The Sussex Beacon
Quality Account 2011-12
‘Meeting the changing needs of people living with HIV’
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Contents
PART ONE
1.1
Statement from the Chief Executive
PART TWO
2.1
Priorities for Improvement
Patient Safety
 Clinical measures to improve safety
 Environmental measures to improve safety
Clinical Effectiveness
Patient Experience
 Volunteer program
 Service user involvement
2.2
Statements relating to the quality of services provided
Review of Services 2011-12
Participation in clinical audit
PART THREE
3.1(a) Review of Quality Performance
General view
Inspections
Complaints
Continuing to improve
Infection Control
Incident Reporting
Risk Management
3.1(b) Last Year’s Targets
Review of Patient Safety
Review of Clinical Effectiveness
Review of Patient Experience
 How we measure the patient’s experience
 Patient and public involvement
 Gardening group
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3.2
Who has been involved in setting the content of the quality account and the
priorities for the forthcoming year?
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Part 1.1
A statement from the Chief Executive
Welcome to the Quality Account for 2011-12, which sets out how we measure quality and how we aim to
continue improving services over the next year. This is followed by a quality review of performance against our
selected quality measures for 2011-12.
The Sussex Beacon provides a clinical Inpatient Unit plus a range of Outpatient services for people affected by
HIV. Patient safety has been a high priority over the year, along with improving clinical outcomes for patients.
Our staff and volunteer teams have continued their commitment to involving patients and improving the
patient experience. Patients have reported improvements this year, for example in our discharge planning
arrangements and the range of information made available to them.
During the year we successfully maintained our good performance on a range of quality indicators, highlighting
that quality of care is embedded in our clinical practice. We improved audit processes, for example by
implementing The Liverpool Care Pathway audit, working with the National Audit Tools Group of Help the
Hospices and implementing effective audit tools across services. We strengthened patient involvement and
feedback processes; introducing a new patient questionnaire, supporting service user representatives and
collaborating with them to help produce a new patient guide and welcome pack. We established a risk
management strategy and made infection control a top priority. Reports of medication related incidents were
down on previous years and below national averages, with none of a serious nature. Improvements were also
made in our sexual and mental health support for patients and individualized care planning.
This Quality Account demonstrates the hard work and commitment of our staff and volunteer team and
celebrates the quality achievements made during 2011-12: Our Infection Control Champion won runner up
award at the 2011 Infection Prevention Society Annual Conference as Hand Hygiene Champion. I would like to
congratulate all our staff and volunteers for the high quality care provided to patients during the year and for
working so hard to keep our costs down, which enabled the organization to remain financially sound during
2011-12. Thank you.
A major focus in the coming year will be to build upon the quality improvements already achieved by:

Appointing lead nurses to ensure patient safety, for example in the management of falls to ensure
patient safety within the clinical environment and on discharge; and by continuing to improve the
physical environment at The Sussex Beacon.
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In terms of clinical effectiveness, by focusing on the ageing population so that we adapt our services
to meet their changing needs; and by devising and implementing a 3 year strategy for clinical audit.
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We will place more emphasis on improving the patient experience by strengthening our Volunteer
Programme to offer patient service support; and by acknowledging the patient as expert we will
continue to place service user involvement at the heart of what we do.
The Sussex Beacon faces the challenge of maintaining quality of care for patients within an uncertain funding
environment. We have worked hard to respond to the changing and complex needs of people affected by HIV
and will continue to listen to our patients in order to anticipate those needs and the funding opportunities that
will help us meet them.
We hope you find this Quality Account interesting and accessible. Any feedback or suggestions on how we
might improve our quality account can be sent by emailing info@sussexbeacon.org.uk or by writing to the
Chief Executive. To the best of my knowledge and belief the information contained in the following Quality
Account is accurate.
Katharine Williams, Chief Executive on behalf of The Board of Trustees, The Sussex Beacon.
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Part 2.1
Priorities for Improvement
Introduction
To help us select our priorities for quality improvement, we have worked closely with our staff, service users
and stakeholders to help in guiding our focus, whilst responding to the many changes within the statutory
regulatory bodies such as the Care Quality Commission.
Patient Safety
Clinical measures to improve safety
Goal:
To ensure falls are being reported accurately and that our responses to reported falls is appropriate and
effective in maintaining patient safety both within the clinical environment and when they are discharged
home. This is in particular reference to patients who fail to comply with safety advice given by professionals.
Rationale:
We see increasing numbers of older people attending the service with complex needs and challenging
behaviour who are at risk of fall and at times do not comply with the advice given to them to keep them safe.
This overall risk needs to be assessed and a strategy for dealing effectively with this should be introduced as a
multi-disciplinary pathway.
Target:
To ensure a clear policy / procedure, detailing the management of falls.
Appropriate training to be made part of the manual handling education program this year
Reporting:
A lead nurse role for falls shall be introduced to devise a system of management along with the service
manager who will feed back the progress to the Clinical Governance Committee and the Service User Forum.
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Environmental measures to improve safety
Goal:
To maintain and improve the physical environment to ensure minimisation of risk to patients and
improvement of general safety of the environment.
Rationale:
Maintaining safety standards throughout The Sussex Beacon environment is a core requirement of
the service and as such we are constantly monitoring the situation and responding to risk
assessments, incidents and service user and staff feedback.
Target:
To conduct a comprehensive health and safety review of the environment and formulate a
prioritised strategy for improvements and implementation. We will decorate more of the patient
rooms and shared environments, continue upgrading the remaining patient bathrooms and upgrade
the garden infrastructure.
Reporting:
Progress will be reported back to The Board of Trustees, the Service User Forum and the Staff
Representative Group.
Clinical Effectiveness
(i)
Goal:
An interview process which aims to explore the needs and views of an ageing population who are
living with HIV as to what their needs, hopes and fears for the future may be, so that we as an
organisation can adapt our services to their changing needs.
Rationale:
The over 50s are the fastest growing group of people living with HIV in the UK. With advances in
treatment people are now living into old age and many will experience complex health needs. With
fewer financial resources and the risk of social isolation, many people are starting to become
concerned and anxious about what the future may hold for them. Service users from The Sussex
Beacon have requested that this piece of work be done – outcomes will explore service user
participation, engagement, involvement and empowerment.
Target:
All patients admitted to The Sussex Beacon over the age of 50 offered a one to one structured
interview with a senior member of the team. Completion of a strategic service development plan
focused on clinical services which have service user views at its centre and appropriate changes
made to the initial assessment process when being admitted to the Inpatient unit (IPU) that are
evidence based and appropriate for our service.
Reporting:
Findings will be shared with the clinical teams, Management Committee, Clinical Governance
Committee, and The Board of Trustees.
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(ii)
Goal:
To ensure that the internal clinical audit program is effective.
Rationale:
Clinical audit is the process by which the service is able to look at the practices within the
organisation and clarify what is working and identify what requires improvement. Findings need to
provide evidence of service level delivery and influence positive developments. The current
approach has been in place for several years and is now due for review by the clinical team.
Target:
To conduct a multidisciplinary review of clinical audit, implement 3 year strategy and instigation of
new audit tools.
Reporting:
Findings will be shared with the clinical teams, Management Committee, Clinical Governance
Committee, and The Board of Trustees.
Patient
Experience
(i)
Volunteer Programme
Goal:
For volunteers to be an integral part of the patient support services and for patients to benefit from
interactions with volunteers.
Rationale:
The Sussex Beacon relies on the commitment and support of its volunteers. Patient service support
is an area of development that would harness the skills and interests of those volunteers who have
an interest and experience of working in clinical settings.
Target:
Volunteers will be working in clinical settings in key roles such as complementary therapists /
befrienders etc.
Reporting:
Volunteer Coordinator and Clinical Manager will ensure regular progress updates are made to staff,
service users and governance committee. Audit will be carried out at 6 months with support from
the Service User Representatives.
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(ii)
Service User Involvement
Goal:
Continued working with the Service User Forum within a structured framework to ensure patients’
views and ideas are addressed appropriately. That service users feel part of The Sussex Beacon
organisation.
Rationale:
Service users are experts in their own illness and the care they need. They can provide a different
perspective about their illness and give alternative approaches to treatment and care.
Target:
To carry out an exercise in partnership with the service user group and the community services we
work with, to map out the ‘patient journey’, providing the team with a deeper understanding of the
experience patients have when using our services.
Reporting:
The findings will be used within the governance and clinical development meetings to influence
change and will be feedback to Service Users through the forum, information board and our website.
Part 2.2
Statements Relating to the Quality of Services Provided
Review of Services
During 2011-12, The Sussex Beacon provided 2630 medical/nursing bed nights as part of contract
agreements with Brighton & Hove PCT, West Sussex PCT and East Sussex PCT.
Data on performance is regularly provided to the commissioning PCT’s and reviewed accordingly.
Topics such as patient demographics, ethnicity, age, sexual orientation and service user feedback are
part of this reporting process.
100% of the income generated from the NHS Service Level Agreement Contracts for this time period
has been used to fund the provision of our NHS services.
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Part 3
Review of Quality Performance
General View
This section describes just some of the ways in which The Sussex Beacon has improved its
effectiveness and arrangements.
Clinical effectiveness is made up of a range of quality improvement activities and initiatives:
•
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•
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The assessment and use of evidence, guidelines and standards to identify and implement the
best and most cost effective practices.
The use of quality improvement tools, such as audit, to review and improve services.
Information systems to assess current practices.
Development and use of systems of learning, both in specific areas and across the organisation.
The Implementation of the Liverpool Care Pathway national tool for the management of the
patient’s dying process. We have provided training to staff in support of this process and
implemented the tool with the support of specialists to enable staff to work in a safer, structured
and more accountable way. On-going audit enables the process to remain relevant to practice and is
evidence based.
Working with the National Audit Tools Group of Help the Hospices has enabled us to develop an
effective audit that is evidence based and nationally recognised. Audit has directly influenced
practices within our service and enables us to prioritise and demonstrate improvements to care.
The introduction of a new patient questionnaire has meant that we have been able to have direct
patient feedback of their experiences, which we as a team can use to help influence our practices. It
has been very useful over the past year and we are adapting the questionnaire to improve on the
quality of data we receive and help demonstrate that we take patients’ comments seriously.
Supported development of the service user forum has created a system by which managers and
service users can share information and guide future developments. The introduction of service user
representatives within all service areas has added another layer of feedback in which patient issues
and ideas can be addressed, an example of which is the collaborative work done between managers
and service user representatives in producing a new patient guide and welcome pack, which is much
more user friendly and effective.
Inspections
The Care Quality Commission has not inspected our services this year and we are currently
registered with them without condition.
The Board of Trustees plan to carry out an independent inspection of services and environment
which was unfortunately delayed so as not to be included in this year’s report.
The Accountable Officer carried out an un-announced spot check on services in relation to the
management and administration of Controlled Drugs which included interviews with all staff on duty
at the time and a report submitted to the Clinical Governance Committee, which showed 100%
compliance
with
standards.
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Complaints
We have received two complaints within this time period, which followed an overhaul of the
complaints policy and procedure. This has made us focus on ensuring patients are aware of how to
complain and that they have many choices in which to choose to do so. Information is now available
in every welcome pack, leaflets are in every room, service user representatives attend the unit every
week and anonymous comments boxes are available.
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Continuing to Improve
Infection Control
The reduction of infection acquired whilst in care is a priority for The Sussex Beacon with targets set
to drive and measure the improvements. The infection control strategy aimed to develop the
infrastructure of the organisation to ensure infection control remains a top priority within the
governance of our services. To this end the following interventions have been put in place:
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Infection Control Overarching Plan has been implemented to support service provision
An Infection Control Statement of Intent has been written to support service provision and
aid communication with service users
Investment in the support and development of the Infection Control Champion role has
continued, with the staff member completing a degree module in infection control
management, attendance of study days and conferences
Partnership working has continued to develop with the local PCT infection control team
Infection control screening and specific care plans have been introduced and are being
imbedded within the nursing process of the unit
Commode Cleaning demonstrations and use of `CLINNELL’ certification tape. This was in
cooperated into training and commodes are inspected for cleanliness
Mattress Inspections done every three months. Mattress covers are inspected for
perforation and any marks on the foam. Damaged mattresses are replaced
Scheduled laundering of window curtains every three months
Information sharing by receiving daily notifications on their cases of MRSA, Clostridium
difficile, Norovirus
Our Infection Control Champion won runner up award at the 2011 Infection Prevention
Society Annual Conference as Hand Hygiene Champion in recognition of the work being
done here at The Sussex Beacon with staff training, information provision and training being
carried out with patients, their families and visitors
Our patient orientated care plans are being shared with other services / organisations as
examples of best practice
Implementation of Infection Control Team meeting has enabled us to have a better focus on
preventive priorities
Annual audits have been carried out to assess practices and the environment, which have
shown that a good standard is being maintained within the service
We have trialled several hand hygiene audit tools during the year but have not found one
which suits our unit’s practices so we will be implementing our own audit tool this year
We had one infection control outbreak of Norovirus during the winter and were able to
manage the situation very effectively following policy and protocols introduced the previous
year.
Overall we are proud of the achievements made and of the continuing commitment of staff to
reduce infections within our clinical areas.
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Incident Reporting
Reporting has remained stable and is anecdotally felt to be a good representation of activity within
the clinical area. The Clinical Governance Committee reviews all incidents and assesses clinical
effectiveness. We reported one ‘serious untoward incident’ this year which was fully investigated
and concluded satisfactorily. Our internal reporting system has been reviewed by the Governance
Group and felt to be effective. With this now rooted within clinical practice we have looked at the
reporting of issues and have updated our Whistle Blowing Policy and implemented information from
the CQC for staff and service users.
Risk Management
Last year saw the initiation of a risk management strategy. An organisational risk assessment process
is now in place and has been carried out as part of the strategic management process enabling us to
identify priorities for the forthcoming year.
Improvement goals for last year and their outcomes
Patient Safety
(i)
Goal:
To ensure that clinical prescribing and the administration of medications are safe and accurate at all
times.
Rationale:
With the improvements made in clinical incident reporting it has been found that approximately
40% of all incidents reported are to do with medication errors. Though it must be stressed that all
are of a minor level and have not resulted in any harm to patients it is an area that should be
improved as there is always a risk.
Monitoring:
The Accountable Officer monitors standards of practice for the prescribing and administration of
controlled drugs. The incident reporting system captures any incidents in relation to this. The
Accountable Officer reports to the local PCT LINS committee which shares findings, issues and best
practices with local services. The Service Manager monitors standards of practice for the prescribing
and administration of all other medications. The incident reporting system captures any incidents in
relation to this. Audit of both processes is carried out.
Outcomes/Improvements:
Reports of medication related incidents were down on previous years and below national averages.
Of incidents reported none were of a serious nature. Random audits of the Controlled Drug
processes are carried out regularly and have demonstrated a high standard with no serious issues
identified. Despite this additional training and education has been recommended and implemented
to support staff practices, update them and help with staff development.
The prescribing medication sheet has been adapted following the audit process to make prescribing
instructions clearer to understand, with a good result.
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(ii)
Goal:
To increase awareness of the importance of correct hand hygiene when in a clinical setting for staff,
patients and visitors.
Rationale:
All care settings are striving to manage the increased prevalence of infections acquired whilst in
clinical environments. The NHS and the CQC both prioritise their guidance, standards and regulations
in the reduction of infection. As an organisation The Sussex Beacon adheres to protocol and
procedures in the effort to minimise potential harm to patients, to comply with national standards
and to ensure clear monitoring and reporting. This is part of an already existing framework of activity
implemented to fight acquired infections.
Outcomes/improvements:
The screening tool for patients being admitted has been redesigned to bring focus to Infection
control and potential risk.
Infection Control Champion has delivered training to staff and patients and continues to work closely
with the local Community Infection Control Team – feedback from staff and patients has been very
positive.
Hand hygiene audit has been addressed by trying out several audit tools but we have decided to
develop an in-house audit tool as we have found that the national tools do not work very well in our
clinical setting. This will be implemented and evaluated this year.
Visual and written information is now available throughout our building to help inform people of the
risks to acquiring infection.
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(iii)
Goal:
Improving patient discharge – by improving patient discharge processes we will reduce the number
of patients experiencing delays in returning home and/or feeling unprepared to cope.
Rationale:
The discharge of patients into the community is an important step in the care process. Discharge
needs to be planned carefully, communicated to other healthcare providers for continuing care
purposes and be sensitive to the needs of the patients and their families and carers.
Outcomes/improvements:
Patient feedback questionnaires showed an improvement when asked the following:
Before leaving did you have an opportunity to discuss your requirements for getting home safely?
(96% responded ‘yes’)
Do you feel your needs have been adequately met to enable you to return home safely? (96%
responded ‘yes’)
The discharge planning system was assessed and it has been agreed to change the format to
streamline process and to improve the transfer of information to the community settings pre and
post discharge.
(iv)
Goal:
Improving the range of information available to patients, we will reduce patient’s knowledge deficit
whilst offering patients more choice and opportunities in which to gain understanding and explore
issues.
Rationale:
Patients require information to enable them to understand their environment, manage their
conditions and make informed choices. This information must be available at all times and in a
medium that is readily understood.
Outcomes/Improvements:
Computers in day rooms with open access to internet.
Notice boards, information stands and patient leaflets are now available in all clinical areas and
patient rooms.
Patient feedback questionnaire:
Were you aware of where to obtain written information on treatments and services? (96%
responded ‘yes’)
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Review of Clinical Effectiveness
(i)
Goal:
Improving Patient’s Sexual health – to offer greater opportunity for patients to talk safely about
experiences and issues, access advice and be referred appropriately and timely for on-going help.
Rationale:
As a designated centre for providing care for those with an HIV diagnosis it is important that The
Sussex Beacon offers opportunity for patients to explore not only issues relating to their HIV but
also the wider implications of sexual health.
The purpose of the screening interview is to particularly cover areas that may not have been
addressed since diagnosis or patients have found difficult to talk about in clinic settings or that
patients require more time to explore.
Outcomes/Improvements:
The Inpatient Unit now has a named nurse for sexual health. The admission documentation has been
up-dated to allow for a better sexual history taking. Employees on the Inpatient Unit have received
sexual health training and motivational interviewing training. We have started a ‘virtual clinic’ and
patients are offered self-testing for chlamydia trachomatis and Neisseria gonorrhoea. Feedback
from the patient questionnaire showed that it is appropriate and acceptable to have this
intervention on the Inpatient Unit. This work has been accepted for oral presentation at the 2012
NHIVNA Conference as part of best practice feedback for nurses in HIV.
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(ii)
Goal:
Improving patient access to emotional and mental health support – to ensure that service users are
offered the opportunity to discuss their mental health needs and access the appropriate services in a
timely fashion.
Rationale:
Emotional wellbeing and mental health are important for everyone. Going through difficult times is
part of life, but from time to time can be very difficult to deal with. Furthermore, some people also
experience mental health problems, such as depression or anxiety; where emotions such as low
mood, feeling helpless, hopelessness and grief carry on for some time and can return again and
again through life. Being diagnosed and living with a serious illness like HIV is likely to have a big
emotional impact, and people with HIV, as a group, have higher rates of mental health problems
than those seen in the general population. It is important that people living with HIV have access to
needs assessments throughout their disease progression and that they have choice to engage with
types of support best suited to them.
Outcomes/Improvements:
There is now a named nurse on the IPU for psychological health and well-being. The psychological
team have reported an improvement in the referral process, which should improve the patient’s
experience and journey and make a better use of resources.
This work has been accepted for oral presentation at the 2012 NHIVNA Conference as part of best
practice feedback for nurses in HIV.
(iii)
Goal:
Patient participation in planning individualised care – to enable patients to fully participate in the
planning and reviewing of care plans, ensuring understanding and informed consent during the
patients stay and allowing further opportunity for patients to be empowered to manage their care.
Rationale:
Patients should be at the centre of all approaches to care and should be offered and encouraged to
take as active a role as they wish in planning their aims and outcomes. This has to be a flexible
approach as some people who are unwell will not wish to focus on this until feeling better.
Outcomes/Improvements:
A change to care planning documentation requires that the patient signs the plan and states when
they wish them to be reviewed, along with space for the patient’s words/descriptions to be
incorporated.
It was the practice to keep the care plans within the nurse’s office central files. These are now kept
within the patient’s room so that they may look at them whenever they wish.
The use of the documentation is still embedding within the nursing process but feedback from the
patients’ questionnaire shows an improvement in patients feeling involved in their care.
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Review of Patient Experience
How we measure the patient’s experience
Patients are asked to complete a questionnaire which is available for them to complete whenever
they wish. It is completely anonymous and can be placed in a collection box on departure or posted
back to us following departure. Patients are encouraged to complete this form but it is the choice of
the patient. Returns during this year have been lower than the previous year at about 31% of
admissions, which is still statistically significant and useful for the team to reflect on practice.
We also have a service user representative who attends the unit every week to speak with patients
to get feedback and ideas for improvement. This is feedback to staff informally and issues and ideas
are taken to the service user forum to be discussed amongst other service users and invited
managers.
Patient and Public Involvement
A Service User Forum has been set up with the aim of establishing an independent and
representative forum, which would have a fundamental role across all our services. The Forum’s
objective is to properly gather and make use of patient feedback, the aim being that their direct
experiences would help us to improve services and communication between service users and staff.
Service users are experts in their own illness and the care they need. They can provide a different
perspective about their illness and give alternative approaches to treatment and care. Forums are
held six times a year and are attended by at least four service user representatives and a service user
support trustee, alongside any interested service users. The forums are confidential and the
managers and CEO are called in to update the forum and to discuss any issues arising. Forum reports
are discussed at the managers meeting and dedicated time is allocated at The Board of Trustees
meetings for discussion of service user issues.
The service user group has evolved into a vocal group of members. The meetings have been
attended by service users, other than service user representatives, who just wish to listen or make
suggestions. Service user representatives have been very proactive in gathering feedback from all
service users. The Service User Forum has had a very influential impact on the organisation as a
whole; on service provision and planning, fundraising and communication strategies.
It ensures we put service user needs first and consider the impact of any changes or developments
upon them. It has resulted in service users and staff working together as a team on a number of
projects and having a voice on key meetings such as the Communications Group and The Board of
Trustees. In turn, it has enabled us to improve the quality of care we provide and helps The Sussex
Beacon deliver excellent services that have integrity.
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Gardening Group
The Sussex Beacon Garden Volunteer Group has been going strong since March 2010 and thanks to
their hard work and care the gardens have never looked better.
The aim of the Beacon Garden Volunteer project is for volunteers, including service users, to work
together to transform the garden, working sensitively with the existing space.
The experience amongst our existing volunteer group ranges from lots, to little or none, but all have
brought incredible passion and zeal. We are so grateful for their dedication and hard work. This
project is constantly evolving and everyone is welcome to volunteer, whether service users or from
the general public and no previous experience, just a sense of enthusiasm is needed.
This year the woodland garden was a mass of glorious spring flowers, the raised vegetable beds have
produced home grown produce for the kitchen. Fragrant pots on clients’ balconies bring a little bit of
the garden to those who cannot manage to get outside and tranquil areas remain, where people can
sit with family and friends in private and restorative surroundings.
Part 3.2 Who has been involved in setting the content of the Quality
Account and the priorities for 2012-13?
Employees have been consulted along with service users who have contributed to identifying
improvements for the forthcoming year.
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