Quality Account:
2012/13 Review & 2013/14 Plans
June 2013
Community Ward
“St. Peter’s put my life back together”
Integrated Care
“I was in crisis and your team came in and cared for my husband
with great respect and dignity, for which I thank them very much”
Children’s Community Nursing
“Every member of the nursing team is amazing and makes us feel
like we are a part of their nursing family. The care and attention
given is always 100 % and we always look forward to seeing them
on Fridays”
“The human touch, they see the child and not just the medical
issue”
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Sexual Health Service
“Staff great, location perfect, great clinic times compared to what
GP offers”
Tissue Viability
“The service was all A1. Thank you very much.”
Continence Service (adults)
“Have become confident to go out and away without worry”
Adults Speech & Language Therapy
“‘[staff member] and [staff member] have been very understanding
and have taken so much time to get me better and gave me
confidence when I made slow progress”
Assessment & Rehabilitation Unit
“Very friendly and helpful staff happy atmosphere pleasant
surroundings”
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Introduction
Central Essex Community Services (CECS) became a Community Interest Company
(C.I.C.) on 1 April, 2011. A C.I.C. is a type of social enterprise. As a social enterprise, we
are an independent provider that provides services for the NHS and others. We are a
staff-owned organisation where we value staff input in designing and managing services
as well as input from other stakeholders including patients, referrers, commissioners and
other key partners. We provide a wide range of services and aim to integrate them where
possible to provide a clear patient pathway. Whilst we will continue to focus on and
improve our existing community services, we will also be able to provide a greater range of
services. Going forward, as a flexible provider of care, we are confident that our
organisation has the skills to thrive and build on its good track record.
Our organisation remains committed to providing services which are safe and of high
quality. We will also continue to improve everything we do. A key part of our business
over the past year has been in developing our strategy so that we are clear how we will
achieve our strategic aims. The business mission, vision, values and strategic objectives
against which we can measure our success are set out below:
Mission
To deliver quality integrated services that will enable and support people to live the best
lives possible.
Vision
To be a leading provider of integrated health and social care delivering quality services
that are effective and safe whilst providing a good patient experience and value for money.
Values
Act with confidence and change the way we work and behave whenever necessary
Listen to each other and to our patients, commissioners, referrers and partners
Learn new and better ways to deliver our services
Together we will all achieve the best outcomes for our customers
Strategic Objectives
We have set ourselves the following six strategic objectives to achieve our vision.
Resources are allocated to reflect our priorities, including those specific to this quality
account. Our performance against each is measured and monitored, with corrective
actions taken, if needed, to ensure we keep on track to achieve our goals.
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1.
To deliver community services that are recognised as effective, safe and give a
positive patient experience and contribute to the wider public health agenda in Essex
2.
To collaborate and work in partnership with other providers in the supply chain to
deliver integrated services for patients and provide seamless care across the patient
pathway
3.
To be an organisation where people want to come and work
4.
To build on our financial position and provide assurances on both the quality of
service and value for money to all commissioners
5.
To build on our good governance practices and deliver/exceed the standards for
safety and quality across our service portfolio
6.
To grow our business within Essex and beyond in both health and social care
provision
Our overall approach within this Quality Account is intended to be consistent with both the
vision we seek to achieve and the values by which we behave.
Our organisation takes quality and safety seriously. It is in fact our priority and top of our
Board Agenda.
We have established processes in place for dealing with all complaints and for collating
compliments, as well as an established programme of surveying our customers to ensure
that we get their feedback and can act on it. All of our team meetings review their
compliments and complaints to learn from and act on them.
We have monthly internal meetings that focus solely on safety and quality performance in
a detailed manner. We review every incident which occurs and have clear and robust
processes for investigating all serious incidents. Our safety and quality assurance is also
reviewed on a monthly basis by our commissioners.
We always have a set of Safety & Quality Assurance Reports at the beginning of every
Board meeting (bi-monthly) which set out what has been happening across the
organisation, how we are managing key risks and what we are doing about any areas of
performance that are not in line with expectations.
We also have a Patient Experience Report at every Board meeting which looks at
complaints (including trends and details of what we have done and learnt as a result),
compliments, Director walk-around visits, patient surveys and any other key information in
relation to patient feedback.
Additionally, we have more informal Board sessions (alternating with formal Board
meetings, also bi-monthly) that concentrate on both strategy and also looking in a more indepth way at key or topical aspects of safety and quality, for example, safeguarding, Stop
the Pressure (eliminating avoidable pressure injuries) and Health Visiting & School
Nursing. Directors also undertake regular walk-around visits to assess the quality of
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experience that we are offering to our patients and to talk to patients about their
experiences. We have also established patient forums where we are providing specialist
services such as Stroke Care, Diabetes and Primary Care. Our Expert Patients’
Programmes ensure that we are in constant communication with our customers and their
opinions of our services.
For 2013/14, we want to ensure that:
quality and safety continues to be at the heart of the organisation
we continue to be a learning organisation and remain relevant to our communities
we listen to what customers and other key stakeholder organisations have to say
As part of our commitment to involving others we will continue to liaise with our
stakeholders and our internal and external Governors. Our strategy is to focus on our
customers to whom we provide services; to seek their views, listen to their responses and
then act by changing the way in which we do things to improve the customer experience.
We have an electronic system to get real-time patient feedback as well as some paperbased surveys. During 2012/13, we used these methods to survey 100% of our services
(up from 60% the previous year) and we used the “Net Promoter Score” question. This
year we are focusing on fewer surveys for key patient pathways, and using a “Friends &
Family” test question, so that we can spend sufficient time ensuring that we make any
appropriate changes based on the feedback we receive. During 2012/13, we also piloted
another new approach with customers and carers to look at how we, and other relevant
providers, could improve the Stroke Pathway. This event was very well received and the
report from it is published on our web site including a section on “you said/we did”. For
2013/14, we will be repeating this approach for the Lower Leg Ulcer Pathway.
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1.
Part 1 - Quality Summary
1.1 During 2012/13, we made good progress on many fronts regarding the safety and
quality of the services we provide.
1.2 Overall, the levels of satisfaction expressed by those using our services have
continued to be high. A small number of the many excellent comments we received
from our customers are included in this report. You can also read about some of our
achievements in more detail in Parts 2 and 3 of this document.
1.3 More specifically, we will build on the work we have done during and across 20102013, so that we continue to collect useful feedback from our customers about their
views on the quality of our services and the outcomes that we are achieving.
1.4 CECS is interested in understanding matters from a wide range of perspectives and
in learning from all sources of feedback. During 2012/13 CECS received feedback
from customers via compliments, complaints, from surveys and from a customer
engagement event specifically focusing on the stroke pathway. Feedback from all of
these sources is considered and acted upon, together with any incidents which
happened, to ensure that we maintain safe and high quality services. CECS has
clear policies in place to govern how it investigates all incidents and complaints. Our
customer engagement event on the Stoke Pathway has been commended by
participants and the Strategic Health Authority as an example of good practice in how
to work with customers to understand their views and use this to make further
improvements to what we do.
1.5 All serious incidents have all been thoroughly investigated, including improvement
actions as appropriate. The themes from our investigations show that we need to
focus on:
improving communication with internal and external partners
maintaining standards around safeguarding training and emphasis on individual
accountability
improving the way that we manage patient expectations in relation to care
management
maintaining standards around falls prevention
1.6 As our vision and values suggest we are always striving to improve even further. In
summary, our approach during 2013/14 focuses on:
continuing to listen to our patients/customers and changing the way we deliver
services and pathways as a result
maintaining our infection prevention rates
improving our focus on preventing pressure ulcers
continuing our work towards meeting all best practice standards in relation to
children with type one diabetes
working with other relevant organisations to develop a holistic and truly
integrated frailty pathway
1.7 We are continuing with our innovative approach in conjunction with a private
organisation providing user-friendly technology to improve the way in which we plan,
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undertake, analyse and act on the results from clinical audits. These audits remain
an important source of information about the quality and effectiveness of what we do.
1.8 We have maintained progress in developing our internal capability and capacity to
report on and monitor performance so that both we and others can be assured that
our services are safe and that improving quality is at the heart of all that we do.
However, we are not complacent and recognise that we need to continue to improve
both our services and information systems so that we can proactively demonstrate
how our service quality is not only maintained but enhanced.
1.9 This Quality Account has been produced by a multidisciplinary team of professionals,
led by clinicians. It has been agreed by the senior management team and the Board.
We have shared this document with our main clinical commissioning group (CCG)
and our local Healthwatch organisation. We have included statements of their views
in Part 3.
Statement
This document has been shared with, and is endorsed by, the Board of Central
Essex Community Services C.I.C. On behalf of the organisation, I confirm that to
the best of my knowledge the information in this document is accurate.
Chief Executive, Central Essex Community Services C.I.C.
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Part 2a – What We Said We’d Do during 2012/13 and How We Got On
What we said we’d do
Measure (this column only
here as an aide memoire)
Progress as at end March 2013
1. Safety Thermometer – this
programme will focus on how
well we are preventing the 4
harms in relation to falls,
pressure injuries, urinary
catheters and venous
thromboembolisms within
Community Hospital wards
and District Nursing
Develop the necessary
systems and capacity to
participate in the national
Safety Thermometer
Programme by uploading
data for 9 consecutive
months.
Our organisation has successfully participated in the Safety Thermometer Programme. We
have developed systems and have uploaded data for 12 consecutive months during the year.
The data shows that:
We have maintained our previous good performance with respect to falls prevention
We have delivered excellent performance against the catheter care bundle -- Integrated
Care 99% and Wards 99.7%
We have achieved performance levels of 98% inpatients and 100% podiatric surgery with
respect to having documented VTE assessments in place across the year
We have reviewed all pressure-relieving equipment on our wards and have also
improved monitoring and reporting of pressure injuries across the organisation to
maintain patient safety. A new pressure ulcer leaflet has been developed and is
available for all patients on admission to the ward to help them and their carers
understand the causes of pressure ulcers and what they can do to prevent them
2. Record Keeping – care plans
reflect appropriate
assessments
Increase of evidence in
patient records via audit with
a target of 80% of care plans
reflecting appropriate
assessments
The 2012/13 record keeping audit that we have undertaken shows that:
76% of records demonstrate evidence of an assessment of the service user’s needs
85% of records demonstrate evidence of a patient care plan
Relevant and up-to-date
information is available to
patients regarding how to
contact our organisation and
what to expect from our
services
We already have:
a Customer Service Team (available by phone between 9:00am and 5:00pm, MondayFriday) which provides information to customers about services and deals with their
queries and acts as the coordination point for more complex matters
posters and leaflets displayed within all locations from which we provide services that tell
our customers how they can provide feedback to us, including how they can make a
complaint or pay us a compliment
a link on our web site to enable customers to contact us via this route should they wish to
3. Improved Information for
patients
From our analysis of results, we are planning to undertake additional work to continue to
further improve data quality and the capture of qualitative information.
During 2012/13, our service areas have been focusing on updating all relevant patient
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What we said we’d do
Measure (this column only
here as an aide memoire)
Progress as at end March 2013
information leaflets and improving other customer-related information so that people can
better understand what to expect from the services that we provide. For example, our
community wards now have Patient Information Folders containing useful information for
both patients and relatives about the ward environment, visiting times, food, parking, care
management, calls bells, privacy and dignity, patient surveys, cleaning plus other information
about the team caring for them.
4. Maintain MRSA and
Clostridium Difficile
performance in line with
contract targets
MRSA contract target = 0
cases
Clostridium Difficile contract
target = 1 case
For the third year running, we have maintained excellent results (in line with contract targets)
by achieving zero cases of MRSA bacteraemia and just one case of Clostridium Difficile. We
have undertaken a full root cause analysis of that particular case and implemented the
appropriate actions from the lessons learnt. These include amended protocols for dealing
with specimens and increasing awareness in our prescribers of the issues around prescribing
antibiotics in patients who are at high risk of acquiring a healthcare-associated infection.
We are continuing to regularly monitor the standards of hospital cleanliness through monthly
audits and the annual PEAT inspections. CECS is proud and very pleased to be consistently
providing very high standards of cleanliness across all of its facilities.
5. Increasing customer
engagement
Pilot a new customer
engagement approach to
broaden opportunities to
collect feedback to improve
service pathways (Stroke
Pathway CEG)
Our first Customer Engagement Group event was held in July 2012 for people with long-term
conditions, focusing on the Stroke Care pathway; this was a new approach that we decided
to take.
The Stroke Care pathway comprises of:
Primary Prevention (provided by both our organisation and also by GPs)
Pre-Hospital (provided by the East of England Ambulance Service)
Acute Hospital Care (provided by Broomfield Hospital)
Community Rehabilitation which comprises of Inpatient, Therapy and Early Supported
Discharge services (provided by our organisation)
Long-Term Care (provided by our organisation)
Our Customer Service Team worked with clinical service teams across the pathway to
ensure that patients and carers who were prepared to commit time to feed back their
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What we said we’d do
Measure (this column only
here as an aide memoire)
Progress as at end March 2013
experiences were able to do so in a well-planned environment with expert engagement that
could respond to our customers’ points of view and provide relevant and current information.
The event was attended by members of the public that had expressed an interest in
attending and people that had had recent experience of stroke care from our organisation
(Central Essex Community Services) within the pathway.
The event was led by clinical specialists in stroke care who were on hand to listen to the
views expressed, answer any questions and provide any support that was needed. It was
also attended by the Chair of our organisation, senior management and representatives from
the local acute trust (Broomfield Hospital) and The Stroke Association.
This pilot event was very successful with valuable feedback being provided from patients,
carers and relatives. Feedback was collected about what we (and the other organisations
involved) do well and what we (and the other organisations involved) could do better. The
feedback received has also been used to feed into commissioning decisions about the future
direction of the pathway/service.
We have produced a summary report which is available on our web site, including details of
“you said/we did or we are doing” i.e. the actions that we have taken and the additional
actions that we are planning to take in response to what people told us about our services
within the Stroke Care pathway.
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What we said we’d do
Measure (this column only
here as an aide memoire)
Progress as at end March 2013
6. Increasing customer
feedback
Surveying customers of
100% of our services
Our organisation has met its target to survey patients across all service areas during
2012/13.
All feedback is analysed and we identify learning points and areas where improvements can
be made. Action plans for implementation of changes and improvements are monitored to
ensure that we use feedback to make a difference by changing what we do.
The vast majority of feedback received is very favourable, with excellent feedback on the
cleanliness and suitability of premises that services are run from. We also have very positive
feedback about our staff and the high standard of care that they are providing.
As a specific example, we survey all patients on discharge from the 3 community wards that
we run. The results show very high levels of satisfaction with the service that we provide, for
example, we are providing excellent food which meets the needs of frail and recovering
patients as well as anyone with special dietary needs.
We recognise that there will continue to be changes that can be made to meet patients’
needs and to give them the best experience that we can. We will therefore continue to use
the feedback that we collect to ensure that all of our services consistently provide the level of
care that we expect to all patients. We will also explore other ways to collect feedback to add
to the sources of information that we already have.
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What we said we’d do
Measure (this column only
here as an aide memoire)
Progress as at end March 2013
7. To evidence accurate
monitoring of the hydration of
patients
100% of Community Hospital
Ward nursing staff receive
update training on fluid
balance monitoring
Maintaining good hydration is an important element of high quality clinical care and our
organisation has been committed to improving the way we offer water to our patients and
support them to maintain good hydration levels. During 2012/13, we have taken the
following action to achieve this priority:
In April 2012, we introduced a set of Ward Hydration Practical Tips to give ward nursing and
domestic staff clear guidance about how and when to offer water to patients throughout the
day. This was accompanied by additional training to explain the new system of providing
water at every opportunity. The document also serves as a handy guide and timetable for
staff to build-in additional opportunities to provide drinking water during the routine ward day.
These guidelines are also laminated and displayed in the ward kitchen and on the ward drug
trolley as an additional aide memoire.
We have updated Ward Fluid Charts to support more accurate recording of fluid intake which
means that staff have a better overview of patient fluid consumption and loss.
A patient information leaflet on Preventing Dehydration While in Hospital: Information &
Practical Tips for Patients has also been devised and will be published by the end of March
2013 to promote and support self-care in patients.
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Part 2b – Priorities for Quality Improvement during 2013/14
Priority
1. Frailty.
Working with other relevant
organisations to develop a holistic
and truly integrated frailty pathway
and identifying people that would
benefit from being cared for on
such a pathway (the most frail and
vulnerable patients in our
community)
2. Pressure Ulcers.
Improve risk assessments in
service areas and our focus on
prevention of ulcers including a
robust system of review. Where
we provide 24-hour care, apply a
zero-tolerance model for avoidable
pressure ulcers
3. Infection Prevention.
Maintain MRSA and Clostridium
Difficile performance in line with
contract targets
4. Customer Engagement.
Building on our pilot approach and
running another event
Measure
Source of Monitoring
Responsible Lead
Audit of Integrated Care Community
Matron caseload using Rockwood Frailty
Score to identify proportion of patients that
would be eligible to be scored using the
Frailty Assessment Tool
Audit information from Integrated
Care service will feed into internal
monthly governance meetings
Director of Operations &
Integration and Assistant Director
of Integrated Care
Incidence of pressure ulcers (grades 2, 3
and 4) categorised by service area, type,
attributable and unattributable
Stop the Pressure Forum will review
all trends and feed into internal
monthly governance meetings
Director of Nursing
MRSA contract target = 0 cases
Clostridium Difficile contract target = 0
cases
Internal monthly governance
meetings
Assistant Director of Community
Hospital Clinical Services in
conjunction with Lead Infection
Prevention & Control Specialist
Nurse
Feedback regarding Lower Leg Ulcer
Pathway CEG event and, ultimately,
publication of report on web site
Internal monthly governance
meetings and Board reporting
Director of OD & Governance
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Priority
5. Children’s Diabetes.
Continuing our work towards
meeting all best practice standards
in relation to children with type one
diabetes in partnership with Mid
Essex Hospitals Trust (Broomfield
Hospital)
Measure
Source of Monitoring
Responsible Lead
Assessment against all best practice
standards for children with type one
diabetes
Internal monthly governance
meetings
Assistant Director of Children &
Young People’s Services
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Part 2c – Required Statements
N.B. These statements are mandated and set out in a specified format which we are
required to complete. Where relevant, we have expanded to help clarify things.
Review of Services 2012/13
During 2012/13, Central Essex Community Services provided and/or sub-contracted
57 NHS services. These are mainly provided within mid Essex, but also across
Essex, in outer North East London and Cambridgeshire.
Central Essex Community Services has reviewed all the data currently available to it
on the quality of care in all of these NHS services.
The income generated by the NHS services reviewed in 2012/13 represents about
86% of the total income generated from the provision of NHS services by Central
Essex Community Services for 2012/13.
Participation in Clinical Audits
During 2012/13, 0 national audits and 0 national confidential enquiries covered NHS
services that Central Essex Community Services provides. This means that there
were no national audits that we were required to participate in that were relevant to
our services and also that there were no national confidential enquiries that we were
required to participate in.
The reports from 11 local clinical audits were reviewed by the provider in 2012/13 and
Central Essex Community Services intends to take the following actions to improve
the quality of healthcare provided:
The Medicines Management Annual Audit was undertaken for all services and
demonstrates compliance with CQC Outcome 9: Medicines Management. The full
report will not be ready until the end of April 2013.
An Injectable Medicines Audit has been undertaken against the relevant safety
(NPSA) alert. We demonstrated over 80% compliance and all relevant services have
an action plan which they are working towards. We are also developing a formal
policy for injectable medicines to support teams.
The Clinical Record Keeping Audit was undertaken within clinical service areas
from September 2012 to January 2013. The objective of this audit was to re-affirm
the importance of good record keeping principles and regular re-audits of clinical
records by managers ensure on-going compliance with quality standards. A total of
1210 records were audited across the organisation. Of these 91 % (1101) were
electronic records and 9% (109) were paper records.
Engagement with services this year has been particularly strong with a 10% increase
in the numbers of records being audited over last year, which reflects our focus on
improvement and also the commitment of our services with respect to improving
record keeping.
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The audit found high percentages of records contained the key information
required to meet professional standards expected for record keeping. This is a
positive reflection of adherence to guidance and good risk management
processes in relation to record keeping.
Recording of basic details such as date of birth (100%), ethnicity (76%), NHS
number (95%) and details of GP (96%) have all improved this year, as well as
the recording of other professionals working with our services (89%) and use of
approved abbreviations (92%)
We will be re-auditing again during 13/14 once relevant actions have been
implemented to ensure that standards are being consistently maintained
The Nutrition Audit aimed to assess how we are performing in relation to standards
set down in our Nutrition Policy and best practice guidance. Following on from the
previous year’s good performance, we wanted to highlight good practice, identify if
we had any remaining areas of weakness and to identify any further training needs
for our staff.
From the audit findings, the assessment showed that performance against our
Nutrition Policy was good, 98% of patients were assessed and weighed using
the ‘MUST’ nutritional screening tool within 48 hours of admission on our
Community Hospital Wards. These practices ensure that patients are identified
for malnourishment or risk of malnourishment from which plans of care are
initiated to prevent deterioration and development of any further risks.
We will re-audit during 13/14 to ensure that these important standards are being
consistently maintained.
The Medical Device & Competency Audit tested that the medical device policy was
in use across all areas; that medical devices were used safely and that members of
staff using equipment were competent to do so. Also, that medical devices are
maintained as required by manufacturer’s recommendations or in line with local and
national protocols, and are procured in a safe and cost effective manner and are fit
for purpose. Finally, that equipment is decontaminated after use as required in
relevant policies. Following on from last year’s audit, we wanted to check that our
policies were being consistently applied across our services and our results showed
that:
Systems are in place and being used effectively to ensure that medical devices
are safe to use and that members of staff are trained to use them safely and
appropriately.
We will undertake spot-checks during 13/14 to assure ourselves that this good
result is being sustained.
The Resuscitation Audit looked to ensure that we are meeting policy standards.
Following on from last year’s audit, we wanted to ensure that: the organisation was
continuing to use the Resuscitation Council Guidance, that equipment in use
continues to be fit for purpose, that members of staff continue to be aware of their
roles and responsibilities and that adequate training continues to be in place. The
results of the 12/13 audit were good and were consistent with the findings from last
year’s audit, indicating that resuscitation equipment is fit for purpose and is well
maintained. The audit also showed that our employees are compliant in all areas of
care and maintenance of equipment and that individuals are aware of their
responsibilities when in a resuscitation situation. Training is in place and being
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monitored by managers, with individuals equally aware of their own responsibility in
booking and attending training sessions.
The Central Alert System Compliance Audit aimed to assure the organisation that
alerts received via the Central Alert System are consistently cascaded to appropriate
clinical services and recommendations/actions are consistently implemented and
completed in a timely manner. Similarly to last year, the audit checked that the
following standards were in place:

Central Alerting System guidance is in use

Equipment in use is fit for purpose

Staff are aware of roles and responsibilities

Adequate responses are received in a timely manner

All unsafe equipment / drugs are not in use
In all areas assessed, high levels of compliance were recorded which is consistent
with the previous year’s audit. It was noted that, where necessary, all re-called
equipment had been removed from use and sent back to the relevant manufacturer.
Members of staff were aware of the relevant policy and the processes that had to be
followed. Information was disseminated out to teams verbally when required.
Responses regarding relevance and / or actions taken were received within internal
timescales.
The Venous Thromboembolism Audit (VTE) aimed to gather data to allow the
organisation to assess if all patients have been assessed for risks of venous
thromboembolism and bleeding on admission to our community hospital wards as an
inpatient or to our podiatric surgery service.
The results from this audit were positive, with 100% of patients attending for
podiatric surgery and 98% of ward inpatients having a documented VTE
assessment and 100% of our patients being prescribed prophylaxis when
indicated.
Monitoring of VTE risk is a national requirement and Central Essex Community
Services is committed to continue with its good record of managing patients
appropriately within it services.
The Blood Transfusion Audit aimed to assess the competency of relevant staff
dealing with patients in need of a blood transfusion. The results were very positive
with all staff involved able to demonstrate the necessary competencies to safely
undertake blood transfusions.
Participation in Clinical Research
The number of patients receiving NHS services provided or sub-contracted by Central
Essex Community Services in 2012/13 that were recruited during that period to
participate in research approved by a research ethics committee was three.
Goals Agreed with Commissioners – Use of CQUIN Payment Framework
A proportion of Central Essex Community Services income in 2012/13 was
conditional on achieving quality improvement and innovation goals agreed between
CECS and its commissioners for the provision of NHS services, through the
Commissioning for Quality and Innovation payment framework.
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The total amount of funding available from commissioners through this payment
scheme was £900K, and CECS expects to secure the majority of this money from its
relevant activities during 12/13.
Statements from the Care Quality Commission
CECS is required to register with the Care Quality Commission and its current
registration status is “registered for Nursing Care, Surgical Procedures, Treatment of
Disease Disorder or Injury, Family Planning and Diagnostic & Screening Procedures”.
CECS has no conditions on registration other than those pertaining to location which
are standard for everyone. The Care Quality Commission has not taken any
enforcement action against CECS during 2012/13.
CECS has not participated in any special reviews or investigations by the Care
Quality Commission during the reporting period. This is because there was none that
we were required to participate in.
Data Quality
In 2012/13, we agreed a Data Quality Improvement Plan with our main
commissioners. This had 3 main themes which are set out below:
Provision of a revised data set
We have agreed formats of datasets and provided in line with plan
We have also exceeded our data quality target of 98% by 31 st March 2012 by
running in excess of 99%
We have also progressed with implementing the Community Information
Datasets, as one of only two pilots in England, and this will be used in
reporting from 1st April 2013
Submitting commissioning datasets to the Secondary Uses Service (SUS)
Delivered reporting of commissioning data sets to SUS
Provision of Revised Activity Plan
To comply with reporting on the new datasets, CECS has implemented a
new Data Warehouse provide management information for both CECS and
Commissioners
For Information Governance, our Information Governance Assessment Report
predicts an overall score for 2012/13 of 72%. This overall rating of 72% equates to 8
requirements scored at Level 3, 28 requirements scored at level 2, 1 requirement at
level 1 and 2 requirements scored as N/A out of a total of 39 requirements. Our
overall aim is improve year-on-year and for 12/13, our aim was to increase the
number of relevant requirements at level 2 (76%) versus 11/12 (64%), so we have
achieved this aim.
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Our score this year of 72% represents a consistent improvement in our overall score
from 10/11 (60%) and 11/12 (69%) and we will continue our work during 2013/14 to
ensure that we improve further.
Central Essex Community Services was not subject to the Payment by Results
clinical coding audit during 2012/13 by the Audit Commission. This is because we
were not required to participate in this.
Part 2d – Involving Others
As previously stated, our strategy for involving others will focus on:
seeking views
listening to responses
changing the way in which we do things in a way which makes sense, is clinically
safe and which improves the experience of our customers and their carers
After we provide customers with a service, we ask them a number of questions about
their experience so that we have specific feedback to act on to improve what we do.
We have recently received some very positive feedback from the Care Quality
Commission about our surveying approach.
We will also continue to use various existing forums to engage our customers, as
above, such as the Expert Patients’ Programmes, the Diabetes Patient Network, the
Chronic Obstructive Pulmonary Disorder Network, the Cardiac Network and our
recently-established Customer Engagement Group.
This coming year, we will be building on the success of our pilot approach to broaden
the feedback we collect about some key service pathways. We will use workshops to
learn further from the views of our customers and carers and then feedback what we
have done as a result of what we have heard. We will also be continuing to use our
externally appointed Governors and our Director walk-around visits as another route
for feedback from customers which will also be useful in influencing our strategic
plans.
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Part 3a – Some of our many Achievements during 2012/13:
During 2012/13, CECS has achieved the following in terms of understanding the
experience of our customers:
Met the objective in our annual plan of surveying 100% of our services, from
which notable results included:
93% of customers on our community wards said that the use of the call bell
was explained to them when they first came on to the ward
93% of customers on our community wards said that they were given enough
privacy when being examined or treated
93% of customers on our community wards said that their hospital room/ward
was very clean
All of our customers receiving care from Community Nursing staff (Integrated
Care for adults) said that members of staff were professional and that, where
they had questions, they got answers they could understand
97% of customers who had seen a Continence Advisor reported that they had
benefited from the treatment and advice received and 100% said that they
had been treated with dignity and respect
Over 97% of our Physiotherapy Service customers said that they were
involved in decisions about their care and treatment as much as they wanted
to be and 100% said that staff explained their assessment in a way that they
could understand
All of the parents of children seen by our Children’s Community Nursing
Service said that they felt involved in the decisions about the care and
treatment of their child
Over 97% of customers seen at Moulsham Grange (Specialist Children’s
Services) said that they felt that they were treated with dignity and respect
Overall: the percentage of respondents giving a “top 2” (scoring us as the 2
most positive answers of 5 possible answers) answer over the last three
years has improved steadily from 85% in 2010/11 to 95% in 2012/13.
No cases of MRSA and only 1 case of Clostridium Difficile all year, with consistently
high standards of cleanliness and hygiene maintained across our services throughout
the year
Audits against relevant standards for both catheter management (99% compliance)
and vascular access devices (100% compliance) demonstrate consistent and
excellent performance across the whole year
Our Owners (we are staff owned) voted at our AGM in September 2012 to donate
£90K to local charities whose work complements our mission
This year, we chose to participate in the Sunday Times Best Companies Staff Survey
during November/December 2012. This was so that we could assess ourselves
against other not-for-profit sector employers from all the types of companies that
enter. The survey provides feedback from our employees on 8 key factors that
provide an insight into employee engagement. The feedback is expressed as a score
ranging from 1 to 7, where 1 is the least positive and 7 is the most positive score. All
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of our scores were above the mean, indicating that most employees have a positive
view of our organisation. The following table shows further detail:
Factor
Overall score
for factor
My Manager – How employees feel about and communicate
with their direct manager.
4.71
Leadership – How employees feel about the head of the
organisation, senior managers and the organisation’s values
and principles.
4.21
My Company – The level of engagement employees have for
their job and organisation.
4.84
Personal Growth – What employees feel about training and
their future prospects.
4.77
My Team – Employees feelings towards their immediate
colleagues and how well they work together.
5.09
Fair Deal – How happy employees are with their pay and
benefits.
4.06
Giving Something Back – The extent to which employees feel
their organisation has a positive impact on society.
4.40
Wellbeing – How employees feel about stress, pressure at
work and work life balance.
4.13
Falls – we have maintained our good performance in preventing inpatient falls, with
none at severe level during 2012/13, through the use of innovative interventions and
rigorous risk-assessments across the year
Pressure ulcers – low rates of attributable (avoidable) pressure ulcers – 5 at grade 3
and 1 at grade 4 in the community and none at grade 3 or 4 on our community wards
(grades 3 and 4 are the most serious levels)
Very little prescribing outside of designated formulary which helps to reduce potential
infection rates and also makes best use of resources
No breaches of single sex/privacy and dignity regulations all year
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Part 3b – Statements from Others
Statement from Mid Essex Clinical Commissioning Group (our commissioners)
This is the first year that Quality Accounts are being commented on by Mid Essex Clinical
Commissioning Group (MECCG).
MECCG welcomes this Quality Account as a commitment to an open and honest dialogue
with the public regarding the quality of care in Central Essex Community Services.
Assurance from MECCG is required to ensure that the information in this Quality Account
is accurate, fairly interpreted, and representative of the range of services delivered.
Though MECCG is commenting on a draft version of this Quality Account, it is pleased to
be able to assure the accuracy of the content in general. MECCG is however unable to
assure all data reported, as some data may have been updated prior to publication.
You describe processes to monitor your own progress through the year, these appear
robust. In your account you also celebrate your quality achievements, and working as
necessary through any issue that might arise in relation to delivering against the priorities
for the last year. You give an outline summary of actions taken in the past twelve months
and your vision for the year to come. You use views and comments from users of your
services to illustrate areas of good practice. The wide breadth of services supplied to
people is shown and your commitment to improving community services is also seen in
your stated mission 'To deliver quality integrated services that will enable and support
people to live the best lives possible.'
Your priorities for improvement in 2012 – 2013, have been supported by MECCG through
the agreement of CQUIN schemes which provide financial incentives to improve quality.
You have made clear links between all targets and demonstrated how you have made
progress and how this has been measured. We note your success for a third year of 'zero'
cases of MRSA bacteraemia and maintaining cases of Clostridium difficile within target.
You give a comprehensive description of your participation in and learning from clinical
audit. You give a summary of findings and learning from all clinical audits undertaken.
In your report there is information about your performance in respect of data quality and
the improvements you have made in the last twelve months, in particular the improvement
in data accuracy. In respect of the information governance (IG) tool kit, you report that you
have achieved an improved score of 72% however as you note, this still remains an area
for improvement with level 2 not being achieved across all areas.
Your priorities for improvement in 2013 – 2014 are:
1. Frailty – developing a holistic and integrated frailty pathway
2. Pressure Ulcers – zero tolerance for avoidable damage
3. Infection prevention – maintain MRSA and Clostridium difficile performance in line with
contract targets both set at zero for the year
4. Customer engagement – expanding customer engagement groups to other pathways
5. Children’s diabetes – working in partnership with other healthcare providers for children
with type 1 diabetes
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MECCG supports these as appropriate areas of focus for quality improvement, some of
which are supported as CQUINs.
In conclusion, Mid Essex Clinical Commissioning Group considers Central Essex
Community Services’ Quality Account for 2012 to 2013 as providing an accurate and
balanced picture of key indicators in the reporting period.
MECCG encourages the organisation to continue to implement the multiple and wideranging efforts and initiatives to improve and be innovative in its delivery of quality in the
community.
Mid Essex Clinical Commissioning Group
28/5/2013
Statement from Essex Healthwatch (independent consumer champion)
We recognise that Quality Account reports are a useful tool in ensuring that NHS
healthcare providers are accountable to patients and the public about the quality of service
they provide. We fully support these reports as a means for providers to review their
services in an open and honest manner, acknowledging where services are working well
and where there is room for improvement.
We welcome the opportunity to provide a patient and public perspective on the Quality
Accounts. As a newly-established organisation (we took on statutory responsibility on 1 st
April 2013), we are not in a position to comment retrospectively on the findings of the past
year. We will, however, cooperate fully in the future production of these reports. We are an
organisation which intends to provide comment rooted in evidence – be it ‘soft’ intelligence
or more extensive, quantitative data. Following the Francis Report, we believe there is a
significant challenge and opportunity for the whole health and social care system to look at
how evidence relating to patient experience can be set on an equal footing with standard
NHS data about performance and quality.
We share the aspiration of making the NHS more patient-focussed and placing the
patient’s experience at the heart of health and social care. An essential part of this is
making sure the collective voice of the people of Essex is heard and given due regard,
particularly when decisions are being made about quality of care and changes to service
delivery and provision.
Our wish is therefore that Healthwatch Essex works with its partners in the health and
social care sector to engage patients and service users effectively and to ensure that their
views are listened to and acted upon.
We look forward to working together in the production of Quality Accounts in the coming
year and making sure that the voice and experience of patients and the public form an
integral part of these documents. At a time when the NHS is facing great change and
financial challenge, patient experience and quality of care are more important than ever,
and we welcome the opportunity to help shape the NHS of the 21st century.
Essex Healthwatch
17/5/2013
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Integrated Care
“I believe I was very well looked after at all times. Very friendly
nurses, who were all very helpful. I would have no doubts about
recommending them to anyone in need”
Rapid Assessment Unit
“The staff were extremely helpful and the whole experience was
stress free”
Early Supported Discharge (Stroke Care)
“The most wonderful care….you should be proud of this service”
Community Diabetes
“Really warm, caring, practical approach. Lots of ways to
communicate. Lots of support, not just 9 to 5 service”
To request this information in Braille,
audio and large print or an alternative
language please contact
Customer Service on 01621 727286/7
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