis service
offered by dedicated professionals have received a high
level of satisfaction from the feedback questionnaires.
Care Planning/Assessment of Need
Delayed Transfers of Care / Discharge
Planning
Our services are now evidencing the benefits of
careful use of care plans, and their support of
patients moving through our services.
As part of the 2011/12 CQUIN scheme the Trust
met goals with regards to discharge summary
provision and work will continue to ensure that
best practice is shared across the new
organisation.
Patients in our services have a care plan and this
helps with the smooth progress through the
process of care the patient undergoes in SCT. We
are moving many of our teams towards a multidisciplinary team (MDT) approach, which ensures
patient care is joined up with nursing, therapy and
social care all factored in. Brighton community
nursing has been re-designed around defined
The targets were:
• Patients to have a discharge checklist and
booklet
• Bed days lost due to Delayed Transfers of
Care.
Graph 1: Number of Bed Days Lost by week due to Delayed Transfers of Care in Brighton & Hove
Grand Total
Mean
UCL
LCL
SPC Rule 2
SPC Rule 1
Brighton & Hove Delays - Weekly Days Lost
140
100
80
60
40
20
29/03/12
15/03/12
01/03/12
16/02/12
02/02/12
19/01/12
05/01/12
22/12/11
08/12/11
24/11/11
10/11/11
27/10/11
13/10/11
29/09/11
15/09/11
01/09/11
18/08/11
04/08/11
21/07/11
07/07/11
23/06/11
09/06/11
26/05/11
12/05/11
28/04/11
14/04/11
31/03/11
17/03/11
03/03/11
17/02/11
03/02/11
20/01/11
06/01/11
23/12/10
09/12/10
25/11/10
11/11/10
28/10/10
14/10/10
30/09/10
16/09/10
02/09/10
19/08/10
05/08/10
22/07/10
0
08/07/10
DaysLost
120
Page 27 of 50
QUALITY ACCOUNT 2011-12
Graph 2: Number of Bed Days Lost by week due to Delayed Transfers of Care in West Sussex
Grand Total
Mean
UCL
LCL
SPC Rule 2
West Sussex Delays - Weekly Days Lost
450
400
DaysLost
350
300
250
200
150
100
50
01/04/12
18/03/12
04/03/12
19/02/12
05/02/12
22/01/12
08/01/12
25/12/11
11/12/11
27/11/11
13/11/11
30/10/11
16/10/11
02/10/11
18/09/11
04/09/11
21/08/11
31/07/11
17/07/11
03/07/11
19/06/11
05/06/11
22/05/11
08/05/11
24/04/11
10/04/11
27/03/11
10/03/11
24/02/11
10/02/11
27/01/11
13/01/11
30/12/10
16/12/10
02/12/10
18/11/10
04/11/10
21/10/10
07/10/10
24/09/10
10/09/10
0
Graph 3: Bed Days Lost to Delayed Transfer of Care as % of Total Beds available (all inpatient units)
14%
12%
10%
8%
6%
4%
2%
0%
Apr
M ay
Jun
Target Achieved
Jul
Aug
Sep
AboveTarget
Electronic discharge summaries were developed
as part of the 2011/12 CQUIN scheme across
SCT. This work with continue to be rolled out into
the other bedded units in 2012/13.
We have robust procedures in place to ensure all
Delayed transfers of Care are resolved in the best
interests of all patients, whilst ensuring correct
use of this vital resource.
NICE Guidance
In the year 2011/12 NICE released 88 pieces of
clinical guidance of which 9 were categorised as
directly applicable to the Trust.
Oct
Nov
Dec
2010/11
Jan
Feb
M ar
Target (10%)
monitoring of applicable National Institute for
Health and Clinical Excellence (NICE) guidance.
The NICE guidance process is overseen by the
Trust’s Clinical Governance and Patient Safety
Committee. For 2012/13 this process has been
reviewed and updated to:
• Include the NICE Quality Standards, Medical
Technologies Guidance and Diagnostics
Technologies Guidance
• Develop the financial assessment of the
implementation of NICE guidance to ensure
the Trust achieves best value for its patients.
Local implementation of NICE guidance is
reviewed by services through the Clinical Audit
process.
SCT has a robust policy and process for the
dissemination, review, implementation and
Page 28 of 50
QUALITY ACCOUNT 2011-12
PATIENT EXPERIENCE
Patient/Carer Experience
In 2011/12 100% of all SCT clinical teams
collected patient feedback data and produced
action plans where issues were identified. This
met the requirement of the 2011/12 CQUIN.
Services collected patient feedback by different
methods e.g. postal surveys, one to one
interviews, user groups.
Electronic feedback using patient experience
trackers, Survey Monkey and NETbuilder have
been trialled but have not generally provided
substantial patient feedback. The Trust is in the
process of using alternative forms of electronic
feedback such as Twitter and redesign of the
Trust web site. This will be taken forward by a
new task group in 2012/13.
There are a range of factors that can affect
sickness absence and use of agency staff. It is
therefore useful to understand the broader context
by reviewing our 2011 staff survey results and
describing how the Trust is working to improve
how its staff are managed, developed and
deployed before focussing on sickness absence
and agency spend in more detail.
Just under 1,700 staff responded to the 2011 staff
survey, providing a response rate of 42%. The
survey shows how positive or negative staff feel
about working for the Trust across a wide range of
areas. It also shows where our performance is
improving or deteriorating. We showed marked
improvement in the number of staff receiving
appraisals, personal development plans and
equality and diversity training. Areas where our
performance deteriorated were related to
increased work pressure, working long hours and
staff experiencing stress. A workshop was set up
to involve staff and managers across the
organisation in contributing to action plans to
address these issues of concern for staff.
Last year, we reported on the large-scale complex
change management process we underwent to
form SCT. That process continued into 2011 as
teams, formed by staff from our two predecessor
organisations, were brought together under new
management structures. We are currently
refreshing
our
Human
Resources
and
Organisational Development Strategy as the new
structures settle down.
The CQUIN for patient experience feedback for
2012/13 will focus on SCT inpatient units. This will
be in the form of a survey of all patients
discharged in June 2012 and January 2013 using
the same set of questions for comparison of
progress/improvement.
Controlling expenditure on pay, while ensuring we
have safe, effective staffing levels, continues to be
a high priority. Last year, we reported that we had
set up an establishment management process
(EMP) for this purpose. In 2011, this process was
devolved to senior operational managers so the
clinical and management expertise needed to
support these decisions can be drawn from front
line services.
Staff Experience
Staff Sickness
In our 2010/11 Quality Account, we reported on
our staff sickness absence rate and use of agency
staff. We chose these particular measures
because consistent, high quality care is
dependent on the availability of staff that know
their service and have a good understanding of
the needs of their patients. High levels of absence
and/or high use of agency staff reduces our ability
to provide consistent good quality care.
Our average staff sickness absence rate rose
from the 3.59% reported last year to 4.08% this
year (this average covers the period February
2011 to February 2012). Our target is 3.5%.
The staff sickness levels for the year are shown in
the chart below:
Page 29 of 50
QUALITY ACCOUNT 2011-12
Programme. In addition SCT continues to support
the implementation of the Productive Ward
Programme as a pre-merger initiative established
by West Sussex Health.
5%
4%
3%
Long term
SHA average
Short term
Trust Last Yr
Feb‐12
Jan‐12
Dec‐11
Nov‐11
Oct‐11
To continue to embed
and sustain the
Productive Leader
Programme across the
organisation.
Sep‐11
Six senior leadership
teams including the
executive team have
now completed the
Productive Leader
Programme and
another leadership
team is currently
undertaking the
programme.
Aug‐11
0%
Jul‐11
2012/13
Jun‐11
2011/12
May‐11
1%
Apr‐11
Productive Leader
Mar‐11
2%
Trust Target
* March figures not yet available
We have been reviewing our sickness absence
rates on a monthly basis and focussing on areas
where this is consistently high. We have also set
up a Health and Wellbeing Group whose remit is
to explore the underlying causes of sickness
absence and develop ideas and actions in
2012/13 for how we can support staff in remaining
healthy and fit for work.
Use of Agency Staff
In 2011/12 we spent 3.06% of our paybill on
agency staff, compared to 4% last year. Our
target for last year was 4.5% of the paybill. In
2011/12 this was made more demanding and
reduced to 3% of the paybill. Our actual
performance therefore improved although we did
not quite meet our target in 2011/12.
Productive Community
2011/12
2012/13
Strategic positioning
workshop undertaken
in conjunction with the
executive team to
agree the
implementation plan,
strategic alignment and
communication plan for
the launch of the
Productive Community
Programme.
We will continue the
implementation of the
Productive Community
Programme as agreed
at strategic level. We
have recruited 4 whole
time equivalent
Productive Programme
Facilitators to support
this process. It is our
intention to have
commenced delivery to
103 out of 175 teams
by 31st March 2013.
Early indications
suggest cost savings
from stock control
reviews and savings in
staff time through
improved efficiency
processes.
Participating teams will
be supported to gather
data (on the Knowing
How We are Doing data
collection tool) in the
following key areas:
patient safety and
reliability, patient
experience, staff health
and well being and
productivity. Processes
are being put in place
to enable the collection
of this data at team
and aggregate level.
Two Productive
Community
Programme test sites
were identified and
The Productive
Programme team will
be supported
organisationally to
The Productive Series Programme
The Productive Series Programme (PSP) was
launched in SCT in January 2011. The PSP has
been given an initial project plan of 2 years to
deliver the implementation of the Productive
Leader
and
the
Productive
Community
To agree a method for
evaluating the
effectiveness of the
Productive Leader
implementation.
Page 30 of 50
QUALITY ACCOUNT 2011-12
supported through the
foundation modules of
the Productive
Community
Programme. These
teams continue to
implement the
remaining modules with
regular sustainability
visits from their
Productive Programme
Facilitator. Positive
improvements have
been identified. The
first full wave of the
Productive Community
commenced in
November 2011.
provide a ‘showcase’
day for participating
teams to share learning
and experience to
further strengthen the
embedding and
sustainability of the
Productive Community
Programme across the
Trust.
adopted by other wards.
In addition a collaborative
project with a local art
college has commenced to
introduce art to ward
corridors in direct
response to patient
feedback.
Patient Experience Steering Group
The Patient Experience Steering Group is now
established with a broad membership of
stakeholders including public and patient’s
representatives, clinical and managerial staff,
Communications staff and a Non Executive
Director.
Patient Experience Strategy
Productive Ward
2011/12
2012/13
The Productive Ward
programme
implementation continues;
there is one remaining
team to commence in
2012. Areas of success
include evidence of
increased time for direct
patient care, improved
medicines rounds and
meal times, improved
handovers and patient
monitoring.
A plan is in place to
introduce relevant
modules from the
Productive
Community Hospital
programme to the
minor injuries unit
One of the wards has won
the Community Hospital
Associations award for
their work around the
Patient Status at a Glance
which has now been
further developed and
In 2011/12 a key piece of work of the group was
the development of a Patient Experience Strategy.
The strategy embodies the Trust’s drive to put
patients at the centre of service delivery and
include their views and opinions in developing
new services. Goals include key elements relating
to how staff interact with patients and therefore
staff wellbeing, training and development
essential to ensuring safe service provision.
The group will focus on taking the strategy
forward over the next three years including
achieving improved participation of minority and
disadvantaged groups. In 2011/12 we have
started to network with gypsies and travellers in
Brighton and Hove, the Black Minority and Ethnic
(BME) Partnership, Crawley and Crawley Ethnic
Partnership. This work will continue into 2012/13.
Patient Surveys
The collection of patient feedback from surveys,
with actions, was required from all SCT clinical
teams by the 2011/12 CQUIN; 100% return has
been achieved.
Page 31 of 50
QUALITY ACCOUNT 2011-12
understanding of what the issues are for patients
when accessing or using the Trust services. The
goal for 2012/13 will be to develop the data
collection system to improve the recording of
qualitative information, so that common issues
can be identified and actions undertaken to
address them.
Complaints
Health User Bank (HUB)
SCT continued to be an active member of the
local Health User Bank participation group in
2011/12. The initiatives from this group are
aligned with the agreed CQUIN target to engage
the patients, carers and public. The group is
currently under review and will be developed in
line with the legal obligations of the NHS Act 2006
(chapter 41) during 2012/13.
Patient Advice and Liaison Service (PALS)
In 2011/12 the Trust received a total of 235
complaints.
•
On average, cases were closed in 39.43
working days
51 (29.82%) cases were closed in 25 working
days or less
128 (74.85%) cases were closed in 50
working days or less.
•
•
Graph 1: Highest categories of complaints
received
16%
14%
The PALS service received 358 enquiries during
the reporting year in relation to SCT services, and
127 enquiries in relation to other providers.
Action from a PALS enquiry
A relative of a patient who had been trying
unsuccessfully to reach them by phone at Bognor Regis
War Memorial Hospital telephoned PALS for assistance.
The PALS administrator was able to establish that there
was a fault with the phone line at Bognor Hospital; this
initiated an investigation and resulted in an immediate
repair to the line.
10%
8%
6%
4%
2%
Diagnosis
Problems
Outpatient
appointments waiting times
Outpatient
appointments access
0%
Staff Attitude
The service provides information about the NHS
complaints procedure and how to get independent
help in making a complaint. The service helps
improve the quality of care and experiences of
patients by ensuring staff who manage services
are made aware of any issues raised.
A
dedicated resource for handling PALS issues has
enabled a more robust recording process. All
PALS enquiries are recorded and monthly reports
showing trends are provided to Assistant Directors
/ Executive Directors.
12%
Nursing Care
The SCT PALS service provides an easy access
service for patients, carers and relatives to
answer questions and resolve concerns as
quickly as possible.
The highest category of complaints received
during the reporting period is ‘Nursing Care’.
Information on the categories of complaint
received is reviewed by the Clinical Governance
and Patient Safety Committee and the NonExecutive chaired Quality and Safety Committee.
Examples of actions taken as a result of learning
from complaints include:
Nursing Care Category
•
•
•
•
Shared learning via team meetings
Additional training being provided
Appraisals being undertaken
Competencies being reviewed.
The development of a database to support PALS
activity has enabled the Trust to gain a better
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Staff Attitude Category
•
•
•
Regular and/or live supervision being
provided
Being Open policy highlighted and
training put in place
Performance management instigated
where applicable.
During the reporting period 7 complaints were
referred to the Parliamentary Health Service
Ombudsman, of which one resulted in an
investigation (ongoing as at 31st March 2012).
In 2012/13 the Complaints team has the following
priorities:
•
•
•
Improve follow up mechanisms to ensure all
relevant actions are identified
Enhance reporting to ensure complaints data
is reviewed against the number of patient
contacts undertaken by a service
Maximise the used of Scholar to link reporting
across clinical, staff and financial data.
Action from complaints:
To ensure patients are informed of the process for referral,
waiting times and how to contact the Physiotherapy
department to discuss their referral, letters will now be sent
once a referral is received from a clinician. Clear
communication from the initial referral informing patients of
the choice and venues for treatment will help reduce the
waiting times some patients have experienced.
Plaudits (Compliments)
The total number of plaudits recorded for 2011/12
is 1,456. Although there is a central recording
mechanism not all services are fully utilising this –
use of the plaudits reporting system will be
developed further in 2012/13 which we believe will
result in an increase in the recorded number.
service now and in the future. Across SCT we
currently have in excess of 500 volunteers who
work alongside our services in a range of settings
including reception, filing, catering, peer support,
befriending, and support to people with life limiting
conditions etc.
A key outcome from volunteering is the benefit it
can make to the volunteer themselves, both for
their own health and wellbeing but also for future
employment. There are many examples where
this has happened, such as the Brighton service
where a volunteer who worked in retail now has
employment with the Trust. A young gentleman
who had been made redundant from a large IT
cooperation a couple of years ago volunteered for
well over a year and has now gained employment
with the Trust.
The volunteering service has a made huge
contribution to how we work with communities and
other organisations. In Crawley Hospital there is
a student volunteering programme and this year
we had 25 students from local sixth forms. They
came for 6 months and each completed 50 hours
of volunteering. One of the students applied for
nursing and was not successful initially, so did
some volunteering once she left sixth form and
subsequently succeeded in getting a place. She
is convinced that this was due to her experience
with us.
Infant feeding
An Infant Feeding Partnership with Acute, Voluntary and
Children & Family Centre Colleagues has been developed
to increase breastfeeding rates in West Sussex. There are
now staff trained as infant feeding advisors in each Health
Visiting Team. Funding has been secured from the
Wellbeing Partnerships to train volunteers as peer
supporters, working alongside health professionals, in
Breastfeeding Drop Ins.
The first peer supporter has graduated.
Volunteers
Volunteers play an important role in the Trust and
we are committed to ensuring that they are
nurtured and developed to enhance a quality
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Our vision is that: “Volunteering is encouraged
and supported as it has the power to improve
quality and health for all”. We recognise that for
us to take this forward we need to further develop
our existing volunteer support services and in
2012/13 we will do this through having the
following:
•
•
•
•
Leadership – developing vision and service to
enhance existing provision
Partnership – working with staff, volunteers
and community organisations – nurturing
Empowering – patients/users, volunteers and
staff to improve or maintain health, or work
integration
Support – for volunteers to create good
experiences, and staff to value their
contribution.
To ensure this is implemented a Voluntary
Services Steering Group will be established.
Privacy & Dignity
Achieving high standards of privacy, dignity and
respect is a key priority for SCT. Standards are
regularly
monitored
through
the
Patient
Environment Action Team, the independent Care
Quality Commission inspection process and the
CQUIN scheme which monitors breaches in single
sex accommodation or toilet facilities. As a result
of clinical need SCT only had one incidence of
non-compliance in 2011/12 where a necessary
action to support overall patient welfare was
taken.
Mixed sex accommodation has been eliminated
across Brighton and Hove and West Sussex.
There may be men and women patients on the
same ward, but they will not share the same
sleeping area, toilets or bathrooms. Every unit has
separate facilities close to their bed.
In 2012/13 we will continue to use a patient
questionnaire as part of the Productive Ward
series to monitor our practice and obtain patient
feedback.
LINks gives individuals and voluntary
community groups the chance to:
•
•
•
Review the performance of health and social
care providers
Comment on the provision of local health and
social care services
Influence the decisions of Commissioning
bodies.
LINks are also empowered to gather information
about local health and social care needs and the
experiences of patients and to make reports and
recommendations to service commissioners and
providers on the basis of this information.
SCT has made a clear commitment to work
closely with the West Sussex LINk and the
Brighton and Hove LINk and to welcome their
input as ‘critical friends’. We welcome and value
the LINks’ interest in our work and their honest
and robust comments on our performance. As
requested by the Brighton and Hove LINk, we
expressed this commitment formally in writing in
2011.
We manage our regular routine relationship with
the LINks through liaison between the SCT
Marketing, Communications and Intelligence
(MCI) team and the host organisation for each
LINk.
We believe that these routine relationships are
enhanced by the strong informal relationships that
have been established between the SCT Chair
and
other
board
members
and
key
representatives of the local LINks. We believe as
well that both LINks view our relationship in a
similarly positive light.
As part of our ongoing relationship:
•
•
Local Involvement Networks
In its report ‘A Stronger Local Voice’ (2006), the
Department of Health set out its plans to improve
patient and public involvement in health and social
care. Its ideas were enacted in the ‘Local
Government and Public Involvement in Health Act’
(2007), which amongst other measures included
the establishment of Local Involvement Networks
(LINks).
and
•
•
•
LINk members regularly attend meetings of
our Board in public, and their contributions to
our Board discussions are welcomed and
valued
We welcome LINk members as active
members of a number of our key internal
meetings, including the Trust Planning Group
and our Patient Experience Steering Group
We invite LINk members to attend key events,
such as the annual general meeting
We send regular news items to each LINk for
inclusion in their mailings to their members
We advise the LINk about our organisational
development or about service change and
improvement, and invite their comments
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QUALITY ACCOUNT 2011-12
•
•
We attend meetings with our LINks, and have
supported/participated in LINk events
We seek advice, guidance and support from
our LINks with regard to public engagement.
Under section 224 of the ‘Local Government and
Public Involvement in Health Act’ (2007), LINks
have a specific power to present us formally with
questions about local services and to receive our
reply. In this way in 2011/12 the Brighton and
Hove LINk has asked for information or comment
in areas such as:
•
•
•
•
Services for people with Parkinson’s disease
Services to members of the city’s Polish
community
The management of services to inpatients
with dementia
Our work under the Department of Health’s
Productive Ward programme.
We are committed to answering LINk questions in
a spirit of openness. We have pledged to deal
with LINk questions with the attention and speed
with which we deal with Freedom of Information
(FoI) requests, although we do not expect the
LINk to presents its questions formally through the
FoI process.
views of the local community. They will champion
patients’ views and experiences, promote the
integration of local services and improve choice
for patients through advice and access to
information.
SCT will work with all appropriate local partners to
support the most effective transition to local
HealthWatch arrangements in both West Sussex
and Brighton and Hove.
Equality and Diversity
The Trust’s Equality and Diversity Board has
agreed the following objectives for 2012-2016 as
required by the Equality Act 2010:
•
•
•
•
Improve patient engagement with Seldom
Heard Groups in order to reduce health
inequalities
Establish widely available and corporately
well-managed accessibility to services
sensitive to patient needs
Meet annual targets for the completion of
mandatory equality, diversity and human
rights staff training, appropriate to their role
Ensure leaders understand their role in the
context of delivering against the Equality Act
2010.
Part 3(b) Explanation of who we have Involved
Clinicians, managers and support staff have all
been invited to contribute to the 2011/12 Quality
Account,
identifying
their
priorities
for
improvement for 2012/13.
Stakeholders who have been involved in the
development of the quality account include:
LINks have powers to enter locations where
services are provided to help them gather
information about the provision of services.
Neither LINk has formally exercised this power in
the twelve months covered by this report, however
a LINk member was present during a CQC review
of Knoll House, Hove (the review resulted in all
inspected areas being assessed as compliant).
In July 2010, the government announced plans to
set up HealthWatch England. Under these
proposals, which have now become law, LINks
will become local HealthWatch organisations.
These organisations will provide a collective voice
for patients and carers, and advise the new
Clinical Commissioning Groups on the shape of
local services to ensure they are informed by the
•
•
•
•
•
Staff
Service users (via the Patient Experience
Steering Group)
Commissioners who have been asked to
comment via letter
Brighton and Hove City Council and West
Sussex County Council who have been asked
to comment via letters to their respective
HOSCs
Brighton and Hove and West Sussex Local
Involvement Networks (LINKs) who have
been asked to comment via separate letters.
All the stakeholders listed above were also given
opportunities to contribute to and comment on the
development and content of this report.
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Part 3(c) Statements Provided by PCT, LINKs,
HOSC and HASC
NHS Sussex
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West Sussex LINk
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Brighton and Hove LINk
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Health and Adult Social Care Select Committee, West Sussex County Council
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Brighton and Hove Health Overview Scrutiny Committee
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Glossary
Term
Assurance
Abbreviation
-
Brighton and Sussex
University Hospitals
BSUH
Care Quality Commission
Clinical Audit
CQC
-
Clinical Coding
Clinical Commissioning
Groups
Clinical Effectiveness
-
CCGS
-
Clinical Governance
-
Clostridium Difficile
Commissioning
C-Diff
-
Commissioning for Quality
and Innovation
Community Information
Dataset
Community Metrics
CQUIN
CIDS
-
Data Warehouse
Department of Health
DH
Department of Health
Operating Framework
Falls Bundle
-
Falls Risk Assessment
Tool
Gold Standard Framework
FRAX
-
Description
Providing information or evidence to demonstrate that
something is working as it should, such as the required level
of care, or meeting legal requirements.
An acute teaching hospital working across two sites: the Royal
Sussex County Hospital in Brighton and the Princess Royal
Hospital in Haywards Heath.
The health and social care regulator for England.
A quality improvement process that seeks to improve patient
care and outcomes through systematic review of care against
explicit criteria and the implementation of change.
The translation of medical terminology as written by the
clinician to describe a patient's complaint, problem, diagnosis,
treatment or reason for seeking medical attention, into a
coded format.
Groups of GPs that will, from April 2013, be responsible for
designing local health services In England.
The extent to which specific clinical interventions do what they
are intended to do.
A system through which NHS organisations are accountable
for continuously improving the quality of their services and
ensuring high standards of care.
A bacterial infection.
The process of ensuring that health and care services are
provided effectively and meet the needs of the population.
Activities include assessing population needs, buying products
and services and monitoring the provision of those services.
A payment framework which enables commissioners to
reward excellence by linking a proportion of English
healthcare providers' income to the achievement of local
quality improvement goals.
The Community Information Dataset (CIDS) makes locally and
nationally comparable data available on community services
to help commissioners make decisions on the provision of
services.
Measures, usually statistical, used to assess the performance
of clinical teams in the community.
In computing, a Data Warehouse is a database used for
reporting and analysis.
The DH a department of the UK government with
responsibility for government policy for health and social care
matters and for the National Health Service (NHS) in England.
A national document that sets out the priorities of the NHS.
A bundle of interventions that support to reduce falls and fall
related injury.
A tool developed by the World Health Organisation to evaluate
fracture risk in patients.
The Gold Standards Framework is a model that enables good
practice to be available to all people nearing the end of their
lives, irrespective of diagnosis.
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QUALITY ACCOUNT 2011-12
Term
Grade 3 or 4 Pressure
Damage
Health Overview and
Scrutiny Committee
Abbreviation
-
HOSC
Description
Pressure damage (previously often referred to as a ‘bed sore’
or ‘pressure sore’) is a localised area of damage to the skin
and / or underlying tissues. A grade 3 is full thickness skin loss
and Grade 4 is extensive destruction, tissue damage to
muscle, bone, or supporting structures with or without full
thickness skin loss
An overview and scrutiny committee may review and
scrutinise any matter relating to the planning, provision and
operation of health services in the area of its local authority.
Committees which scrutinise health services such as The
Health Overview & Scrutiny Committee (HOSC) and Local
Integrated Networks (LINKs)
Hospital Episode Statistics is the national statistical Data
Warehouse for England of the care provided by NHS hospitals
and for NHS hospital patients treated elsewhere.
Health Scrutiny
Committees
-
Hospital Episode Statistic
-
Information Asset Owners
IAO
An Information Asset Owner (IAO) is a senior member of staff
who is the nominated owner for one or more identified information
assets within their part of the Trust.
Information Governance
Toolkit
-
Intranet
-
Liverpool Care Pathway
-
A system which allows NHS organisations and partners to
assess themselves against Department of Health Information
Governance policies and standards.
An Intranet is a computer network that uses Internet
technology to share information amongst employees within an
organisation. The Trust’s Intranet system is called The Pulse.
The Liverpool Care Pathway is a set of guidelines for looking
after people in the final days or hours of their life.
Local health user groups with the aim of providing everyone in
the community – from individuals to voluntary groups - with the
chance to say what they think about local health and social
care services.
MUST is a five-step screening tool to identify adults, who are
malnourished, at risk of malnutrition or obese. It also includes
management guidelines which can be used to develop a care
plan.
A tool to help NHS organisations and healthcare teams
assess their progress in developing a safety culture.
A bacterial infection.
Local Involvement Network
Malnutrition Universal
Screening Tool
LINk
MUST
Manchester Patient Safety
Assessment Framework
Methicillin-Resistant
Staphylococcus Aureus
Metrics
MPSAF
National Institute For
Health Research
National Institute of Health
and Clinical Excellence
NIHR
National Patient Safety
Agency
NPSA
National Reporting and
Learning System
NRLS
MRSA
-
NICE
Measures, usually statistical, used to assess any sort of
performance such as financial, quality of care, waiting times,
etc.
A government body that coordinates and funds research for
the NHS in England.
An independent organisation responsible for providing
national guidance on promoting good health and preventing
and treating ill health.
Lead and contribute to improved, safe patient care by
informing, supporting and influencing organisations and
people working in the health sector.
A NHS national reporting system, in England and Wales, to
report on patient safety incidents. This information is used to
develop tools and guidance to help improve patient safety.
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Term
NETbuilder
NHS Brighton and Hove
NHS Sussex
Abbreviation
NETbuilder is a leading provider of specialist software, IT and fully
managed services in finance, Government and commercial markets.
-
NHS West Sussex
Patient Advice and Liaison
Service
PALS
Primary Care Trust
PCT
Productive Series
Programme
-
Productive Ward
-
Quality, Innovation,
Productivity and
Prevention
QIPP
Root Cause Analysis
RCA
Secondary Users Service
SUS
Senior Information Risk
Owner
SIRO
Service Business Unit
SBU
South Coast Audit
SCA
South Downs Health
SDH
Southern Programme for
IT
Stretch Targets
SPfIT
-
Survey Monkey
Sussex Community NHS
Trust
Description
SCT
Formerly Brighton and Hove Primary Care Trust.
An amalgamation of the legacy organisations Brighton and
Hove Primary Care Trust and West Sussex Primary Care
Trust.
Formerly West Sussex Primary Care Trust.
A service providing a contact point for patients, their relatives,
carers and friends to ask questions about their local
healthcare services.
A Primary Care Trust is an NHS organisation responsible for
improving the health of local people, developing services
provided by local GPs and their teams (called primary care)
and making sure that other appropriate health services are in
place to meet local people’s needs.
A set of practical tools, such as patient experience surveys,
developed by the NHS Institute for Innovations and
Improvement, to help NHS services redesign and streamline
the way they work.
Ward based element of the Productive Series.
National NHS programme involving NHS staff, clinicians,
patients and the voluntary sector which improves the quality of
care the NHS delivers whilst making up to £20 billion of
efficiency savings by 2014-15.
A Root Cause Analysis (RCA) is a way of conducting an
investigation into an identified problem that allows the
investigator, and other involved parties, to understand the
root, or fundamental, cause of the problem so that it can be
put right.
The single, comprehensive repository for healthcare data
which enables a range of reporting and analyses to support
the NHS in the delivery of healthcare services.
The SIRO is an Executive Director of the Trust who takes
ownership of the Trust’s information risk policy, and acts as
advocate for information risk on the Board.
A segment of the business entity, which both receives revenue
and controls expenditure.
Internal auditors used by Sussex Community Trust
NHS Trust covering community health services in Brighton
and Hove prior to the formation of Sussex Community NHS
Trust.
A programme of works to enhance the information technology
systems within the NHS in the South of England.
Targets to achieve ambitious, long-term goals which can
increase the Trust’s ability to achieve breakthrough results.
Survey Monkey is a private American company that enables
users to create their own web-survey, using free and
enhanced paid products and services.
Community NHS Trust covering Brighton, Hove and West
Sussex, formed by the integration of West Sussex Health and
South Downs Health on 1st October 2010.
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Term
Twitter
West Sussex Health
Abbreviation
WSH
Description
Twitter is an online social networking service and
microblogging service that enables its users to send and read
text-based posts of up to 140 characters, known as "tweets".
The part of NHS West Sussex that provided (as opposed to
commissioned) community health services in West Sussex
prior to the formation of Sussex Community NHS Trust.
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Quality Account Feedback Form
We would very much welcome your feedback regarding what you think about our Quality Account. Please
use this form to let us know your thoughts and whether you would like us to include anything else in next
years report.
1. Who are you?
Patient or family member/carer
Other
Member of staff
Please specify
2. What did you like about this report?
______________________________________________________________________________________
______________________________________________________________________________________
3. What could we improve?
______________________________________________________________________________________
______________________________________________________________________________________
4. What would you like us to include in next year’s report?
______________________________________________________________________________________
______________________________________________________________________________________
5. Are there any other comments you would like to make?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
6. Sussex Community Trust is applying to become a Foundation Trust. Are you interested in
becoming a member of SCT? If so please provide your name and address below.
______________________________________________________________________________________
______________________________________________________________________________________
Thank you for taking the time to read this report and give us your comments.
Please email or post the form to:
Clodagh Warde-Robinson
Acting Chief Executive
Sussex Community NHS Trust
A1 East, Brighton General Hospital
Elm Grove
Brighton
East Sussex
BN2 3EW
Assurance-team@nhs.net
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