1
Contents
PART ONE ....................................................................................... 3
1.1 Statement from the Chief Executive ........................................ 3
PART TWO ...................................................................................... 4
2.1 Priorities for improvement & Statement of Assurance ............ 4
2.2 Priorities for improvement ...................................................... 5
2.3 Other Priorities for implementation during 2013/14............... 10
2.4 Participation in Clinical Audits ................................................. 11
External Audits - 2012 .............................................................. 12
Forward Plan of Audits for 2013 .............................................. 13
2.5 Key target areas 2012/13 ......................................................... 13
2.6 What others say about Care Plus ........................................ 15-17
2.7 Data Quality ............................................................................. 18
PART THREE .................................................................................... 19
3.1 Review of Quality and Performance Measures for 2012/13..... 19
PART FOUR...................................................................................... 20
Statements from Health Watch, Overview and Scrutiny
Committees and Clinical Commissioning Group ....................... 20/21
4.1 Comment from Health Watch .................................................. 22
4.2 Comment from North East Lincolnshire Clinical
Commissioning Group .............................................................. 22
PART FIVE ....................................................................................... 23
5.1 How to provide feedback on the Quality Account ................... 23
Part One
1.1 Statement from the Chief Executive
Lance Gardner Chief Executive
2012/13 has seen
us with meaningful feedback in a way that is
Care Plus Group
accessible to them. We then seek to use this
grow in prominence
feedback, both good and bad, to improve
as a key provider
service quality at every opportunity. Care Plus
supporting
Group is absolutely committed to continuous
the delivery of
improvement.
exemplary outcomes
for patients and service users across North
East Lincolnshire.
of new performance indicators in order to
assess the quality of care we provide to the
The past year has seen us further develop
local population. Over the coming 12 months
improved systems and processes to ensure
we intend to build on this to ensure we are
that the care we provide is of an excellent
measuring performance against the issues
standard, and meets the expectations of
that really matter to the population we serve.
patients and service users.
We will focus more intently on patient and
Our staff continue to work tirelessly to
provide the highest quality of care within
the locality. Care Plus Group is proud to
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Over the last year we have introduced a range
service user satisfaction to ensure we are
getting it right from the patient or service user
perspective.
employ such dedicated, hardworking and
The forthcoming year brings further
compassionate individuals, who seek to
challenges to Care Plus Group, not least in
improve the lives of patients, service users,
relation to the requirement for additional
families and carers at every opportunity. Over
efficiency savings. As an organisation we are
the past year we have developed 10 customer
committed to ensuring that these further
care standards that we feel are vital to ensure
efficiency savings do not impact negatively
patient and service user satisfaction remains
on frontline service delivery or the exemplary
high. In addition we pride ourselves on
quality care patients and service users have
enabling patients and service users to provide
come to expect from the Care Plus Group.
Part Two
2.1 Priorities for improvement & Statement of Assurance from
the Board
Care Plus Group
Care Plus Group remains committed to
Board are pleased
listening to the views and opinions of
to receive and
staff, people accessing our services, their
approve the Quality
families and carers in order to improve
Account for 2013.
services at every available opportunity. As
an organisation we have sought to make it
Val Waterhouse Chairman
2012/13 has
proven to be an exciting year for Care Plus
users, families and their carers to tell us what
Group, however, it has not been without its
we are doing right and where we can improve
challenges.
in order to ensure continuous improvements
Despite the need to respond effectively to
are made.
required efficiency savings over the past year,
Reducing health inequalities remains a
we have successfully embedded Care Plus
strong focus for 2013/14. In order to do
Group into the fabric of care provision across
this effectively, Care Plus Group recognises
North East Lincolnshire.
the need to work in partnership with other
The Care Plus Group Board continue to
focus on ensuring that all services delivered
are of an excellent quality. Patient and staff
organisations in both the private and public
sector. This remains a key priority for the
forthcoming year.
safety also remains a key priority for the
I am satisfied that the indicators contained
organisation, and considerable work has
in the Quality Account give a balanced
been undertaken to provide assurance to the
view focusing on successes as well as
Care Plus Group Board that staff and patient
illustrating areas that have been identified
safety is managed effectively across the
for improvement during 2013/14. Our aim
organisation.
is to ensure we work on the identified areas
As with last year, the Board would like to pay
tribute to all staff within the organisation for
their absolute commitment over the past year
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as easy as possible for staff, patients, service
for improvement in order to ensure that Care
Plus Group further embeds its ambition to
become the provider of choice.
and their tireless on-going work to serve local
I can confirm that the information contained
people.
within this report is true and accurate.
2.2 Priorities for improvement
Care Plus Group continues to play a key role
Innovation Scheme (CQUINs) and Care Quality
in the delivery of health and social care across
Commission compliance as well as ensuring a
North East Lincolnshire, working with our
focus on the following three key areas:
partners to ensure that services are personal
to all individuals, meeting their specific
• Patient Safety
requirements.
• Clinical Effectiveness
A key focus for us in 2012/13 has continued to
be the Intermediate Tier and this will continue
for the foreseeable future, involving us in key
work with the local acute trust with demands
on Accident and Emergency departments
locally and nationally under unprecedented
pressures.
Care Plus Group also continues to lead crucial
work in relation to the very difficult time
of supporting people at the end of their
lives. This work is vital to both patients and
their families and its importance has been
highlighted with further funds identified to
extend and improve the support that we are
able to provide.
Priorities for 2013/14 have been agreed in
conjunction with staff within Care Plus Group
and with our local commissioners. These
priorities reflect the requirements identified
within the Commissioning for Quality &
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• Patient Experience
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IDENTIFIED PRIORITY
DOMAIN
OUTCOME
Reduction in the number
of falls experienced by
patients within the care
of Care Plus Group
1. Patient Safety
Reduction in the number of
falls of patients and improved
understanding of how to avoid
circumstances that may lead an
individual being subject to a fall
Reduction in the number
and grades of pressure
ulcers developed by
patients whilst in the care
of Care Plus Group
1. Patient Safety
3% of all individuals
using services across the
organisation will receive
a service user feedback
form from the Quality &
Performance Team within
Care Plus Group
3. Patient Experience
This will be non-biased as it
will be sent out centrally and
individuals’ views will be taken
into account when making
decisions in relation to the
specific services
Implementation of the
“Six values essential to
compassionate care”
3. Patient Experience
Improvements in standard of
care for all patients
End of Life Care - all
care that people receive
in relation to end of
life is compassionate,
appropriate and gives
people choices in how
they are cared for and
where they die
3. Patient Experience
Individuals will choose how
they are cared for and where
they die, whilst ensuring
that they end their lives with
respect and dignity
Implementation of NICE
Quality Standards to
ensure that patients and
service users receive
the best clinical and
social care interventions
possible
1. Patient Safety
Standards will be evidenced
across the organisation in
accordance with agreed
national best practice
3. Patient Experience
2. Clinical Effectiveness
3. Patient Experience
2. Clinical Effectiveness
3. Patient Experience
High levels of reporting of
pressure ulcers at a low grade
to ensure they are treated as
a priority and prevented from
becoming more serious
Priority One
Priority Two
Reduction in the number
of falls experienced by
patients within the care
of Care Plus Group
Reduction in the number
and grades of pressure
ulcers developed by
patients whilst in the
care of Care Plus Group
Domain(s) – Patient Safety, Patient
Experience
Current Status – All falls are recorded on
Effectiveness, Patient Experience
our incident monitoring system and are
Current Status – There has been a lot of
investigated as appropriate. Care Plus
work carried out in North East Lincolnshire
Group also has its own specialist team
to ensure that pressure ulcers are prevented
that implement a “Falls Rehabilitation
wherever possible. All patients that access
Programme”. This is for individuals
who have been identified
as vulnerable to falls and
services have an initial risk assessment
and are monitored throughout their
care. Pressure Ulcers that are
teaches them techniques to
classed as serious (Grade 3 & 4)
improve balance and reduce
have been cut by 50% within Care
reoccurrence.
Plus Group patients in the last 12
Goal – Reduce the number of
falls.
How we will monitor – All falls will
continue to be monitored as now but in
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Domain(s) – Patient Safety, Clinical
months.
Goal – It is intended that the good
work will continue and the levels will drop
even further within 2013.
addition will be monitored via the NHS
How we will monitor – Every incident of
“Safety Thermometer”. There will be a
pressure damage is logged on a central
financial penalty implemented if a reduction
system and these are monitored on a case by
is not achieved.
case basis. This work will continue.
Priority Three
Priority Four
3% of all individuals
using services across the
organisation will receive
a service user feedback
form from the Quality &
Performance Team within
Care Plus Group
Implementation of the
“Six values essential to
compassionate care”
Domain(s) – Patient Experience
Current Status – Currently the Service User
Experience forms are distributed by the
individual teams to patients and service users
that access their services.
Domain(s) – Patient Experience
Current Status – This has been newly
introduced for 2013/14 and focuses on the six
areas highlighted as being a priority to ensure
compassion in care:
1 Care
4 Communication
2 Compassion
5 Courage
3 Competence
6 Commitment
Goal – From 1st April 2013, this will become a
Goal –
central function and this means that a non-
Improvements in the overall standard and
biased approach is assured and patients/
quality of care provided to all patients and
service users can feel completely free to give
service users. The values will be embedded
open and honest responses.
within the organisation by ensuring that they
How we will monitor – The feedback forms
will be returned to the Quality & Performance
Team who will collate and analyse all of the
responses, identifying relevant issues and
are emphasised within:
1 Induction Training for new staff within
Care Plus Group
2 Ensuring that all patients sign their
trends where appropriate. Where appropriate
individual care plans to say that they feel
lessons learned will be shared to ensure that
that the values have been adhered to
services continue to improve and meet the
during their care
needs of the public.
3 All Training & Education will contain the
ethos of the 6 C’s
How we will monitor
1 Service User Experience Feedback
2 Staff Surveys
3 Supervision of staff
4 Reduction in the number of
complaints linked to staff attitude
Please see the link below for full details on the Six
Values Essential to Compassionate Care:
http://www.england.nhs.uk/wp-content/
uploads/2012/12/compassion-in-practice.pdf
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Priority Five
Priority Six
End of Life Care - All care
that people receive in
relation to end of life is
compassionate, appropriate
and gives people choices in
how they are cared for and
where they die
Implementation of NICE
Quality Standards to
ensure that patients and
service users receive the
best clinical and social care
interventions possible
Domain(s) – Patient Experience
Effectiveness, Patient Experience
Current Status – Ensuring that people receive
Current Status – The current Quality
the best End of Life Care is a priority for North
East Lincolnshire as a whole and the focus
continues to be on a locality wide approach,
ensuring that all organisations involved in care
work towards the same high standards. The
focus in good End of Life Care needs to be the
wishes of the individual and their families.
This is monitored by the North East
Lincolnshire Strategic Lead for Palliative
Care and End of Life Care who is a Care
Plus Group employee. The model that has
been implemented has been based on the
recommendations within the NICE Quality
Standards for End of Life Care.
Goal – Continue with the good work that
is already taking place across the locality,
ensuring all staff are aware of the priorities as
Standards that are relevant to Care Plus
Group have been
identified as the
following:
QS2 – Stroke
QS6 – Diabetes
QS11 – Alcohol dependence & harmful
alcohol use
QS13 – End of Life Care for Adults
QS15 - Quality standard for patient experience
in adult NHS services
QS23 - Drug Use Disorders
QS24 - Nutrition Support in Adults
Specific individuals within Care Plus Group
have been identified as leads for the
implementation of the above standards.
well as the requirements of patients and their
Goal – All aspects of best practice will be
families.
implemented across Care Plus Group with
How we will monitor – Quarterly requests for
evidence in relation to implementation of the
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Domain(s) – Patient Safety, Clinical
new Quality Standards being identified and
implemented as appropriate.
Quality Standards will be requested, as well
How we will monitor – Quarterly updates
as reviewing positive news stories that are
will be requested from all of the identified
received from families directly and
leads and these will included in quarterly
through Patient Opinion.
performance reports.
2.3 Other Priorities for implementation during 2013/14
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Performance
Measure
Target
Current Status/ RAG rating
Reduction in
the number
of complaints
linked to staff
attitude
Improve the experience of
patients and their families and
evidence this with a reduction in
the number of complaints linked
to staff attitude
Training has been implemented aimed
at all staff in relation to improvements
in staff attitude. A specific course is
currently being designed that will focus
on customer care
Improvements
in Record
Keeping
All areas of the business will use
standardised templates to reduce
the number of opportunities for
errors and to increase patient
facing time
Information analysts are employed
to support staff and to focus on
highlighting issues and improving
data quality. Introduction nationally
of the Community Information Data
Set has increased the requirement for
the data to be as accurate as it can be
(See 2.8 Data Quality). Templates have
been created for several of the clinical
areas reducing the options that can be
inputted and improvements are already
being evidenced
Staff
compliance
with
Mandatory
& Statutory
Training
Care Plus Group is working
towards a target of 100% as
it is intended that following a
new electronic system being
introduced and implemented in
2013, it will be possible to carry
out gap analysis to identify what
courses are most in demand and
the availability can be adjusted
to match the organisational
requirements
A new system for monitoring
compliance via an electronic database
is being introduced from 1st April 2013
and this means that the compliance
levels will be able to be demonstrated
with much greater accuracy
Reduction in
the number
of medication
incidents in
relation to the
Beacon Care
Facility
Care Plus Group would like to
see a reduction in the number of
medication incidents in relation
to the Beacon Care facility
Through reviewing the National
Reporting and Learning System (NRLS)
data in relation to medication incidents,
it is apparent that Care Plus Group has
a lower than national average number
of medication incidents in comparison
with all reported incidents. However,
as an organisation we are committed
to ensuring a reduction in medication
related incidents in order to enhance
patient safety
2.4 Participation in Clinical Audits
Care Plus Group has established an internal
The following planned Audits were not
Clinical Audit Team to forward plan and agree
completed within the year by East Coast
the requirements for the following 12 months.
Consortium:
This team consists of:
Lead Nurse – Complex Case Management
Glucometer Compliance
The identified lead for this audit, took the
Senior Nursing Officer
decision to delay this audit. This has been
Head of Service for Governance
Quality & Performance Manager
timetabled for 2013.
Medicines Management (including Injectable
The team has been specially identified
Medicines)
to ensure that quality and governance
Due to staffing issues within East Coast Audit
requirements are included, as well as clinical
Consortium it was not possible to undertake
requirements being achieved. All members of
this audit this year, therefore this will
the Clinical Audit Team have been registered
completed during 2013.
to complete training entitled “Mastering
Clinical Audit” to ensure that the audits that
are being carried out internally reach the
required national standards.
External Audits - 2012
Injectable Medicines
Due to staffing issues within East Coast Audit
Consortium it was not possible to undertake
this audit this year, therefore this will
completed during 2013.
East Coast Audit Consortium were commissioned in 2012 as external auditors to carry out the following:
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AUDIT TITLE
Assurance
Level at Time
of the Audit
Comments
Current status
Palliative
Care Audit
Limited
Assurance
Considerable focus has
been placed on this area of
work since the audit was
undertaken and considerable
improvements have been
made
Significant
assurance
Internal Audits - 2012
AUDIT TITLE
Assurance
Level at Time
of the Audit
Comments
Current
RAG Rating
Waste
Management
Audit
Limited
Assurance
Actions are still ongoing in
relation to this audit. Of
concern was the limited
number of clinical staff who
responded to the audit
Limited
Assurance
Liverpool Care
Pathway Audit
Report
Significant
Assurance
Examples of excellent
practice identified but a
need for standardisation
was identified
Significant
Assurance
Audit of Medication
processes at
The Beacon
Limited
Assurance
Considerable focus
has been placed on
improving practice
given the high number
of medication related
incidents at the Beacon
Limited
Assurance
Significant
Assurance
These audits are undertaken
frequently throughout the
year to ensure compliance
across the organisation.
It is prudent to note that
CQC have also undertaken
a number of inspections in
the last year which have all
had a positive outcome
Significant
Assurance
(Community Ward)
Audit undertaken
by consultant
Pharmacist
CQC
compliance
audits
Forward Plan of Audits for 2013
The following Clinical Audits have been identified to take place in the next 12 months:
1 Record Keeping Audit
2 Glucometer Audit
4 Health & Safety Audit (including clinical elements)
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3 Medication Management Audit (including Injectable Medicines)
2.5 Key target areas 2012/13
Use of the CQUIN payment framework
care contained within the pathway and these
A proportion of Care Plus Group income in
continue to be implemented with the focus
2012/13 was conditional on achieving quality
being on the requirements of patients and
improvement and innovation goals agreed
their families. Work continues to ensure that
between Care Plus Group and any person or
all patients receive the best possible care and
body they entered into a contract, agreement
are treated with dignity and respect as they
or arrangement with for the provision of
approach end of life.
NHS services, through the Commissioning
for Quality and Innovation (CQUIN) payment
framework.
Percentage of Patients that died at their
preferred place of death – Wherever possible
The following is a list of the areas that were
the patient will always be enabled to die in
included for 2012/13:
their preferred place of death and everything
possible is done to ensure this is achieved.
Percentage of Patients identified as End
of Life who are on the Care Pathway/Gold
Standards Framework – The Gold Standards
Only exceptional circumstances where the
patient is too ill for their wishes to be adhered
to would result in this not being achieved.
Framework contains a series of steps for
implementation for those individuals that
Number of patients identified as end of life
are identified as end of life. The aim is for
who have a symptom management plan in
at least 80% of all individuals to be placed
place – This has been implemented across
on this pathway and the target continues to
the whole of North East Lincolnshire with
be achieved across the locality, illustrating
the patient’s personal requirements being
compliance with best practice in relation to
paramount. All patients within the locality
patient care for individuals identified as end
who are deemed as being at the end of life
of life.
have a personalised plan in place in relation to
their care.
Percentage of relevant patients that died
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that were on the Liverpool Care Pathway
Number of admission alerts received that
(LCP) – There has been a lot of negative
resulted in the case manager responding
national press within the last 12 months
by means of in-reach to Diana Princess of
linked to the use of the Liverpool Care
Wales Hospital to support the discharge
Pathway. There are some important parts of
management process – All patients in North
East Lincolnshire who are identified as
recovery of the individual. The initial target
having more than one long term condition
was for the number of pressure ulcers overall
are supported by a Complex Case Manager
to reduce by 50% within the 12 month period.
from Care Plus Group. Processes have been
This was later revisited and resulted in the
put in place to ensure that if a patient with
requirements for the grades being looked
a long term condition is admitted into the
at separately. The significance of this is that
local hospital their allocated Complex Case
high levels of identification at the lower level
Manager is aware. This enables the required
Grade 2 means that the ulcer should not then
treatment paths and support to be identified
progress into a Grade 3 or 4, at which level
in preparation for the discharge of the patient
it is classed as serious; with recovery and
from hospital.
treatment more difficult. Current status is as
follows:
Number of service users supported by a
PP Number of Patients with a Pressure Ulcer Telecare service – This area of business
Grade 2 – Extensive work has been carried
will continue into 2013/14 as the use of
out to ensure that if a pressure ulcer forms on
technology in the home to support vulnerable
a patient it is identified as soon as possible.
individuals becomes more widespread. There
Initial Risk Assessments are carried out on
have been delays with the implementation
all new patients and checks are carried out
process within North East Lincolnshire due to
regularly on individuals deemed vulnerable or
issues with the company responsible for the
susceptible. The figures continue to be high in
provision of the equipment and these have
line with best practice.
now been addressed. The use of Telecare
equipment helps people remain living
independently in their own homes with the
support of staff from Care Plus Group.
PP Number of Patients with a pressure ulcer
Grade 3 & 4 – Due to the work that has been
carried out in relation to early identification,
the number of serious pressure ulcers (grade
3 & 4) has reduced by 50% in the last 12
Number of Patients with a pressure ulcer
– A good deal of work has been carried out
over the last 12 months in relation to the
identification and treatment of pressure
14
months.
For further guidance in relation to the CQUINs
framework, please see the following link:
ulcers. The earlier an ulcer is identified, the
http://www.england.nhs.uk/wp-content/
easier it is to treat and the speedier the
uploads/2013/02/cquin-guidance.pdf
2.6 What others say about Care Plus Group
Care Quality Commission (CQC)
North East Lincolnshire. Healthwatch came
Care Plus Group is required to register
in to existence from 1st April 2013 and will
with the Care Quality Commission and was
be the voice of the residents of North East
registered by the Care Quality Commission
Lincolnshire.
under the Health and Social Care Act
2008 on 28/06/2011, Certificate Number
Council of Governors
1-283163016. Care Plus Group has the
Care Plus Group’s Council of Governors
following conditions of registration: Personal
represents Members and the wider
Care; Accommodation for persons who
community of North East Lincolnshire within
require nursing or personal care; Treatment
Care Plus Group, and is a link between the
of disease, disorder or injury; Diagnostic and
Members, North East Lincolnshire community
screening procedures; Transport services,
members and the Care Plus Group Board.
Triage and medical advice provided remotely.
A number of Care Plus Group’s services were
This group includes:
inspected in 2012 and all of these had a
Care Plus Group Chairman
positive outcome.
8 elected staff members, (4 of which are
employed in a non‐management role)
Local Involvement Network (LINk)
2 Local Authority Elected Members
Good relationships have been established
1 GP governor appointed by North East
across the locality to support the commitment
Lincolnshire Clinical Commissioning Group
that we have to ensuring that everyone within
4 community members, (including 1
North East Lincolnshire is represented and
volunteer)
has the opportunity to influence decisions
in relation to Care Plus Group. There have
The committee receives a copy of the
been changes nationally within the NHS
quarterly report and members are able to
meaning that some relationships and links
provide comment and challenge to Care Plus
that were previously in place have changed
Group in relation to any area of business.
due to both role and structural changes.
The Local Involvement Network (LINk),
responsible for highlighting the views and
opinions of local neighbourhood groups in
relation to Health & Social Care, no longer
15
For further details on the Council of Governors,
who they are and their purpose as a group,
please see the following link:
exists as a separate entity, but will become
http://careplusgroup.org/who-we-are/our-
part of the newly formed Healthwatch for
council-of-governors/
Staff Advisory Committee
Comments, Complaints & Compliments
This forum was established in July 2011 to
The Complaints Team continues to operate
ensure that every member of staff within Care
Monday to Friday 0900-1700, taking calls in
Plus Group has a voice in relation to decisions
relation to complaints, compliments, queries
that are made about the organisation
and concerns.
and its members. The group has recently
been renamed and is now known as “Staff
Voice”. The Committee includes members
from across the organisation who act as
representatives for the discussion of issues.
All complaints are allocated an Investigating
Officer and a full investigation is carried
out within a deadline agreed with the
complainant.
Complaints
Service User Experience
During 2012, the main themes for
A new process is being implemented across
complaints were:
Care Plus Group, whereby service user
experience forms are sent out to individuals
who have accessed the service from a central
point within the organisation. This ensures
that feedback is received for all teams and
that the process is unbiased.
Patient Opinion continue to support feedback
as an independent, non-profit mechanism
giving people the option to access an
independent, publicly available, open site to
comment on their experiences, whether these
are positive or negative.
The link below gives access to Patient
Opinion and gives further detail about the
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1 Staff Attitude to either patient or family
2 Communication breakdown
Many of the complaints reported were
following on from times of great stress for the
patient and the family, such as crisis points
and at times of bereavement. All complaints
were fully investigated and, where necessary,
disciplinary action was taken in relation to
relevant staff.
Care Plus Group takes all complaints
very seriously and implements actions as
appropriate. In order to respond to issues
of staff attitude, a widespread training
organisation.
programme was undertaken in winter 2012
http://www.patientopinion.org.uk
frontline staff. Conflict Resolution training is
concerning Dignity and Respect aimed at
also delivered on an on-going basis as part
Examples of compliments we have received
of Statutory and Mandatory Training for all
are:
staff, aimed at tackling staff attitude and
the impact of this and managing difficult
situations in stressful circumstances. A new
training package currently in development
that focuses solely on Customer Care. Once
implemented, all staff who have contact with
patients and service users will be required to
attend this course.
“You are doing a great job!!”
“Just brilliant as always, Many
thanks”
“Thank you very much for your
kindness”
“Very competent and capable and
gave her a great confidence in the
service”
“I would like to thank your team for
the way you all looked after Mum.
You always treated her with dignity
and cared for her as if she was your
own. This meant a lot to me”
Compliments
Despite us having identified that there are
a minority of staff and situations that are
the subject of complaints, Care Plus Group
are inundated with compliments about the
service we provide via telephone, letters,
thank you cards, and through comments
books at the various service bases.
17
17
2.7 Data Quality
Care Plus Group places a high priority on data
The nurses have given positive feedback
quality improvements within the organisation.
about this support and the system is working
Good data enables us to be clear how we
well, with errors reducing at a noticeable rate.
are performing and enables us to gain an
overview of service requirements and gaps in
needs for the future to be identified.
SystmOne Optimisation - SystmOne is the
primary clinical tool used across North East
Lincolnshire and is the system of choice for
Care Plus Group. An Optimisation Group has
been established to improve the systems
in relation to both time efficiency and data
quality. This group looks at ways of simplifying
processes to reduce paperwork and inputting,
enabling staff to increase patient and service
user contact time.
Community Information Data Set (CIDS) This is a national requirement and Care Plus
Group are ahead of many other areas in the
country in relation to preparing for this to
be brought fully online. The introduction of
CIDS provides national definitions for the data
required to generate consistent person based
data from care records, which should be used
for reporting and to monitor and manage
Standardisation across Community Nursing
Teams - A data analyst has been assigned to
the Community Nursing Teams to support
improvements in data quality. Feedback is
given directly to the nurses to show where
they are not recording accurately and
the changes that need to be
made.
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Community Health Service provision.
Part Three
3.1 Review of Quality and Performance Measures for 2012/13
Care Plus Group has strategic priorities in place, which provide the framework for all governance
processes for the organisation in order to support and monitor all areas of our business:
VISION
VALUES
Putting
People First
Taking
Responsibility
Delivering
Quality
Services
Working
Together
Investing
in local
communities
PRIORITIES
Supporting
independence
and healthy
lives
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Business
Development
& Growth
Performance measures have been identified
Committee, as well as for commissioners.
for Care Plus Group and these all fall within
This report illustrates where Care Plus Group
one of the priority areas shown above. A
is against the targets that have been set
quarterly report is produced for the Care
and details the achievements that are being
Plus Group Board and Integrated Governance
delivered.
For 2012/13, measures were highlighted within the
Quality Account for closer scrutiny:
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Priority Area
Performance
Measure
Target
Year End
Achievement
SUPPORTING
INDEPENDENCE
& HEALTHY
LIVES
All Patients and Service
Users will have a
personalised Care Plan
in place
85% of all patients and
service users will have a
personalised Care Plan
97.99% - The only
individuals that do not currently
have a personalised Care Plan in
place are those who are new to
the caseload and therefore there
has not yet been the opportunity
for this work to be completed.
SUPPORTING
INDEPENDENCE
& HEALTHY
LIVES
All Patients will receive
nutritional screening
and a pressure ulcer
risk assessment as
part of their initial
assessment
100% of patients will
have a nutritional
screening and risk
assessment as part of
their initial assessment
100% - This is completed by all
nurses on initial visits to patients.
People are assessed to establish
whether they are at risk from
malnutrition or suffering from a
pressure ulcer
SUPPORTING
INDEPENDENCE
& HEALTHY
LIVES
All care that people
receive in relation
to end of life is
compassionate,
appropriate and gives
people choices in how
they are cared for and
where they die
Improve the quality
of life of individuals in
relation to end of life
care and ensure that
family members feel
supported and included
within the decisions that
are made
Work continues to ensure that
all services across the different
agencies linked to End of Life
Care work together towards
common goals. Additional
investment has been awarded for
2013/14 to further improve this
area of care
EFFECTIVE
GOVERNANCE
Improve the timeliness
in response to
complaints
All complaints will be
investigated within 12
weeks of the date that
they were made to Care
Plus Group
12 weeks achieved for all
complaints during 2012/13
EFFECTIVE
GOVERNANCE
Improve the process
in relation to the
management of risks
and the associated
Action Plans
The intention was to
improve the process
adopted by Care Plus
Group in relation to
the management of
corporate risks
A revised risk management
process has been implemented
over the recent year, and this
has led to more proactive risk
management being undertaken
across the organisation
EFFECTIVE
GOVERNANCE
Process for
implementation
of Lessons Learnt
from complaints
and incidents to be
improved
Ensure that all Lessons
Learnt are disseminated
and implemented across
Care Plus Group as an
organisation
The priorities for this year
have been implemented as a
result of the Lessons Learnt
from complaints and incidents
during the last 12 months. The
Action Plans are in place and the
relevant requirements have been
identified
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Priority Area
Performance
Measure
Target
Year End
Achievement
BUSINESS
Increase the number
of active Volunteers
supporting Care Plus
Group in the community
Increase the
number of
volunteers
employed within
Care Plus Group
There are currently 186 active volunteers
supporting Care Plus Group. This is not
an increase in the number that was
listed a year ago but has remained
constant. There have been improvements
however in the active involvement of the
volunteers. There have also been changes
to their terms and conditions and a
volunteer now also sits on the Council of
Governors Board. This is to ensure that
consideration is also given to this sector
of the workforce
BUSINESS
Restructure
Community Nursing
Teams within Care
Plus Group to improve
services offered to
patients within North
East Lincolnshire
Nurse Managers
to be put in place
with Team Leaders
working at each of
the GP Surgeries
Restructuring has taken place and the
working hours have also been revisited to
offer an extended services across North
East Lincolnshire
VALUE FOR
MONEY &
EFFICIENCY
Financial Position
The target was for
the sheets to be
balanced
Efficiencies have been achieved to meet
required targets
VALUE FOR
MONEY &
EFFICIENCY
Continue to evidence
value for money via the
savings that are made
through the interventions
that are provided to
enable patients to remain
in their own home
The year-end
target for savings
was £1.8 Million
There has been a yearend reported
saving of nearly £4 Million associated
with the interventions that have been
put in place to enable patients to remain
in their own homes
SKILLED &
ENGAGED
WORKFORCE
THROUGH
EFFECTIVE
LEADERSHIP
Staff Compliance with
Mandatory and Statutory
Training
Ensure that all
staff are compliant
with all Statutory
and Mandatory
Training
The levels of compliance have improved
but there is still scope for further
improvement. New processes to enable
electronic monitoring have been
implemented from 1st April 2013 and
this will again be a priority for 2013/14
SKILLED &
ENGAGED
WORKFORCE
THROUGH
EFFECTIVE
LEADERSHIP
Compliance with
Supervision and Personal
Development Review
requirements
80% of all staff will
have the required
level of supervision
from their line
manager
Levels continue to improve across the
organisation, so much so that the figure
for 2013 has been raised to 100% for all
staff
Part Four
Statements from Health
Watch, Overview and
Scrutiny Committees
and Clinical
Commissioning Group
to give a reflection on what has happened in
During the previous two years, the Local
following link:
Involvement Network (LINk) and North
http://www.healthwatchnortheastlincolnshire.co.uk
East Lincolnshire Care Trust Plus (CTP) have
commented on the Quality Account that
has been produced for Care Plus Group.
They reflected on the views of the general
public and also reviewed the document
from a commissioning perspective. Due
to the national changes that have been
implemented, both LINk and CTP ceased to
exist from 31st March 2013, being replaced
by Health Watch North East Lincolnshire and
Clinical Commissioning Group (CCG) from 1st
therefore not able to be included for this year.
For further information and to volunteer or
pass on your views on Health and Social Care
in North East Lincolnshire, please visit the
4.2 Comment from North
East Lincolnshire Clinical
Commissioning Group
North East Lincolnshire Clinical Commissioning
Group is the lead commissioner for Care
Plus Group and we are pleased to have the
opportunity to comment on this Quality
Report.
April 2013.
Over the past 12 months we have worked
4.1 Comment from
Health Watch
together with Care Plus Group as our key
Health Watch North East Lincolnshire is
The introduction to the report sets out in
the new independent consumer champion
detail progress that has been made in the
created to represent the views of the public
last financial year and well as setting clear
in North East Lincolnshire. Healthwatch will
priorities and goals for the year ahead.
play a role at both national and local level and
will make sure that the views of the public
and people who use services are taken into
account.
Health Watch have stated that as a new
Governing Body, they are currently not in
a position to
comment fairly
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the previous 12 months. Their comments are
provider of a wide range of community based
services.
The report is well formatted and concise and
presented in a way that will appeal to both
staff, key partners as well as the public and
patients that Care Plus Group serves.
It is pleasing to note that Care Plus Group has
identified its key risks and have significant and
robust systems in place to mitigate them.
on the Quality
As commissioners, we recognise and
Account or
understand that the significant financial
pressures that exist across the health and
• Clinical effectiveness – Applying the best social care economy will require Care Plus
knowledge, derived from research, clinical
Group to manage its resources effectively.
experience and preferences of service
users to ensure best outcomes are
achieved for service users
Care Plus Group will need to work closely
with commissioning, and other health and
social care colleagues to ensure that the high
• Service user experience – Listening to and standards that are evident around patient
acting on service users views in order that experience are maintained.
the provider delivers the best service and experience possible
With the recent publication of the Francis
Report, there are increased expectations of
Priorities for 2012/13 are set with key
both the public and commissioners to see real
themes chosen which are broadly in line
change and progress in the way local services
with commissioning intentions of North East
are shaped and delivered. We look forward to
Lincolnshire Clinical Commissioning Group-
working with Care Plus Group to realise some
we look forward to working in partnership
of those changes.
with the provider to ensure that the Quality
There is good evidence to demonstrate that
the key areas are linked to governmental
strategy in terms of...
• Service user safety – Ensuring service users do not come to harm whilst in the providers care
priorities will be delivered upon. It is pleasing
to see strong evidence of service users and
their families being involved in the setting
of the organisational priorities in terms of
quality standards.
Paul Kirton – Watson
Strategic Lead - Quality and Experience
North East Lincolnshire Clinical
Part Five
Commissioning Group
5.1 How to provide feedback on the Quality Account
Care Plus Group welcome any feedback
in relation to the contents of the Quality
Account. We hope we have made it as
easy as possible for you to contact us by
offering as many options as possible.
If you have any issues, questions,
concerns or recommendations in
relation to this report, please contact
the Care Plus Group Quality and
Performance Team via any of the
methods below and we will ensure that
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the most appropriate person responds
to you as quickly as possible.
In Writing
Quality & Performance Team
Care Plus Group, ABP Port Office
Cleethorpes Road, Grimsby
North East Lincolnshire, DN31 3LL
Via Email - CPG.CarePlusAssure@nhs.net
By Telephone - 01472 266976
www.careplusgroup.org
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