-1-
Contents
Section
1.0
1.1
1.2
1.3
1.4
1.5
2.0
3.0
4.0
4.1
Introduction
2012/13 Directors’ Statement
About our services
• Who we are
• What we do
• Our mission, vision and values
Executive summary
• Development goals
Quality Goals 2013/14
Our Quality Account
• What does the Kent Community Health Trust (KCHT) Quality
Account include?
• How did we produce this Quality Account?
• Transformation
• Transforming our people
• Transforming clinical support systems
• Transforming partnerships
A snapshot of our activity and performance
Achievements in 2012/13
Our response to the Francis Report
Governance statements
Safe Care Deliverables
Infection Control and Prevention
• Clostridium Difficle
• How we performed in 2012/13
• MRSA
• Hand hygiene
• Patient Experience Action Team (PEAT)
• What we need to do in 2013/14
Page
6
8
9
11
15
17
19
20
21
22
23
24
4.2
Pressure Ulcers Reduction
• How we performed in 2012/13
• Data Quality and Completeness
• Shared Care
• Innovation Grant
• Safety Thermometer
• Venous Thrombo-Embolism (VTE)
• What we need to do in 2013/14
27
4.3
Falls Prevention
• How we performed in 2012/13
• NHS Benchmarking Network
• What we need to do in 2013/14
• Patient Story
30
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Section
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11
Nutrition and Hydration
• How we performed in 2012/13
• Nutrition Link Roles
• Clear Criteria for MUST Exclusion
• Re-launch of Nutrition and Hydration Campaign Training
• Case Study
• What we need to do in 2013/14
Transfer of Care
• How we performed in 2012/13
• What we need to do in 2013/14
Patient Safety Walkabouts
• How we performed in 2012/13
• What we need to do in 2013/14
Health Visiting
• How we performed in 2012/13
• Early Implementer Site
• Active Baby
• Family Nurse Partnership
• What we need to do in 2013/14
Safeguarding
• How we performed in 2012/13
• Safeguarding Children
• Safeguarding Adults
• Mental Capacity Act/Deprivation of Liberties (MCA/DoLs)
• What we need to do in 2013/14
Dignity and Respect
• How we performed in 2012/13
• 15 Steps
• Quality Standard
• Single Sex Accommodation
• What we need to do in 2013/14
End of Life Care
• How we performed in 2012/13
• End of Life Care audit
• Working in Partnership
• What we need to do in 2013/14
Patient Experience
• How we performed in 2012/13
• FACE Tool
• Patient Engagement Network
• Patient Experience Committee
• Patient Information Library
• Complaints and PALS
• What we need to do in 2013/14
Page
32
34
35
36
38
41
42
43
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Section
5.0
Health and Wellbeing
• How we performed in 2012/13
• Chlamydia
• Interreg Commission Research Project
• Stop Smoking
• Health Checks
• What we need to do in 2013/14
• Patient Story
Page
47
6.0
Developmental Goals 2012/13
• Neuro-disability
• Dementia
• Acute pain management
• Reducing the length of stay
• Review baseline audits and set targets
• Benchmarking against comparable organisations
• What we need to do in 2013/14
50
7.0
Patient Safety
• Serious Incidents
• Pressure Ulcers
• Falls
• Confidentiality
• Never Events
• NICE
• What we need to do in 2013/14
Inquests/Claims
52
8.0
9.0
10.0
11.0
Morbidity and Mortality
• Learning from events
• Data collection
• Global Trigger Tool
• Morbidity and mortality meeting
• Reporting and monitoring arrangements
• What we need to do in 2013/14
Workforce Development
• Revised appraisal process
• Values into Action framework
• Supporting the reduction in agency use
• Supporting integration
• Pulse survey
• The Change Champion network
• Equality Delivery System
• What we need to do in 2013/14
Quality and Education Programmes
• Competencies
• Clinical education
• Professional practice standards
55
56
57
60
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Section
12.0
13.0
Page
• Compassionate care
• Accountability conference
• Clinical supervision
• What we need to do in 2013/14
Continuous Quality Improvement using Clinical Audit
• National audit
• Local audit
• Identifying and monitoring actions
• What we need to do in 2013/14
Innovations in 2013/14
• Wound Infection Risk Evaluation (WIRE) Tool
• Out Patients Parenteral Antimicrobial (OPAT) IVs in the
community
• Diabetes algorithms
63
68
14.0
15.0
Research
Information Governance
• Data quality statement
• Background and requirements
• Assurance
• Governance
• Action Plans
• Monitoring
• Reporting
• NHS number and general medical practice code validity
• Information governance toolkit attainment levels
• Readmission to community hospital within 28 Days
• What we need to do in 2013/14
69
70
16.0
17.0
Care Quality Commission
External Review
• Clinical Commissioning Groups
• Healthwatch
• External Assurance
Appendix 1 - Overview of achievements against 2012/13 Quality
Goals
72
74
-5-
Introduction
Welcome to our second Quality Account.
Kent Community Health NHS Trust (KCHT) is one
of the largest NHS community trusts in the country.
Our aim is to continue to deliver the very best
healthcare to people in the community and closer to
home.
The quality account is one of the most important
documents that we publish each year. The
regulations have been amended and are reflected
in this account - to ensure that the Trust responds
to central changes, the Trust Secretary provides
the organisation with a weekly alert updating the
executive team and senior managers on any
changes to requirements by the Secretary of State
or Department of Health.
In this year’s document we outline the progress that
we have made in 2012/13 and areas where we
need to improve further. It highlights the priorities
for improvement in 2013/14.
Our quality priorities for 2012/13 were developed
with our staff, patients and partners and reflect
what is important to you. We continue with our
clear commitment to improving patient safety as we
recognise the care provided has a large impact on
both the patient and their family.
We also recognise how important it is for us to
strengthen
our
partnerships
with
Clinical
Commissioning Groups and GP colleagues, acute
hospitals, the county and district councils, the
voluntary sector and our communities in order to
make a real difference to people’s lives and to help
develop improvements in the wider economy.
We are committed to working collaboratively with
the users of our services and all key partners. All
stakeholders’ views are pivotal for us in helping to
shape our ongoing transformation plans and
ensure that we have the right care provision at
each stage in the patient journey.
We want to work closely with our partners to deliver
integrated care pathways and to achieve the best
possible outcomes for patients. These will be
reflected in the new set of outcome measures that
will form part of the Trust’s performance report in
2013/14.
Our staff and services want to be able
respond promptly to help people recover
quickly as possible and provide support
people to live with any long-term condition
actively as possible.
to
as
for
as
This year has seen many improvements in the
Trust including a significant restructure within
the organisation. It has been a challenging time
for staff but they have worked hard to implement
initiatives which are designed to improve quality
and you will find many examples detailed in
case studies in this Quality Account. The Trust
has also seen changes at a senior management
level this year with Dr Peter Maskell appointed
as Medical Director.
The three pillars of quality, safety to those
receiving care, the clinical effectiveness of
treatments and interventions offered and the
experience of those using our services are at
the heart of everything we do in the Trust,
whether it is in community hospitals or in
patients’ homes. Patients do not expect to be
harmed when receiving care and this needs to
be evident in the everyday experience of people
accessing our services.
We know that 2013 will be a challenging year for
the NHS. We know that we must also become
more efficient and make better use of our
resources, including being financially resilient.
We also know that our commitment to quality
and our transformation plans will enable us to
improve the efficiency and effectiveness of our
services while significantly reducing cost,
necessary to meet current and future demand
The progress we have made over the last twelve
months has been encouraging. However, there
is more to achieve. Whilst we have seen
improvements in how patients rate our services
through patient experience measures we still
have more to do to reduce harm to patients,
such as reducing the incidences of pressure
ulcers
and
falls,
improving
medicines
management and optimisation and improving
mandatory training and appraisal targets
It is important that we can also demonstrate
effectively the quality of our services. We want
to continue to develop and improve our quality
and performance dashboards and expand our
patient and staff experience feedback systems
across the Trust. This will help to provide our
clinicians and managers with real time
-6-
information and performance data for services so
we can be more responsive and dynamic in making
improvements.
Our progress against the goals in 2013 will be
monitored and reported through our governance
systems, especially the Quality Committee which is
firmly embedded in the organisation and reviews
information and performance of local teams through
to the board on a monthly basis.
At the moment we are in the process of becoming a
Foundation Trust. This is part of the government’s
programme to create a “patient-led” NHS. We
believe this will enable us to continue to provide the
best care and treatment by focusing on communityled services and bringing important benefits to the
communities we serve. The Trust is making good
progress on this journey and is hopeful that this will
progress further during 2013/14.
As an organisation we found the findings of the Mid
Staffordshire NHS Foundation Trust report (The
Francis
Report)
deeply
disturbing.
The
recommendations of the Francis Report are clear,
that the whole system must revolve around quality,
accountability and transparency. The quality
account describes our efforts to ensure that the
delivery of high quality, patient-centred care
remains central to our work.
As a result of discussions with key stakeholders,
the quality goals for 2013/14 have been agreed and
focus on patient safety, clinical effectiveness and
patient experience and the continued need to
support a healthy organisational learning culture.
It is of utmost importance that we deliver excellent
safe care, importantly based on listening and
responding to what patients and their families and
our commissioners tell us.
I want to take this opportunity to thank all our staff
for continually striving to improve the care that they
deliver; staff and service users for providing
valuable feedback on our services as well as
colleagues for their continued partnership working.
Yours sincerely
Marion Dinwoodie
Chief Executive
Thank you for helping us to develop our quality
priorities.
You can become more involved in the work of
the Trust and in helping us to improve services
by becoming a Trust member, you can sign up
online on our website www.kentcht.nhs.uk or
call us on 01622 211964 for a membership form.
If you would like to receive this report in an
alternative format or language please contact
our Customer Care Team on 0300 123 1807, by
emailing kcht.cct@nhs.net or by writing to
Customer Care Team, Kent Community Health
NHS Trust, Trinity House, 110-120 Upper
Pemberton,
Eureka
Business
Park
Ashford, Kent, TN25 4AZ.
-7-
2012/13 Directors’ Statement
Integration of community services has continued to
be a major undertaking for the organisation. During
2012/13 we continued to work with our patients, the
public and our staff to understand the community
we serve. This has helped to shape the Clinical
Strategy for the next five years and we will continue
to focus on delivery of consistently high quality
services in partnership with our patients, the public
and staff.
•
•
•
The 2012/13 Quality Account demonstrates our
commitment to patients receiving high quality safe
care. We are also serious about using our
resources efficiently, eliminating waste and
duplication where it exists and maintaining focus on
getting the basics right. Mandatory training and
appraisal targets are reinforced in our strategy.
There will be a continued focus on prevention,
avoiding the need for acute care where appropriate
and support for early discharge from hospital.
There has been a huge amount of work undertaken
by our staff over the year to achieve this. However,
we know there is much more to do to demonstrate
effectively the impact on the whole health care
system.
In this account we have highlighted many of the
areas that we will be targeting during 2013/14,
building on the results from 2012/13 in areas that
we believe will make the biggest difference to our
patients, families and carers. Our programme of
quality improvement will support the organisation’s
journey to sustainability and becoming a
Foundation Trust whilst maintaining our vision to be
the provider of choice by delivering excellent care
and improving the health of our communities.
•
There are proper internal controls and
reporting measures of performance included
in the quality account, and these controls are
subject to review to confirm they are working
effectively in practice
The data underpinning the measures of
performance reported in the quality account
is robust and reliable, conforms to the
specified data quality standards and
prescribed definitions and is subject to
appropriate scrutiny and review
The quality account has been prepared in
accordance with Department of Health
guidance
The directors confirm to the best of their
belief and knowledge that they have
complied with the above requirements in
preparing the quality account.
Assurance process
The organisation’s Board was pivotal in setting
the Quality Goals for this year, in addition to
other stakeholders and staff.
The Quality Committee and the Board were
provided with an opportunity to review the
Quality Account before the final version was
agreed, thus ensuring as far as possible that the
information is accurate and directors believe to
the best of their knowledge that the quality
account is accurate.
Directors’ Statement of Responsibilities
Directors are required to prepare a quality account
every year. The Department of Health has issued
guidance on the form and content of the quality
account. In preparing the quality account, directors
are required to satisfy themselves that:
•
•
The quality account presents a balanced picture
of the Trust’s performance over the period
covered
The performance information in the quality
account is reliable and accurate
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1.0
About our Services
Who we are
There are seven minor injury units across Kent,
open seven days a week, which treat a range of
minor illnesses and injuries.
Kent Community Health NHS Trust (KCHT) is one
of the largest providers of NHS care in patients’
homes and the community in England.
KCHT also provides emergency and specialist
dental treatment across the county and beyond.
We had a budget of nearly £214 million in 2012/13
and employed approximately 5,400 members of
staff in a wide range of clinical and support roles.
We serve 2 million people, 1.4 million people living
in Kent and we provide services to around 600,000
people in areas outside of Kent.
The Trust is currently working towards achieving
Foundation Trust status and held a public
consultation during the summer of 2012. We
recruited more than six thousand public members
(in addition to our staff membership). Their
involvement in the Trust will ensure it is truly patient
focussed.
The range of services KCHT provides includes:
Adult community nursing services including 24hour
district nursing and community matrons. We
provide care for patients in their own home and in
other locations including nursing homes, health
clinics, minor injury units, children’s centres and GP
surgeries.
Services for children and their families including
advice and support for children’s emotional and
physical health and wellbeing from a range of
services including health visitors, school-based
nurses, children’s community nursing teams,
speech and language therapists and occupational
therapists.
Nursing and therapy teams provide care in
people’s homes and help in supporting patients
and their carers manage their long-term
conditions, so they can remain as independent
as possible and don’t have to go into hospital
unnecessarily.
KCHT also has a rapid response service which
runs 24 hours a day, seven days a week.
Experienced nurses respond to requests from a
GP or other health professional and will assess
a patient’s needs within two hours. Interventions
include a supportive package of care to enable
the patient to stay at home rather than attend an
acute hospital.
If people do need in-patient care, for example
while recovering from an illness, staff support
people to get back home by providing
rehabilitation at home and in community
hospitals.
KCHT provides in-patient and out-patient
services from the 12 community hospitals
across Kent to: •
•
facilitate early discharge from acute
hospitals where patients need further
rehabilitation before returning home
assist GPs or Intermediate Care Teams to
avoid acute hospital admission by providing
a “step-up” facility from home.
Rehabilitation and therapy services include
physiotherapy, occupational therapy, podiatry and
speech and language therapy. These are provided
in the community so that people can get treatment
close to home without having to go into hospital
We work closely with our commissioners, GPs,
local authorities, voluntary organisations and
other healthcare providers, to make sure people
receive healthcare which is co-ordinated and
meets their needs.
End of Life care for people with complex ongoing
needs or chronic illness.
Our clinical staff include doctors, community
nurses, dieticians, health visitors, dentists,
podiatrists, health trainers, family therapists,
occupational
therapists,
physiotherapists,
clinical
therapists,
pharmacists,
health
improvement specialists and many more.
Health and wellbeing services support people to
make positive lifestyle choices. Help is available to
increase exercise, eat healthily, quit smoking and
assist with wider health and social care needs.
Sexual health services encourage safe sex and
provide contraception and treatment.
.
-9-
For more information about our full range of
services
please
visit
our
website
www.kentcht.nhs.uk or contact us using the
information on the back of this report.
Our mission, vision and values
Our mission is to provide high quality, value for
money community-based services to prevent
people from becoming unwell, to avoid going into
hospital or to leave hospital earlier and to provide
support closer to home.
Our vision is to be the provider of choice by
delivering excellent care and improving the health
of our communities. We will achieve our vision
through our five core values and these will underpin
everything we do:
•
•
•
•
•
Caring with compassion
Listening, responding and empowering
Leading through partnerships
Learning, sharing and innovating
Striving for excellence
Our strategic goals
The Trust’s five-year Clinical Strategy provides the
strategic goals for the organisation. These goals,
listed below, provide the framework for the care
and services we deliver.
1. To prevent people from becoming unwell and
dying prematurely by improving the health of
the population through universal targeted
services.
2. To enhance the quality of life for people with
long-term conditions by providing integrated
services to enable them to manage their
condition and maintain their health
3. To help people recover from periods of ill health
or following injury through the provision of
responsive community services.
4. To ensure that people have a positive
experience of care and improved health
outcomes by delivering excellent healthcare.
5. To ensure people receive safe care through
best practice
In 2013/14 the quality goals are aligned to our
strategic goals, our mission and values.
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1.1
Executive Summary
This is our second Quality Account as Kent
Community Health NHS Trust following the
integration of the two legacy organisations West
Kent Community Health and Eastern and Coastal
Kent Community Health NHS Trust in April 2011.
This account details our progress against the key
areas of quality improvement set for 2012/13. It
details the successes but also where we need to
make further improvements.
This year in our Quality Account we have
included additional sections to better reflect all
the elements that contribute to quality:
•
•
•
•
•
•
Safe Care Deliverables
Workforce Development
Clinical Education and Standards
Inquest and Claims
Innovation
Transformation
Quality Goal
2012/13
Performance
Improvement
against
on 2011/12
aims/objectives
Infection
Control
Good progress has been made on infection
control targets with no MRSA infections since
July 2011 and achievement of the Clostridium
Difficile (C.diff) target.
Hand hygiene remains the single most
important measure in reducing the spread of
infection and further work is needed to continue
to ensure that all staff remains compliant with
their training and education.
All of the community hospitals received an
excellent or good rating from the Patient
Environment
Action
Team
(PEAT).
Unfortunately two hospitals dropped from
excellent to good and action has been taken to
remedy the shortfalls.
The last twelve months have proved to be
challenging but successful for the Trust’s delivery
of quality. Contributions from staff and key
stakeholders have helped with that success.
Maintaining and improving our Healthcare
acquired infection standards and reducing C.diff
by 30% remain continued goals for 2013/14
(Section 4.1)
In the last year the Trust Board has provided
strong leadership to the organisation in a number
of key areas:
Quality Goal
2012/13
•
•
•
•
•
•
the development of the Clinical Strategy
improving patient experience
Foundation Trust preparation
Values into Action framework
efficiency and effectiveness
improving information and assurance
The clinical strategy, sets out clear commitments
to the quality of care that will be delivered and
identifies priorities for improvement in the next
five years.
In developing the Values into Action framework
the Board has engaged with staff and patients to
set out the values and behaviours required by all
staff employed in the Trust. The framework is
being implemented and will be included in the
Trust’s appraisal process for staff. It is of
particular
importance
following
the
recommendations in the Francis Report.
Performance
Improvement
against 12/13
on 2011/12
aims/objectives
Pressure Ulcers
This year we identified that pressure ulcers
were one of the most common quality issues
across our services. It was an area that we
needed to continue to be proactive in tackling to
reduce the number of avoidable and attributable
grade 3 and grade 4 pressure ulcers. This has
been a continued challenge.
There has been progress as 75% of teams
have achieved zero avoidable attributable
grade 3 and 4 pressure ulcers with a further
13% of teams having only one incident in the
year and a 15% reduction in grade 3 and 4 heel
pressure ulcers. This is a considerable
improvement on the previous year. However it
is clear that there is still more work to do in
driving further improvements to reach zero and
this will remain a key priority for 2013/14
(section 4.2).
..
- 11 -
Quality Goal
2012/13
Performance
against
aims/objectives
Improvement
on 2011/12
Falls
The Trust has achieved real improvements in
falls in the year, achieving a 19% reduction in the
number of falls, however the level of harm has
not reduced. In addition to the introduction of best
practice standards additional equipment to
support patients has also been purchased.
Whilst this improvement has been encouraging,
further work is required in 2013/14 to reduce the
level of harm experienced by patients when they
fall as well as reducing the number of falls
(section 4.3).
Quality Goal
2012/13
Performance
against
aims/objective
s
Improvement
on 2011/12
Quality Goal
2012/13
Nutrition and
Hydration
Transfer
Care
Performance
against
aims/objective
s
Improvement
on 2011/12
of
Patient Safety
Walkabout
The Trust has consistently met the Health
Visiting Programme target. Increasing the
number of health visitors by 63 wte. This has
led to improvements in the active baby
programme with an increase in the number of
children who achieved the ability to crawl from
34% to 90% in the first 12 months. The
introduction of the family nurse partnership has
shown results consistent with the national
programme. The ongoing recruitment of health
visitors will continue in 2013/14 in aiming
towards our target and further Family nurse
partnerships will be developed (section 4.7).
Quality Goal
2012/13
Improved discharge processes were highlighted
as an area that patients and relatives wanted us
to focus on. Whilst some progress has been
made it has not been sufficient to address the
patient experience issues and this will be the
target for the year ahead. The development of
key care pathways such as end of life care will be
a priority to support improvement. (section 4.5).
Quality Goal
2012/13
Performance
Improvement
against
on 2011/12
aims/objectives
Health Visiting
Programme
Practices to ensure our patients nutritional needs
are met have been successfully implemented.
This has been confirmed through audits and
assurance visits. The area where we have to
improve further is hydration. Actions have been
put in place including participation in the national
Hydrant project and will be one of the key nurse
indicators being measured in 2013/14 (section
4.4).
Quality Goal
2012/13
In January 2012 the Board introduced Patient
Safety Walkabouts as a proactive measure to
engage with frontline staff across the Trust.
Each week an Executive and Non-Executive
Director
spend the morning out in clinical areas meeting
staff to discuss patient safety issues and gain
insight into the working environment. Staff
found these visits very beneficial and a number
of key changes have been brought about as a
result, including issues such as improvements
in lone working, improved equipment provision
and more localised training for staff groups. The
goal for 2013/14 will be to move further from a
bureaucratic culture towards a proactive culture
of patient safety as identified in the Manchester
Patient safety Framework. Further details can
be found in section 4.6.
Performance
against 12/13
aims/objectives
Improvement
on 2011/12
Performance
Improvement
against
on 2011/12
aims/objectives
Safeguarding
Safeguarding
services
have
developed
significantly in 2012/13 and the Trust has
continued to work closely with partners in social
care. All statutory duties have been met for both
adults and children. Significant progress has
been made in the organisation with training
compliance and the use of the Mental Capacity
Act and “no decision about me – without me”.
All areas of safeguarding will remain a key
focus in 2013/14 (section 4.8).
- 12 -
Quality Goal
2012/13
Dignity
Respect
Performance
against
aims/objectives
Improvement
on 2011/12
and
Quality Goal
2012/13
We have
maintained
our
Single
Sex
Accommodation standard and introduced a
privacy and dignity standard. We have introduced
the 15 Steps Challenge which measures the first
impressions and perceptions of care when
entering an area. This was positive in most areas
but highlighted some areas for improvement in
community hospitals. With the involvement of our
patient representatives, these will continue in
2013/14 (section 4.9).
Quality Goal
2012/13
End of
Care
Performance
against
aims/objective
s
Improvement
on 2011/12
Life
End of Life Care - this year the audit indicated
that 99% of patients died in their preferred place
of death and 88% of patients had their specialist
palliative needs assessed. However we want to
make further progress to in all areas of the care
pathway and so to support this work in 2013/14 a
Nurse Consultant in Palliative Care has been
recruited who will provide the organisational
leadership to drive this forward. (section 4.10)
Quality Goal
2012/13
2013, will be in the areas that report below 95%
satisfaction (section 4.11).
Performance
against
aims/objective
s
Health and
Wellbeing
In the last year the Health and Wellbeing
directorate has provided services aimed at
improving health outcomes and reducing health
inequalities across Kent. Areas of focus have
included Chlamydia screening; HIV point of care
testing; Stop Smoking and Health Checks. In
each of these areas significant improvements
have been made. For example the Trust met the
target to offer 10,000 health checks in East Kent
and has now been commissioned to provide the
service in West Kent as well. This means that the
people of Kent will all have access to this
programme.
Plans are underway to further
improve prevention and health outcomes in
2013/14 (section 5.0).
Development Goals
In addition we set ourselves some developmental
goals for 2012/13 and have made some progress
through the year, but there is still further work to
do in these areas: •
Improvement
on 2011/12
•
Positive patient
experience
In the last year the Trust has rolled out Meridian
which is the ‘real time’ patient feedback tool. The
Trust receives more than 1300 individual patient
feedback surveys via this method each month.
This has given frontline services the ability to
respond to feedback more quickly. Some of the
changes that have been introduced this year
include an increase in daytime activities for
patients receiving rehabilitation in community
hospitals and improved patient leaflets, letters
and information. The results of these surveys
show an overall satisfaction rate with services of
above 95% However we know that this hides
peaks and troughs in services so the focus in
Performance
Improvement on
against
2011/12
aims/objectives
•
•
•
Benchmarking
against
comparable
organisations - this has started, but national
data is limited in community services, so Trust
data is having to be used in some instances
(section 4.0).
Patients with neuro-disabilities feel safe, in
control and involved in decisions regarding
their care and management. Results showed
that twice as many patients achieved or
exceeded the desired outcome (section 6.0).
Acute pain assessment and management in
both adults and children - a professional
practice standard has been developed and
the baseline audit has been undertaken. and
work will continue in this area (section 6.0).
Reducing the length of stay in community
hospitals - the target set was not met in all
hospitals and this will be a key priority in
13/14 (section 6.0).
Reporting on Mortality rates - data collection
in community trusts is different from acute
trusts and thus it has been necessary to
develop measures. Morbidity and mortality
reviews have started and work is ongoing to
- 13 -
•
•
•
facilitate data collection more robustly (section
9.0)
During the year clinical services have been reorganised. This has made the working
environment unsettling for many of our staff. In
recognition of this the Trust has commissioned
a review of staff health and wellbeing to make
sure that the right processes are in place and
that staff have access to adequate support and
that the cause of stress amongst staff is
understood (section 10).
Developing the 1st Class Care Programme - in
2012 we focused on the development of
competency frameworks, practice standards
and clinical supervision, work which will
continue in 13/14 (section 11.0).
The Trust undertook a number of national and
local clinical audits, which brought about a
number of changes in practice in the year
(section 12.0).
During the last year the Care Quality Commission
has undertaken three inspections of community
hospitals one of which was a follow-up inspection.
Each of them has received good feedback with no
major concerns. Two minor concerns around
nutrition and patient medication were noted and
these were fully rectified. Re-inspection by CQC
resulted in full compliance being awarded (section
16).
To ensure trusts are complying with best practice
patient safety measures the NHS Litigation
Authority has an established assessment process.
The Trust was assessed in March 2013 against 50
standards for level 1 and achieved compliance with
all 50 standards, a rare achievement for any Trust.
This year the Quality Impact Assessment (QIA)
process has been further refined. The QIA is an
assessment that the Trust uses to screen and
score the potential impact on quality and safety of
any changes or cost reductions to services. The
Areas of Quality
Improvement
Indicator
Safety
Thermometer
% implementation
25-100% 34
61
0.2%
% harm free
95%
90.7 90.4
care (HFC)
Improve Performance against established baseline
Personalised
95%
95
96
care planning
Management
95%
94
94.9
measure
0.4%
Drug/dose ACE/
66.07% 65.8 68.1
ARB measure
Drug/dose
BB
44.43% 45.2 43.9
measure
End of Life
TBC
52.7 55.6
measure
Improve
80%
96.1
responsiveness to 0.28%
personal needs of
patients, children
and families
Enhancing
Quality
Programme
Patient
Experience
Weighting
Target
Director of Nursing and Quality and the Medical
Director together review and sign off all
efficiency focused plans only when they are
satisfied that there is an improvement in quality
or the changes will not affect quality. This is a
safety mechanism to ensure that risks to quality
are identified, mitigated and continuously
monitored.
The CQUIN framework aims to ensure that
there is a shift in Quality within the NHS and
stretch targets are set. This means that
payments are made to providers upon the
achievement of the nationally and locally
agreed quality goals. For KCHT 2.5% of the
contract depended on the CQUIN target in
2012/13 being met. All CQUIN goals were
achieved.
Through the commitment of our staff and
support from our Patient Engagement Network
we have achieved significant improvements
against many of our goals. There is real pride
across staff and professional groups at all
levels of the organisation in what has been
achieved in 2012/13 and a commitment to build
on this for all services in 2013/14. Details of the
goals that have been set for 2013/14 are in
section 1.2 and the Trust’s performance
against the goals for 2012/13 are in Appendix 1.
During the year there were four significant
issues in regard to the governance of the
organisation and these were notified to external
bodies. These are detailed in section 3.0 and
relate to: • Information Governance
• Cleaning systems in one of the
Hydrotherapy pools
• Pressure Ulcers
• Delayed identification of a deteriorating
patient
Table 1. CQUIN Performance Card
Apr 12 May 12 Jun 12 Jul 12
Aug 12 Sep 12 Oct 12 Nov 12Dec 12
Jan 13 Feb 13 Mar 13
75
91
84
93.2
95
94
97
94
97
94.8
98
94.6
99.2
95.2
100
95.1
99.2
94.1
99.2
94.1
96.2
96.4
96.7
96.8
96.1
97.5
97.6
97.6
97.6
97.6
92.5
93.7
94.8
95.3
95.9
97.1
97.3
97.2
97.2
97.1
67
68.1
67.5
67.1
68.4
69.5
69.5
69.7
70.4
70.4
44.3
45
44.7
45.2
45.8
45.7
45.6
46.1
46.7
46.6
71.6
73.8
92.6
92.9
90.4
89.9
89.3
89.4
89.6
89.8
97
97.8
96.2
96.8
98
97.3
98.8
98.9
98
99.2
- 14 -
Statement
Commissioning for Quality and Innovation
A proportion of the Trust’s income in 2012/13
was
conditional
on
achieving
quality
improvement and innovation (CQUIN) goals
agreed with NHS Kent and Medway through the
CQUIN. All CQUIN goals for 2012.13 were
achieved.
Further details of the agreed goals and
performance against those goals for 2012/13
and 2013/14 are available in our performance
reports to the Board available on our website
www.kentcht.nhs.uk
1.2
Quality Goals 2013/14
Priorities for Improvement
The quality goals for 2013/14 have been refined
in a number of discussions with the Trust Board,
clinicians, managers, staff and patient groups.
They cover the three domains of quality, patient
safety, clinical effectiveness and patient
experience and will ensure that we continue to
work towards a culture of transparency.
They are linked to the five overarching strategic
goals of the organisation which align to the
Clinical Strategy and the NHS Outcomes
Framework. They also reflect the findings of The
Mid Staffordshire NHS Trust enquiry. This has
resulted in some new priorities as well as the
extension of those requiring further action from
2012/13. The Quality Committee is embedded at
the heart of the organisation and will provide
robust monitoring of the quality goals in 2013/14.
This year the smaller number of overarching
goals followed feedback from stakeholders. Each
directorate and team will be able to easily
articulate and “own” their contribution to the
overarching strategic quality goals. They are
meant to be inclusive to all groups of staff and the
specific goals for each service can be locally
determined. Inevitably a number of the
underpinning work streams overlap and the
examples highlighted below are not exhaustive
but an example of some of the work streams.
- 15 -
Table 2. Provides an overview of work streams that will underpin each goal.
Goal 1 Patient
safety/Domain 5
Measurable year on
year improvement in
every area of patient
safety in community
services
Reduction in health care
associated
infections
e.g. a 33% reduction in
c.diff, and no MRSA
Falls Prevention and
reduction by 10% and
10% reduction in falls
resulting in harm
Goal 2 Clinical
effectiveness/Domain 1,2
&3
To improve outcomes by
developing integrated care
pathways ensuring the
right care, right place,
right person, right time
Improving transfer of care by
developing care pathways in
four areas e.g. end of life
care
Improve
optimisation
medicines by 20%
of
Reduction in Pressure
Ulcer s by individual
locality trajectories in the
20% of poor performing
areas
Measure Patient outcomes
in four key pathways and
increase
the
use
of
telemedicine
Deliver 95% harm free
care for new harms with
less than 2% rolling
harms
95% of patients asked about
smoking as part of their
assessment
and
90%
offered referral to stop
smoking services
No child or adult waits more
than 18 weeks for an
outpatient appointment
Introduce
a
new
performance
dashboard,
based on benchmarks and
outcomes,
Implement the Early
warning trigger tool
across all services.
Refreshing
Patient
Safety Walkabouts to
move
from
a
bureaucratic culture to a
proactive culture.
Reduce length of stay to
28
days
in
all
community hospitals
Goal 3 Patient
experience/Domain 4
Goal 4 Patient
safety/Domain 5
Goal 5 Clinical
effectiveness/
Domain 1,2,3
Measurable year on year
improvement in patient
experience, engagement
and satisfaction
Promoting a culture
of accountability
and openness
20% of patients undertake
friend and family scores
and achieve a result of
+80 per month on the Net
Promoter Score
Over
95%
patient
satisfaction in all service
areas
using
Meridian
surveys and at least 15%
coverage
Stakeholder engagement
in service changes is
increased by 15%
Decrease the number
of cases implicating
KCHT
in
safeguarding
concerns
Implement the Values
into Action framework
across the Trust.
Ensure that every
service change and
cost
improvement
undergoes a quality
impact assessment
Increase the number
of health visitors in
line with the plan by
64
Improved recruitment
and retention process
and decrease the
number of vacancies
to less than 10%
Reduction in sickness
absence to 3.75%
Implement person centred
care planning in at least
50% of services
Improve
Incident
reporting across the
organisation by 10%
Trust wide appraisal
at 95 %
Implement the six areas
of the CNO Caring and
compassion strategy
Implement
Nursing
Indicators in 100% of
community
hospitals
including nutrition and
hydration and pain
Implementing in full
the
“being
open“
policy in all incidents.
Implement
the
Speaking
Out
(whistleblowing)
campaign
Mandatory training at
95%
Strengthen morbidity
and
mortality
reporting
in
community hospitals
Decrease the number
of
stress
related
absences by 10%
Improving delivery,
capacity and
capability in all
areas
10% reduction in
bank and agency
usage
Reduce length of stay
in
community
hospitals to a median
of 28 days
- 16 -
1.3
Our Quality Account
What is a Quality Account
The primary purpose of the Quality Account is to encourage Boards and leaders of healthcare
organisations to assess quality across all of the healthcare services they offer. It allows leaders,
clinicians and staff to demonstrate their commitment to continuous, quality improvement and to
explain their progress to the public.
Quality Accounts present performance from the previous year and crucially they explain what the
organisation has identified as priorities for improvement over the next financial year.
What does Kent Community Health NHS
Trust Quality Account include?
Since the publication of the 2011/12 Quality
Account on NHS Choices and the Trust’s website,
we have focused on improving our performance on
achieving quality and strengthened our approach to
monitoring and evidencing our performance across
the three areas of quality defined by the
Department of Health:
•
•
•
patient experience
clinical effectiveness
patient safety
This has helped to drive standards of care we
deliver to patients and carers and helped us to
respond to the areas where improvements are
needed. The quality account provides the public
with an update on the progress that has been
made.
For 2012/13 the Trust set 10 Quality Priorities and
8 Developmental Goals. The Quality Account
provides details on the Trust’s achievements; areas
requiring further focus and our priorities and
developmental goals for 2013/14.
How did we produce this Quality Account?
To ensure that KCHT priorities reflect the priorities
of our patients, the wider public and the people we
work with, we engaged with different groups to
develop the report, including staff groups and
members that have been recruited to the Trust.
KCHT has a dedicated Patient Engagement
Network and Patient Engagement Committee which
provided comments and feedback right from the
start of the drafting process in February this year.
The membership of these groups includes
patients,
voluntary
organisations,
representatives from Healthwatch Kent and
clinical and managerial members of our own
staff. We hope that this group will continue to
provide feedback throughout the year as we
implement the plans laid out in this report.
Transformation
KCHT is transforming and improving services
so that we can meet today and tomorrow’s
health
and
financial
challenges.
The
Transformation framework, called ‘The Human
Touch’, is the Trust’s way of implementing the
clinical strategy.
The transformation framework focuses on our
three core strengths:
•
•
•
Our heart: Putting our values at the centre
of all we do and encouraging positive
attitudes all round.
Our hands: Being practical and creative in
how KCHT transforms services.
Our head: Making sure we have a clear
vision and strategy, underpinned by robust
systems.
We are improving our services in five major
ways. These are the ‘five a day’ to bring about
healthy transformation:
Transforming models of care
The Trust is transforming services to be more
integrated and patient focused. The aim is to
support people to remain living at home at
times of vulnerability, rather than be admitted to
hospital. The Proactive Care project is an
example of how we are doing this.
- 17 -
The project offers a 12 week intensive package
to support people to better manage their long term conditions. There is multi disciplinary input
across health and social care, with support from
health trainers to connect the patient to their
local community support network. Following the
12-week programme people move onto self
management which might include the use of
telecare.
Transforming the times
where we provide care
and
The Trust aims to deliver the following key
outcomes for patients:
•
•
•
places
KCHT is adding to its traditional health care
settings by offering more services either within
people’s own homes or close by in community
venues, making good health part of everyday
life. KCHT’s telehealth projects include the
Whole Systems Demonstrator and 3 Million
Lives pathfinder. KCHT is also developing
smart phone applications, websites and
investigating the use of on‐line web clinics.
Transforming our people
•
•
A reduction in long-term conditions through
preventative approaches.
A reduction in A&E attendances and
admissions to hospital, particularly for
patients with long-term conditions.
Better outcomes for frail, older people,
avoiding hospital stays and supporting more
people, better, at home.
More planned care closer to home
Greater access 24/7 and expert support for
people at moments of crisis or vulnerability.
The Trust attended the Health Innovation
EXPO, Europe’s largest health conference, held
at the Excel Centre in London following a
competitive process. The Transformation
Framework was launched at a stand at the
event.
KCHT had a highly visual stand,
showcasing five key transformation projects
and was very well attended by delegates and
key stakeholders.
KCHT is looking at developing generic roles
across directorates and functions, for example
combining elements of the health care assistant
role and the health trainer role to support the
long‐term conditions pathway. KCHT is also
developing more services and roles that are led
by extended role practitioners.
Transforming clinical support systems
KCHT is supporting better access for patients
and more efficient ways of working through
technology,
including investment
in a
community information system that will
transform our clinical and business practices.
Transforming partnerships
KCHT is working with its partners to integrate
health and social care teams across services.
We are keen to develop innovative joint
solutions with our partners and to support wider
health and social care system transformation.
We are using a range of improvement tools
including:
•
Lean Six Sigma, Productive Community
Services, social marketing, the Influencer
Strategy and improvement techniques to
redesign and reduce variation.
- 18 -
1.4
A snapshot of our activity
and performance
re
Over
3,153
Over 2,700
patients identified
More than
as having
Chlamydia
following
screening and
offered treatment
patient contacts
were for planned
therapy in a clinic
setting
patients were
admitted to our
Community
Hospitals
500,000
Over
100,000
patients have been
treated at our minor
injury units,
on average 320 a
day, 7 days a week
More then
Care was
provided by over
3,600 staff from
many professions
2.35 million
patient contacts
were provided in
the community
8,413
patients supported
to quit smoking
The average length
of stay in our
Community
Hospitals was
13,000
new born babies
were seen by our
Health Visitors
New referrals
were seen within
18 weeks in our
consultant-led
services in over
99% of cases
27 days
Over
1.5 million
of our patient
contacts were
provided in the
patients’ own place
of residence
9,916
Health Checks
have been carried
out across Kent
- 19 -
1.5
Achievements in 2012/13
•
For the second year we have had no MRSA bacteraemia in our community hospitals
•
19% reduction in the number of patients sustaining a fall and those resulting in severe harm
•
We met all of our CQUIN targets
•
We achieved the Safety Thermometer target of 95% harm free care
•
99% of children and adults were seen with 18 weeks
•
Three of our nurses attained Queens Award status
•
99.4% of our patients attending one of our MIUs were seen and treated within 4 hours
•
15% reduction in the number of patients acquiring an avoidable grade 3 or grade 4 heel
pressure ulcer. 75% of teams had zero avoidable grade 3 & grade 4 pressure ulcers
•
We launched our Clinical Strategy that focuses on patients and the outcomes we achieve for
them
•
From our Health Visiting programme two case studies will be published by the DH, one of
which we have been invited to present at the International Public Health Conference in Ireland
Where we need to improve
•
Despite significant improvement during the year, some of our patients still acquired avoidable
grade 3 and grade 4 pressure ulcers. This is not good enough for our patients and we will continue
to strive for further improvements
•
Our patient feedback tells us that we are not consistently achieving good results when transferring
care between healthcare organisations. We will continue to work with our partner organisations to
make the improvements that our patients deserve
•
Coroners have the power to make a Rule 43 where they believe actions should be taken. We
received two this year both related to pressure ulcers and the standard and quality of assessment
and record keeping. Actions have been taken and reported to the coroner
•
This year we have been committed to improving data quality pathways from data entry at source to
reporting at board level. There is still work to do we will continue to build on the improvements that
have already been made
- 20 -
2.0
Our response to the Francis
Report
The final report of the Mid Staffordshire NHS
Foundation Trust Public Inquiry from Robert
Francis QC, was published in February 2013.
The public enquiry and the subsequent Francis
Report focused on the care delivered by one
organisation but its conclusions have far reaching
consequences and recommendations for all
organisations and every individual providing care.
Kent Community Health NHS Trust reviewed all
of the recommendations of the first report,
published in 2010, to make sure we complied with
them and implemented all of the learning from
that report.
In light of the recommendations of the second
Francis Report, we have reviewed what currently
happens at KCHT. We are not complacent and
are always seeking to improve care and thus
have identified some positive steps to be taken to
strengthen quality assurance in the future. A
number of these were already underway and
happening prior to the publication of the report.
Our aim is that all our staff always strive to
provide excellent care for people, 100 per cent of
the time. To do this we will continue to develop
the education and training of our staff to make
sure they have the right knowledge and skills to
understand the priorities and the organisation’s
expectations of them. We want all staff to
demonstrate the right values. We have developed
these values with our staff in a “Values into
Action” framework.
These values are being embedded in our
recruitment processes, performance appraisal
and objective-setting for all staff.
It is vital that our focus is on patient care and
outcomes, at all levels of our organisation “from
ward to Board”. We will maintain our focus on the
experiences of patients, their carers and users of
our services so we are constantly improving the
care we receive. We will do this by ensuring our
Board hears the stories of patients and they are
incorporated in training for all our staff. We will
also continue to capture and monitor information
about what is happening on the frontline of care.
We will continue to communicate and listen to our
staff’s views and build on the existing ways that
we do this so we always use their feedback and
suggestions to help us continually improve quality.
Additional surveys to capture staff as well as
patient feedback were started in March this year.
We record feedback from our patients in “real
time” giving us instant reports. We already
include the “NHS Friends and Family Test” in our
surveys, which asks patients how likely they are
to recommend our services to their family and
friends. From 1 April we have be asking all
inpatients in our community hospitals, minor
injury units and our walk-in centre this question.
We also invite the public to give feedback on our
website, where they can also “rate” our services.
We are strengthening the recording of patient
information, the care patients receive and the
outcomes they experience as a result of their
care, by rolling out a new electronic system for
managing this information, as well as a suite of
nurse indicators. We will continue to develop
these programmes so that we can be sure we are
getting the most accurate information possible.
We review all incidents and complaints and we
will strengthen the “duty of candour” to ensure
that lessons are learnt and changes are made to
prevent them happening again.
Over the coming year, we will review our current
practices in a number of areas to identify any
changes
that
are
required
to
deliver
improvements in patient care.
3.0
Governance Statements
The Trust is committed to high quality safe care for all patients and users of our services. There has been
a real focus on strengthening systems and processes, embedding best practice and data quality.
However, detailed below are the four significant issues that have been raised to external bodies this year
and the actions implemented to address the gaps.
Significant Issue Description:
Remedial Action Taken and Plans for Mitigation:
A small number of boxes containing
patient records were lost while being
put into archiving. The organisation
made a self-referral to the Information
Commissioner.
A working group was established chaired by a Non-Executive
Director and attended by the Chief Executive to look at the
systems for record keeping and archiving. An extensive action
plan was developed including staff training, system
improvements and improvement of the specification for
archiving which was tendered and successfully awarded.
Compliance for staff training in IG has improved to almost
100% of available staff. The Information Commissioner
reviewed the actions taken by the Trust and determined no
further action was required by his office.
Weaknesses in the system for
cleaning
one
of
the
Trust
hydrotherapy
pools
may
have
resulted in three members of the
public acquiring an infection. The
Health and Safety Executive gave the
organisation an improvement order in
relation to the pool.
Actions which have been taken include a full risk assessment
of all Trust hydrotherapy pools. A specialist has been
appointed to assess the cleaning processes and standards for
all pools and the use of the pools have been strictly limited to
hydrotherapy. The Health and Safety Executive has found the
Trust to be compliant in response to actions taken.
While clear progress has been made
in the year regarding pressure ulcers,
significant concern still exists in some
areas either due to delays of reporting
incidents or in relation to prevalence
in specific geographical areas.
Each pressure ulcer occurrence is subject to an immediate
and in depth root cause analysis with an action plan which
includes wider dissemination of lessons learnt. These action
plans are reviewed by the Director of Nursing and Quality and
the Director of Operations, Adults. There is an overarching
Trust action plan and Pressure Ulcer Project Board in place
led by the Director of Nursing. The Board oversees progress
and trends in this area which are reported at all formal and
informal meetings. During the year, specific actions taken
have included tendering and awarding a new contract for the
provision of pressure relieving mattresses; developing closer
working relationships with nursing homes, improving patient
information and targeted training provided to teams about
reporting. Management action has been taken where
appropriate.
Immediate additional support to the team and full assessment
of the clinical standards and protocols in place with actions
identified and implemented. Frequent re-audits of the area to
determine whether the standards are maintained and
extension of the lessons learnt across all relevant areas.
Close Board scrutiny of the progress.
Delayed
identification
of
a
deteriorating patient which may have
adversely
affected
the
patient
outcome.
Table 3. Governance Statements
4.0
Safe care deliverables
Statement
The Trust’s rate of patient safety incidents is 1
per 1,000 patient contacts and of this 0.3%
resulted in severe harm or death, which
largely related to patient falls.
When compared to 2011/12 the overall number of
incidents has reduced in 2012/13 but the rate of
incidents remains consistent against activity. We
want to do better and will continue to strive to
create an environment that:
•
•
•
We have taken action to improve and will
continue to do so in 2013/14.
promotes the safety of each and every patient
equips all staff with the knowledge, skills and
competencies to do so
embeds and spreads the learning from
incidents and near misses
To improve this in 2013/14 we will map all our
quality improvement activity against NHS
England’s four key areas:
•
•
•
•
•
Understanding patient safety
Creating conditions to improve patient safety
Building capacity for patient safety
Supporting a whole system response to
patient safety
Improving key patient harms
Apr
2011/12
Attributable Patient Incidents
May
Jun
Table 4. Safe Care Performance for 2012/13
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
249
280
326
306
287
323
365
391
267
341
323
378
Pressure ulcers (number of forms)
32
34
37
36
64
66
90
109
70
90
108
150
Falls
88
102
78
82
64
76
76
78
75
90
65
79
Safemeds
64
77
87
78
79
87
72
91
44
63
46
40
Severe Harm
0
1
1
0
0
0
0
2
1
2
1
2
Death Harm
1
0
0
0
0
0
1
0
0
0
0
0
Total Severe and Death
1
Patient contacts
‐
1
273645
1
286854
0
264091
0
253943
0
272430
1
269892
2
284473
1
235671
2
278068
1
259344
2
263335
1.0
1.1
1.2
1.1
1.2
1.4
1.4
1.1
1.2
1.2
1.4
0.4
0.3
0.0
0.0
0.0
0.3
0.5
0.4
0.6
0.3
0.5
Incident Rate per 1000 patient contacts
% of Severe and Death Incidents
0.5
Apr
2012/13
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Attributable Patient Incidents
328
370
325
325
380
281
287
299
275
318
297
337
Pressure ulcers (number of forms)
137
156
121
113
135
89
91
86
89
106
105
104
Falls
62
64
73
60
71
63
72
51
49
79
59
70
Safemeds
59
47
58
73
84
55
50
65
54
51
54
66
0
0
0
0
0
0
1
0
0
0
2
0
2
0
1
0
0
0
0
0
3
Death Harm
1
0
Total Severe and Death
1
0
0
0
1
0
2
2
1
0
0
3
251186
290510
247138
277948
250261
251853
281534
274945
217873
259516
216623
219162
1.3
0.3
1.3
0.0
1.3
0.0
1.2
0.0
1.5
0.3
1.1
0.0
1.0
0.7
1.1
0.7
1.3
0.4
1.2
0.0
1.4
0.0
1.5
1.2
Severe Harm
Patient contacts
Incident Rate per 1000 patient contacts
% of Severe and Death Incidents
Attributable Patient Safety Incidents
Reported Incidents
450
400
350
300
250
200
150
100
50
0
Data Extracted 02-05-2013
2011/12
2012/13
0
4.1
Review of 2012/13 goal –
Infection control and
prevention
The Quality Goal 2012/13: No one to
contract Clostridium Difficle or MRSA
in any of our community hospitals.
Clostridium difficile (C.diff) is a bacterium which
can cause serious harm to susceptible patients.
During the year we had no outbreaks (2 or more
linked cases) of Clostridium difficile infection).
How did we perform in 2012/13?
Our target was to improve or not exceed the total
C.diff incidents in 2011/12. We achieved this as
there were 14 incidents of infection in total. This
gives an overall rate of Clostridium difficile
infection of 0.013 per 100,000 occupied bed days.
Statement
The Trust considers that this rate has been
achieved for the following reasons:
•
•
•
The work of the Infection Control and
Prevention Team (IPCT) supported by staff
The Diarrhoea care pathway is widely
embedded across all hospitals. This ensures
that when patients have symptoms they are
promptly isolated and appropriately treated
Improved antimicrobial prescribing
However, two community hospitals reported a
period of increased incidence of Clostridium
difficile infection, where two patients were affected
simultaneously. These were investigated to
establish if the cases were linked, this was found
not to be the case.
Each incident was effectively managed with staff
instigating full infection control measures
immediately and using the diarrhoea care
pathway. All patients responded to treatment and
recovered fully.
Statement
KCHT has taken actions to improve the rate of C.
difficle, and as a result the quality of its services.
Putting Lessons Learnt into Action
Root Cause Analysis (RCA) is carried out for
every case of Clostridium difficile infection, MRSA
Bacteraemia and all outbreaks of infection e.g.
Norovirus to ensure areas for improvement are
promptly identified and addressed to reduce the
risk to patients in the future.
The good practice and areas for improvement
which are identified during RCA are shared with all
relevant persons immediately after publication of
the report.
The key improvements from these RCAs have led
to:
A review of the antimicrobial prescribing
across the whole health economy to reduce
risk of Clostridium difficile infection
Awareness raising regarding the use of proton
pump inhibitors in conjunction with
antimicrobial medication to reduce risk of
Clostridium difficile infection
A new specimen protocol ensuring best
practice.
Improved communication between podiatry
clinic staff and GP practice nurses by the
introduction of patient held communication
sheets of infection status e.g. MRSA positive
Refined reporting arrangements
Revised cleaning systems in community
hospitals
Antimicrobial Stewardship is a priority for us:
Kent Community Health NHS Trust has
adopted the Health Protection Agency (HPA)
Antibiotic Formulary for use across all sites
A sub-group of the Medicine Management
Committee has been established to monitor
the use of antibiotics within the Trust
An audit has been carried out across all 12
community hospitals to examine compliance
with the HPA formulary and to identify the
number of patients who are prescribed both
antibiotics and proton pump inhibitors
KCHT is collaborating with other healthcare
providers and Public Health England to raise
awareness among healthcare workers,
patients and public about the proper use of
antibiotics.
A monthly audit of hand hygiene compliance is
carried out within all in-patient units with
feedback given individually to clinicians.
Although hand hygiene is the focus of this audit it
- 24 -
gives an indication of the standards of infection
control within the department.
•
MRSA - There have been no cases of MRSA
bacteraemia (blood stream infection) since July
2011. This significant achievement is the result of
embedding best practice standards such as: •
•
•
•
•
Careful use of aseptic technique and skin
preparation when administering intra-venous
therapy and wound care to reduce organisms
on the skin
Effective hand hygiene to avoid cross infection
from staff to patient
Reduction of insertion of urinary catheters to
reduce the risk of infection for the patient
99% compliance with MRSA screening of
patients admitted to community hospitals to
identify and isolate at risk patients which allows
treatment to start, reducing further risk to the
individual and other people
100% screening of patients receiving surgery to
optimise recovery and reduce the risk of post
operative infection or complications.
Hand Hygiene
Hand hygiene is the single most important measure
in reducing the spread of infection.
KCHT prioritises hand hygiene for all care
activities and has focused on this throughout
2012/13. The infection prevention and control
team
has
successfully
developed
and
implemented a hand hygiene policy which
includes a zero tolerance approach to non
compliance for all staff groups. This enables the
Trust to take corrective action where staff
repeatedly fail to meet the essential standards
after training and support has been given.
Series1
ry
ua
br
Fe
ar
y
nu
r
Ja
be
ce
m
De
ve
m
be
er
No
ct
ob
O
be
em
r
90
88
r
% com pliance
98
96
94
92
pt
•
All infection prevention and control policies
have been updated to reflect best practice and
national guidance and guide staff to deliver best
practice and reduce the risk to patients.
The infection prevention and control link worker
network has been extended to ensure one link
worker for each clinical team to promote best
practice by leading by example and reducing
risks to patients.
Link workers carry out on site hand hygiene
audits, training sessions and competency
assessments of their peers. This development
reduces the time spent in classrooms for
training sessions helping clinical areas to
deliver high quality care.
102
100
Se
•
Hand Hygiene Audit in Community Hospitals
Month
Figure 1. Hand Hygiene Audit results
The Trust promotes the use of the World Health
Organisations (WHO) five key moments of
hand hygiene (below). All community hospitals
have been carrying out hand hygiene audits
since September 2012 and these results are
reported to the Trust’s Board. The target is
95% (as per WHO guidance).
Infection
prevention and control practitioners support and
guide link workers and other staff to challenge
non compliance in their colleagues, where non
compliances are noted, and reinforce the zero
tolerance message.
Essential Step Re-Audit – P/085/10
Essential steps to safe, clean care is a monitoring
process which supports individual teams to use best
practice to prevent infections and ultimately improve
patient safety. The re-audit was undertaken to
ensure that the actions taken from the first audit
were effective and fully implemented.
The Essential Steps programme monitors practice
of urinary catheterisation and enteral feeding and
also the use of sharps and hand hygiene in
healthcare. The use of this monitoring tool ensures
awareness of best practice with Standard infection
control precautions (SICPs) which reduces the
overall risk of infection to patients and stops the
spread of infection between patients.
Findings/outcomes
• Hand washing technique generally carried out
correctly by all groups of staff
• Use of gloves overall 96% compliant with policy
• Use of aseptic technique around catherisation
was 100% which will prevent infection
• Hand hygiene practice is reiterated through
posters and leaflets and the introduction of a
zero tolerance policy across the Trust
2012
PEAT management
Results
• Sharps
and disposal is part of the
mandatory training update for all staff.
• Staff have
an increased awareness
Patient
Environment
Actionof standard
Team
infection
control
precautions
which should
(PEAT)
reduce the risk of infection for patients
- 25 -
The environment in which we provide care to
patients contributes to their health and wellbeing
and has an important place in our plans to reduce
the risks of hospital acquired infections.
PEAT is an annual inspection that considers nonclinical aspects of patient care and ensures that
standards of cleanliness in the care environment,
the food and privacy and dignity are high. Table
1, shows the results from the PEAT assessments.
Environment Score: This section takes into
account the décor, lighting, cleanliness and
tidiness, odour, furnishings, maintenance, signage
inside and out, floors, linen, arrangements for
personal possessions and waste management.
Maintenance issues are still the main cause for
concern across all sites and would account for
any drops in level from the previous year. These
issues are isolated to minor ones that have not
affected our overall scores and in some sites the
scores have improved to excellent. Where there
has been a drop in score from the previous year,
an action plan has been put in place and
monitored to completion to resolve any identified
issues and to improve the environment for
patients.
Hospital
Faversham
Queen
Victoria,
Herne Bay
Sittingbourne
Sheppey
Deal
Whitstable &
Tankerton
Edenbridge
Gravesham
Hawkhurst
Livingstone
Sevenoaks
Tonbridge
Enviro
Good
Excellent
Food
Excellent
Excellent
P&D
Good
Excellent
Privacy Score: This section includes equality
and diversity training on all sites showing more
awareness of patient needs, concerning
confidentiality, privacy, modesty, dignity and
respect. The Trust continues to ensure that all
staff achieve compliance with equality and
diversity mandatory training requirements to
strive for excellence in this area.
Scoring - Each category is scored using a
scale of 1 to 5.
1. Excellent standards - consistently high;
exceeding expectations.
2. Good standards - almost always meet
expectation and often exceed them.
3. Acceptable standards - usually meet
expectations; room for improvement in some
areas.
4. Poor standards - regularly fail to meet
expectations, significant room for
improvement.
5. Unacceptable standards - fail to meet
expectations in most areas, improvements
are required urgently.
Several hospitals improved on their standards
from 2011:
•
•
Excellent
Good
Excellent
Good
Excellent
Excellent
Excellent
Excellent
Excellent
Good
Excellent
Excellent
Good
Good
Excellent
Good
Good
Good
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Good
Good
Table 5. PEAT results
Food Score: This section reflects the level of cooperation between catering and ward staff to
ensure that the availability of food and beverages
meet the patient’s dietary requirements. The
introduction of the Patient Experience Group
(PEG) and the Nutritional Steering Group has
provided two different forums where all aspects of
patient’s food requirements can be reviewed and
changes made. Plans for the year ahead in food
and hydration will improve PEAT performance.
•
•
Whitstable
and
Tankerton
Hospital
improved in privacy and dignity to achieve
an excellent rating
Livingstone Hospital also improved in the
privacy and dignity category
Sevenoaks improved from acceptable to
good for the environment
Tonbridge also improved from acceptable to
good in the environment category
Unfortunately two hospitals have dropped
categories from 2011:
Sheppey Community Hospital dropped from
excellent to good in the environment category
due to some areas needing to be painted which
was added to the Capital Programme and
completed within the financial year. They also
dropped from excellent to good in the privacy
and dignity category due to some areas within
the clinical area not having sufficient privacy
curtains e.g. at bathroom door. These were
also added to the programme for the landlord to
address and followed to completion.
Deal Hospital dropped from excellent to good in
the privacy and dignity category due to a
designated private area for confidential
- 26 -
In each of these areas the hospital management
team liaised with the facilities team within NHS
Kent and Medway, who owned the buildings, to
make improvements to the environment and
address privacy and dignity concerns within the
hospital through the PCT capital project
programme.
A new system for assessing the quality of the
hospital environment has been developed
nationally. This replaces the Patient Environment
Action Team (PEAT) and is known as Patient-Led
Assessment of the Care Environment (PLACE).
This was due to begin in April 2013.
What we need to do in 2013/14 (Quality Goal
1; 2; 3; 4)
•
•
•
•
•
•
•
•
Increase public representation in our
assurance group and involve those reps in
the public/patient hand hygiene campaign
during infection control awareness week in
October.
Implement patient led PLACE visits.
Implement the Trust action plan for zero
tolerance of MRSA and put a plan in place to
reduce C.diff by 30 per cent. This is in
collaboration with medicines management,
clinical teams and is part of the whole health
economy approach to reducing C.diff.
Further reduce urinary tract infection and
catheter associated urinary tract infection by
50 per cent overall. So far a 25 per cent
reduction has been achieved.
A short term working group has been
established to support this including reps from
the bladder and bowel team and community
hospital matrons to share best practice and
improve service access to bladder/bowel team
and specialist services - including continence
products, approved catheter list.
Ensure all guidelines reflect national best
practice.
Produce an annual report on infection control
and prevention service.
The Quality Committee will monitor quarterly
performance and quality.
Review of 2012/13 Goal –
Pressure Ulcer Reduction
The Quality Goal 2012/13: Embed
and measure quality improvement in
services in relation to pressure
ulcers
For patients pressure ulcers are a painful and
often debilitating experience that leads to
extended length of stay or treatment.
Reducing the incidents of pressure ulcers has
been a key priority for the Trust and a key
focus for continual improvements. Last year
the goal was to achieve zero attributable
avoidable grade 3 and 4 pressure ulcers. We
did not achieve this and we are extremely
disappointed and concerned that this has not
been achieved in all areas this year.
How did we perform in 2012/13?
Despite the apparent increase in reported
incidents the graph figure 3 demonstrates a
downward trend for pressure ulcers that have
been acquired and are attributable whilst under
the care of KCHT. However, a number of
pressure ulcers are inherited from other care
providers and settings that are not attributable
to KCHT. In this regard we have started to
work with other health partners and clinical
commissioning groups (CCGs) to try and
address these issues.
In 2012/13 75% of teams achieved zero
attributable avoidable grade 3 & 4 pressure
ulcers and a further 13% had only one incident.
The nursing and quality teams are now
working with the successful teams to identify
factors that make the greatest difference in
practice. Additional support is also being given
to teams to embed best practice and enhance
quality improvements to support further
reduction of pressure ulcers for 2013/14.
300
Pressure Ulcers (Grade II - IV) split by Attributable and
Not Attributable
250
Reported Pressure Ulcers
conversations – this has been resolved and a
quiet room is available on the ward for patients to
use for confidential meetings with healthcare staff,
visitors or for faith. A room is also available for
these uses in another location within the hospital
for other departments to use e.g. out patients.
200
150
100
50
0
-1 2 b-12 ar-12 pr-12 ay-12 un-1 2 ul-12 g -12 ep -12 ct-12 ov-12 ec -12 an-1 3 eb-13
J
S
O
J
N
D
F
J
A
M
J an Fe
Au
M
Figure 2. Pressure Ulcers incidents
Attributable (II - IV)
Not Attributable (II - IV)
- 27 -
Data quality and completeness has been a huge
challenge across our more than 100 community
teams. The move from a paper-based collection to
an electronic reporting system has resulted in
improved data capture processes, reporting
standards and close monitoring of the level of
compliance by each team. It was anticipated that
with raised awareness it was likely that there
would be an increase in reporting as previously
there had been under reporting. For us this
means that potentially more of our patients had a
poor experience and poor outcomes in our care or
within the health economy of Kent than was
previously reported.
Ongoing analysis identified two key issues:
Both the framework and practice standard have
been updated during the course of the year
ensuring responsiveness to lessons learnt.
To address the high incidence of pressure ulcers
on the feet a shared care pathway has been
developed with podiatry and implemented. In
addition an awareness campaign alerted staff to
how damage can be prevented on the feet.
Percentage of Team -Months per Locality w ith No
Avoidable Pressure Ulcers
120%
100%
80%
60%
40%
Percentage of TeamMonths w ith No
Avoidable Pressure
Ulcers
20%
•
•
Shared care - In response KCHT has
developed and implemented a shared care
protocol. The aim of this is to improve
communication and the approach to shared care
between domiciliary agencies, residential and
nursing homes.
This high profile focus has led to a significant
reduction of 15% in the numbers of pressure
ulcers on the feet. The activity included:
•
•
•
W
K
T
W onb
K
M ridg
ai
ds e
to
ne
D
As GS
h
Sh for
ep d
w
a
S y
D wa
ov l e
er
De
T al
C han
an
te e t
rb
ur
y
0%
Figure 3. % of teams per locality with no avoidable pressure ulcers
Investigations into all attributable avoidable grade
3 & 4 pressure ulcers have continued and the
sharing of good practice and lessons learnt has
been encouraged. Some teams have been
extremely innovative in their approach to improve
patient care to ensure the lessons learned change
practice.
Learning
“The team was devastated that a patient had
developed a pressure ulcer under their care.
Many lessons have been learnt and a simple
change in practice has been implemented to
ensure mattress settings are set appropriately
for the patient’s weight with a laminated guide
for all staff. This resource is being shared along
with proactive education with care home staff
on the importance of pressure ulcer prevention.
This approach has improved communication,
patient safety and outcomes. The laminated
guidance has been adopted across the locality
and is available for all KCHT staff.”
District Nurse Team Leader
where a patient’s care is shared between
two or more services the associated risks
are increased
69% of grade 3 & 4 attributable avoidable
pressure ulcers occurred on the feet
•
•
•
•
posters highlighting the issues and
preventative actions
screen savers on all Trust computers
working with the moving and handling team
to ensure training addressed the associated
risks
working with occupational therapists to raise
awareness on seating
involving the wheelchair service for advice
on transfers and the equipment provision
team to ensure a slide sheet for the feet is
supplied with a hoist
the assessment form for a bed request now
incorporates prompts for staff to consider
pressure damage to the feet,
The tissue viability team has developed a
prompt, signposting staff to complete a
lower limb assessment.
During the year we were successful in a bid for
an innovation grant. This project focused on
pressure ulcer prevention and management
training for staff working in nursing and
residential homes. An early indication is that this
training has increased the confidence and
competence of the staff who have undertaken
the programme in a number of ways:
•
improved
referrals
for
patients
for
assessment by the District Nursing teams
- 28 -
•
•
•
Identification of people at risk of Pressure
Ulcer damage and the need to change
patient’s position
Identification of moisture lesions that need
prompt intervention to prevent deterioration
into a pressure ulcer
Understanding the need for a timely referral to
key professionals.
More details can be found in section 11.
An example of the programme’s success
A care home staff member identified a moisture
lesion on one of the residents. A prompt
referral to the district nursing team and
appropriate action ensured that by the following
day the moisture lesion had healed. For this
resident it meant the avoidance of the
development of painful pressure damage.
Learning from our RCAs and discussions with
staff we identified that Allied Health Professionals
(AHPs) were not routinely included in our
education programmes on pressure ulcers.
This staff group often see patients who are
potentially at risk who have no community nursing
input. This gap has been addressed with AHPs
and Podiatry teams receiving the necessary
training in assessment of pressure damage and
prevention using the Waterlow tool.
The Nutrition and Hydration campaign has run
throughout 2012/13 providing advice and
resources for patients and staff to support the
reduction of pressure damage.
An audit has been undertaken against the
pressure ulcer standard. The results showed that
81% of the reported pressure ulcers were
unavoidable. Key areas for improvement include
undertaking and documenting:
•
•
•
•
•
•
•
•
•
•
provision of written information to patients
and carers
further implementation of the Influencer
Strategy
Further competency based training for
staff
Work with remaining teams that have
failed to achieve zero
Ensure that 100% of teams adhere to the
pressure ulcer standard
Implement the pressure ulcer pathway as
part of the wound medicine project.
Safety Thermometer
The NHS Safety Thermometer is a national
improvement tool for measuring, monitoring
and analysing patient harms and ‘harm free
care’. A survey of patients is undertaken
across the whole county each month on a
specific day. The tool provides a ‘temperature
check’ on harms and enables teams to see
the proportion of patients that are ‘harm free’
on that day.
How did we perform in 2012/13?
The
safety
thermometer
has
been
successfully implemented within the Trust
achieving the CQUIN target.
KCHT’s percentage of harm free care (HFC)
has been on average 93.4% this has been
consistently higher than the National and
Regional benchmarks:
•
•
HFC National: 92.24%
HFC South of England:92.36%
holistic assessment and reassessment in a
timely manner by a senior clinician
provision of written information to patients and
carers
further implementation of the Influencer
Strategy
What we need to do in 2013/14
Key areas for improvement include undertaking
and documenting:
•
holistic assessment and reassessment in a
timely manner by a senior clinician
Figure 4. Safety Thermometer performance
- 29 -
We have been recognised nationally for the
numbers of patients being surveyed each month.
Total patients surveyed for 2012/13 was 31,868.
Pressure ulcers new and old are the highest
cause of harm to patients.
The safety thermometer data is continually
monitored and is triangulated with other
information as part of our focused ‘deep dives’
into specific areas where harms are outlying. The
data is being analysed at CCG level and is being
used in conjunction with other data to highlight
areas for improvement and identify where harm
free care is high.
Continue to aim for zero attributable 3 & 4
pressure ulcers and to aim to achieve a
reduction in the numbers of avoidable
grade 2 pressure ulcers.
Develop a virtual ward approach to
managing and supporting teams where
figures are high.
Set trajectories for each locality for team
leaders and clinical sisters’ competency
assessment sign off.
•
•
•
4.2
Review of 2012/13 Goal –
Falls Prevention
Venous Thrombo-Embolism
Sept
90.0
%
Oct
98.0
%
Nov
96.0
%
Dec
95.0
%
Jan
96.0
%
Feb
96.0
%
Mar
98.5
%
Statement
KCHT considers that this percentage is as
described for the following reasons: •
•
Gaps in the knowledge and skills of staff were
addressed
Exclusion criteria was put in place
The Trust intends to continue to provide
education and training to staff and build on the
high level of compliance achieved and embed the
Safety Thermometer
What we need to do in 2013/14 (Quality Goal
1; 2; 4; 5)
•
•
•
•
•
sustain and improve the percentage of harm
free care across KCHT.
ensure teams are acting on their safety
thermometer results to improve patient
outcomes and reduce harms.
work in partnership with other stakeholders
such as acute hospitals and nursing homes to
deliver a whole health economy approach to
the reduction in pressure ulcers.
work in partnership to improve shared care
with
domiciliary
agencies,
residential
and nursing homes.
Set trajectories for a reduction in attributable
unavoidable pressure ulcers.
The Quality Goal 2012/13: Embed and
measure quality improvement in
services in relation to patient falls
Falls prevention and management is an
important quality goal for us, as it is well
documented that although falling is not an
inevitable result of ageing, the risk of falling
increases as people get older. For many
patients once they have a fall the subsequent
fear of falling and loss of confidence in carrying
out their normal activities can be extremely
debilitating. Although most falls don’t cause
serious injury, a fall can cause a broken bone,
which may be difficult to recover from.
How did we perform in 2012/13?
In August 2012, a multi-professional Falls
Prevention Group was established to drive
improvements in clinical practice and achieve a
reduction in the number of severe and
moderate harm falls and improve outcomes for
our patients.
Attributable Patient Falls
120
100
Reported Falls
Within the safety thermometer is the assessment
of patients at risk of venous thrombo-embolism.
The target set nationally was (95%) and from a
starting point in September of 90% the Trust
achieved 98.5% by the end of the year.
80
60
2011
40
2012
20
0
r
Ap
y
Ma
J un
J ul
g
Au
p
Se
t
Oc
v
No
c
De
J an
Feb
r
Ma
Figure 5. Falls incidents by month
The trend is demonstrating a significant
month on month reduction from 2011/2012
results. The target we set was a reduction of
- 30 -
falls of 10%. We have exceeded this target by
19%.
NHS
Benchmarking Network - NHS
Benchmarking Network (NHSBN) based on
2011/12 figures average falls with injury at 45.58
per month. KCHT’s comparison to the NHSBN
benchmark is 24.5 falls with injury per month.
•
A clinical audit has been undertaken and
results are pending
What we need to do in 2013/14 (Quality
Goal 1; 2; 3)
•
•
•
•
•
•
•
hold a falls conference to share and
promote best practice
identify further service gaps
improve training and education to staff and
patients in collaboration with other agencies
introduce ‘night care plans’
work with patient groups to carry out
observational audits
continue to improve patient nutrition and
hydration
implement the action plan arising from the
clinical audit
A patient story
Figure 6. Falls by level of harm
The following actions have been implemented
during 2012/13 which have contributed to the
improvements in the number and severity of falls:
•
•
•
•
•
all older people in contact with any of our
healthcare professionals have a falls risk
assessment undertaken routinely
an effective communication measure for staff
is the colour coded wrist band. This indicates
whether the patient is independent; requires
supervision or assistance to mobilise. This
was developed by one of our teams and has
been adopted across all of the community
hospitals.
Policies reviewed and implemented to reflect
best practice e.g. NICE.
Twenty new high low beds and chair sensors
have been purchased to help reduce falls in
community hospitals
Patient information leaflets and booklets have
been developed and are available for patients
and carers.
A patient with a history of falls at home was admitted to a
community hospital from the acute trust for rehabilitation.
Whilst in the community hospital the patient had a
•
witnessed
fall sustaining a fractured neck of femur and
was re- admitted to the acute trust.
Best practice and lessons learned from previous
incidents.
• A full admission assessment was completed within
the 24 hour timeline.
• The patient was allocated a high low bed and was
nursed in a observable bed as it was known that the
patient had a history of falls
Areas for action
• The patient became anaemic (low haemoglobin) this
led to an acute episode of confusion. During this
period the patient had a fall sustaining a fractured
neck of femur
a. Alert staff to risks associated with anaemia
b. Falls prevention pathway for patients with acute
confusion to be developed
Lessons learned
KCHT continues to strive to learn from serious incident
investigations, especially those incidents that result
in harm to patients. Investigations can also provide
evidence that learning from previous incidents have
been
this case demonstrates
and
4.4 embedded
Reviewwhich
of 2012/13
Goal –
is used Nutrition
to show goodand
practice
as
well
as
areas
for
Hydration
improvement.
All incidents of falls are reported and a Root
Cause Analysis (RCA) is undertaken to ensure
that best practice has been followed and to
identify any organisational learning:
• a Board review is undertaken monthly
• updates to staff on falls is available on the
intranet and there our Lessons Learnt and
Quality Newsletters to embed learning.
• The Pharmacy team undertake medication
reviews for all patients in community hospitals
to reduce the risk of them falling.
- 31 -
4.4
Review of 2012/13 Goal
Nutrition and Hydration
–
The actions taken in response to the findings
are proving effective and include:
•
The Quality Goal 2012/13: Embed and
measure quality improvement in services
in relation to food and nutrition
•
•
•
Malnutrition affects over 3 million people in the UK
with approximately 1.3 million being over the age
of 65. The Trust has sought to further strengthen
the detection and treatment of malnutrition
amongst all patients under our care.
How did we perform in 2012/13?
Data across the different services within KCHT
shows that we are continually exceeding our local
standard of 85% of MUST screening being
completed within 24 hours in all community
hospitals.
Our vision is to go beyond MUST screening to
ensure implementation of care plans with the
inclusion of hydration as a key component of
basic care.
Nutrition link roles – this role has been
reviewed across the Trust. To improve practice
the Trust is moving from link workers to ‘Nutrition
being everyone’s business and everyone is
accountable’ and this will be audited in 2013/14
Clear criteria for MUST exclusion – where it
is inappropriate for a MUST assessment to be
undertaken. This has been clarified and the
action to be taken for these groups of patients has
been introduced in the revised documentation
Facilitating change in behaviours and
embedding new practice – a knowledge
survey was undertaken across two services to
understand the current behaviours and levels of
practice.
%
77%
70%
49%
44%
Introduction of specific resources for staff to
give to patients as first line advice
Weekly updates available on the Trust
intranet
Updated education modules on the 2013/14
1st Class Care programme
Nutrition and Hydration campaigns
Re-launch of the Nutrition and Hydration
campaign training – a revised module was
introduced in the 1st Class Care Programme
delivered to our newly qualified nurses. The
evaluations by the staff were excellent. The
impact on practice and outcomes for patients
will be monitored through our clinical audit
programme.
Following an incident in a community hospital
where the consistency of puree meals was
noted to have been incorrect a catering training
programme is being rolled out across the Trust.
To date seven out of twelve hospitals have staff
trained on puree diets and catering for patients
with swallowing problems. Whilst no one came
to any harm this training has served to give
assurance of the type and level of puree needed
and improved the knowledge of catering staff. It
also raised the need for more up to date kitchen
equipment for puréed meals.
A baseline clinical audit on hydration was
carried out across the community hospitals to
assess the level of compliance with the
standard that there must be a minimum of eight
drink rounds a day for our patients. Audit results
showed an average of 5-6 drink rounds across 7
hospitals. Our action plan following this audit
includes increased drinks being offered. The
Trust has also signed up to be part of a national
study to improve fluid intake of hospitalised
patients using a piece of equipment called a
Hydrant (pictured below). The project will start in
May 2013.
Nutritional Knowledge Survey:
Findings: 44 Staff
Understood and felt confident using MUST
Were aware that nutrition was important in
wound care
Were unaware of the first line advice to give
patient with wounds
Were unsure of practical first line advice to
promote fluid intake
Table 7. Knowledge Survey results
- 32 -
The Director of Nursing’s team are out in clinical
practice each week. This is known as Clinical
Assurance Days (CAD). The aim is to work with
staff; provide opportunities to share concerns;
identify gaps in knowledge or practice and support
staff to improve practice. Between December
2012 and January 2013, the dietetics team joined
the senior team to undertake CADs focused on
nutrition and hydration. This demonstrated:
•
•
•
•
•
high compliance with MUST assessment and
weekly review
Protected meal times well established
Food charts in place to monitor patient intake
where required
good documentation in relation to care plans
most areas promoted meal times as a social
event
Areas where there were variations noted as:
•
•
inconsistent
implementation
of
weekly
weighing of patients
Available information for patients and relatives
This year the Trust’s dietetics and nursing teams
actively participated in the National patient safety
week which was focussed around nutrition and
hydration. This involved a high prolife campaign in
March 2013 (which was covered by radio and
newspapers) to raise awareness amongst nursing
staff. This also saw the launch of a useful
resource: Nutrition and Hydration: Guide for
community nurses. This pocket handbook was
designed as a quick reference tool to support
nurses in delivering excellent nutritional care to
our patients. Copies were printed and distributed
across the Trust.
A large part of the week also focussed on our
recruitment campaign for meal companions to
provide support to non-complex patients across
our community hospitals.
This volunteer role provides assistance to patients
to meet their nutritional needs. Volunteers have a
defined role and receive specific training and
assessment prior to taking on this role. One
volunteer was interviewed by a local radio station
interested in the importance of this role.
Since nutrition and hydration week, we have
noted an increased interest in this role and aim for
at least two volunteers per ward during meal
times. In community hospitals we have achieved
100% consistent compliance with protected meal
times since 2011.
Fig 7Nutrition and Hydration Handbook for community nurses
Case Study: Concern
A concern was raised at one of the Trust’s
public meetings by a patient with an interest in
Interstitial cystitis. She noted that the drinks
trolleys / menus in the community hospitals
routinely offered caffeinated beverages to all
patients. Such beverages can be potential
irritants to patients living with this condition.
She raised the issue of particular diagnoses
where patients may be specifically sensitive to
caffeinated beverages and would need to be
offered alternatives routinely.
We noted that not many patients in our
community hospitals are admitted or referred
to dietetics with this complaint. However the
issue was escalated to one of our specialist
dieticians for discussion. The needs for such
alternatives was substantiated and though not
common in our inpatients as a primary
diagnosis, it was felt that we could proactively
support patients with Interstitial cystitis with
such needs for alternative caffeine free
beverages.
The issue was raised at our Nutrition Steering
group and the catering team agreed to support
such requests for herbal teas on request from
wards.
Wards will also specially buy in such drinks as
needed for specific patients. Further work is
ongoing looking at a specific assessment tool
which nurses will use on admission to
ascertain any individual hydration and dietary
needs to ensure we meet the needs of our
patients.
The patient who raised this issue is now our
patient representative on the Trust’s Nutrition
Steering Group.
- 33 -
What we need to do in 2013/14 (Quality Goal
•
1; 3)
•
•
•
•
•
•
Ensure that no patient suffers from
dehydration or malnutrition
Ensure that every patient has a nutritional care
plan specific to their needs
Repeat the staff knowledge survey
Repeat the nutrition and hydration CADs
Evaluate and action the results of the Hydrant
project
Implement actions from the clinical audit on
hydration and repeat audit
4.5
•
•
Review of 2012/13 Goals –
Transfer of Care
Developing and networking with key
personnel to launch and promote the new
policy has already been effective in alerting
staff to the risks and issues associated with
the transfer of clinical care.
Multi-agency groups have been established
with three of our local acute Trusts to work
in partnership to agree standards and
practices to ensure a coordinated approach
to transfer of care, thus improving patient
safety and patient experience across
organisational boundaries
To enhance the standard of internal
‘handover’ of care within and between teams
a new tool is being introduced which
provides guidance to staff on the minimum
data required
What we need to do in 2013/14 (Quality
The Quality Goal 2012/13: Embed and
measure quality improvement in
services in relation to Transfer of Care
Goal 3; 5)
•
•
Last year patients and carers told us that transfer
of care was an area that they wanted KCHT to
focus on.
Through our review this year we found that there
were a number of contributory factors that led to
problems when patients’ care was transferred
between services:
•
•
•
•
a variety of templates in use for recording
patient information needed for transferring or
discharging into/from another service, agency,
or provider
many different standards and approaches to
transferring or discharging patients
acute sector transfers did not always include
key information required by the community
nurses or the community hospitals
staff were not routinely reporting these cases
as they were viewed as an inconvenience
rather than an incident or ‘near miss’.
How did we perform in 2012/13?
•
A new policy has been developed. This sets
out the expectations and standards in relation
to transfer of care and mandates the standard
of communications and documentation to
enable accurate and appropriate information
to be shared prior to, at the point of and
following patient transfer.
•
•
•
•
Ensure that there are no gaps in patients
care due to transfer
Continue to work with other providers to
develop integrated care pathways
Continue the work in Children’s services to
improve the transition to adult services
Develop a patient held discharge passport
Undertake a clinical audit to assess the level
of compliance with the new policy
Improve the reporting system for reporting
transfer of care incidents and establish
routine reporting and monitoring of these
incidents
KCHT working with East Kent Hospitals
Foundation Trust
A newly designed template that provides a
minimum dataset of patient information
that staff are required to receive/give has
been
developed
jointly
between
organisations to ensure the right
information and equipment is transferred
with the patient.
The pilot is being
extended to other areas.
Teams meet regularly. All transfer of care
incidents are investigated and the learning
is used to improve the care of patients.
- 34 -
Transfer of Care
The Infection prevention and control team has
led the development and implementation of a
patient held urinary catheter passport. This
document improves patient care by:
•
•
giving patients and carers clear advice on
what they can do to reduce the risk of
urinary tract infection
allowing continuity of care between health
care professions who are able to share
information across organisations relating to
interventions or problems with the catheter
MaPSaF Scores
18
16
14
12
10
8
6
4
2
0
More than 6000 copies have now been
delivered to clinical teams and patients.
Patients and carers report an increased
knowledge and awareness of how to care for
the catheter and a more positive experience
when attending accident and emergency or
out of hours services with catheter problems.
4.6
Review of 2012/13 Goal –
Patient Safety Walkabouts
The Quality Goal 2012/13: Embed and
measure quality improvement in
services in relation to executive patient
safety walkabouts to move from a
culture of bureaucratic to a
proactive/generative organisation
The Patient Safety Executive walkabouts
programme initiated in January 2012 continues
with regular visits to a range of teams and
services. The visits were set up as part of the
organisation’s commitment to patient safety and
‘Board to ward’ communication. Staff have met
with an Executive Director and Non Executive
Director (NED) to share examples of best practice
and highlight any patient safety concerns.
How did we perform in 2012/13?
We have achieved 79% of the possible 47 visits to
date with an average of three walkabouts per
month. The Manchester Patient Safety Walkabout
framework has been used to classify the maturity
of the patient safety culture for teams visited. This
has demonstrated a classification of “D –
Proactive: we are always on the alert/thinking
about patient safety issues that might emerge.”
A
B
C
D
E
Figure 8. Patient Safety Walkabout
How did we perform in 2012/13?
The results of the visits have identified key
issues which have been grouped into six
patient safety related themes and actioned:
Communication:
• include improvements to communication
within and between teams and requests for
more feedback on service developments,
restructuring and information dissemination
at team and locality meetings.
• The Trust’s Change Champions have
undertaken a review of the communication
process from ‘board to frontline to board’.
The results are currently being analysed.
The aim is to understand the issues and use
the results to improve how key messages are
deployed
Risk management:
• concerns about lone working have been
addressed with teams reminded of the policy
and accessing of available equipment.
• Risk registers are included in team meetings
and we are increasing staff awareness of local
risks
Equipment:
• issues included requisitioning and access to
pressure relieving equipment. This has
improved since the introduction of the new
contract.
• Other concerns related to the provision of
mobile phones and coverage which local
managers are reviewing with their teams;
• Identification of available funds for equipment
enabling printers and additional thermometers
to be provided. The League of Friends
provided more sensor alarms in a community
hospital
- 35 -
Staff value meeting with the Executive Team and
the opportunity to voice concerns and showcase
good practice.
“All the staff have indicated that it was a very
positive experience and that the opportunity to
talk with and to be listened to by a senior member
of the Executive Board and a member of the
Trust management has resulted in them feeling
that they have been acknowledged as a
significant part of the organisation and feel able to
raise concerns.” Service Manager
“I would like to thank you for your time visiting my
team. It was a very positive experience for all of
us to be thought of and listened to. I will make
sure that your findings will be followed up and will
keep you informed of the progress we make”.
Service Manager
Action Theme
50
45
40
35
30
25
20
15
10
5
0
Training
Transfer of Care
Staffing / workload
Service
Staff developm ent
Role standardisation
Recruitm ent
Risk m anagem ent
Pharm acy
Quality and safety
Patient involvem ent
IV
Lean working
IT
IPC
Inform ation
Incident learning
Equipm ent
Estates/Environm ent
Docum entation
Com m issioning
Series1
Com m unication
Incident reporting and learning:
• making sure teams always receive feedback
after an incident and ensuring staff know how
to use the reporting system
• The Lessons Learnt newsletter: has been
re-launched and the Trust’s team meeting
agenda now includes discussion of risks and
incidents
Service development:
• included developing and publicising a
directory of services and ensuring the new
Clinical Commissioning Groups are aware of
what the Trust can offer. One action focused
on ensuring a joined up approach to service
delivery such as copying GPs into all
correspondence, and involving GPs as
partners in care where appropriate, such as
end of life care
Requests for training
• in one day and closer to base were a
frequent request and issues around training
were fed back to Learning and Development
• initiatives making it easier for staff,
particularly clinical teams, to keep up to date
with mandatory training:
• Booking time and PC access within
clinical teams for e-learning.
• the Skills Marketplace facilitated by CEST
which will enable clinical staff to maintain
competence in essential skills
• the Information Governance Pod has been
taken out to bases and includes displays
and IG guidance, and the IG questionnaires
which can be completed and marked
immediately.
Figure 9. Action Themes
What we need to do in 2013/14 (Quality
Goal 1)
•
•
•
continue the walkabouts across all sites
revise the way data is captured to make the
analysis of patient safety easier
introduce a pre visit questionnaire based
on ‘Silence Kills’ as a Patient Safety
barometer
4.7
Review of 2012/13 Goal –
Health Visiting
The Quality Goal 2012/13: Embed and
measure quality improvement in
services in relation to the Health
Visitors’ Programme
KCHT has worked hard to fulfil its commitment
to the delivery of the Health Visiting
Implementation Plan (HVIP)
How did we perform in 2012/13?
One element of the plan is to achieve an
increase in the number of Health Visitors to
342.5 wte by 2015, from a starting position of
154 wte in April 2011. KCHT achieved the
March 2013 target of 217 wte,
The HVIP aims to:
•
ensure that the new Health Visiting service
model delivers an aligned public health and
healthy child programme for all children
aged 0 to 5 years and their families
- 36 -
•
allow all children to have access to early
intervention, prevention and health promotion
services which will help them achieve their
optimum health and wellbeing.
As the number of health visitors increases, we will
be able to deliver the new four level service model
so that all families can expect the following:
•
•
•
•
a range of services within the community
including some Sure Start services. Health
visitors will work to develop these and make
sure families are aware of them.
full provision of the Healthy Child Programme
to ensure a healthy start for children and
families (for example , health and
development checks) and support for parents
a rapid response when they need specific
expert help, for example with postnatal
depression, a sleepless baby, weaning or
answering any concerns about parenting.
ongoing support and advice with more complex
issues over a period of time. These include
services from sure start children centres, other
community services including charities and
where appropriate, the Family Nurse
Partnership.
To improve our services this year we have been
able to start to offer a targeted antenatal contact,
helping build early relationships and provide
support to parents.
We have increased our uptake of the two and a
half year development check, we are now half
way to having 100% cover across KCHT. We
have reintroduced the 1-year check across KCHT
and achieved 60% uptake
We have achieved this increase through a variety
of ways: •
•
•
being successful in attracting qualified health
visitors and practice teachers to join our team
from both within and outside Kent.
attracting health visitors back to practice, by
working with the local universities to offer a
variety of bespoke ‘return to practice’ courses.
training of new health visitors through the
Specialist Community Public Health Nurse
(SCPHN) courses at Christ Church Canterbury
and Greenwich universities.
Leading the Way
To facilitate the HV training we have trained
additional Practice teachers and Specialist
mentors to provide the practical elements of
the course. KCHT has introduced a band 5
development post, this allows students to have
several months to familiarise themselves with
the role and prepare for the course. This
initiative has started and is replicated across
the county. This is similar in intent to the
recommendations made in the Francis Report
for the proposed development of general
nurses
training, including skills and performance
monitoring and tripartite meetings with the
universities. This helps us to ensure that we
maintain the competencies and qualities of our
future health-visiting workforce. Some of the
actions we have implemented have been
recognised of innovative and adopted
nationally, including:
• working with our local universities, to develop
a ‘specialist mentor’ role, which assists with
the support and supervision of the students.
By 2015 the Trust wants to achieve delivery of
the Healthy Child Programme across the whole
of KCHT. This year we have been able to
increase our core offer to include a targeted
antenatal contact, 50% uptake of the 2.5 check
and 60% of the 1 year check.
Evaluation
The evaluation of the first local pilot where
Health Visitors and Early Years staff were
trained to promote the ‘Active Baby‘ to
families, showed an impressive rise in the
number of children who achieved the ability to
crawl from 34% to 90% in the first 12 months.
According to neuro-scientific research active
movement, as demonstrated when crawling
in the first 12 months, enhances emotional,
intellectual, and physiological growth of the
child, helping them achieve their full potential.
Early Implementer Site
Once on the course students have a wide range
of support to help them gain the most from the
In 2012, KCHT was accepted as a 2nd wave
Early Implementer Site (EIS), giving KCHT
support from the Department of Health (DH)
Health Visitor EIS team. The Health Visitor
- 37 -
Leadership team has attended regular workshops
and meetings and had the support of our EIS
coach to develop our service delivery. In addition
two case studies, will be published by the DH as
best practice one of which we have been invited
to present at the International Public Health
Conference in Ireland. The two case studies
demonstrate new ways of working around early
intervention and prevention.
‘Active Baby’
It is acknowledged that the start of life is a
crucial time for children and parents, in laying
the foundations of good health and wellbeing in
later years. A child’s early experience and
environment influences their brain development
during these early years, when warm, positive
parenting helps create a strong foundation for
the future. Active baby has been found to
promote
cognitive
development
through
movement and positive parenting through
interaction.
This work has highlighted a growing issue of
children arriving at school ill prepared to learn.
This includes issues such as poor toilet control.
Health Visitors and School Nurses have
responded to this issue by developing a
programme to support children and families.
All health visitors will be trained to promote
‘active baby’ and all children centre and early
year’s staff will be trained in this approach.
The Family Nurse Partnership (FNP) is a
preventive programme, usually offered to first-time
young
mothers in line with government policy. In KCHT
the first team was in Thanet and Swale and was
introduced over a year ago, 50 families are now
benefiting from the programme. A second team
has been introduced in Maidstone.
National evaluation shows that those mothers on
the programme demonstrated improved health
related behaviour than those not on the
programme in areas such as:
•
•
•
•
•
good nutrition during pregnancy
lower smoking and alcohol use
better breast feeding rates
babies are less likely to require stays in
special care baby units
growth and development at six months
was found to be average or above.
Initial results for Thanet and Swale reflect the
national findings.
What we need to do in 2013/14 (Quality
Goals 2; 3; 5)
•
•
•
increase the number of families benefitting
from FNP programme across Kent
to roll out a universal antenatal contact for
all families recognising the importance of
early intervention and building networks for
early
support
and
preparation
for
parenthood, in areas such as breast feeding
roll out the early intervention and
prevention. models
4.8
Review of 2012/13 Goal –
Safeguarding
The Quality Goal 2012/13: To promote
a culture of safeguarding across all
areas of the organisation which is
embedded in the holistic care that we
provide to children and vulnerable
adults
Safeguarding sits at the heart of all care that we
provide to our service users. To this effect, we
set a number of goals last year, to address
areas where previously we may not have been
as effective in ensuring peoples’ safety as we
could have been.
How did we perform in 2012/13?
Safeguarding Children
During the year, we worked closely with our
partners in social care to ensure that our staff,
who work predominantly with children and their
families,
understood
the
multi-agency
thresholds that have been developed to help
them identify and manage safeguarding and
child protection concerns.
An in-year audit of how our staff applied these
thresholds showed:
•
that they have a sound understanding of
how to use them appropriately and are
confident in challenging partner agencies
decision-making where they think the
decisions made may not have been in the
best
interest
of
the
child.
- 38 -
•
where it was identified that children and their
families could benefit from early intervention
services, we were able to provide access to
them by the timely use of the Common
Assessment Framework (CAF). This meant
that vulnerable children and their families
received early support from one or more local
agencies, to prevent their situation becoming
serious.
As a result of these interventions, whilst the
overall number of child protection referrals
remained steady during 2012/13, only those
children who were identified at risk of significant
harm were made subject to a Child Protection
Plan. The number of re-referrals and the number
of children subject to a Child Protection Plan for
longer than 18 months reduced.
In 2010, Ofsted and the Care Quality Commission
identified poor use of the CAF process by local
agencies. The Kent Improvement Board set a
target for KCHT to complete 150 CAFs by 31
March 2013 so that early and often intensive
support was made available to address the needs
of more vulnerable children and their families.
In 2012/13, a detailed multi-agency audit of
agencies’ statutory responsibilities under section
11 of the Children Act 2004 was undertaken by
the Kent Safeguarding Children Board (KSCB).
KCHT was identified as an exemplar organisation,
in terms of the arrangements in place to
safeguard and protect children and young people
and the robustness of the evidence.
KCHT also completed a detailed piece of work
to ensure that all of the actions identified in local
Serious Case Reviews were completed. KCHT
was commended for the organisation’s ability to
demonstrate that the protective services we
provide to children, young people and their
families are evidence-based and of the highest
standard.
Child Protection Safeguarding Supervision Audit –
P/033/11
The audit was undertaken to ensure that staff were
accessing Safeguarding Protection Supervision and
utilising it effectively to safeguard children.
Findings/outcomes
• 97% of staff surveyed stated that they had attended
Child Protection Supervision
• Results of the audit have been used to inform the
development of a new Kent-wide Safeguarding
Supervision Policy
• Staff stated that the Child Protection Supervision is
very valuable and they feel supported.
• A robust action plan ensures the child is better
safeguarded and the professional feels more
contained, less worried and on firmer ground
Safeguarding Adults
During 2012/13, KCHT raised over 200 Adult
Protection (AP) alerts involving other agencies,
e.g. care homes, residential homes, carers.
During the year 26 Adult Protection alerts were
raised against KCHT, either by another agency,
or KCHT itself and mainly related to pressure
ulcers. The details of the cases raised within
KCHT services were as follows
Types of abuse
Neglect1
Financial
Physical
Psychological
Number of Adult
Protection alerts
21
(16
pressure
Ulcers)
1
3
1
Table 8. Number of Adult Protection alerts
Following investigation of the above Adult
Protection alerts raised in relation to KCHT, the
outcomes recorded by Kent social services
were as follows
Abuse confirmed
Abuse discounted
Abuse not
confirmed
Abuse
not
substantiated
Abuse
partially
substantiated
Cases
still
open/under
investigation
2
2
2
3
1
10
Table 9. Category of alerts
Eleven of these cases were classified as a
Serious Incident Requiring Investigation (SIRI),
10 of which were investigated under the
category of neglect and 1 as physical abuse.
For each SIRI an internal investigation,
supported by a local action plan was
completed
(root
cause
analysis),
to
demonstrate that the main causes of the
incidents
had
been
identified
and
organisational learning agreed, to ensure that
such an incident may not happen again.
These reports were formally submitted to the
responsible commissioner, and an internal
Lessons Learned newsletter provided a
- 39 -
summary of key findings, best practice and
learning opportunities to all frontline practitioners
and was included in training programmes. Whilst
the 26 Adult protection alerts for 2012/13 is a
marked improvement (42% reduction) compared
to the 62 cases raised during 2011/12, this
performance is not good enough and KCHT
intends to ensure this is reduced next year to
ensure that ultimately, no future cases of adult
neglect can be attributed to our care.
Mental Capacity Act/Deprivation of
Liberties (MCA/DoLs)
Intrinsic to providing high quality care, is the need
to ensure ‘No decision about me, without me’,
which supports a vision of healthcare where the
patient is, if not an equal partner, then certainly
an active participant in decisions regarding their
care. The Mental Capacity Act (MCA) 2005 aims
to empower and protect people who may not be
able to make some decisions for themselves and
all of our staff have access to training and
specialist support from our safeguarding service,
to ensure that the people they care for can make
decisions for themselves, unless they have
proven they cannot.
An in-year audit of how well staff understand and
use the Mental Capacity Act in day-to-day
decision-making identified that KCHT has
significant work to complete including:
•
•
•
•
enabling staff confidence and competence at
undertaking and documenting capacity
assessments
improving record keeping arrangements
undertaking initial inpatient assessments
introducing MCA champions
In response to these findings, KCHT reviewed
MCA/DoLs training packages to include case
studies and case law examples.
KCHT ran a large number of extra MCA training
sessions, which has increased MCA training
compliance from 28% at the start of the year to
99%. Safeguarding services have also been
realigned so that they can provide dedicated,
ongoing support to key service areas.
MCA/DoLs.
The benefit for patients is that
they are more involved in day-to-day decisionmaking regarding their care and ensuring
appropriate ‘best interest’ decisions are made
for those people who are not able to make
decisions for themselves.
What we need to do in 2013/14 (Quality
Goals 1; 3; 4)
•
•
•
•
•
•
Further improve the training compliance. A
further re-audit is planned in 2013/2014
extend our internal MCA networks
to introduce MCA/DoLs champions at local
level
support staff who may be less confident
around
MCA/DoLs
legislation
and
procedure.
Identify DOLS champions
Work in collaboration with partners to
implement multiagency interventions
Safeguarding training for adults and children
– target 85%
11/12 12/13
76%
56%
28%
80%
79%
80%
Safeguarding children’s training
Safeguarding adults training
Mental Capacity Act (MCA)Training
To address the remaining compliance gaps:
• SVA and SGC e-learning packages, which
have been endorsed by the Department of
Health) have been introduced and will
support the achievement and maintenance
of associated compliance targets within the
first quarter of 2013/14
• There are enough Face-2-Face MCA
sessions in place throughout 2013/14 to
support the training needs of staff who are
not compliant
• Operational managers are required to risk
assess their services where compliance
levels are low, to ensure ongoing patient
safety
Table 10. Training performance and actions
This new arrangement means that, safeguarding
specialist practitioners can regularly meet with
frontline staff to support mental capacity
assessment work, discuss complex cases and
identify/provide additional training to improve staff
awareness, knowledge and application of
- 40 -
4.9
Review of 2012/13 Goal –
Dignity and Respect
health care support workers and newly qualified
registrants (Preceptees).
The purpose of the 15 Step Challenge
is:
The Quality Goal 2012/13: Ensure
patients report a positive experience in
relation to dignity and respect
•
A key factor in ensuring that each of our patients
receives compassionate care as outlined in the
Francis report is the delivery of privacy and dignity
to every patient.
•
•
How did we perform in 2012/13?
15 Step Challenge
One of KCHT’s
objectives was to introduce the 15 Steps
Challenge. This was completed in all community
hospitals in September 2012. The challenge was
undertaken by a matron or clinical sister alongside
someone from outside the service to provide an
objective view. The matrons found the approach
extremely useful and with their teams have
developed action plans that have been
implemented that included:
•
•
•
•
•
providing areas for activities or rest away from
the patient’s bedside
providing an area for relatives who are staying
on the ward with very unwell patients
improving the meet and greet to visitors on
arrival to the ward
providing catheter drainage bag covers to
protect patients’ modesty
improved information for patients and visitors
on the wards
KCHT has introduced a patient leaflet that
explains how staff aim to deliver 1st Class Care excellence every time. This means respectful and
dignified care and a care experience that respects
individuality and their choices.
•
We monitor patient feedback in relation to staff
attitude and behaviour. Last year this was an
area where the majority of our patients have a
positive experience.
However during the
course of the year we did receive a number of
complaints. These are dealt with on an
individual basis.
Single Sex Accommodation - visibly
affirms commitment to maintaining patient
dignity. During the year we have reviewed the
community hospitals and found some areas
where environmental factors and practice could
be improved. These areas are part of a
programme
of
estate
and
practice
improvements.
What we need to do in 2013/14 (Quality
Goals 3; 4)
•
Quality Standard -
To support this KCHT has
implemented a Privacy and Dignity Quality
Standard which sets out for staff what is expected
for all patients, along with the support available to
help them achieve the standard consistently.
To embed privacy and dignity through
compassionate care we have introduced this as a
core module in our education programmes for our
to measure first impressions to capture
the perceptions people have regarding
the care they consider they are likely to
experience on arrival at the ward
to help staff, patients, service users
and others, to work together to identify
improvements that can enhance the
patient or service user experience
to provide a way of understanding
patients and service users first
impressions more clearly
a method for creating positive
improvements and dialogue about the
quality of care
•
•
To extend the involvement of our Patient
Engagement Network members in helping
us to improve by participating in the follow
up to the 15 Step Challenge.
We intend to introduce the 15 Step
Challenge in our outpatient and community
settings
The teams will be undertaking further
Observational Audits to assess the level of
compliance with the Privacy, Dignity and
Respect policy and Professional Standard.
- 41 -
•
•
•
Undertake bi-annual inspections of single sex
accommodation compliance
Feedback from our patients tells us that there
are two key areas that they want us to focus
on which are being involved in their care and
feeling anxious about adequate support to get
to the toilet. Both of these will be high
priorities for us in the coming year.
Undertake PLACE inspections in all
community hospitals
4.10 Review of 2012/13 Goal – End
of Life Care
The Quality Goal 2012/13: Ensure
patients and their relatives report a
positive experience in relation to end of
life care
During 2012/13 we continued to make progress
toward our goal of ensuring patients and their
relatives report a positive experience in relation to
end of life care.
•
•
•
we provide all the information patients and
their relatives/carers need to enable them to
fully understand and make informed
decisions about how they are cared for and
the treatments they receive
we understand and document when
carers/relatives want to be contacted
we fully document how care and treatment
decisions/choices are made
The audit showed that in the majority of cases
we achieved our 2012/13 goal to ensure that
end of life patients have their pain levels
routinely reviewed (88%) and have pain relief
prescribed (96%). The audit also demonstrates
a high level of compliance at 99% with the
preferred place of death indicator
Was the patient's preferred
place of care/death achieved?
1%
Yes
How did we perform in 2012/13?
No
We undertook an audit of end of life care which
was based on the End of Life Quality Markers (DH
2012) and the Liverpool Care Pathway. The audit
indicates that the majority of patients and their
relatives/carers receive good quality care but
improvements are required as the starting point of
88% for effective communication and assessment
of palliative care needs was below the 90%
standard required.
Was the effectiveness of
comm unication w ith the
patient assessed?
Were the patient's specialist
palliative care needs
assessed?
12%
7%
5%
Yes
Yes
No
No
No t needed
88%
88%
Figure 10 Audit results
The main areas we need to make improvements
in are ensuring:
99%
Figure 11. Audit result
Individual localities are making progress in
engaging with other providers in order to work
together to improve the quality of care we
provide.
A project has started in our Dartford,
Gravesham, Swanley and Swale locality in
partnership with the Ellenor Lions Hospices
which aims to demonstrate that managing and
coordinating care effectively will reduce
unnecessary admissions to hospital; ensure
that if patients are admitted to hospital they are
discharged home as soon as possible and
enable patients to be cared for and die where
they want to with supportive care in place 24
hours a day 7 days a week.
Within the East Localities, Project Invicta (led
by Pilgrims Hospices) aims to bring together
professionals from all relevant agencies to
improve the patient experience in line with
- 42 -
National End of Life Care Strategy. This group is
actively involved in promoting the ‘My Wishes’
register to enable up to date recording of patients’
preferences.
The Care Navigation Centre is a relatively new
service based at Pilgrims Hospices for single point
of access to hospice services e.g. Consultant,
Clinical Nurse Specialist, hospitalized patients. In
the interim an End of Life proforma was devised to
prompt clinical staff to consider all aspects of
holistic care when assessing patient needs.
During this process, anticipating and planning for
the patients’ needs was high on the list of
priorities so issues such as a lack of equipment or
medication would not delay a discharge from
hospital or lead to an unnecessary admission.
•
We have recently recruited an End of Life
Consultant Nurse who will work with and
support staff to make further improvements in
end of life care across all localities.
assessment tool which is already used by
social services. The benefit for patients is that
it improves interagency communication, sharing
of information and supports patients and
families to be actively involved in decisions
about their care. It reduces the number of
times patients are asked the same questions.
The tool is being rolled out across the Trust, as
a paper based document but this is proving
challenging as the tool is meant to be used
electronically. This will be addressed during
the implementation of the Community
Information System (CIS) over the next 18-24
months.
The
Patient
Engagement
Network
-
provides a means for patients and their families
to get involved in improving and shaping KCHT
services. It now has around 100 members who
have joined a range of committees including
Medicines Management, Infection Control, 1st
Class Care and the Clinical Audit Group.
What we need to do in 2013/14 (Quality
Goals 2; 3)
•
•
•
•
Ensure that all patients’ wishes around death
continue to be met.
arrange an engagement event with staff and
key stakeholders to identify and agree actions
for further improvements
continue to work with our Hospice colleagues
and roll out programmes
develop a Trust End of Life Care Strategy
4.11
Review of 2012/13 Goal –
Patient Experience
The Quality Goal 2012/13: To achieve
year on year improvement in patients
reporting a positive experience
There are many elements that contribute to
whether a patient has a positive experience.
KCHT identified several areas that would help us
to better understand our patients’ experiences and
implement strategies to improve.
How did we perform in 2012/13?
FACE - One aim was to start to use the ‘FACE’
Network members have also been involved in
reviewing policies and procedures, providing
the patients’ perspective.
Some of the
members of the network participated in the
Accountability Conference and provided
valuable insights into the issues discussed as
well as learning about the challenges faced by
staff.
The Patient Experience committee oversees
the Trust’s patient experience programme. At
these meetings members are able to hold
services to account for how they use patient
feedback to improve services. The committee
is made up of Trust staff, patients and Kent
Healthwatch (formerly LINk) representatives.
The committee also acts as a sounding board
for services who want help with communicating
complicated information to patients and
families. It carries this work out with support
from a dedicated Patient Information sub-group.
Examples of its work include a patient-friendly
guide to the eligibility criteria for an NHS
wheelchair and the Trust’s Customer Care
Charter. Members are also able to support
communication with their local communities.
Good, accessible patient information is
essential to enable patients to make informed
decisions and choices. The committee and
members of the network have made significant
contributions in helping us to get this right.
- 43 -
“Having been in pharmacy all my working life, when
the opportunity to become involved as a patient
representative in community health, I was happy to
learn more. I have attended workshops, read the
frequent newsletters and put myself forward to take
part in particular groups which especially interest me
I find helping to shape community services in some
small way is very worthwhile and I feel my comments
are really valued. I would thoroughly recommend
anyone interested in their community to become
more involved in shaping our health services by
joining Kent Community Health NHS Trust.”
Sittingbourne Public and Patient Engagement
representative
Patient Information Library - The Trust now
has a Patient Information Library on its website.
This enables both services and patients to easily
print off advice sheets.
This is now being
developed to include Easy Read versions of
information on a range of topics, including how to
raise a concern or make a complaint. There is
also an easy read version of the Quality Account.
In the coming year we will add British Sign
Language versions of a number of leaflets. The
aim for 2012/13 was to roll out the Meridian realtime feedback system across the Trust. This was
successfully implemented with tablets in place
across all services. With this system patients and
users are able to complete surveys on tablet
devices. The responses are uploaded directly
onto the system allowing services to immediately
see how they are doing in relation to patient
experience. There is an average of over 1300
responses each month. Feedback is overall very
positive, and services are able to access real time
detailed data that helps them make timely
improvements to services. Improvements include:
•
•
•
•
an increase in day-time activities for patients
receiving rehabilitation in community hospitals
a welcome pack for in-patients
additional cook and eat sessions for people
who’ve been on the healthy weight
programme.
improvement in patient information leaflets
and letters
Patient Experience Results 2012/13
Of the 13,752 surveys completed that include
this question we had an overall satisfaction
score of 93.88%. This is a significant
improvement on the previous year’s results.
The table below shows this by district:
District
Involvement in
decisions about
care and
treatment
Ashford
95.31%
Canterbury
92.90%
Dartford
95.39%
Deal
92.88%
Dover
94.81%
Gravesham
93.89%
HM Prisons
85.71%
Maidstone
90.26%
Medway
94.94%
Newham
90.94%
Sevenoaks
94.30%
Shepway
93.16%
Swale
95.43%
Swanley
98.53%
Thanet
94.37%
Tonbridge and
Malling
94.74%
Tunbridge Wells
95.61%
Whitstable
93.08%
Trust Total
93.88%
Table 11. Patient experience results by locality
The Trust provides dental services in some HM
Prisons and this is the one area where
satisfaction levels are below the 90% target the
Trust set. Dental services are working with HM
Prisons to undertake further work to identify
and resolve the issues where possible.
We asked our patients “Did staff involve you in
decisions about your care and support you to
make choices that are important to you?”.
- 44 -
Overall patient satisfaction for 2012/13 is 94.4%:
commissioners are kept informed of such
complaints.
Like all providers we will be expected to be
more open about the complaints and feedback
we get and what action we’ve taken as a
result. We will need to publish this on our
website and provide it to commissioners.
The attitude of our staff has a direct effect on
patient experience and was a particular area
highlighted in the Francis report. The Trust
monitors this closely as shown:
Locality
Surveys
Staff Attitude
Ashford
1,326
99.42%
Canterbury
2,044
98.74%
Dartford,
Gravesham
and
Swanley
1,794
98.45%
Dover, Deal
and
Shepway
3,022
99.14%
West Kent
2,597
98.83%
Medway
6,11
99.21%
Other
(Newham
and HM
Prisons)
224
98.36%
1,172
98.70%
894
99.75%
13,684
98.94%
Swale
Thanet
Trust Total
Table 12. Patient Experience responses
Complaints and PALS
The Trust now has a wealth of data telling us
what patients are experiencing. The challenge
for services in the year ahead is to ensure that
we are learning from this feedback and putting
measures in place to reduce the likelihood of
complaints or negative comments on the same
issues reoccurring.
We can’t always address every concern. There
will be times when the ways services are
commissioned mean that there is very little we
can do. It’s important that the CCGs and other
This data needs to be shared in such as way
that it does not compromise the confidentiality
of the complainant, and therefore we will be
publishing themes and trends by subject,
service and locality.
Complaints
In 2012/13 the Trust received 300 complaints.
This includes 27 Level 1 complaints that we do
not have to report in the annual return to the
Department of Health.
Looking at the 273 complaints reported to the
DH, we received 53 fewer complaints than the
previous year. We believe that a significant
factor in this is that the Trust no longer
manages a number of APMS Managed
Practices on behalf of the PCT. This contract
ended in December 2011. In 2011/12 we had
36 written complaints about these practices.
Another factor is that in April 2012 the Trust
introduced a session on Customer Care in the
corporate induction programme. All new staff
attend this. We believe this is beginning to
have a positive impact.
Furthermore better promotion of our Customer
Care Team phone number (and the
subsequent increase in calls) means that
concerns are quickly resolved and thereby
complaints are reduced.
Of the 273 Level 2 to Level 4 complaints 102
were upheld. This means that the outcome
lead to a service change or improvement, staff
training or staff being disciplined. It does not
include complaints where the Trust’s response
was simply an apology or wider learning. In
future we will consider complaints upheld if
there was any learning from them. This will
help to shift the balance from formal action
plans to a more supportive approach where
learning is encouraged.
Of the 300 complaints we investigated and
responded to, 31 complainants came back to
us as they were not happy with the response.
Nationally most trusts consider a ‘bounce back’
- 45 -
rate of 10% or less good, which means our rate is
slightly higher.
From discussions with other NHS trusts in Kent
the themes of our complaints are broadly similar
to theirs. All other trusts in Kent have seen a
trend of
a rise in complaints and the complexity of
complaints. Therefore the fact that our complaints
have reduced should be seen as particularly
positive.
The table below sets these out by subject and
locality. It shows that not only the total number of
complaints varies across the localities but also the
number in the top five complaint subject, which
are:
• Treatment
• Communication
• Attitude
• Equipment
• Access to services
It should be noted that West Kent includes four
large towns – Maidstone, Sevenoaks, Tonbridge
and Tunbridge Wells, which accounts for a third of
the population of Kent.
Therefore a higher
number of complaints is not unexpected.
It should be noted that West Kent includes four
large towns – Maidstone, Sevenoaks, Tonbridge
and Tunbridge Wells, which accounts for a third of
the population of Kent.
Therefore a higher
number of complaints is not unexpected.
During 2012/13 there were 41 PALS enquiries
related to the attitude of KCHT staff, 27 of which
related to Adult services, and 10 to Children and
Young People’s services.
•
•
Themes in 2012/13 included:
• Calls about difficulties in getting through to
services, or messages not being returned
• Calls about delays in picking up beds and
other equipment from the homes of
• General dissatisfaction with the treatment /
advice given
In addition to these there were a significant
number of calls about other trusts. This may
be due to better promotion of our Customer
Care Team number and the fact that the phone
lines are staffed rather than a voicemail.
What we need to do in 2013/14 (Quality
Goals 3)
Over the coming year the Trust will build on
achievements and will aim to continue to
improve patients experiences in all areas of
services. This will include: •
•
•
•
•
•
ensuring paper surveys are available in all
areas for patients who are unable to use
the tablets
increase response rate in areas that are
low, and work with services to identify the
issues that need to be resolved
Patient Engagement Network members will
participate in our Observations of Care
audits and 15 Steps audits to ensure that
the patient and user perspective are
captured
Improve the mechanism for capturing
actions taken by services in response to
patient feedback
Involve service users in decisions about
changes in services
Hold more patient engagement session
and events.
Most PALS enquiries relate to treatment
deceased patients
Calls chasing up visits by community nurses
or access issues.
Table 13. % of Kent population
CCG
Ashford
Canterbury
Dartford, Gravesham & Swanley
South Kent Coast
West Kent
Swale
Thanet
Population
118,400
150,600
199,400
225,900
507,500
136,300
134,400
Percentage of Kent population
8.1%
10.3%
13.6%
15%
34.5%
9.3%
9.2%
- 46 -
5.0
Review of 2012/13 Goal –
Health and Wellbeing
As a community health care provider we
have a responsibility to improve health
outcomes and reduce inequality.
Therefore, health and wellbeing is an
important service we provide to our local
population including:
• Promoting healthy living
• Providing support to help patients
manage their long term conditions
• Sign-posting patients to NHS and
voluntary services as required
How did we perform in 2012/13?
out young people 15-24 years at highest risk of
poor sexual health.
In the east of the county the target has now
been met for the first time in seven years. It is
well documented that poor sexual health is
higher in the areas of social deprivation and
the east of the county has several districts with
challenges. The west of the county is more
complex, it is generally more affluent and
finding the pockets of poor sexual health is
difficult. However there is now good data
collection in place and by mapping this and
using other sources of information we can
target resources much better and plan to get
better at identifying young people at risk of
Chlamydia.
This targeted approach has resulted in a
change of focus of work, with targeting of
minority groups where we know there are
young people who are more likely to be
engaged in risk taking behaviour. Nightclubs,
gay bars and public sex environments are
venues being targeted. The work has been
supported by the new media campaign called
Sex Bomb which gives a clear message that
Chlamydia can cause lasting damage to fertility
if untreated yet it is simple to avoid with
condom use.
HIV Point of Care
Figure 12. Chlamydia screening results
Chlamydia
The Chlamydia target has been revised and
agreed with our commissioners. The target is
now focussed on the number of patients
diagnosed rather than the number of patients
tested. This change means that the team can
provide a much more targeted approach where
higher risk clients are approached. This will
improve the quality of our service as more clients
will be positively diagnosed and therefore treated
more effectively.
The new positivity target means the focus is on
identifying clients at high risk of Chlamydia rather
then simply screening large numbers of low risk
clients in order to reach targets. This new way of
working has enabled staff to plan their work
through an evidenced based approach to seek
During the year Sexual Health Services will be
exploring how new technology can help in the
screening of undiagnosed HIV infection and
facilitate improved earlier rates of HIV
diagnosis. The service is working in
collaboration with East Kent Hospitals
University
NHS
Foundation
Trust’s
Microbiology department to develop a quality
assured service. This will ensure that there is
suitable training and guidance supporting any
introduction of technological solutions.
When the facility for point of care testing
(POCT) for HIV is launched in February it will
allow clients to be tested and receive results of
their HIV test within the same visit. If the test is
positive a confirmatory test is undertaken.
Having this facility for immediate results
encourages clients to take a HIV test. In areas
where POCT has been rolled out they have
found that high risk groups including men who
have sex with men and minority communities
are more accepting of the test. The test can be
available on their territory and doesn’t rely on
access to a sexual health service. We expect
- 47 -
the clients requesting an HIV test to increase
because access is easier and results immediate.
This will increase the diagnosis rate and more
importantly the early diagnosis rate. The majority
of patients test for HIV when they are
symptomatic rather than
for screening and late diagnosis is significantly
worse in terms of health outcomes for the patient.
KCHT will be participating in an Interreg
commissioned research project. The project is to
look at ‘Reasons for late diagnosis for HIV’. This
initiative is across number of organisations and
extends to healthcare in France (Picardy). The
research project is for 2 years and the partners
from Kent & Medway include:
•
•
•
•
•
KCHT
Kent County Council
Maidstone Tunbridge Wells NHS Trust
Medway Hospital
Christ Church Collage.
The project will support the Sexual Health
Outcome framework where one of the key
objectives is to increase the number of early
diagnosis of HIV.
•
•
•
•
•
6 persons normal spirometry results
1 person failed to make appointment with
GP for spirometry.
1 person moved out of area.
3 persons still awaiting results from surgery.
1 person already diagnosed with COPD.
Overall there has been good client feedback,
where participation at the Lungs for Life
awareness days was very well received with
most people wanting to see how healthy their
lungs were. People seemed to be interested to
learn more about pre-spirometry tests and took
away leaflets and information.
At subsequent quit clubs, the feedback from the
advisers was also very positive, with the majority
of participants willing and wanting to have a test.
Being involved with the Health Check MOT with
Beats and Breathes in Swale has been an
advantage as the service has been able to work
collaboratively with other Health and Wellbeing
services, while raising the awareness of COPD
screening and the Stop Smoking Service. The
Lung Function test has been offered alongside
blood pressure, Cholesterol, Pulse and BMI.
Stop Smoking
Health Checks
It is estimated that there are approximately 3.7
million people in the UK with COPD. Only
900,000 are currently diagnosed and receiving
appropriate care and treatment. COPD is the fifth
biggest killer in the UK. And it is estimated that 90
to 95% of all those identified with COPD have
been long term smokers. There is only a 45%
identification rate of this disease; one of the most
costly inpatient conditions treated by the NHS. In
response to this the stop smoking teams will be
working with two Clinical Commissioning Groups
to indentify and help with early diagnosis of this
disease. The service has set up a screening
service alongside current service delivery.
The Trust successfully met its target to offer
10,000 health checks and have now been
commissioned to deliver the full programme
across West Kent. We aim to ensure there are
seamless pathways from screening to accessing
relevant community services or sign posting to
their GP to ensure patients are reviewed in a
timely manner
The trial has been completed in Swale CCG
locality and the results are as follows:
•
To date the numbers of people seen is
encouraging with a total of 205 people having
had a lung function test A total of 29 referral
letters were sent to GPs. 14 people needed
no further investigation 13 people referred on
for full Spirometry.
Follow up February 2013.
• 1 person diagnosed with COPD
• 1 person diagnosed with moderate COPD
In 2012/ 13 the health checks team invited
24,175 people to have a health check and 9,916
people came for a health check. Although the
team did not meet their annual figure this is a
great achievement for the first year of delivery
and in comparison to East Kent’s first full year of
delivery West Kent offered 4,000 more invites
and conducted 2,000 more health checks. This
provides the Trust with confidence that in this
coming year 2013/14 the processes and
systems are now in place to meet the full year
target.
The main focus has been to engage and work
with the 98 GP practices across West Kent
enabling them to carry out effective Health
Checks. Many practices were unaware of the
various lifestyle programmes that were available
to their patients that are run by KCHT and other
- 48 -
local agencies, so particular focus has also been
around increasing awareness so that there are
clear referral pathways for patients and therefore
improving patient care.
The Health Checks team has worked hard at
building good working relationships with the GP
practices and with the LMC. There are robust
systems in place for the full delivery of the health
check programme in 2013/14.
KCHT's community team has also undertaken a
large number of Health Checks in community
venues on behalf of GP practices and worked
innovatively by delivering checks in work
places(Maidstone Community Care Housing
(MCCH) Society, community settings such as
Gravesend Gurdwara. Health checks team
continue to work with Pharmacies and Prisons.
Finally, KCHT in 2013/14 were awarded the health
checks programme in East Kent by Public Health
Commissioners therefore, the programme will be
assessed across Kent and its success will be
measured on the number of invites and number of
actual health checks. There is also an emphasis
around measuring patient outcomes so the service
will be measuring the number of people with high,
medium and low Qrisk scores as a means to
evaluate the programme..
What we need to do in 2013/14 (Quality Goals
2; 3, 4; 5)
•
•
•
•
Ensure we are able to accurately record and
report patient outcomes of an NHS Health
Check
Continue to develop a fully integrated sexual
health service
Review performance against NICE guidance
Develop lifestyle programmes for staff working
within KCHT
“Making the most of my life”
Just nine months ago, Fred
Ward was lying on the sofa in his
Ashford home, unable to move.
“My godson had to break the
door
down
to
let
the
paramedics in,” explains Fred,
66, from his home in Bentley
Road. “I was in agony from
chronic gout and I was totally immobile.”
A week in hospital saw Fred discharged home
but determined to make some changes to his
lifestyle. Born with club feet and hammer toes,
Fred always had issues with walking and his
knees have been operated on in the past. He
also has type 2 diabetes, which affects his
eyesight, and osteoarthritis. “I wanted to make
changes to my diet,” says Fred, “but I couldn’t
seem to get the right advice from anyone. I had
gout and diabetes, and the advice for each of
those conditions was very conflicting.”
Eventually Fred found out about the Expert
Patient Programme – a course run by Kent
Community Health NHS Trust to help people
with chronic illness to manage their condition
more effectively. “At first I was sceptical,”
admits Fred, “but after the third week I really
‘got it’. I made a plan to tidy up my garden,
which was a mess. That weekend, I got on and
I DID IT. I realised that the key was selfmanagement. I’d been looking to others to fix
things for me but what I really needed to do was
fix things myself.”
Fred was keen to help impart his new found
knowledge to others and decide to train as a
tutor for the course. It was at one of the EPP
training days that he talked to a healthy weight
advisor, who told him about the ‘Fresh Start’
programme from the NHS. “I knew that I was
overweight and that it wasn’t helping. I signed
up for the 12 week plan which meant seeing a
pharmacy advisor every week at Charing
Surgery. She gave me lots of advice about
portion sizes, healthy eating and so on.
I cut out the junk and took on all the advice that
she gave me, which was from the British Heart
Foundation. It worked!”
Fred stuck to the advice and lost almost 10
kilograms (a stone and a half) in three months –
10 per cent of his body weight. His BMI has
dropped from 31 to 27 and he says he feels
great; “I’ve got a lot of my mobility back. I am
fully aware that my osteoarthritis and diabetes
will never go away but I am going to do what I
can do. I am proud to say my New Year’s
Resolution is to start walking properly again in
the beautiful Kent countryside. You’re a long
time in your box; I’m making the most of my life.
It’s absolutely brilliant.”
- 49 -
6.0 Developmental Goals 2012/13
•
Neuro-disability
In the neuro-rehabilitation unit patients and their
carers are participants in their care. Goal setting
is a core principle in assisting patients to achieve
their rehabilitation potential.
•
•
•
From admission patients are the decision-makers
regarding their care and plans for rehabilitation.
This is done using the Goal Attainment Score
(GAS) that is worked through with each patient
and their Key Worker.
The tool provides a common language for staff in
relation to baseline and rehabilitation goals,
documentation; and reporting progress. This
ensures for patients that all staff are working
towards the same goals and plans are
consistently implemented.
One example of how we are improving the
care we deliver to our patients and carers with
dementia is:
•
The score provides a clear measurement of
improvement; level of participation by patient and
quality of life. As shown in figure 14 in a 6 month
period twice as many patients achieved or
exceeded expected outcome compared to those
falling below expected outcome
50%
Less than expected level of
outcome (24.4%)
46.10%
Achieved expected level of
outcome (46.1%)
45%
40%
Better than expected level of
outcome (7.8%)
35%
30%
24.40%
25%
21.70%
20%
Treatment ongoing or did not
complete treatment (21.7%)
forging links with University partners and
will participate and contribute to research
that will make it better for people with this
condition
developed a dementia strategy which is
being implemented
reviewing the services provided in our
Community Hospitals
assessing e-learning packages so that we
can start Dementia Awareness Training for
our staff and make this available to carers
and the public, creating a Dementia
Friendly community
In Sheppey Hospital 2 Bays are being
developed for people with Dementia.
Specialist signage is being purchased and
staff are being trained using the Butterflies
scheme.
The
Butterflies
training
programme
enables
a
deeper
understanding of the patients needs as well
as improving competence and increasing
staff confidence in communicating with
people with Dementia. As such we will be
able to enhance a personalised and person
centred approach through staff having a
more meaningful understanding of what the
experience of Dementia.
Acute Pain Assessment and
Management in both Adults and
Children
15%
7.80%
10%
5%
0%
Figure 12. Goal Setting
KCHT has developed an pain assessment and
management professional practice standard.
This clearly identifies the structures that are
required to ensure staff are able to deliver best
practice in the management of a person’s pain.
The standard focuses on: -
Dementia
In response to the Prime Minister’s challenge to
improve care for patients with dementia and their
carers we are currently: •
recruiting a Consultant Nurse and 3 Dementia
Specialists who will work with frontline clinical
staff to support them in planning and
delivering appropriate care and ensuring they
have the additional competence required.
•
•
•
staff carrying out a comprehensive and
holistic assessment of a patient’s pain
what the person experiencing pain has
found helpful in the past
what they would find acceptable
The standard focuses on the patient and health
care professional working together to manage
the pain symptoms so that patients are
empowered to self manage in the future
- 50 -
The standard will be rolled out across the Trust
initially in Children’s and Young Peoples
Community Services
and ITC Services
(Community Hospitals). The standard will be
monitored 2 months post launch in the
Community Hospitals to provide a baseline
assessment of current practice that we can
compare each quarter.
Work is underway with teams to improve on
this: -
Reducing the Length of Stay
Reviewing baseline audits and set targets to be
monitored
and
benchmarking
against
comparable organisations.
The Trust set 28 days as the average length of
stay target. This target was not met as the end of
year average was 31 days.
Community Hospital Discharge Review –
P/012/11
This audit was undertaken to ensure that
discharge planning with estimated dates of
discharge (EDD) was effectively conducted within
Community Hospitals.
Findings/outcomes
Use of the estimated discharge date was not
being used effectively. Results of the audit
prompted the following actions:
• Introduction of a letter for the patient and/ or
carer explaining the role of the multidisciplinary team (MDT) and the aims of
patient admission goals, discharge planning
and setting EDDs, encouraging the patient or
carer to inform the MDT of any issues they
feel may contribute to discharge planning.
• Incorporation of issues raised by patients or
carers into the goals and EDDs by the MDT
at the care planning meeting.
• Key worker for each family to be allocated at
the MDT meeting.
• MDT to work more effectively and in a more
timely manner to achieve goals
• Individual wards to arrange local access to
therapy notes by all members of the MDT
including community staff.
A re-audit was undertaken in August 2012. This
showed an increase in percentage compliance in
6 out of 8 key standards.
Some of the issues that have contributed to this
includes:
•
•
•
Both of these development goals have been
taken forward during the year. The Clinical
Audit programme has been revised to ensure
that audits are an integral part of our quality
improvement activity.
Benchmarking for Community Trusts remains a
challenge as there are limited benchmarks
specifically for community services. However
where they do exist the Trust uses them and
uses
acute
sector
benchmarks
where
appropriate.
What we need to do in 2013/ (Quality Goals
2; 3; 5)
•
•
•
•
•
•
•
•
•
•
•
Sheppey – has a long waiting time for
patients requiring residential or nursing home
placements due to there only being one of
each of these in the area
Variation in the level of compliance with best
practice standards across the hospitals
Lack of consistent implementation of the
Choice Policy
Comprehensive review of the Community
Hospitals including the admission criteria
Development of a Discharge Planning
Improvement plan
Education and training plan
•
•
Establishing a portfolio of education
programmes to meet the needs of staff at all
levels and across all services
Implement the dementia strategy
Contribute to the development of dementia
friendly communities
Arrange an engagement event with patients,
carers , staff, other health care providers and
the voluntary sector to review dementia care
pathways including end of life care
Develop a plan for roll out of the Goal
Setting model of care
Roll out the pain professional practice
standard
Complete the Community Hospital review
and implement the arising actions
Implement
the
Discharge
Planning
Improvement plan
Implement the education and training plan
Continue to improve Clinical Audit
programme and benchmarking with national
comparators
- 51 -
7.0
Patient Safety
Serious Incidents
Reducing levels of preventable harm remains a
major priority for the organisation and requires a
shift in attitudes and behaviours in both health
professionals and patients. The Trust recognises
and values the importance of a culture where
staff are aware of the need to report any
incidence affecting either patients, the staff or the
environment.
Many of the trends and themes have been placed
as priorities for improvement, such as falls and
pressure ulcers.
The safety of patients, staff and visitors is a key
priority. It is also very important that the
organisation learns from such incidents, which is
why each incident is investigated thoroughly
using NHS best practice “Root Cause Analysis”
investigation tools. This enables the trust to drill
down and identify the root of the issue so that
steps can be put into place to minimise the risk of
a similar incident taking place.
Serious patient safety incidents that occur within
the services provided by KCHT are escalated
immediately to senior managers within the trust
and are reported to and monitored by our
commissioners.
When these incidents occur they can have a
devastating and far reaching effect. It may have
an impact on those directly involved, patients,
relatives, staff or visitors, and also on the
reputation of the healthcare organisation, the
service or the profession within which the incident
occurred, and the wider NHS.
Reported Inc idents
Attributable Patient Safety Incidents
400
350
300
250
200
150
100
50
0
2011/12
2012/13
l
A prM ay J un J u Aug S ep Oc t No vDe c J an Feb M ar
may have occurred at opposite ends of the
county, much in the same way as the airline
industry prevent planes from flying until a fault
that occurred on the other side of the world has
been checked.
A total of 77 serious incidents were reported by
KCHT during 2012/13 which is a reduction from
the 84 reported in the previous 12 months. Five
of these cases were later identified as not
attributable to KCHT and were downgraded by
our commissioners. The most prevalent
category is patients with pressure ulcer which
represents 62% of all serious incidents
reported. Falls is the next category which
represents 13% of serious incidents followed by
breaching confidentiality which represents 7%.
Table 14 shows numbers and categories of
serious incidents reported by month during
2012/13
Table 14. Serious Incident Categories
2011/12 2012/13 Change
0
2
+2
Missed Diagnosis
2
1
-1
Delayed Diagnosis
1
0
-1
Allegation of
Abuse
9
5
-4
Adverse Media
2
5
+3
Sexual Health
2
0
-2
Pressure Ulcer
Category 4
0
1
+1
Pressure Ulcer
Category 3
1
0
-1
Fall
1
0
-1
Medication
55
30
-25
Confidentiality
32
24
-8
Coroner Rule 43
1
0
-1
HSE Improvement
Notice
1
1
0
Infection Control
2
2
0
Child Death
0
1
+1
Medical Devices
13
12
-1
Radiology
4
0
-4
Safeguarding
126
84
-42
Total
Key lessons learned and examples of actions
taken from serious incidents include:
Figure 14. Patient Safety incidents
This year KCHT has undertaken much work to
ensure that learning from investigations is rapidly
disseminated to staff in similar services. This
ensures that services learn from incidents that
Pressure Ulcers
Lessons:
• That there are limited options of suitable
pressure relieving equipment available to
- 52 -
manage prevention of pressure to feet –
guidance for staff was developed to support
prevention of pressure ulcers on the foot. This
includes ways to reduce pressure to the foot
which does not require equipment
E.g. use of emollients to keep skin
moisturised, correct positioning of feet,
appropriate footwear
• Carers, patients and care agencies should be
provided with clear guidance on how to use
equipment – equipment information available
to staff on the Trust’s intranet Staffzone
• All teams to use wound cameras to assist in
the assessment and monitoring of pressure
damage for reference – additional wound
cameras and colour printers purchased
• All senior staff must understand accountability
and the requirement to follow practice
standards – Accountability Conference held
in March 2012 for clinical staff.
Falls
•
•
•
Patients, even in the last phases of their
rehabilitation, can still be at high risk of falls
and need to be observed.
Outcomes of nursing and therapy
assessments must be communicated to the
multi-disciplinary team to ensure a
consistent plan of care is implemented
Falls risk assessments and re-assessments
must be completed
KCHT has updated its falls leaflet for staff and
prepared a falls booklet for patients. To reduce
the risk of patient falls and injury, additional
equipment has been purchased. This includes
low nursing beds for patients at risk of falling out
of bed but for whom bed rails are not appropriate
and sensory alarms which alert staff when
venerable patients start to mobilise without
assistance.
The KCHT Patient Falls Policy has been updated
and is available to staff, along with the falls risk
assessment tools, on the Trust’s intranet
Staffzone. Data collection relating to falls has
been refined to provide better understanding of
when and why patients fall and this will be
supported by an observational study which has
commenced.
Confidentiality
•
All staff, whether clinical or administrative,
must be appropriately trained so that they are
fully aware of their personal responsibilities in
respect of record
•
keeping and records management, and that
they are competent to carry out their
designated duties
Staff must follow policies relating to
information governance and confidentiality
of patient identifiable information.
KCHT has exceeded its target for training staff
in information governance. This was achieved
by ensuring training in KCHT policies and staff
roles
and
responsibilities
relating
to
confidentiality and information governance was
accessible to staff through, for example elearning and a mobile training programme.
Never Events
Never events are serious, largely preventable
patient safety incidents that should not occur if
the available preventative measures have been
implemented by healthcare providers.
The Department of Health “Never Events Policy
Framework” was re-issued in Oct 2012 and has
extended the list of never events to 25. Within
the policy it clearly states that failure to learn
the lessons of a single never event or a
prevented never event could be perceived as
organisational failure on grounds of patient
safety for which Board leaders, particularly the
Chief Executive and Medical and Nurse
Directors are accountable.
Key performance indicators within the board
report continue to show that no never events
have been reported since forming as a trust in
April 2012.
Table 15. Never Events
NICE
The National Institute of Health and Clinical
Excellence (NICE) was set up in 1999 to
reduce variation in the availability and quality of
NHS
treatments and care. KCHT is committed to
following best practice issued by NICE and has
a robust process to review, assess and
implement all relevant NICE guidance within its
services. This offers an excellent opportunity to
examine performance and check how well
services are complying with best practice.
- 53 -
Introducing this evidence-based guidance for the
population of Kent helps resolve any uncertainty
about which medicines, treatments, procedures
and devices and therefore presents the best
quality of care and value for money for our
patients.
Monitoring of the implementation of NICE
guidance is carried out rigorously by senior
managers across Kent and the Trust Board
members receive monthly updates on how the
Trust is performing and any risks associated with
implementation. This monitoring incorporates
what the impact is to patients and on trust
resources
During 2012 KCHT carried out a review of all
NICE guidance issued since 2000 to ensure that
the current best practice was in place. 749 pieces
of guidance were assessed over a six month
period which resulted in just over 80 pieces of
guidance that remains relevant to the services
provided by the trust. Out of the 34 clinical
guidelines implemented last year the following
are two significant examples:
Clinical Guideline 29 - The management of
pressure ulcers in primary and secondary care.
This guidance identifies the main areas to be
implemented as part of this best practice
including:
• Holistic assessment – Included as part of the
band 7 practice standards. Incident
investigations continue to show inadequate
assessment of patient needs as a
contributory factor. KCHT is working with staff
to understand barriers to completion of a full
documented
assessment,
including
introducing and electronic documentation
which will allow sharing of patient information
between teams and facilitate review of the
quality of the assessment.
• Nutritional support – use of the MUST tool
embedded with the trust. Use of this tool
currently being introduced to therapists in
order to identify patients at risk from pressure
ulcers.
• Pressure relieving support surfaces –
Contracts in place to provide appropriate
pressure relieving mattresses 24/7 across
Kent.
• Clinical Guideline 21 - The assessment and
prevention of falls in older people was
reviewed and implemented in 2012. Some of
the key areas within this guidance includes:
• Risk Identification – Kent wide falls screening
tool in place
•
•
Multifactor fall risk assessment – Post falls
assessments undertaken for all falls
Strength and balance training – Embedded
as part of patients care plan to facilitate
rehabilitation. Falls prevention service is
available in Folkestone, Ashford, Swale
and Thanet localities with a plan to role this
service out Kent wide.
In terms of Quality Standards the Trust has
reviewed and assessed as compliant against
the following:
•
•
•
•
Venous Thrombo-Embolism prevention
End of Life Care for adults
Patient experience in adult NHS
Lung Cancer
What we need to do in 2013/14 (Quality
Goals 1; 3; 4; 5)
•
•
•
•
Continue to reduce the rate of incidents and
serious incidents
Effective implementation of serious incident
action plans
Maintain our zero Never Events
Undertake clinical audit to confirm level of
compliance with NICE guidance
8.0 Inquest/Claims
Inquest
A coroner must hold an inquest if the cause of
death is still unknown or if the person:
•
•
possibly died a violent or unnatural death
died in prison or police custody
The purpose of an inquest is not to apportion
blame but to answer four questions:
•
•
•
•
who died
when they died
where they died
how they died
The Trust actively participates in inquests
throughout the year, when the coroner may
request to review a patient’s clinical records or
for our clinicians to provide a report of the care
they provided to the patient.
One of the powers available to a coroner is to
make a Rule 43 report. The coroner will write
- 54 -
to a person or organisation when s/he believes
that action should be taken to prevent future
deaths.
The Trust has received two such letters in
2012/13 and we were obliged to consider and
respond within 56 days.
The first Rule 43 report related to the treatment
and prevention of pressure ulcers.
This
highlighted concerns regarding:
•
•
•
•
•
to ensure that where delays in formal nursing
assessments are expected or anticipated
appropriate resources are allocated to
ensure that these delays are reduced to a
minimum
to clarify the process for standard visits to
ensure a more holistic assessment occurs on
each visit
all nurses to attend record keeping training.
improve relationships and communication
with carers
to work with counterparts at acute trusts to
improve communications especially in relation
to the provision of
These actions have been addressed with the
specifically with the team concerned and included
in the Trust action plan to ensure that sharing and
embedding the learning is trust wide: •
•
•
•
education,
training
and
competency
assessment
clinical supervision
implementation of practice standards
renewed the contract for pressure relieving
equipment
The second Rule 43 report related to frequency of
nursing assessments and quality of record
keeping. The Trust has responded to these
recommendations, reviewing practice, identifying
action in response and ensuring implementation
which is monitored by the Trust Pressure Ulcer
Eradication group.
The Coroner’s Rule 43 letter and the Trust’s
response is be sent to the Lord Chancellor and a
report published by the Ministry of Justice half
yearly naming those organisations that have
received a Rule 43 letter, the nature of the letter
and whether a response has been received.
Claims
During the year 2012/13 the Trust had seven
clinical claims. We have defended one claim
and are awaiting a response from the
claimant’s solicitors. The other six are still
being investigated.
We also had four non-clinical claims made
against us in this period. One claim was
repudiated and the other three are still being
investigated.
The Trust’s legal service team works to ensure
that lessons have been learnt through close
review of all cases in the same way that
complaints
and
serious
incidents
are
scrutinised and these lessons are shared
across the trust as detailed in other sections of
this account.
9.0 Morbidity and Mortality
Learning from Events
The Trust promotes an open learning culture
where incidents, complaints and concerns are
investigated thoroughly to determine the cause
and action taken, where possible, to improve
services as a result. The Trust also actively
seeks to learn from other organisations for
example through self assessment against
recommendations from national enquiries,
such as Airedale, Mid Staffordshire and
Winterbourne enquiries.
The inquiry into Mid Staffordshire NHS
Foundation Trust (Francis Report) made a
number of recommendations about the
importance of having accurate information
available; including having knowledge of
patients that have died or whose condition has
deteriorated. Data collection and reporting
arrangements for community trusts are
different than for acute trusts. Therefore KCHT
cannot currently collect the same data as an
acute
trust. However it is important that KCHT is
monitoring trends and themes.
Public health researchers have established that
only 10 to 20 percent of errors are ever reported
and, of those, 90 to 95 percent cause no harm to
patients. In addition, a significant proportion of
errors (probably the majority) do not result in
harm for the patient, either because they are
detected and mitigated or they are trivial.
- 55 -
Therefore, KCHT has worked hard to improve
understanding of this in 13/14 and by developing a
programme of data collection and case review that
includes a number of additional ways to identify and
learn from events that could have or do cause harm
to patients.
together, facilitated by the Director of Nursing
and Quality, to discuss cases that did not end
as well as expected. The patient may have died
or their condition deteriorated. If the staff
conclude that the outcomes possibly could
have been prevented, they search for actions to
ensure better results in the future.
Data Collection
Data collection methods in the community hospitals
are currently being reviewed and amended to
ensure that all admissions to these hospitals are
clinically coded. We have entered into a contract
that alerts to any differences between expected
patient outcomes and actual patient outcomes in
inpatient mortality, long length of stay and
emergency readmissions within 28 days. This work
is expected to conclude in quarter two of 2013/14.
This will enable more detailed analysis of
unexpected deaths occurring in Koch’s hospitals
and a basis (where relevant) for improvements in
practice to be made.
Case Review
The Global Trigger Tool
This methodology includes a retrospective review
of a random selection of patient records using
“triggers” (or clues) to identify possible (actual or
potential) adverse events. KCHT have adapted
the acute hospital tool for use in community
hospitals and are embedding its use.
Examples of findings so far include:
The focus of the programme is on process and
system change, with the aim of developing
recommendations to prevent a similar adverse
outcome in the future.
Examples of the actions taken so far include:
•
•
•
•
•
Staff training and assessment and sign off
of staff competencies in relation to full and
accurate completion of patient at risk (PAR)
observation
forms
and
subsequent
interventions required
Personalised care plans to ensure all staff
are aware of the treatment plan relevant for
each patient
Each patient has and knows their named
nurse from admission to discharge
Re-introduction of “end of bed” handover
which includes input from the patient.
Steps
to
improve
multi-disciplinary
communication methods
Reporting and Monitoring
Arrangements
A brief written report is compiled for each of
the case review processes and action plans
developed and implemented by the relevant
Matron or Head of Service. Action plan
monitoring is undertaken via the service
governance route, including discussion at team
and locality meetings, and exception reporting
to directorate Quality Groups.
•
Patients transferred to community hospitals for
whom that was not the most appropriate care
setting and requiring referral to other health
trusts as medically unstable or requiring acute
mental health care
•
Possible missed early signs of urinary retention
(unable to pass urine) which required the
patient to be catheterised
A quarterly summary report including themes,
actions and service improvements is presented
to the trust’s Board via the Quality Committee.
•
Patient being admitted to KCT hospital with
pressure ulcer
This programme is in the early stages and will
be developed further during the year.
Mortality and Morbidity Review (MMR)
Meetings
MMR meetings involve the multidisciplinary team
in a review of the systems and processes leading
to deaths and adverse events within the service.
During each monthly session, clinical staff come
What we need in 2013/14 (Quality Goal 4; 5)
•
Extend the scope of the MM meetings to
include other elements of CG including
review of NICE guidance and clinical audits.
- 56 -
10.0
Workforce Development
Revised Appraisal Process
A good performance appraisal process is vital for
effective
people
management.
Individual
employees need to understand how their
objectives contribute to the Trust’s corporate,
directorate and team objectives. Their managers
must ensure that staff are competent and, in the
case of clinical staff in particular, safe to practice.
Managers and staff must have regular
constructive discussions about performance
which inform a Personal Development Plan
(PDP).
In June 2012 the Performance Appraisal Policy
was approved. To support the implementation of
the policy the training for both appraisers and
appraisees was updated to enable individuals to
contribute positively to and gain maximum benefit
from the appraisal process need appraisal
The revised appraisal process ensures a positive
experience and an opportunity for individuals and
their line manager to:
•
•
•
•
agree individual objectives that link to
corporate objectives
discuss performance;
identify learning and development needs
plan how to implement new learning in the
workplace consider career aspirations; and
continuously improve their performance.
Key to the policy is regularly monitoring the
number of appraisals completed to provide
assurance that appraisals are being carried out
within the annual timeframe which corresponds to
the Trust’s business planning cycle.
The Values in Action Framework
The framework describes the behaviours which
demonstrate that Trust staff work in line with each
of the agreed core values of the organisation and
address some of the core concerns raised within
the Francis Report. . Acting in accordance with
these behaviours will ensure that staff carry out
their jobs well in a caring and compassionate
manner and demonstrate that they are working in
line with the Trust’s and NHS Constitution values
in delivering patient care.
the organisation, increase capability and
improve team and individual performance and
ultimately patient care.
A series of staff engagement sessions were
held across Kent and involved 250 staff. The
primary aim of the sessions was to test out the
vision and values so that the Board could be
presented with a view from staff to inform the
final vision and set of values.
As a result of these sessions the values were
amended and further developed. The staff
engagement sessions also explored the
behaviours which demonstrate that staff were
working in line with each of these core values,
and those behaviours that did not. These
behaviours have been developed into the
“Values into action” Framework which will
support all activity; recruitment, induction,
performance appraisal and learning and
development.
Work has begun on incorporating the
Framework into recruitment activity under the
banner “Recruit for Attitude, Train for Skill”. The
Framework has already been used for some
selection activities in Trust’s restructuring. The
framework is already widely recognised and
understood by our staff.
Supporting Work to Reduce use of
Agency Staff
All NHS Trusts need a flexible workforce that
enables it to adapt to changing needs. An
essential element of this workforce is temporary
workers who
enable the employer to respond to peaks in
activity or to unforeseen gaps in its own
workforce. However KCHT is working to reduce
the numbers of agency staff it uses to improve
the continuity and quality of patient care and
better value for money.
A new process has been introduced whereby
all agency requests must be approved by a
member of the Executive Team prior to
booking.
A date has been set for the transfer of the
existing in-house bank workers to NHS
Professionals (NHSP) and a consultation
process is currently being undertaken.
The Framework helps staff to understand what the
organisation expects from them. This clarity plays
an important role in helping to build the culture of
- 57 -
Supporting Integration with Social Care
The Health and Social Care Integration
Programme is a large scale change programme
which aims to bring about improved outcomes for
service patients and users. It is intended that
health workers and social care staff will
increasingly be working side-by-side, sharing
information and taking a more co-coordinated
approach to the way services delivered. People
with long-term health conditions will be the first to
benefit from these changes to: -.
•
•
•
•
•
•
help get rid of out of date processes that are
duplicated across both health and social care
reduce waste and bureaucracy by working as
a more efficient combined unit
enable people in different parts of our locality
to have equal access to care and support
minimise delays in care and give people the
right support at an earlier stage so they are
less likely to experience worsening of their
condition
reduce the need to go into hospital and
enable people to better manage their
condition and live as independently as
possible
improve the sense that services are
'fragmented' by reducing the number of
professionals that need to be involved in one
person's care, and ensuring those who do are
working more closely together.
With these changes, the process will become
much smoother. Staff such as district nurses,
community matrons, therapists, social workers
and other professionals will be in a position to
communicate with each other on a more regular
basis and share information to support people
better. Eventually patients may have a single
point of access, a ‘Health and Social Care Cocoordinator’ who is their main contact point.
By working together, staff from all sides can more
easily identify which patients are most at risk – for
example, of going into hospital – and then put
together a combined package of care, support
and lifestyle advice designed to keep them
healthier and independent for longer. If someone
ends up in hospital, staff from the ospital can
work with those in the community to help them
leave with the right support in place thereby
reducing the risks associated with Transfer of
Care.
Mutual understanding of the key aims and
objectives of Health and Social Care Integration
has been developed between KCHT and Kent
County Council (KCC). In addition Clinical
Commissioning Groups specific Health and
Social Care Improvement Plan Integration
plans and working groups has been
developed.
KCC and KCHT staff in a number of areas
have been co-located. A number of joint roles
have been developed, including that of the pilot
Health and Social Care Co-ordinator position.
The restructure of a number of Long Term
teams to support the requirements of
integration have commenced. Integration will
ensure patients/service users receive a
responsive integrated service reducing the
need for hospital admissions.
‘Pulse’ Survey to Investigate Staff
Satisfaction “
This is a time of rapid change within the NHS. It
is important that staff feel that they have a voice
and that their issues are taken seriously and
addressed properly.
The Trust participates in an annual national
staff satisfaction survey and received a score
of 3.53 in Key Finding 24 in the National Staff
Survey for both 2011 and 2012 which is
average when compared to other Community
Trusts.
Statement
KCHT considers that this percentage is as
described because of the significant amount of
change which the organisation has been going
through and still continues to do so.
KCHT has undertaken a stress risk
assessment which has highlighted stress as a
significant issue for many services and in April
an external facilitator will be running solution
groups with a view to recommending areas for
improvement for the Trust which will contribute
to this score
Although
the
survey
provides
useful
information it is only a once a year snapshot
and the results from the survey (which is
conducted in November each year) are not
available until February or March the following
year. This does not therefore allow much time
to implement actions in response to survey
results before the next survey commences. By
running our own “Pulse” surveys in addition to
- 58 -
the national survey the Trust hopes to elicit more
representative information throughout the year
rather than only annually and to be able therefore
to respond quickly to any trends that emerge.
The Change Champions Network was developed
in response to staff engagement sessions, where
discussions took place about creating a
framework which would help the organisation
change culturally and move forward. The Change
Champions have conducted focus groups and
been involved in developing action plans to
address issues.
Although the survey has been developed in
2012/13 it is anticipated that the roll out will
largely be in 2013/4.
Assessment Processes and action Plans
for Equality Delivery System
The Department of Health’s Equality Delivery
System (EDS) is a performance improvement
framework for equality. The System supports the
Trust to meet its Public Sector Equality Duties
under the Equality Act 2010. The System will
also allow the Trust to identify performance, in
relation to equality and diversity, across its
functions and services.
The Goals in the EDS are:
•
•
•
•
Better health outcomes for all
Improved patient access and experience
Empowered, engaged and well supported staff
Inclusive leadership at all levels
For Goals 2 and 3 engagement events were held
so that our stakeholders could determine our
progress against each goal. For Goal 2 a series of
locality public engagement events ere held where
the public graded our performance on the Equality
Delivery System.
For Goal 3 a panel consisting of a Staff-side
representative, representatives from the 2 staff
equality networks and a staff volunteer graded
performance. Goal 4 was reviewed at a session
by the full Trust Board. Action plans have been
developed with identified leads for all 4 Goals
Action plans are in place for all 4 Goals. Staff and
the public are beginning to understand the EDS
and believe in the Trust’s commitment towards it.
Two of the goals have been assessed by
stakeholders. The remaining two have undergone
a self assessment process. An additional
achievement, which provides some external
assurance, was that the Trust achieved a place
in the Stonewall Workforce Equality Index for
the second year running.
Compliance with the Equality Delivery System
shows our patients, the public and our
commissioners that we value diversity and
ensure equality of service delivery.
What we need to do in 2013/14 (Quality
Goals 1, 3, 4, 5)
Systems are being rolled out across the
Trust providing greater assurance of both
appraisal
and
mandatory
training
compliance with managers having access to
real time information on training and
development.
• Work will continue to integrate the
Framework into recruitment processes and
into learning and development activities.
The possibility of screening candidates at
the initial application stage will be
progressed possibly through the use of online testing. The Trust will work with NHSP
to identify areas where recruitment
campaigns could be effective to sign up
new workers
• Reducing agency staffing will reduce costs
and improve patient care by ensuring
continuity of care and fewer incidents
• We will continue to restructure of LT teams
to support the requirements of integration.
We will also continue to develop
infrastructure to
enable integrated working between KCHT
and KCC.
• Further opportunities will be developed for
health and social care staff to increase
understanding of roles and processes
therefore highlighting opportunities for joint
working and increased efficiency.
• We will explore the benefits of integrated
induction processes and review the
outcome of the Health and Social Care Coordinator pilot programme.
• The Equality and Diversity Steering Group
will continue to monitor progress against
the action plans. All four Goals will be
graded by an appropriate stakeholder
group during 2013/14
•
- 59 -
11.0
Quality and Education
Programmes
The 1st Class Care Programme is the Trust
framework for delivering clinical ‘excellence
every time’. Since 2008 the definition for quality
has been accepted across the NHS to be
patient experience, safety and clinical
effectiveness. However to deliver consistently
high quality services to our patients we believe
that there are three additional domains which
are:
•
•
•
Competencies
Clinical Education
Professional Practice Standards
How did we perform in 2012/13
Competencies
Over the last year we have been developing a
competency framework that sets out a role
profile for each of our staff groups and will give
clarity on the knowledge, skills and
competencies expected for each role. These
will guide and inform practice, supervision and
education provision. This means on completion
of any programme staff will have to complete
the relevant competency assessment which will
also be aligned to the Appraisal process.
We have also started changing the focus of our
education programmes ensuring that they are
focused on patient outcomes feedback through:
-.
•
•
•
•
•
•
Complaints and compliments
real-time feedback through the Meridian
system
Incidents including serious incidents; safety
thermometer and other quality measurement
Clinical audit results
PLACE assessments
15 Steps results and Observations of Care
audits
This will provide powerful learning opportunities
for our staff to understand and gain insight into
the real impact they have on patients and their
families. All programmes are going through our
Validation Process to ensure that they meet this
standard.
We are currently working very closely with our
two main university providers (Higher Education
Institutions) to adopt this approach to the
education programmes provided to our
registered health care professionals.
Clinical Education
The First Class Care Core programme for
Unregistered Support Workers has been
designed to cover the core clinical skills and
knowledge required by all unregistered staff,
irrelevant of role, to ensure all patients receive
high quality care and have a positive
experience under our care. This aligns to the
recommendations in the Francis Report.
The course is designed as a modular
programme and has six competency based
units. Four of these units are mandatory and
two are open modules which can be designed
to suit a specific job role.
The underpinning principles across all of the
modules include record keeping and related
documentation;
patient
experience;
psychological and social wellbeing.
The
modules:
•
•
•
•
•
•
Introduction Mandatory
Observations
and
Specimen
Taking
Mandatory
Wound Care Open
Pressure Area Care Mandatory
Medicines Management Open
Falls and Presentations Mandatory
The open modules allow the course to be
flexible across the diverse services within the
Trust Community Services.
A workshop approach ensures reflection on
practice, a powerful participatory method.
Feedback from the groups that have
undertaken the programme have been highly
positive.
All
modules
contain
an
element
of
documentation, equality and diversity, health
promotion and accountability to ensure that
these elements are embedded in practice. All
teaching is related to the patient experience
under our care and the impact of illness on both
their psychological and social well being.
Three courses have run this year and the noted
benefits are:
• HCSW feel more confident in performing
their duties
- 60 -
providing patients with explanations about
procedures
giving first line information to patients
providing feedback to their registered nurse
colleagues
relevant or transferable to the community
setting. The limited evidence in regards to
community health makes benchmarking some
aspects of our services impossible.
Up to March 2013 151 of our Healthcare Support
Workers (HSW) had completed our HSW
programme.
A conference was held to which all grades of
Registered Staff were invited and a total of 50
attended. The conference was opened by our
CEO and was facilitated by our Director of
Nursing and Quality. Speakers included
representative from the Royal College of
Nursing, the Trust Solicitor
•
•
•
Other programmes that have been developed and
implemented over the last year include
Preceptorship which is for newly registered
professionals and provides them with support and
supervision from a senior professional and
facilitated learning.
Professional Practice Standards
To ensure all of our staff work in an environment
that promotes quality improvement and provides
the necessary support we have focused on
establishing a Learning Environment Standard.
This sets out what must be in place in all our
clinical services and the roles that must be
available. These include Mentors for pre and
post registration students; Preceptors; Mentors
for Quality Improvement.
In addition to this we have produced Professional
Standards for pain management, privacy and
dignity and Comfort Rounding
The National Commissioning Board launched the
6 Cs in December 2012. This sets out the national
focus on delivering compassionate care through
addressing 6 key areas: •
•
•
•
•
•
Care
Compassion
Competency
Communication
Commitment
Courage
KCHT has commenced a gap analysis against the
6Cs to ensure that clinical practice development
and education programmes are enhanced to
reflect the key indicators and assist KCHT to
deliver compassionate care to all of our patients.
Accountability Conference
The most positively evaluated session was
given by a Head of Service and Clinical Team
Leader who gave an honest account of what
happens when patient harm occurs, how that
feels for all concerned and how they turned it
round in their unit from not good enough to
excellent.
During the conference delegates were given
real life scenarios from practice where
Registrants had been held to account. Based
on the stories presented the delegates had to
make decisions about the fictional characters
fitness to practice. Their decisions were then
presented to the wider conference and a
scrutiny panel chaired and lead by the Director
of Nursing, the Deputy Director of Nursing,
Trust Solicitor, AHP representative, a Principle
Lecturer, and RCN Officer. The outcome of this
experiential approach was that the delegates
reflected on what their accountability meant to
people they provide care to, their profession
and themselves.
Many described in their evaluations of the day
that it made them much more aware of their
professional responsibility and their role in
wider fitness to practice issues.
Following the conference the delegates have
been asked to deliver an abridged version to 5
colleagues. This will be followed up by the
Nursing and Quality Directorate in a call to
action to ensure that the messages from the
conference are shared with a wider number of
clinicians
‘Building our Reputation’ is a project that has been
undertaken with our university colleagues to
support staff to publish and promote community
healthcare and the excellent work undertaken by
our staff. Much of the evidence available and
focus is on acute services which is not always
- 61 -
Clinical Supervision
Clinical supervision is a relationship based
clinical education that brings practitioners and
skilled trained supervisors and or peers together
to reflect on practice. Supervision aims to identify
solutions to problems, improve practice and
increase understanding of professional issues.
This year we have focused on monitoring
compliance with the policy. This has highlighted
variation in the uptake across the Trust and
differing models in place within the professional
groups. The Allied Health Professional (AHP)
group have been found to have a robust
approach that aligns to staff appraisal objectives
that are focused on improving aspects of patient
care. The gaps identified in the nursing model
include: •
•
•
a shortfall in the numbers of trained
Supervisors in nursing
no effective way of measuring the impact and
outcomes for staff or patients
many staff do not attend prioritising care
delivery
What we need to do in 2013/14 (Quality
Goals 1; 3; 4; 5)
•
•
Complete the Validation Process for all of our
education programmes
Complete the review of the HSW roles across
the Trust and developing a Trust wide
strategy to direct the development of this role
for the future.
•
•
•
•
•
Develop and implement a wide range of
professional practice standards in a
handbook for staff. This will provide further
clarity on the delivery of compassionate
care to our patients
Monitor compliance of our Professional
Practice Standards
Roll out the Competency Framework
Nursing Clinical Supervision model will be
revised to reflect the model in place for
AHPs
Continue the ‘build our reputation’ and
achieve 5 publications by our staff in
national journals
12.0
Continuous Quality
Improvement using
Clinical Audit
Clinical audit is a way of improving the quality
of patient care; it means analysing a service to
see whether it meets particular standards (for
example, NICE guidance), and identifying ways
in which the service could improve. We see it
as a very important way of understanding how
we can continuously improve the quality of our
services. By the start of each financial year
KCHT has agreed an appropriate planned
programme of clinical audit activity. The
programme includes national and local audits.
National Audit
Trusts are required to consider a number of
national clinical audits, funded by the
Department of Health and report participation in
the Quality Account.
Statement
During 2012/13 three national clinical audits and zero national confidential enquires covered NHS
services that KCHT provides. During the year KCHT participated in 100% of the national clinical
audits which it was eligible to participate in.
The national clinical audits that KCHT was eligible to participate in during the year are as follows:
• National Epilepsy audit
• National Paediatric Diabetes audit
• Falls and bone health in older people
•
Chronic Pain
- 62 -
Table 16. KCHT participation in National Clinical Audits 2012/13
National
Clinical Audit
Title and Lead
organisation
1. National
Epilepsy audit
12 – P/021/11
Standards
Status
Findings/Outcomes
NICE
SIGN
guidelines
Completed
•
In the main there was good compliance with
the guidance
Outcome of neurological examination not
included in one case out of five.
Good compliance with recording of children’s
developmental progress, education and
behaviour
Number of episodes not recorded in one case.
This would ideally be recorded.
Results discussed in clinical practice meeting
and areas for improvement noted: history
taking and neurological examination process
reiterated
Standards will continue to be audited in round
2 of the National Audit, against the 12 key
indicators derived from NICE and SIGN
guidelines.
This is not a core service
for KCHT
Local findings and actions include:
• Incorporating fall screening tool 1 into the new
electronic community information system to
ensure all patients receive relevant falls
assessment
• The screening tool will be on the staff intranet
for easy staff access in the interim
• On line training is available through the staff
intranet for community hospitals staff and has
been added to the training needs analysis
under essential to role
• Falls awareness training is being introduced
for all clinical staff within KCHT
• A patient leaflet and booklet to provide advice
about falls prevention has been developed.
Patients were included
in this audit
•
•
•
•
•
2. Falls and
bone health in
older people –
I/002/10
East Kent
Hospitals
University
Foundation
Trust
4.Chronic pain
(National Pain
Audit)
• National
Service
Framework
for Older
People
• NICE
guidance –
falls and
osteoporosi
s
Action plan
awaiting
committee
ratification
Participated
in part one
of this audit
Comment
5 met inclusion
criteria/one treated for
epilepsy and
completed the
questionnaire
This involved completing
an organisational/service
questionnaire. This was
reported in last year’s
quality accounts. Please
note that part 2 of the
audit is more acute
focused and so the Trust
did not take part.
No patients in part 2
- 63 -
The Trust also participated in 2 other national clinical audits. These audits were not funded by the
Department of Health or Healthcare Quality Improvement Partnership (HQIP) as listed here:
Table 17. Other national audits
National
Clinical Audit
Title and Lead
organisation
1. National
Audit of
Treatment
& Care of
HIV
infected
inpatients
- I/003/10
Standards
Status
Findings/Outcomes
This is a
retrospective
national audit
to review the
number of HIV
positive
individuals
treated as
inpatients
between April
to October
2010.
Awaiting
action plan
•
2. National
Patient
Involvement
project: Older
peoples
experience of
falls and bone
health services
– 1071
Information
was gathered
from patients
about their
experience of
therapeutic
exercise as
part of a local
falls prevention
service
Completed
Comment
A national report was produced and the Trust
was 1 of 29 centres who responded
• The national results were reviewed, however no
local results were provided
• The Trust is adhering to the majority of the
national recommendations. Areas of noncompliance related to:
1.
clinicians should receive training from and
meet regularly with clinical coding teams.
This was not achieved as HIV inpatients
are admitted under the acute trust and
clinical coding is done by acute trust
coders and not KCHT Sexual Health
medical staff
2.
HIV inpatient audit. KCHT have proposed
an annual audit is undertaken with the
acute trust but do not manage HIV
inpatient services.
• In line with other providers, and good practice,
HIV inpatients are jointly managed under the
care of an HIV consultant with an admitting
consultant
•
Complex inpatients are transferred to a tertiary
HIV centre in line with locally agreed pathways
• The testing for HIV is now more widely
promoted through a variety of training methods
and community events
• The service and programme has been
restructured to ensure it meets the needs of
local people and is evidence based. This was in
response to patient and staff feedback
indicating that many NHS providers are not
delivering completely evidence-based
interventions for reducing falls.
• A competency framework is being agreed
against the national guidelines for band 3 and 4
rehab assistants. This will then be extended to
include all other staff involved in the
programme. Annual appraisals with 6 month
reviews will be on-going for all staff to ensure
staff are appropriately trained and monitored
• Data collection forms and a database have
been constructed specifically to achieve
monitoring locally.
• Patient surveys will be given to patients
attending the programme. These have been
designed locally, and may be available on the
Meridian I pad to ensure quality outcomes from
a patient view.
- 64 -
Local Audits
There were 163 local clinical audits registered
in the period 1 April 2012 to 31 March 2013. 51
projects were closed by year end.
Audits are commenced at different times during
the year, therefore at year end a proportion will
be at various stages of the audit cycle such as
data collection, analysis, report writing or
implementing action plan. In addition, audits
are not considered closed until the action plan
is fully implemented.
audit reports have been reviewed by our
Audit/Quality Groups and the Clinical Audit
Group (CAG). The CAG produces a highlight
report for the Quality Committee chaired by a
Non-Executive Director. The Annual Report is
presented at the CAG, Quality Committee and
to the Board.
Audits are also undertaken to evidence, for
example, the level of compliance with standards
(E.g. NICE guidance) and trust policies and
processes. Two examples are shown.
Hence 105 are reported to be carried over into
the 2013/14 clinical audit year. The clinical
Table 18. Examples of audits against the trust’s Quality Goals are included in this report.
Local Audits
Standards
1. Re-audit of
Body Mass
Index in the
national
Chronic
Obstructive
Pulmonary
Disease
Patients –
P/026/11
The purpose of this
audit was to ensure
that the actions
taken from the first
audit were effective
in improving patient
care and the
recording of
patients BMI had
increased.
Standards for this
audit were
measured against
NICE guidance
NICE Technology
Appraisal 151
2. Insulin
Pump
Therapy
Audit –
P/014/10
Status
Findings/Outcomes
•
•
•
•
•
•
•
•
•
•
•
Comment
Increase in the percentage compliance for 13
standards as seen in graph below
28% improved recording of Body Mass Index
(BMI) at the first assessment
76% of the patients had their BMI reassessed in a
more consistent timeframe
Standards will continue to be monitored through
ad hoc checking of notes.
Use of national guidelines will ensure patients are
provided with information specific to their BMI and
MUST screening score
Pump therapy is being prescribed appropriately
and patient outcomes have improved
75% reduction in admissions to hospital and 12%
reduction in outpatient visits
10 out of 12 patients (83%) daily insulin dose
reduced after insulin pump therapy
10 out of 14 patients (71%) HbA1c levels
dropped. The greatest reduction was 6.1%
Higher demand for pump therapy than staffing
levels or funding could provide has resulted in
development of a business case for increased
funding
Clinic format and efficiency has also been
reviewed to manage capacity.
Table 16 Local Audits
- 65 -
Improvements in standards for measurement and use of body
mass index in the chronic obstructive pulmonary disease
patient
Ref erral to a dietitian if needed af ter re-assessment
Both verbal & w ritten dietary advice given
Dietary advice given w here applicable
Further action taken w here BMI abnormal af ter reassessment
Patient's BMI re-calculated since initial assessment
Patient's w eight re-assessed
2011
Patient ref erred to a dietitian
2010
Nutritional supplements requested f or BMI below 20
Dietary advice given f or abnormal BMI
Action taken f or abnormal BMI w here applicable
Patient's BMI recorded at the initial assessment
Patient's height recorded at the initial assessment
Patient's w eight recorded at the initial assessment
0%
20%
40%
60%
80%
100%
Figure 15 Improvement in standards for measurement
Identifying and monitoring actions
A total of 393 actions have been identified from
clinical audits in the current audit year. These
include 207 process actions and 186 quality
and safety actions. The quality and safety
actions have been themed into the 10 areas
shown in the graph. The actions are monitored
by the Audit /Quality Groups through production
of monthly action plan monitoring reports.
What we need to do in 2013/14 (Quality Goals
1, 2, 3, 4, 5)
•
•
•
•
A programme activity to of clinical audit
engagement and activity
Further work to develop the annual audit
programme it continues to meet national
requirements
Extend the scope of audit to include quality
improvement assurance
Report to both the Clinical Audit Committee
and Quality Committee on outstanding
actions on a regular basis and report on the
level of risk associated with delays in
completion
- 66 -
13.0 Innovations in 2013/14
Wound Infection Risk Evaluation (WIRE)
Tool
Chronic wounds are generally contaminated
with bacteria. The presence of bacteria is
termed ‘colonisation’.
The degree of
colonisation will have an impact on whether
there is clinical infection resulting in signs and
symptoms such as delayed wound healing.
Visual evaluation of the wound is the standard
approach to determining the level and stage of
wound infection. The clinician considers the
level and type of discharge; the degree of
inflammation and pain as key indicators on
deciding the appropriate wound management
strategies to be implemented to treat the
infection.
KCHT is working with University of Hamburg
and the German Wound Academy to develop
and implement a new wound care service
model.
Wound Care Delivery Redesign
This model embeds integrated care and utilises
modern technology for early intervention from
the right specialists at the right time avoiding
unnecessary delay. This will lead to improved
healing rates / reduce complications the
outcomes that our patients want.
The model will include the use of: •
•
This is subjective and open to variation and
relies on the competencies of the healthcare
professional.
To improve outcomes for patients there is a
need to standardise chronic wound care within
a defined framework. To achieve this we are
attempting to develop tools that will provide
consistent and standardised guidance for our
staff. This will enable staff to implement a plan
of care based on agreed wound care
management strategies for the various stages
in the wound cycle. It is envisaged that this
approach to chronic wound care will improve
quality outcomes that can be benchmarked and
measured.
So far we have developed a visual analogue
tool that scores a wound and identifies the
stage of the cycle. It involves infection risk
prediction, treatment and outcomes markers.
For each stage there is a care-pathway to
follow, with a best choice dressings and the
competencies necessary to manage the wound.
The objective is to reduce infection rates in
wounds, and allow early intervention by
competent staff.
After full internal and external validation the
tool, supported by education and training will be
implemented across the trust.
Innovation is key to improving patient
experience, safety and clinical effectiveness
and is at the heart of the redesign of the service
•
tele-medicine, - available to all levels of
health care professional looking after
wounds with established care pathways and
wound assessment tools with remote
support from specialists
wound care centres- specialists TVN led
centre for early intervention
virtual complex wound care centre – holistic
specialist virtual wound management unit
involving hospital consultants and other
specialists for patient with complex non
healing/ difficult wounds with several comorbidities
wound early intervention and
reduce bench marked healing times/rates.
Out Patients Parentral Antimicrobial
Therapy (OPAT) – IVs in the Community
The NHS Outcomes Framework has five target
areas two of which are intended to drive
improvement in safe early discharge and
admission avoidance for patients with Long
Term Conditions. We have identified that many
of our patients remain in hospital sometimes for
many days purely for the administration of
intravenous therapy. We are now working with
our four acute hospitals and commissioners on
the service model required to embed this
across the county.
To deliver this service has required expanding
the total number of staff available across the
Trust with the correct skills and competencies.
A steering group was established in June 2012
to provide the leadership to take this agenda
forward.
The Intravenous Nurse Specialists have been
instrumental in the progress that has been
made having trained and competency assessed
staff across the Trust.
This enables us to provide a seamless service
to our patients, therefore improving the patient
experience. In collaboration with our patients
we have developed delivery models that are
supported by:
•
•
•
•
•
a patient risk assessment tool
disease specific care/ patient pathways with
agreed list of antibiotics and early
intervention sign posting
standardised documentation to enable
smooth transfer and minimise potential
interface issues
trouble shooting and with roles and
responsibilities clearly defined
supporting education and training with
achieve described competencies.
This project is being considered by the
Outpatient Parenteral Antibiotic Therapy
(OPAT) national committee and NICE as a
model to be promoted nationally.. KCHT has
been invited to join the national working group
to help develop guidelines for community based
OPAT services.
Diabetes Algorithms
KCHT is leading on a project to develop an
integrated approach to better manage insulin
dependent patients who require third party
intervention.
The aim is to: • eliminate the operational barriers that exist
for staff across acute and primary care
including community nursing
• reduce rates of insulin related complications
• improve blood glucose levels combined with
Weight management
• help reduce the number of incidences that
result blood glucose levels falling below
clinically safe levels.
• reduce hospital admissions.
NICE guidelines suggest that patient who for
various reasons are unable to administer their
own insulin and are dependent on third party
insulin administration should be considered for
once daily basal insulin administration.
To enable this and conform to NICE guidelines,
our team has developed a ‘Once daily basal
insulin’ patient review algorithms which involves
a community nurses, the patient’s GP and
Acute hospital team supported by the Diabetes
Nurse specialist.
14.0 Research
Research and Development Account for
2012/13
“The number of patients receiving NHS services
provided or sub-contracted by Kent Community
Health NHS Trust in 2012/2013 that were
recruited during that period to participate in
research approved by a research ethics
committee was 15
Participation in clinical research demonstrates
Kent Community Health NHS Trust commitment
to improving the quality of care we offer and to
making our contribution to wider health
improvement. Our clinical staffs stay abreast of
the latest possible treatment possibilities and
active participation in research leads to
successful patient outcomes.
Kent Community Health NHS Trust was
involved in conducting 4 portfolio research
projects in Stroke, Older People and Children
during 2011 / 2012. Out of the four clinical
research, 1 are Topic Studies, specifically
Stroke and Primary Care which falls under the
speciality
of
“Rehabilitation”.
For
Comprehensive Clinical Research Network
studies, 3 specialities involved are “Oder
people” and “Children”.
The improvement in patient health outcomes in
Kent
Community
Health
NHS
Trust
demonstrates that a commitment to clinical
research leads to better treatments for patients.
There were 7 of clinical staff participating in
research approved by a research ethics
committee at Kent community Health Trust
during 2011/2012. These staff participated in
research covering 3 of specialities.
As well, in the last three years, 0 publications
have resulted from our involvement in NIHR
research, which shows our commitment to
transparency and desire to improve patient
outcomes and experience across the NHS. Our
engagement with clinical research also
demonstrates Eastern and Coastal Kent
Community Health NHS Trusts commitment to
testing and offering the latest medical
treatments and techniques.
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15.0
Information Governance
Data Quality Statement
Effective delivery of patient care relies on good
quality information and is essential if
improvements in quality of care are to be made.
Historically the quality of data captured by
services working in a community setting has
been poor due to a lack of investment in
information systems.
Background and Requirements
The Trust has a number of statutory
responsibilities relating to the collection and
reporting of information. These range from the
requirement to complete a number of national
returns, to the need to collect specific data sets
for various services that the Trust provides.
There are also a number of local contractual
requirements such as the need to supply a local
commissioning data set to the Trust’s
commissioners on a monthly basis for many
services and the requirement to accurately
report levels of activity and performance against
a number of key performance indicators. In
addition there is also the requirement to provide
accurate information internally to support
clinical and business decision making.
KCHT does not have a single, centralised,
integrated patient records system, but the
implementation of the new Advanced Health
and Care Community Information System (CIS)
will address this. The current information
system estate does not generally support
robust data capture and reporting as system
data quality is negatively impacted by the
underpinning (mainly manual) data collection
processes. Data quality is further impacted by
the lack of integrity of the Trust’s ageing legacy
systems. There are some exceptions such as
the systems used by the Community Dental
Service, the Minor Injuries Units and Walk-in
Centre, Children’s Audiology and the Sexual
Health Service for example.
During 2013/14 Kent Community Health NHS
Trust will be taking a number of actions to
improve data quality.
Assurance
Policy: KCHT has a Data Quality Policy in
place. An updated version has recently been
drafted and is in the process of being formally
adopted by the Trust. The policy is intended to
raise the profile of data quality and the
subsequent information derived from it within
the Trust. The policy advises on basic principles
to be applied to ensure good data quality as
well as outlining the roles and responsibilities of
all staff in relation to data quality. The policy
describes the need to have a robust programme
of data quality audits to enable the adherence
to the policy to be monitored. The governance
arrangements for monitoring the policy
implementation are also outlined within the
policy.
Governance:
The
Information
Quality
Improvement Group (IQIG) meets on a
quarterly basis and has a membership which
includes all key information system leads, as
well as leads from the trust’s Information
Governance and Information Technology
teams. The main focus of the group is driving
the implementation of the data quality policy,
ensuring that all systems have standard
operating procedures in place and that best
practice is being followed wherever possible.
The group also reviews the results of any data
quality audits and oversees the implementation
of any resultant action plans.
A Business Intelligence & Information Quality
Assurance Group (BIIQAG) was established in
July 2012 under the recommendation of the
Strategic
Health
Authority
to
oversee
improvements in data quality and completeness
for all information used by KCHT to provide
assurance
to
internal
and
external
stakeholders. The remit of this group is wider
than IQIG covering all data used internally by
clinicians, services, the Performance &
Business Intelligence Team and the Board as
well as data provided to external stakeholders
e.g. the Trust’s commissioners and the
Department of Health.
Action Plans: There are various action plans
in place that aim to improve data quality on the
Trust’s corporate and clinical systems. These
range from system specific plans put in place
following audits, to higher level plans covering
local or national data sets / data standards.
Baseline audits are currently being carried out
on corporate systems and action plans are in
development.
Monitoring Internally data quality action plans
are monitored via the IQIG and the BIIQAG.
The Trust’s commissioners also monitor the
action plan which has been put in place to
improve the quality of data provided for contract
management purposes.
A trajectory for full Community Information Data
Set (CIDs) and Monitor’s Compliance
Framework Data Completeness Improvements
has been developed. This trajectory is based on
the deployment of the CIS which is fully CIDs
compliant. The target for full CIDs compliance is
April 2014. This trajectory will be monitored by
the IQIG and BIIQAG and will be incorporated
in the Integrated Performance Report.
Reporting The data quality and completeness
indictors included in Monitor’s Compliance
Framework have been incorporated into the
Integrated Performance Report. In addition,
data quality flags are to be added to this report
along with additional indicators to raise the
visibility of this issue.
NHS Number and General
Practice Code Validity
Medical
Statement
KCHT submitted records during April 2012 to
January 2013 to the Secondary Uses Service
(SUS) for inclusion in the Hospital Episode
Statistics which are included in the latest published
data.
The percentage of records in the published data
which included the patient’s valid NHS number was
99.38% for admitted patient care.
The percentage of records in the published data
which included the patient’s valid General Medical
Practice Code was 98.76% for admitted patient
care.
It should be highlighted that data are currently
only submitted to SUS for two of the twelve
Community Hospitals which KCHT has
responsibility for. The Trust are working with the
acute providers in Kent and Medway (whose
information systems are utilised within these
facilities) to address this issue in the first
quarter of 2013/14.
Information
Governance
Attainment Levels
Toolkit
Statement
KCHT has shown significant improvement in the
IGTA for the period 2012/13. The target
compliance for 2012/13 has been exceeded and
the current position is 76%
All requirements will have met the minimum
level 2 compliance and the IGTA will be rated
green “Satisfactory”.
Additionally, South Coast Audit have also
provided significant assurance that the evidence
held, within the controls audited, was robust and
of a high standard. The work plan for 2013/14
will include continued auditing of compliance
with legislation and policy within working
practice, and the continued promotion and
delivery of training.
Statement
KCHT was not subject to the Payment by
Results clinical coding audit during 2012/13 by
the Audit Commission
Readmission to Community Hospital
within 28 Days
The readmission rate with 28 days in 2011/12
was 5.99% and 6.60% in 2012/13.
Statement
KCHT considers that reasons for these
percentages are described for the following
reasons: • the measure does not fit well with a
community hospital model for example: • A patient is stepped down from an acute
trust to a community hospital to facilitate bed
capacity within the acute trust. The patient
on arrival is found to be inappropriate for the
community hospital setting so is discharged
back to the acute trust. A few days later the
patient is stabilised and is then readmitted to
the same community hospital for rehab (an
appropriate admission on this occasion).
• A patient has a stay in a community hospital
for rehab and is discharged home under the
care of Intermediate Care Team (ICT) Within
28 days the patients has an exacerbation of
another condition and the ICT team step the
patient up into a community hospital bed for
a couple of days to be stabilised then
discharged back home under care of the ICT
service
What we need to do in 2013/14 (Quality Goals
1; 2; 3; 4)
•
•
•
•
Implementation of the Community
Information System
Continue to strengthen data capture
and reporting
Improve on the Information
Governance Toolkit Score
Revise the process for reporting
readmissions
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16.0 Care Quality Commission
KCHT is registered with the Care Quality
Commission for services in thirty two locations
across Kent and beyond. and its current
registration status is registered without
conditions. .A number of new sites have been
successfully registered in 2012/13. In order to
be registered organisations must show that they
are meeting the essential standards of quality
and safety.
The Care Quality Commission has not taken
any enforcement action nor undertaken any
special reviews of Kent Community Health NHS
Trust and the Trust is not subject to any
periodic review by the Care Quality
commission.
A condition of registration can be imposed
upon a provider where there is evidence that
they are not compliant, to limit or restrict what
they can do.
The Trust has a robust assurance process that
requires services and subject matter experts (in
areas such as safeguarding, medicines,
consent, learning and development and equality
and diversity) to self assess compliance against
the CQC’s 16 Quality and Safety Outcomes.
The Trust test the quality of these self
assessments by holding panel meetings that
subject matter experts and heads of services
attend to present their evidence and any action
plans
The CQC’s Quality Risk Profile (QRP) for the
Trust is updated nine times each year. Each
new version is reviewed to ensure any areas of
concern have been addressed.
The data
available to the CQC is
populate the QRP has increased since last
year. The current QRP shows 18 negative data
items; nine of these relate to issues identified
during CQC review/inspections, but did not
relate to any compliance actions and are being
addressed by the Trust
Six relate to staff
survey results that are being addressed via the
Trust’s staff survey action plan and pulse
surveys referred to in section 10
The majority of items on the QRP are either
positive (70 items) or neutral (66 items). These
data items relate to areas such as positive
comments from CQC reviews and inspections,
Information Governance Toolkit results, Food
Standards Agency ratings, positive staff survey
results, our response to safety alerts from the
Medicines and Healthcare products Regulatory
Agency (MHRA) and positive comments left by
patients on NHS Choices.
The Trust was reviewed by the CQC in three
unannounced inspections one of which was a
follow up inspection during 2012/13 and the
outcomes are reported in the table below. All
areas were compliant except for two minor
concerns at Whitstable and Tankerton hospital
relating
to
nutrition
and
medicines
management.
These
were
immediately
actioned by the Trust and were compliant on reinspection.
Compliance is also tested by a programme of
unannounced internal inspections to services
undertaken by the Standards Assurance
Management with subject matter experts and
senior managers. Areas of good practice have
also been identified such as the introduction of
training and development passport for clinical
staff and use of symbols above patients beds to
identify nutrition and communication needs
Some of the areas for improvement found
through these inspections
have been
consistency and accuracy of documentation,
staffs’s understanding of mental capacity and
consent and staff’s access to clinical
supervision.
All learning is shared at the Trust’s CQC
Registration Standards Monitoring Group and
the group reports to the Quality Committee.
- 71 -
The Group ensures that action plans are in place for internal and external visits and any area identified as
being non-compliant by the service or subject-matter expert.
Outcome
Whitstable and
Tankerton Hospital
27.06.12
Outcome 1 Respecting and
involving people who use
services
Compliant
Whitstable and
Tankerton Hospital
re-visit 13.09.12
Outcome 2 Consent to care
and treatment
Rohan Learning
Disability Unit
24.01.13
Compliant
Outcome 4 Care and welfare
of people who use services
Outcome 5 Meeting nutritional
needs
Compliant
Outcome 7 Safeguarding
Compliant
Outcome 9 Management of
medicines
Minor concern –
Compliance action
Minor concern –
Compliance action
Compliant
Re-inspection of
Compliance actions
– now Compliant
Re-inspection of
Compliance actions
– now Compliant
Compliant
Outcome 10: Safety and
suitability of premises
Compliant
Outcome 12: Requirements
relating to workers
Outcome 13 Staffing
Compliant
Compliant
Outcome 17 Complaints
Compliant
Table 19. CQC Inspections
17
External Review of Quality
Account
In the Department of Health Quality Account
Toolkit (2010), Trusts must share their Quality
Account with key stakeholders ahead of
publication for scrutiny and comment which are to
be included in the account.
The Trust shared the draft account with all of the
Kent Clinical Commission Groups, the local area
team and Healthwatch and received the following
feedback:
Clinical Commissioning Group (CCG)
South Kent Coast Clinical Commissioning Group
(CCG) as the lead commissioner, coordinated the
responses from all CCGs.
The CCG responded that it agreed with the
Trust’s assessment of its performance and the
goals and targets set for the year ahead.
Contract quality monitoring meetings are in place
between the CCG and providers. The Quality
Goals and deliverables will be monitored by the
CCGs.
Healthwatch
Healthwatch England established in April 2013 is
the independent consumer champion for health
and social care.
Healthwatch works with a
network of 152 local Healthwatch teams to
ensure that the voices of consumers and those
who use services reach the ears of the decisionmakers.
experience and satisfaction with the care and
services received.
External Assurance
Last year the Department of Health stipulated
that all acute Trusts not currently foundation
trusts (this role is undertaken by Monitor) had
to undergo external scrutiny by auditors.
Community trusts were not required to
undergo this external assurance process
The audit process was to provide the public
with external assurance of the Quality
Accounts. The Indicators set are to allow for
comparisons across the whole of the NHS.
Whilst
not
a
requirement
KCHT
commissioned internal audit to review the
Quality Account against the Department of
Health regulations..
The key
indicator
chosen relevant to the community trust was
•
% of incidents resulting in severe harm
or death.
The auditors assessed the process from the
incident reporting stage to the board report. As
part of the review the auditors spoke to staff at
all levels to gain insight into the process and
staff perspectives
As a result the auditors have been able to say
that there were no key areas of concern
identified.
Although in place since April 2013, Kent
Healthwatch is still in the development phase:
•
•
of providing a voice to the public and users of
health and social care services in Kent
gaining insight and understanding of the
issues in Kent
For this reason Kent Healthwatch have advised
the Trust that they are unable to provide a critique
of the account and quality goals.
We look forward to working in partnership with
Healthwatch in the future to improve patient
- 73 -
Appendix 1 – Full overview of Achievements against 2012/14 Quality Goals Scorecard
Aim/Objective
Progress
Infection Control and Prevention
Monitoring compliance against MRSA screening, providing local
support to areas of poor performance
Challenging existing assurance mechanisms and validate self
assessment
Following up sub-optimal standard of hand hygiene by small minority Hand hygiene results are fed back to
of staff
service managers and discussions held with
individual staff where necessary
Reducing the number of post 48hr E.coli bloodstream infections
Focusing on decontamination of instruments/equipment
Ensuring that all national standards such as NICE for infection control Compliant
are implemented
Improve waste management
Compliant
with
Health
Technical
Memorandum 07/01-2
Hold an Infection Control Conference
Conference took place in November 2012
Improving the cleaning scores to 95% within community hospitals
Complete
Improving the PEAT inspections scores and focus environment issues Complete- see section 4.1
Undertaking thematic reviews on any Clostridium difficile cases within Completed
the Trust
To continue to strive for no avoidable Health Care Associated Infection See section 4.1
To extend the Link Worker Network to all services and to include the Link Worker Network is in place and the
Essential Steps programme in the remit of the Link Workers
Essential Steps programme has been rolled
out
To increase the quality assurance of the surveillance data
Complete
To increase visibility and accessibility of the Infection Control and All community hospitals have an allocated
Prevention team
Infection Control specialist and visited at
least once a monthly
To deliver a reduction in the catheter associated urinary tract Complete Catheter Passport launched in
infections by January 2013 as part of the innovation project
October 2012; Safety Thermometer in
place:
Pressure Ulcers
Audits against best practice standards expecting an increase in the Audit undertaken; data currently being collated
percentage of teams compliant
Can now put compliance figures in
Trust wide implementation of the Safety Thermometer to monitor 100% implementation of Safety Thermometer
incidence of harm events to patients and contribute to the national
data capture
Continued compliance with Team Leader Practice Standard and Audit undertaken; data currently being collated
Pressure Ulcer Quality Standards
54% teams compliant with standard
Working in partnership with other stakeholders such as acute Pilot training programme developed and
hospitals and nursing homes to deliver a whole health economy delivered to 5 residential and 5 nursing homes.
Course is currently being evaluated
approach to the reduction of pressure ulcers
Monitoring of pressure ulcer incidents including compliance with Complete All staff are reporting incidents on
reporting timescales and trends and themes identified. the e-incident system
Implementing team, service and organisation level actions to
address findings
Working with our services such as podiatry who have been Complete Podiatrists and other AHP receive
included in the wound management training programmes and are training
involved in the investigation of pressure ulcers that occur on the
feet
Ensuring increasing focus on the factors known to assist in Complete Dieticians participate in delivering
prevention such as nutrition and hydration
wound care management training including
pressure ulcer
Implementing a behaviours framework in all areas in relation to Influencer strategy
pressure ulcers
Falls
Reducing the number of falls by 10%
19% reduction and 14% reduction in moderate
and severe
Focusing on improved interventions for patients with dementia
Guidance for high risk patients in place;
Dementia strategy developed;
Undertaking an annual audit of the falls quality care bundle
Ensuring that a serious incident investigation is undertaken for all
falls that result in harm to our patients
Participating in the monthly Safety Thermometer tool reporting on
falls
Ensuring that all new patients medications in community hospitals
are reviewed by the medical and pharmacy team to ensure that
medication combinations that patients are admitted on are not
worsening the patients condition
Undertaking a review of the un-witnessed falls to identify the
themes and develop an action plan to help in reducing these
incidents
Nutrition and Hydration
Continuing the interventions of the previous year
Nutrition link nurse on each ward/unit who will coordinate
Malnutrition Universal Screening Tool (MUST) training attendance
Clear criteria for exclusion such as patients on the Liverpool Care
Pathway, certain cases of dementia. In such cases a clear process
will be in place to give assurance of appropriate care provision
Facilitate the change in behaviours and embed new practice which
demonstrates nutrition and hydration is integral to patients
wellbeing
Empower practitioners to own and understand their responsibility
and have clear referral pathways, sign posting options and
resources
Improve the quality of care for patients and minimise harm
Review the Intentional Rounding and ensure hydration and nutrition
is monitored effectively
Nursing and Quality Team Clinical Assurance Days (CAD) will
include nutrition and hydration
Transfer of Care
Reduce the number of incidents relating to transfer of care
Continue to strengthen links with nursing and residential homes
across Kent e.g. developing and delivering training packages
Ensure transfer of care incidents are consistently captured on the
incident reporting system and monthly reports are available and
shared with other providers
Ensure involvement in and initiate locality based transfer of care
groups with acute hospital colleagues to review and resolve
common causes of transfer of care incidents
Work with partners to improve the processes and information
across Kent including undertaking a review of transfer of care
documentation e.g. community nursing referrals by acute hospitals
and nursing homes
Patient Safety Walkabouts
Move from a bureaucratic culture to a proactive/generative culture
Reduce the number of patient safety incidents and level of harm
Complete the executive patient safety walkabout in all areas of the
Trust
Implement timely action arising from the walkabouts
Empower staff in prove safe care at all times
Health Visitors Programme
Achieve the Health Visitor programme recruitment target of 218.65
in post in 2012/13 and by end of 2015 have 345 in post
Delivery of an aligned public health and healthy child programme
for children aged 0-5 years and their families
Audit undertaken; data currently being collated
100% falls with harm are fully investigated;
action plans monitored;
100% compliance
Compliant
Review has been undertaken. Action plan is
currently being developed
Actions from previous year in place
Achieved
Achieved
Staff
knowledge
survey
undertaken;
competency based training approved
Complete Nutrition folders established in all
areas
Hydrant project in place;
Complete Intentional Rounding reviewed and
documentation revised and rolled out across
the community hospitals
Complete CAD on nutrition undertaken
Implementing actions to improve data capture
on e-incident reporting system
Complete Pilot training programme developed
and delivered to 5 residential and 5 nursing
homes. Course is currently being evaluated
Work is in progress to improve the e-incident
reporting system
Complete groups established
3 of the 4 localities have established groups
with the acute trusts in the locality to address
transfer of care issues
Programme of visits continue to be well
received by staff. Process to be revised to
provide mechanism to measure improvement
79% of areas have had a visit; visits take place
on average 3 times a month
Complete Actions are monitored until
completed
Complete performance dashboard.
Target achieved
Active Baby has been piloted in Thanet and
Swale and Family Nurse Partnership in being
- 75 -
All children aged 0-5 years will receive early intervention,
prevention and health promotion services which will help them
achieve their optimum health and well being
Traditional ‘hard to reach’ groups of children who are vulnerable
due to ill health, disability and or disadvantaged are reached in a
timely manner to benefit from and receive the health input required
Outcomes for children as identified in national strategies are
achieved
Roll out of Family Nurse Partnership across the Trust, the next
team will be recruited in September 2012.
Safeguarding
Gaining a common understanding of children and adult thresholds
across the partnership, including a reduction in the number of rereferrals to social care
Addressing the high number of children in Kent subject a CCP
Increasing the number of CAFs within the context of scrutiny of
Kent’s early intervention strategy
Reducing the number of cases of adult neglect attributed to us
Implement the finding of the external review of the Mental
Capacity audit
Ensure the MCA training is 95%
Ensure that there is increased focus and reporting in regard to
Deprivation of Liberties
Dignity and Respect
Robust implementation of the privacy and dignity standard
Re-energise the dignity in care campaign across the services
including an increase in the number of dignity champions
st
Develop and implement the 1 Class Care Programme which will
provide a modular training programme
Sustain compliance with single sex accommodation requirements
Implement the actions from the community hospital 2011 privacy
and dignity survey at local level
Introduce a new privacy and dignity leaflet that describes what
people can expect from our staff in terms of privacy and dignity to
make explicit what good quality care should look like
Introduce 15 Steps in our community hospitals
End of Life Care
Review the cases where this standard was not achieved to better
understand what the issues were so that an action plan can be
developed and put in place to make improvements
Hold an end of life engagement event for staff and partners to
highlight further areas for improvement
Work with the Pilgrims Hospice on end of life care project to
further drive improvement across the system
Ensure that all patients receive adequate pain relief during end of
life care
Patient Experience
Community hospitals will roll out the use of signs to identify
patients with visual impairment
The new public website, including a directory of services and
information library, will go live
Community nursing teams will start to use the ‘FACE’ assessment
tool used by social services
Kent wide roll out of the Expert Patient Programme
Roll out across our services the Meridian an electronic approach
to capturing real-time feedback from our patients and users
Developmental Goals
Acute pain assessment and management in both adults and
piloted
Active Baby has been piloted in Thanet and
Swale and Family Nurse Partnership in being
piloted
In progress
In progress
Achieved. 50 families have benefited from the
programme; roll out continues
Achieved
In progress
Achieved
Achieved
Completed
Achieved
Training in place
Complete standard in place
In progress
Achieved HCSW; Preceptorship; nutrition and
hydration; pressure ulcer; wound care are some
of the programmes in place
Achieved
Acheived15 Steps introduced
Achieved
Achieved
In progress
Planned for 2013
In progress
Audit demonstrates 88% achievement
In progress
Achieved
Achieved
Achieved
Achieved
Achieved
- 76 -
children
Reducing length of stay
Patients with neuro-disabilities admitted to community hospitals
feel safe, in control and involved in decisions regarding their care
and management
Reporting on mortality rates
st
Developing the 1 Class Care programme including measures
•
•
ongoing
Complete Goal Attainment is in place and drives
patient and carer involvement in decision
making
Morbidity and mortality reviews in place
Development of professional practice standards
and competency framework is ongoing
Standards for nursing practice
Establishing a competency based assessment framework
Review baseline audits and set targets which can then be
monitored through our local and board quality reports
Benchmark against other comparable organisations
Dementia Care Strategy
Complete
Complete
Complete
- 77 -
- 78 -