Quality Account
2012-13
Quality care, closer to you…
Chief Executive’s statement
On behalf of Peninsula Community Health (PCH), I welcome the opportunity to present our
annual Quality Account to demonstrate our continued commitment to delivering high
quality patient care. Whilst there has been much publicity about the quality of care
provided to some patients in hospitals in England and Wales over the last year, I am
always pleased to receive excellent feedback from our patients and their relatives across
both the community and hospital services we deliver. This demonstrates to me that we
strive to ensure our patients receive high standards of clinical care, delivered by caring,
compassionate staff. We believe and commit to Putting the Patient First by making
patient safety and experience our number one priority every day, in other words Quality
care closer to you.
Despite the continued, challenging economic climate during 2012-2013, we are steadfast
in our commitment to maintaining quality, and ensuring our frontline teams are able to
undertake their roles as our community expects. We have been working closely with other
health and social care partners in Cornwall and the Isles of Scilly, to enable responsive
and personalised care to our patients. Some of this work is still in the early stages of
change and we are committed to making this work for our patients. In May 2013, PCH
Dental Ltd was formed. This company is part of the PCH family and contains all of the
dental services we are commissioned to provide. The formation of this company will allow
its Board to have a truly focused attention on improving and expanding the services
provided.
I am pleased that PCH has gained funding for an innovative project called ‘Kinda Magic’.
Kinda Magic was one of nine projects chosen from over 100 that entered the Patient
Feedback Challenge, which was supported by the Institute for Innovation and Change and
the Department of Health in July 2012. The innovative project was to spread PCH’s current
good practice in gathering patient feedback and to share the process which was viewed as
excellent because it provided metrics at an organisational level as well as providing
immediate feedback at ward level. The second part of the project is to develop tools that
will enable vulnerable groups of the community, who are currently excluded, to provide
feedback. This will include people with cognitive or communication difficulties including
people with Dementia. PCH has worked across England with a number of organisations to
progress this project and our spread has been wide. This project has attracted both
national and local attention, and PCH’s aim is to present and share our tools at an event in
October 2013.
The Quality Account indicates our priorities for the future and demonstrates and reviews
our performance over the past year. This Quality Account allows us to evidence our
commitment to continuous, evidence-based quality improvement, to draw your attention to
the standards achieved, and the progress we have made, and the approach we intend to
continue. It enables you the opportunity to assess the quality of our performance across
the healthcare services we offer.
Page 2 of 60
I am very pleased that we have been able to improve our services across the communities
we serve in 2012/13. The areas of particular achievement include:














69% reduction in the incidence of clostridium difficile
No cases of MRSA bacteraemia
Nil breeches in Mixed-sex Accommodation
Upgrade of x-ray facilities in St Mary’s Hospital, Isles of Scilly
Co-location of health and social care staff at St Mary’s Hospital, Isles of Scilly
Continued high performance in risk assessing and providing preventative
treatment for venous thrombo-emboli
Continued high performance in medicines reconciliation across all community
hospitals
Care of the Deteriorating Patient
Implementation of Early Intervention Service in Cornwall
Reducing harm from falls
Introducing Acute Care at Home across Cornwall
Expansion on delivering Nursing and Patient Experience Metrics
Maintaining Essential Standards for Registration with the Care Quality
Commission
Expansion of specialist respiratory services in North and East Cornwall
The areas we have chosen as our quality improvement targets for 2013-2014 have once
again been set following consultation with the local health scrutiny committees, local
involvement networks, our commissioners and importantly, by talking to staff, patients and
carers.
Progress described within this document is based on data and evidence collected locally
and nationally, much of which is presented as part of our performance framework each
month and in our public board meetings and to our commissioners.
To the best of my knowledge the information given in this document is accurate.
Helen Newson
Interim Chief Executive
Page 3 of 60
1.0 Priorities for Improvement .......................................................................................... 5
2.0 Statements of Assurance from the Board of Directors .......................................... 12
2.1 Care Quality Commission ...................................................................................... 12
2.2 Research ................................................................................................................. 12
2.3 Audit participation.................................................................................................. 13
2.4 Goals agreed with commissioners ....................................................................... 18
2.5 Data Quality ............................................................................................................ 19
2.6 Information Governance ........................................................................................ 20
2.7 Clinical Coding Error Rate ..................................................................................... 20
3.0 Review of our Quality and Safety Performance 2012/13 ........................................ 22
3.1 Performance Review – The priorities we identified in 2012/13 ........................... 22
3.1.1 Nutrition ............................................................................................................ 22
3.1.2 Documentation................................................................................................. 22
3.1.3 Dentistry ........................................................................................................... 23
3.1.4 Dementia Care.................................................................................................. 23
3.1.5 Complaints ....................................................................................................... 25
3.2 Maintaining Essential Standards for Registration with the Care Quality
Commission .................................................................................................................. 26
3.3 NHSLA Assessment ............................................................................................... 26
3.4 The East Cornwall Integrated Respiratory Team ................................................. 26
3.5 Parkinsons Disease Service .............................................................................. 31
3.6 Safety Thermometer ........................................................................................... 31
3.7 Blood Transfusion Management ....................................................................... 36
3.8 Safeguarding Adults ........................................................................................... 37
3.9 Nursing Metrics and Patient Experience Measurement during 2012/13 ........ 39
3.10
Eliminating Mixed Sex Accommodation (ESMA) .......................................... 45
3.11
Complaints and Compliments ........................................................................ 45
3.12
Focus on the Isles of Scilly ............................................................................ 51
3.13
PEATs ............................................................................................................... 53
4.0 Response to this report from our stakeholders ...................................................... 54
4.1 Cornwall Overview and Scrutiny Committee ....................................................... 54
4.2 Isles of Scilly Overview and Scrutiny Committee ............................................ 54
4.3 Kernow Clinical Commissioning Group ........................................................... 54
5.0 Glossary .................................................................................................................... 56
6.0 Statement of Directors Responsibilities in Respect of the Quality Account ....... 60
Page 4 of 60
1.0 Priorities for Improvement
How we identify our quality improvement priorities
Our quality monitoring systems continue to capture information throughout the year, about
the quality of services we provide and the risks to service users. We continually monitor
the experiences of patients and how we perform against the range of national and local
standards.
We strongly believe in the importance of establishing meaningful dialogue with patients,
patients’ representatives and carers, to help us develop our quality improvement plans for
the coming year. In March 2013, the potential priorities for inclusion in the Quality Account
were circulated to the following bodies asking their opinion as to the level of priority of
each subject:










Overview and Scrutiny Committees for both Isles of Scilly and Cornwall
Healthwatch IOS
Healthwatch Cornwall
Royal Cornwall Hospital
Plymouth Hospitals NHS Trust
Cornwall Partnership Foundation Trust
Peninsula Community Health staff
PCH Non Executive Directors
NHS Cornwall and Isles of Scilly (now Kernow Clinical Commissioning Group)
Cornwall League of Friends
PCH, in collaboration with the above groups has established five quality improvement
priorities for 2013/14. We have organised them into three domains, consistent with the
core domains for quality patient care identified by Lord Darzi in the ‘NHS Next stage
Review: High Quality Care for All’. They reflect what we believe are the priority areas for
achieving the best possible outcomes for those we serve:

Patient safety

Clinical effectiveness

Patient experience
These quality improvement priorities are detailed on the following pages and include the
development of work that is already underway as well as new work that we consider to be
equally important.
Page 5 of 60
Domain
Priority
Source
Prevention and Management of Pressure
Ulcers – Pressure ulcers are both
extremely painful and debilitating. This
topic aims to explore a new methodology
for investigation of pressure ulcers to
enable learning from experience and
reduction in numbers of new pressure
ulcers.
Learning from Complaints
Dementia – We want to raise the
standards of knowledge and skills in staff
being able to proactively deal with
patients that become acutely distressed
and confused on our wards. We aim to
provide education to enable staff to
increase their skills and feel confident in
the way they manage and de-escalate
situations.
National Policy
Patient Safety
National Policy
Feedback from Care Quality
Commission visits
Serious untoward incident learning
Learning from complaints
Safeguarding and serious incident
learning
South West Dementia Strategy
Learning from Complaints
Discharge Planning. Aim to improve
effective discharge planning to reduce National Policy
length of stay and to ensure patients and Feedback from CQC visits
carers are informed and involved in all
stages of the process, leading to
reduction in readmission rates.
Clinical
Effectiveness
National Policy
To safeguard and meet the needs of
patients with severe cognitive impairment CQC National Reports
we need to improve the way our staff
assess and record Mental Capacity and
determination of Best Interest. To ensure
that
they
respect
the
patient’s
choice/wishes, they are using and
reviewing the process appropriately, that
they fully understand what it is for, and
that this is communicated appropriately
with families
Learning from Complaints
Patient
Experience
Implementation
Practice (6C’s)
of
Compassion
in National Policy
Francis Report
Page 6 of 60
Patient Safety
Priority 1
Reduction in Pressure ulcers
Pressure ulcers are areas of localised damage to the skin and underlying tissue caused by
pressure, shear or friction, or a combination of these. Many hospital acquired pressure
ulcers can be avoided.
What are we going to do: To reduce health care acquired pressure ulcers
How much: 25% reduction in hospital acquired pressure ulcers across all clinical areas
By When: March 2014
Board Sponsor: Trish Cooper Acting Director of Nursing and Professional Practice
Implementation/Programme Lead: Nicci Kimpton Tissue Viability Lead Nurse
How are we going to do it:

Community District Nursing Teams are working with the Tissue Viability Team to
collect reliable data on pressure ulcer figures
 Intentional Rounding has been spread across the organisation. This means that
where required, patients receive regular turns so that they are not lying in the same
place for too long. The intentional rounding document will be reviewed to ensure all
components of the SKIN Bundle are included. This is a proven method of reducing
pressure ulcers and ensures that the following are reviewed regularly:
I.
Surface - for example, is the patient on the right mattress?
II.
Skin - is the patient’s skin intact, are there any red areas?
III. Keep Moving - does the patient require turning?
IV. Incontinence Management - does the patient require help with toileting needs?
V.
Nutritional Management - is the patient hydrated?
 We aim to completely eliminate all preventable grade 3 and 4 hospital acquired
pressure ulcers
 To work collaboratively with commissioners, nursing and residential homes and
other health and social care providers to identify areas where improved
communication and training can aide prevention
Priority 2
Dementia care
Dementia currently affects 800,000 people in the UK which is expected to rise to over a
million people by 2021.
What are we going to do: We want to raise the standards of knowledge and skills in staff
being able to proactively deal with patients that become acutely distressed and confused
Page 7 of 60
on our wards. We aim to provide education to enable staff to increase their skills and feel
confident in the way they manage and de-escalate situations
How much: 100% of appropriate staff to receive dementia training and every clinical area
to have a Dementia Care Champion
By When: March 2014
Board Sponsor: Trish Cooper Acting Director of Nursing and Professional Practice
Implementation/Programme Lead: Sue Greenwood Dementia Lead
How are we going to do it:






















Having board level commitment to continue to work towards becoming Dementia
Friendly
Dementia Lead within the organisation
Network of Dementia Ward Champions
Continue to implement Dementia Care Mapping across the organisation
Commitment from the board to review the environment within our community
hospitals
Continue to promote dementia friendly approaches in our communications
Share our plans and progress collaboratively
Use local and national networks
Produce a Dementia page on our organisation’s website
Introduce a communication passport that has been developed locally by
another provider
Continue to promote “This is me”
Continue to work in partnership across the pathway with all providers and
volunteering organisations
Launch activity of the Dementia Care Action Plan and promote the plan during
Dementia Awareness week
Introduce volunteers and a befriending service within our organisation
Continue to build partnerships and work closely with local voluntary services
Working in partnership with all other providers ensure that we promote safety
and early discharge with improved personal and community support
Working in partnership with all other providers and voluntary organisations
ensure that people are not inappropriately admitted and are supported to return
home as quickly as possible
Promote early diagnosis of dementia by working in partnership with our acute
services
Continue to improve the way we assess and plan care involving the person with
dementia, their relatives and carers
Working in partnership with our acute providers ensure that we work together to
agree a screening tool that is used consistently across the pathway
Continue to work in partnership with the Alzheimer’s society to develop
information for clinical areas regarding services available in the community
Continue to promote the completion of Dementia Awareness workbooks across
the organisation
Page 8 of 60




Develop and roll out a training program that sets out to reduce distress amongst
our patients with dementia, equipping staff with the knowledge skills and
understanding
Improve the physical environment within our community hospitals and clinics
Carry out a focused piece of work to review and improve our signage across all
locations where services are provided
Introduce purposeful occupation in at least 6 of our community hospitals
Clinical Effectiveness
Priority 3
Discharge Planning
Effective discharge planning leads to better outcomes for patients and reduces the need
for readmission and emergency care. Discharge planning should commence from the very
first day of admission and should include collaboration and seamless services from health
and social care.
What are we going to do: Aim to improve effective discharge planning to reduce length of
stay and to ensure patients and carers are informed and involved in all stages of the
process, leading to reduction in readmission rates
How much: To reduce length of stay in community hospitals to an average of 23 days.
By When: March 2014
Board Sponsor: Helen Newson, Interim Chief Executive
Implementation/Programme Lead: Nicky Harvey Intermediate Care and EIS Lead
How are we going to do it:
 Baseline review of discharges within the last 6 months, identifying when the
patient was ready for discharge and why, if any there was a delay
 Utilise the learning from this review to identify priority action areas
 Development of Unscheduled Care Strategic and Operational Groups to lead
this work
 Enhanced training for staff
 Patient experience metrics to be completed, asking the patients and their carers
if they were involved in their discharge planning
Priority 4
Safeguarding the needs of vulnerable adults
What are we going to do: To safeguard and meet the needs of patients with severe
cognitive impairment we need to improve the way our staff assess and record Mental
Capacity and determination of Best Interest. To ensure that they respect the patient’s
Page 9 of 60
choice/wishes, they are using and reviewing the process appropriately, that they fully
understand what it is for, and that this is communicated appropriately with families
How much: To ensure that 100% of appropriate staff have received training and are
competency assessed
By When: March 2014
Board Sponsor: Trish Cooper, Acting Director of Nursing and Professional Practice
Implementation/Programme Lead: Jan Summers-Deane Acting Safeguarding Adults
Lead
How are we going to do it:
 To monitor and investigate all safeguarding alerts raised, to ensure the best interest
of the patients have been met
 To review the Whistleblowing Policy to ensure it is fit for purpose
 Patient experience metrics to be completed
Patient Experience
Priority 5
Compassion in Practice
Compassion in Practice is the new three year vision and strategy for nursing, midwifery
and care staff drawn up by Jane Cummings, the Chief Nursing Officer for England (CNO)
at the NHS Commissioning Board, and Viv Bennett, Director of Nursing at the Department
of Health. It was launched at the CNO annual conference in Manchester on December 4th
2012 following an eight week consultation with over 9,000 nurses, midwives, care staff and
patients. The vision was underpinned by six fundamental values: care, compassion,
competence, communication, courage and commitment - with six areas of action to
support professionals and care staff to deliver this excellent care. In particular, the vision
identifies that we all need to work together to ensure we meet the needs of older people –
the largest group of people who use services - and treat them with the dignity and respect
that they deserve in joined up health, care and support services.
What are we going to do and how much: Implement all six areas
By When: March 2014
Board Sponsor: Trish Cooper, Acting Director of Nursing and Professional Practice
Implementation/Programme Lead: Alison Rundle Patient Safety Facilitator
How are we going to do it:
Implement the actions as shown in the chart overleaf
Page 10 of 60
Page 11 of 60
2.0 Statements of Assurance from the Board of Directors
This section contains statutory statements concerning the quality of services provided by
PCH. These are common to all NHS provider organisations’ Quality Accounts and can be
used to compare us with other organisations.
During 2012/13 PCH provided and/or sub-contracted 36 NHS services. The income
generated by the NHS services reviewed in 2012/13 represents 100% of the total income
generated from the provision of NHS services by PCH for 2012/13.
PCH works from over 100 locations throughout Cornwall and the Isles of Scilly including
14 community hospitals. PCH reviews all the data in regard to these services monthly.
Since May 2013, PCH has a subsidiary company – PCH Dental Ltd, providing NHS
Commissioned dental services throughout Cornwall and Isles of Scilly.
2.1 Care Quality Commission
In 2012/13, PCH continued to be registered with the CQC to provide regulated activities at
19 locations. Post May 1st 2013 and the formation of PCH Dental Limited, this has reduced
to 16 locations.
From September 2012 – end of March 2013, the Care Quality Commission visited 18 PCH
registered locations, as part of their scheduled inspections programme. All of these visits
were unannounced and were not as a result of any concerns raised.
Overall, the visits went well and the feedback was very positive. For example, both in the
final reports and at verbal feedback, the inspectors described observing care which
respected the dignity of patients, patients very satisfied with the care they were receiving
and staff appeared knowledgeable and able to implement policies to ensure the safety of
patients, such as safeguarding.
The final reports show non-compliance in Outcome 14 (Regulation 23) at 3 locations and
Outcome 13 (Regulation 22) at one location. The non-compliance relates to clinical
supervision and training, and action plans have been created in order to rectify those
issues.
2.2 Research
In 2012/13 PCH continues to be a research partner working closely with the research
team, which is based within the local acute organisation. PCH is informed, and approval
sought, for any research taking place within, or near to the services we provide.
Page 12 of 60
2.3 Audit participation
Clinical Audit
Clinical audit is a systematic process of improving the quality of patient care by looking
closely at current practice, evaluating the quality of care provided to patients based on
best practice and nationally set clinical standards, modifying it where necessary and
evaluating the outcome.
The main aim of clinical audit is to provide assurances that the clinical services are
meeting the needs of service users and at the same time providing internal assurance that
staff are following best practice based on research evidence.
PCH is committed to improve the quality and outcomes of patient care by establishing a
culture where high quality clinical audit can be sustained. The 2012-13 Audit Plan
incorporated a programme of over 40 clinical audits in addition to a record keeping audit of
all services in addition to any national clinical audits which the organisation was eligible to
participate in.
National Clinical Audit Participation
Although it is not mandatory for community services to undertake national clinical audits it
is good practice.
During the period April 2012 to March 2013, four national clinical audits and zero national
confidential enquiries were relevant to NHS services that PCH provides.
During that period, PCH participated in 50% of the national clinical audits and 100% (zero
eligible and therefore zero participated in) national confidential enquiries of the national
clinical audits and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that PCH was eligible to
participate in during 2012-13 are as follows:




Parkinson’s occupational therapy audit
Parkinson’s physiotherapy audit
Parkinson’s speech & language therapy audit
National Audit of Intermediate Care
PCH took part in the physiotherapy and occupational therapy elements of the Parkinson’s
audit in 2011-12.
Parkinson’s UK advice is “The National Parkinson's Audit takes place every year, but we
recommend that services take part every other year to give time for them to respond to
the findings”. In light of this advice in 2012-13 PCH did not take part in the physiotherapy
and occupational therapy having taken part in 2011-12. Having not taken part in the
Page 13 of 60
Speech & Language Therapy Parkinson’s audit in 2011-12, Peninsula Community Health
took part in this in 2012-13.
The national clinical audits and national confidential enquiries that PCH participated in
during 2012-13 are therefore as follows:


Parkinson’s speech & language therapy audit
Intermediate Care Audit
The national clinical audits and national confidential enquiries that PCH participated in,
and for which data collection was completed during 2012-13 are listed below alongside the
number of cases submitted to each audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or enquiry.
Parkinson’s speech &
language therapy audit
Intermediate Care
Number of cases
submitted
Number of cases submitted as
a percentage of eligible cases
20
100%
10
100%
Improving services through participation in national audits
The reports of 1 national clinical audit (report not received yet for Parkinson’s speech &
language therapy audit) were reviewed by PCH in the period April 2012 to March 2013 and
PCH intends to take or has taken the following actions to improve the quality of healthcare
provided
National Audit
Parkinson’s
Physiotherapy Audit
(undertaken in 2011 but
due to delay in national
report action plan
developed in 2012)
Actions planned/taken





Primary Clinicians involved in Therapy and Nursing now have
access to published evidence in journals, measures and Pilot
group information as an educational resource posted in the
Parkinson’s shared drive
Parkinson’s Nurse letters referring to physiotherapy are to
have date of Parkinson’s diagnosis and information on known
previous physiotherapy access
Community Physiotherapists have been informed of the
common outcome measures and Parkinson’s quick reference
cards. These are kept as a resource on the shared drive
Band 6 Physiotherapists are offered opportunities for
developing skills and competency in PD management and
service forward planning e.g. delivering pilot
Enhancement of aerobic capacity in Parkinson’s has been
identified as a component for management in the Parkinson’s
population. This is included in the group exercise in the pilot.
Feedback on treatment that targets aerobic capacity is now
Page 14 of 60

reported in discharge summaries to referring clinicians to
raise awareness of the wider physiotherapist’s role
Education of Physiotherapists on the key findings in the audit
was fed back to the Community physiotherapy teams through
in-service education on Parkinson’s, Team Lead meetings
and the Professional forum
Intermediate Care

Data collected and submitted. Awaiting report
Parkinson’s speech &
language therapy audit

Data collected and submitted. Awaiting report from
Parkinson’s UK before formulating action plan
Local Audit
Clinical audit is supported by the Governance team. All local clinical audits are reported to
and monitored by the Clinical Quality and Safety Committee. Reports are reviewed and
action plans for quality improvement are monitored by this committee.
The reports of 10 local clinical audits were reviewed in the period April 2012 to March 2013
and PCH intends to take or has taken the following actions to improve the quality of
healthcare provided.
Local Audit
Actions planned/taken
Record keeping audit

A comprehensive record keeping audit was undertaken of all
services. Of the 23 standards audited, 18 had improved from
the previous year’s audit results. Specific areas for
improvement were identified for each service and are the
subject of individual service action plans to be
communicated via service team meetings. A re-audit in the
next 12 months will monitor the effectiveness of the action
plans in maintaining and improving record keeping quality
Discharge Audit –
Medicines Management

The 2012 audit showed an increased number of patients at
discharge who were provided with a Medicines Reminder
Chart to support compliance with medication since 2011
audit
A Compliance Aids Assessment tool has been introduced to
support staff in identifying patients who would benefit from
blister packs and to avoid issuing blister packs if
unnecessary

Antibiotic Audit

Following the 2012 Audit, a focus was placed on reducing
the risks of Clostridium Difficile through reductions in the use
of inappropriate antibiotic prescribing and promoting the use
Page 15 of 60

Clinical Prescribing
Audit




Missed Doses Audit


of local guidelines
Updated antibiotic guidelines have led to a significant
decrease (40%) in the use of co-amoxiclav in PCH hospitals
A number of concerns regarding the sustainability and
robustness of safe prescribing, and documentation of
administration, were noted in this audit of the community
hospital drug chart
As a result a new drug chart has been developed to address
the issues identified in the audit. The chart allows clear
documentation
Pharmaceutical Advisers will be delivering staff training on
the new drug chart across the county
Prescribers, nursing staff and other healthcare professionals
have had opportunities to contribute to the contents of the
drug chart, to ensure it meets professional requirements to
support patient safety
This audit highlighted the problem of nursing staff failing to
document administration of medication accurately. It was
often difficult to ascertain if a dose had been missed or if
administration had not been documented. As a result the
following action has been taken:
When developing the new drug chart, action was taken to
ensure it fully supported documentation of drug
administration and missed doses (increased space for ‘when
required’ medicines and improved layout for documenting
accurately on each day the drug chart is in use)
Controlled Drugs Audit

Action taken to introduce clear plastic bags for storage of
patients medications in controlled drugs cupboards, to allow
easy identification due to the patient name and drug name
being clearly visible
Parkinson’s Patient
Experience Audit

Following the audit, a pathway for acute deterioration in
Parkinson’s disease symptoms has been developed for
primary/secondary care use
PCH has engaged with pharmacists to improve medication
management of Parkinson’s patients within both PCH and
the Royal Cornwall Hospitals Trust (Acute service provider)
Educational programmes have been put in place for Royal
Cornwall Hospital Trust and other health organisations staff


Allow a Natural Death
documentation Audit

Process put in place to ensure patients transferring into a
PCH community hospital have their existing AND forms
reviewed within 72 hours
Page 16 of 60
Resuscitation
Equipment Audit

Following the audit there has been an improvement in the
documentation of review dates and patient capacity

In the 2012 audit, 21 out of the 28 resuscitation trolleys had
improved compared to the 2011 audit in terms of adequate
and appropriate levels of emergency equipment being
available
The need to ensure that all trolleys are kept sealed and
required daily and weekly checks undertaken has been
reinforced
Guidance to be produced for staff on the process for
recording all cardiac arrests on DATIX to replace the
previous paper recording form


Safeguarding Adults &
Children Staff
Awareness Audit




Action plan put in place to increase safeguarding training
compliance amongst all staff
Campaign to be put in place to raise staff awareness of the
appropriate training required for their specific job role
Safeguarding Information leaflet circulated to all areas and
teams
Re-audit planned after 6 months to measure improvement
Page 17 of 60
2.4 Goals agreed with commissioners
CQUIN – A proportion of Peninsula Community Health income in 2012/13 was conditional
on achieving quality improvement and innovation goals agreed between Peninsula
Community Health and our commissioners NHS Cornwall & Isles of Scilly. The 2012/13
CQUINs performance are awaiting final approval.
National: Venous-thromboembolism
To reduce avoidable death, disability and chronic
ill health from Venous-thromboembolism (VTE)
National: Patient Experience
To improve patient experience in 3 areas
identified as requiring improvement in
community hospitals through the patient
experience metrics
3
National: Dementia
Improve awareness and diagnosis of dementia,
using risk assessment, in a community hospital
setting
4
National: Safety Thermometer
Improve collection of data in relation to pressure
ulcers, falls, urinary tract infections in those with
a catheter and venous-thrombo emboli.
5
Local: Reduction in avoidable emergency
admissions
To reduce avoidable emergency admissions of
frail elderly patients
6
Improve the care of patients with long
term conditions
Increase telehealth across Cornwall
7
Support Plymouth’s ‘Shifting settings of
Care Programme’
To reduce the length of stay at Liskeard Hospital
8
Support Plymouth’s ‘Shifting settings of
Care Programme’
To increase Chronic obstructive pulmonary
disease rehabilitation in line with the National
Institute of Clinical Excellence
9
Improve patients’ outcomes
To Improve outcomes for 2 specific conditions
1
2
Page 18 of 60
The CQUINs for 2013/14 have been agreed with Kernow Clinical Commissioning Group
and they are:
1
National: Safety Thermometer
Improve awareness and diagnosis of dementia,
using risk assessment, in a community hospital
setting
2
National: Patient Experience
Implementation of Friends and Family Test
3
Whole System CQUIN - Unscheduled
Care
Whole System Multi-agency integrated
unscheduled care plan
4
Local: Innovation
Increase flow and volume through PCH CIC
community beds.
5
Local: Hospital Discharge
Improve Internal Hospital Discharge Process
2.5 Data Quality
Good data quality is an indicator that an organisation has robust systems and methods for
capturing accurate information about their patients. PCH submitted records during April
2012 – March 2013 to the Secondary User Service (SUS) for inclusion in the Hospital
Episode Statistics which are included in the latest published data. These are one of the
measurements that the Care Quality Commission use to monitor our on-going compliance.
As per the SUS Data Quality Dashboard April 2012- March 2013:
NHS number compliance
Inpatient = 99.9%
Outpatient = 99.9%
Minor Injury Units = 95.8%
GP Practice compliance:
Inpatient = 100%
Outpatient = 100%
Minor Injury Unit = 98.1%
There is a late data entry issue which is being monitored monthly with performance
reviews and local action plans have been initiated. We anticipate that with the introduction
of a new clinical IT solution it will significantly reduce any data entry delays as the system
will be used real-time.
Page 19 of 60
2.6 Information Governance
PCH has declared compliance with Level 3 of the Information Governance Toolkit for
2012/13.
2.7 Clinical Coding Error Rate
PCH was not subject to a Payment by Results clinical coding audit during 2012/13.
Page 20 of 60
Review of our performance in 2012/13
Summary
PCH employs
2098 people
734,725 patients were seen by
services provided by PCH
Physiotherapists carried out
a total of 90,542 outpatient
appointments
There have been 3,867 inpatients
in our 14 Community Hospitals
in 2012/13
Community nurses undertook
292,435 patient visits
93,588 patients were seen in
our Minor Injury Units
40,919 appointments were undertaken
by Peninsula Community Health's
Dentists
Page 21 of 60
3.0 Review of our Quality and Safety Performance 2012/13
3.1 Performance Review – The priorities we identified in 2012/13
3.1.1 Nutrition
Improving the nutrition of patients in hospital – nutrition is a high priority across
healthcare and is an area that the Care Quality Commission has highlighted as
falling below standard and below public expectations nationally.
PCH has a very successful Nutrition Group. Within 2012/13, the priority of this group was
to identify ways in which to enhance the nutrition of patients within our community
hospitals. Meal-times are a priority within all our community hospitals and throughout
2012/13 we have seen an increase in patient satisfaction with not only the quality of food,
but also presentation and how much help patients receive. We now offer cooked
breakfasts in all hospitals and these have been received very well. Alerts through the ‘Red
Tray Initiative’, to ensure staff are aware and assist patients as required with their meals, is
now standard throughout all the hospitals.
3.1.2 Documentation
Improving clinical documentation – during 2011 a great deal of work was
undertaken to redesign and improve the inpatient documentation. To further this
work, all other clinical documentation across our community services require
review – to ensure patients are informed and consent to plans of care. An area of
particular concentration will be in regard to patients discharges from hospital,
ensuring that patients remain fully informed and consentual to the discharge plan –
this has been added following the consultation.
PCH has implemented new and improved documentation throughout the County. The
changes have been commended by the Care Quality Commission. Time was taken to
ensure that the documentation fit the purpose with small tests of change and comments
from staff considered. Patient safety has been a consideration throughout the development
of the documentation. CMews (early warning score), a Falls assessment, Frailty score and
Pressure ulcer skin bundles recommended by the NHS Southwest Patient Safety Initiative
are all included and with the risk assessments, are audited monthly via the Nursing
Metrics. The Nursing Metrics scores have improved in all sections since implementation of
the new documentation.
A training powerpoint was produced and is stored on the ward shared drives for all staff to
have unlimited access. This reminds staff of the NMC standards for documentation. For
areas where problems have been identified early, face to face training in the use of the
documentation has been offered.
Care has been taken on the appearance of the documentation so it is now recognisable as
PCH’s documents.
Page 22 of 60
The Community nurse documentation has been restyled as per the hospital documentation
and is currently being printed following extensive trials by the community teams.
Outpatient therapy documentation has been reviewed during 2012/13.
Updated discharge documentation has been implemented but further work is required in
2013/14 to enhance discharge procedures in collaboration with our health and social care
partners.
Future plans for 2013/14 include: updating all specialist nursing documentation and the full
integration of therapy and other clinical notes within the community hospitals
3.1.3 Dentistry
Improving dental pathways for patients with Learning Disabilities with an emphasis
on prevention and dental hygiene
PCH Dental services have undergone a great deal of organisational change this year, with
the resultant formation of PCH Dental Ltd, which is still part of the PCH family.
PCH Dental has a lead senior Dentist for the care of patients with learning disabilities and
a number of leaflets, providing supporting information have been developed for patients,
carers and relatives.
Work is on-going with the learning disabilities service to provide support into the clinics
and a pilot is taking place in one location, to evidence the positive effect of enhanced
reception cover.
3.1.4 Dementia Care
Protect the quality of care and dignity of patients with dementia
As an organisation we are committed to improving the services we provide to the people of
Cornwall who have dementia.
A programme of work has been undertaken in a number of our Community Hospitals
which has led to some real improvements in relation to:
 Care delivered on a daily basis
 Improvements to the caring environment
 Improvements and understanding of the screening tools used within PCH
 Raising staff awareness of Dementia across the whole organisation
 Increased partnership working with all of the 3rd sector charities and organisations
 Partnerships have grown and developed between all provider organisations within
Cornwall NHS
 We continue to work towards the South West Hospital Standards for Dementia Care
 Our progress so far has been recognised regionally, a number of staff were invited
to present this and share our learning at a regional event in August 2012 held the
Strategic Health Authority
Page 23 of 60


We have started to review the environments in which we deliver care to look at how
we can best support and encourage a healing environment for patients, carers,
families and friends
Developing and supporting local Dementia Champions in all 14 of our community
hospitals is our next exciting step
Developing a Dementia Friendly Organisation.
We recently presented our first Gold Award to the Day Services Team at Camborne
Redruth Community Hospital.
This award has been introduced across the organisation and is in recognition of our staff’s
continuing commitment to provide the highest quality of care to the community we serve.
The team completed an educational workbook based on essential dementia awareness
and person centered approaches.
Future developments include the introduction of locality based Action Learning Sets which
will aim to support our staff in the development of new initiatives and share learning and
experiences so that we continually reflect on our practice.
Collaboration with Alzheimer’s Society
We are delighted to be working in partnership with the Alzheimer’s Society on a number of
really exciting initiatives:


Three of our community hospitals now have comprehensive information areas that
are aimed at any health or social care concern with leaflets that patient’s carers and
family members can take away. It also signposts local groups and further support
A number of training events are taking place across our organisation which is
predominantly aimed at our staff and will look specifically at:
1. The patient experience
2. The family and carer experience
3. A very personal experience of someone who’s family member had dementia
We are continually striving to work with all of our partners across health and social care
and as a result have carried out Dementia Care Mapping in a number of our hospitals.
This process is recognised nationally and will help us to better understand the patient
experience.
Earlier in 2013, we held a Dementia Champions Day. Organisations present included:
AgeUK, Alzheimer’s Society, Volunteer Cornwall, Royal Cornwall Hospitals Trust, Cornwall
Partnership Foundation NHS Trust, Cornwall Council, Peninsula Community Health, Arts
for Health, League of Friends and Sensory Trust.
Page 24 of 60
The Dementia Champions made a pledge to respond to Standard 1 of the 8 Southwest
Hospital Standards in Dementia Care: People with Dementia are assured respect, dignity
and appropriate care and encompass the top five ingredients ‘SPACE’ for supporting good
Dementia care as highlighted by the Royal College of Nursing.
Staff who are skilled and have time to care
Partnership working with carers
Assessment and early identification of Dementia
Care plans which are person centred and individualised
Environments that are dementia friendly
3.1.5 Complaints
Complaints handling – to improve the timeliness of complaints handling, to enhance
the quality of root cause analysis and investigation of incidents and ensure learning
across the organisation – this has been added following consultation
Over the past 3 months, PCH has enhanced the service we provide to the public who raise
a complaint or concern. The complaints team now work very closely with the Safeguarding
Adults and Children’s team, to ensure that any concern that is raised about care is
immediately screened to safeguarding.
Historically, the local manager has always undertaken a complaint investigation for their
service, but recently we have commenced independent managers undertaking
investigations and root cause analysis as required.
Complex and serious complaints are now discussed as part of our risk summits, which are
held with a non-executive director and executive director, along with service leads. This
ensures that the Board is informed of the detail of concerns/complaints, not just an
overview.
Page 25 of 60
Other areas of our quality performance in 2012/13
3.2 Maintaining Essential Standards for Registration with the Care Quality
Commission
PCH is required to register with the Care Quality Commission and its current registration
status is without condition. The Care Quality Commission has not taken any enforcement
action against PCH during 2012/13.
PCH has not participated in special reviews or investigations by the Care Quality
Commission as at 31st March 2013.
3.3 NHSLA Assessment
There was no formal assessment for general NHSLA standards during 2011/12.
3.4 The East Cornwall Integrated Respiratory Team
The East Cornwall Integrated Community Respiratory Team (ICRT) was commissioned in
late 2012 and became operational on 4.2.13. The team consists of a full time Clinical
Specialist Physiotherapist whose role is combined with Team Leadership. Specialist
Respiratory Nursing, Occupational Therapy (OT), Speech and Language Therapy (SALT)
and Physiotherapy Support Worker are the other posts contained within the team. The
existing Respiratory Specialist Nurse post within East Cornwall has also been integrated
into this team.
The team was commissioned to improve the management of patients with respiratory
conditions, specifically Chronic Obstructive Pulmonary Disease (COPD), for adults in East
Cornwall. Its remit was to look at drawing together existing infrastructure, the development
of clear referral pathways and improving links with acute care providers thereby improving
integrated care for patients.
The overarching objective of the new team, working in conjunction with other community
respiratory resources is to provide care closer to home for patients with respiratory
conditions thereby reducing unplanned hospital admissions to Derriford Hospital, Plymouth
and Liskeard Community Hospital. In developing the initial business case, the focus was
on the management of patients with COPD. The team, however, are managing a wide
range of adult patients referred with respiratory conditions.
Initial Objectives
1. To increase the capacity and ease of access to pulmonary rehabilitation in East
Cornwall
2. To improve communication with referrers and integrated working with other
community respiratory resources
3. To understand professional roles within the team and other Peninsula Community
Health (PCH) provided services including the Acute Care at Home Team (AC@H)
and Community Matron service
Page 26 of 60
Pulmonary Rehabilitation
Historically, pulmonary rehabilitation has been provided for East Cornwall at Liskeard
Community Hospital. These have been cohort groups lead by the Specialist Respiratory
Nursing Service with support from physiotherapists within the Community Rehabilitation
Teams.
From work carried out to predict demand for pulmonary rehabilitation, it was evident that
there was a very significant shortfall in capacity in East Cornwall.
Modelled estimates of Prevalence of COPD GP Practices (combined) East Cornwall,
Eastern Region Public Health Observatory, October 2009
Expected
number
with COPD
in practice
Number on
QOF
register
June 2011
2850
1908
QOF
register as
a
percentage
of expected
prevalence
70%
Expected
number
with MRC
score of
between 2 5
1278
Capacity
for PR
before
ICRT
Current
capacity
48
350
(excluding
rolling
programme)
This data captures the expected under diagnosis of COPD in the East Cornwall GP
practice area and the increase in capacity for pulmonary rehabilitation since the ICRT has
been in post.
East Cornwall is a rural area and for some patients access to Liskeard is difficult. As well
as the existing Liskeard groups, new groups have been established in:
 Saltash - St Barnabas Community Hospital
 Lewannick Village Hall - Launceston
Other venues that will provide PR are being sourced at:
 Torpoint
 Callington
 Looe
Other changes to the provision of pulmonary rehabilitation include:
 Full day joint assessments for appropriateness to attend pulmonary rehabilitation.
This includes specialist nurse and physiotherapy assessment. The assessment
includes functional capacity testing (Incremental Shuttle Walk Test) and a swallow
screening
 Risk stratification of patients per baseline assessment to a specific level of exercise
Page 27 of 60
 Three levels of exercise at each of the 12 exercise stations – yellow, green and







purple. Patients can therefore progress at each station as appropriate
Patients exercise for two minutes at each station with an emphasis on pacing and
breathing control. The stations alternate between muscle strength/ endurance and
cardiovascular for the yellow and green levels and for the purple level full
cardiovascular
Warm up and cool down 10 – 15 minutes
Within the groups, exercise is performed first followed by the education session so
that patients can be carefully monitored during their recovery period
Education sessions are kept to 30 minutes in duration to maximise participants’
attention span
Patient education topics have been reviewed to reflect the skills within the team. All
members of the team participate in delivering pulmonary rehabilitation and can
cover for other members of the team. This safeguards the running of the groups in
the event of sickness / unexpected team absence
Outcome measures have been re-evaluated. The Incremental Shuttle Walk test –
especially considering statistically significant improvements (Singh et al 2008), HAD
score, Chronic Respiratory Questionnaire (self-reported) and patient satisfaction
questionnaire are now used
Links have been made with third sector support. These include University of the
Third Age walking groups, Tamar Valley Walk and Talk groups, the local Breathers
and Breathe Easy groups. For patients with transport issues, the Saltash Hopper
and The Little Red Bus Company are keen to support the groups in East Cornwall
All the above changes are underpinned by the latest evidence supporting clinically
effective and safe provision of exercise for patients with COPD.
Page 28 of 60
Outcomes of first Saltash Group
Pulmonary Rehabilitation Saltash Group 1
 Out of 9 people assessed for the programme 6 people completed the programme.
 There was a 33% combined UTA and DNA drop out rate.
 There was an average increase of 4.2 additional shuttles completed per person in




comparison with initial assessment
There was an average increase of 0.26 METs (metabolic equivalents) per person in
comparison with initial assessment
On average there was a 10.88% improvement in aerobic fitness using the Heart Rate
Walking Speed Index (HRWSI). 10% is considered to be significant. The greatest
individual improvement was 22.3%
There were 2 patients that showed a significant improvement greater than 47.5 meters
and 1 patient who achieved greater than 78.7% (Singh et al, 2008)
There was an average improvement in the HAD anxiety and depression scores by 1.2
and 0.6 respectively
Oxygen Clinics/ Respiratory Consultants – Derriford Hospital
Monthly oxygen clinics at both Liskeard and Launceston Hospitals have been running
since February. These clinics are run by the PCH Specialist Respiratory Nurses and are
supported by two respiratory consultants from Derriford Hospital. They offer follow up
reviews for all patients in East Cornwall on oxygen. For new patients, a clinic is due to
commence in June, led by the Consultant Respiratory Nurse from Derriford Hospital.
Derriford consultants are referring into the service and communication links are good.
Patient Feedback from Pulmonary Rehabilitation
Patients Comments during Pulmonary Rehabilitation
(Quotes are summarised, not patients’ exact wording)
“I was able to do some light gardening, weeding for the first time in two years.”
“This is my second time of doing pulmonary rehab here in the hospital and I think that it is
much better this time around. It is more paced so that I am able to achieve more, rather
than going as quickly as I can and then needing 5 minutes to recover.”
Page 29 of 60
“I went swimming for the first time since being diagnosed with my lung condition. The
breathing techniques and the pacing helped greatly.”
“Since starting the group I have lost weight, I have more energy and I feel more motivated
to keep active.”
“I have bought a step and some weights and have been doing the home based exercise
programme regularly. I really enjoy it.”
“I have been able to walk back up the garden path without needing to stop due to
breathlessness.”
“I have found playing golf, especially the walking between holes much easier and I have
found that when I’m fishing all day, my stamina to stand all day has improved greatly.”
“The education session on inhaler technique has really helped me, it has made such a
difference.”
“I am now finding that I am thinking about my breathing when I’m doing any activities and
I am using the breathing techniques I have learnt. It is helping me a lot.”
“The course has been really beneficial, all components.”
Conclusion
This 3 month evaluation demonstrates real progress in delivering improved respiratory
services for patients across the clinical pathway. The admission data looks very
encouraging and suggests the impact of partnership working across the respiratory
pathway is contributing to fewer emergency admissions. It is very evident from patient
feedback that the new service is making a real difference to people’s quality of life. Further
evidence of this will be captured with the Clinical Outcome Measures being used by the
team.
There is currently no wait for patients to attend pulmonary rehabilitation if they are
prepared to travel within East Cornwall and the team are able to offer a fast (within 24
hours) service for acute referrals.
Page 30 of 60
3.5 Parkinsons Disease Service
Here are examples of the innovative work being undertaken within the Parkinson’s
Disease service:
1. Joint Parkinson’s / Therapy project
Within the west of the county, two disease specific education / exercise groups
have previously been developed for people with Parkinson’s. One group aims to
provide specific information to newly diagnosed people with Parkinson’s and
focuses on effective signposting, engagement with different healthcare professions
and empowering people to self manage their condition. This has been combined
with preventative exercise. The other group focuses on disease specific education /
exercise for those people diagnosed for a longer duration, but aims to prevent
problems such as falls. The commissioners agreed to fund two pilots for people
newly diagnosed with PD within mid / north & East Cornwall and two further groups
within the same areas for people with more advanced disease.
These four pilot groups have now been completed. Early evaluation reveals that
people felt better equipped to manage their long term condition, not only through
the provision of exercise / education, but also through the development of
relationships with other group members. More in depth evaluation is currently taking
place and the results of these pilot groups will be presented to Kernow Clinical
Commissioning Group in the near future.
2. To reduce Parkinson’s Hospital admissions by development of a pathway that
identifies the reasons why people with Parkinson’s acutely deteriorate
One of the Parkinson’s Nurse Specialists in conjunction with the Parkinson’s team
has developed a pathway for primary / community services to identify and manage
the acute deterioration of Parkinson’s symptoms. It is known that people with
Parkinson’s are admitted to Hospital when infection (for example) may be present.
In this situation it is preferable to identify and manage the signs of infection rather
than increase Parkinson’s medication. This pathway has been presented to the
Prescribing GP leads and forms part of the 2013 – 14 Medicines Optimisation Plan
(formerly QIPP). It has been adapted for RCHT use (to reduce Hospital stay) and
will form part of an educational event in the near future. The aim will be to reduce
Hospital admissions by effective and ongoing use of this pathway.
3.6 Safety Thermometer
The NHS Safety Thermometer is a national improvement tool, to assist in reducing harm to
patients. The NHS Safety Thermometer was intended to be a local improvement tool for
measuring, monitoring and analysing patient harms and ‘harm free’ care.
Page 31 of 60
The safety thermometer was developed throughout 2011 with over 160 NHS provider
organisations involved in the development and testing.
The tool measures four high-volume patient safety issues (pressure ulcers, falls resulting
in harm, urinary infection in patients with a catheter and treatment for venous
thromboembolism).
It was then adopted as a National CQUIN and introduced nationally from April 2012. In the
first 12 months the CQUIN was based on successfully implementing the safety
thermometer across all applicable services in the organisation.
In the initial guidance the inclusions and exclusions were open to interpretation and it was
the case that different organisations implemented in different teams. In the main in the first
year, most organisations have surveyed inpatients and community/district nurses. This
guidance has been clarified for 2013-14.
The safety thermometer process involves recording against the four harms one day a
month on the same day across the entire organisation. All patients in an inpatient area on
the survey day are included, as well as everyone seen in the community on that day.
N.B. Patients seen in groups or outpatient clinics are not currently included in the safety
thermometer process.
Locally it was agreed that to meet the requirement of the 2012-13 CQUIN PCH would be
required to implement the safety thermometer in all inpatient wards by April 2012 and all
applicable community services by September 2012.
Following presentations to Ward Sisters and Matrons the safety thermometer was
successfully implemented in all wards in April.
In the community a phased approach was taken with District Nurses and some other
community services implementing in July and all applicable teams by September. This was
achieved through briefings with teams, production of in-house guidance on data collection
and recording and good communication links between the Governance team and service
leads and team members.
Feedback from all teams involved has been very positive and appreciative of the support
provided by the Governance team.
Since implementation a total of 3290 inpatients have been surveyed with on average over
270 per month.
In the community since July 9588 patients have been surveyed for the safety thermometer
with an average of over 1065 patients per month.
Page 32 of 60
In total 12878 patients have been surveyed. Of these 11518 have suffered no harm
89.44%. A number of these were harms acquired before being admitted to PCH care (for
example patients who were admitted with a pressure ulcer).
When looking at those with new harms only, acquired since coming under PCH care,
12323 suffered no harm (95.69%).
Whilst the safety thermometer is not primarily a benchmarking tool it is worth looking at the
national safety thermometer harm levels to ensure PCH is not significantly different to the
national picture.
When looking at all organisations and all settings the overall harm free care percentage for
the year to date at 91.62% is higher than PCH and the new harm free care percentage
slightly higher at 96.32%
When comparing PCH wards to all community hospital wards we compare slightly better,
with 90.94% and 97.33% all harm free and new harm free respectively compared to all
community hospital wards of 87.88% and 95.68%
When looking at PCH community services compared to all community based services
nationally PCH compares slightly less at 88.92% and 95.13% all harm free and new harm
free care respectively compared to 91.19% and 96.6% for all community settings
nationally.
The following charts show PCH performance against the 4 harm measures for combined
ward patients and community patients:
Percentage of patients with ANY pressure ulcer
11.00%
9.89%
8.00%
8.36%
10.29%
7.55%
8.56%
7.68%
7.25%
6.51%
7.13%
6.57%
6.83%
5.00%
4.26%
2.00%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
All PCH Services %
Median
Page 33 of 60
Percentage of patients with evidence of harm
from a fall
3.00%
2.77%
2.50%
2.27%
2.12%
2.06%
2.00%
1.50%
1.06%
1.00%
1.07%
1.29%
0.93% 0.90%
0.72%
0.50%
0.60%
0.70%
0.00%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
All PCH Services %
Median
Percentage with an in dwelling urethral urinary
catheter & receiving treatment for ANY urinary
tract infection
3.00%
2.50%
2.44%
2.00%
1.50%
1.54%
1.46%
1.24%
1.07%
1.00%
1.01%
0.71%
0.68%
1.00%
0.50%
0.62% 0.60%
0.00%
0.00%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
All PCH Services %
1.50%
Median
Percentage receiving prescribed anticoagulation
treatment for treatment of a NEW documented
VTE event
1.00%
0.92%
0.85%
0.50%
0.89%
0.65%
0.58%
0.51%
0.36%
0.46%
0.35%
0.38% 0.38%
0.35%
0.00%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
All PCH Services %
Median
Page 34 of 60
The final two charts show the two key harm measures.
All Harm Free Care
Percentage with no PU, harm from fall, urinary infection (in patients
with urinary catheter) or NEW VTE (ALL HARM FREE)
95.00%
93.62%
93.00%
91.65%
91.59%
91.67%
91.00%
89.00%
90.66%
89.86%
89.15%
88.67%
88.50%
89.79%
87.00%
86.63%
86.13%
85.00%
Apr
May
Jun
Jul
Aug
Sep
Oct
All PCH Services %
Nov
Dec
Jan
Feb
Mar
Median
New Harm Free Care
Percentage with no NEW PU, harm from fall,
NEW urinary infection (in patients with urinary
catheter) or NEW VTE (NEW HARM FREE)
100.00%
98.00%
98.91%
98.23%
97.14%
96.92%
95.83%
96.00%
95.12%
94.00%
96.63%
95.03%
94.45%
96.17%
94.74%
93.36%
92.00%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
All PCH Services %
Median
Page 35 of 60
3.7 Blood Transfusion Management
PCH staff administered approximately 900 units of blood per year across the County. Most
of these are 2 unit transfusions. In 2012/2013 20% of all blood supplied from the
transfusion Laboratory in RCHT was transfused in the Community. Patients are transfused
as inpatients or day patients in all the Community Hospitals except Fowey and Poltair: The
Acute Care at Home team transfuse patients at home in the mid and west of the County.
Blood fridges are in place at Bodmin, St Austell, Newquay, Camborne Redruth, Falmouth,
Helston, St Marys, Liskeard, Launceston, St Barnabas and Stratton.
To comply with NPSA SPN14 ‘Right Patient-Right Blood’ staff are required to complete
transfusion training and face to face competency assessment on a two yearly cycle. Since
April 2012 PCH nursing staff have maintained 98% compliance. Training and assessment
has been on going in all areas to maintain this level. Staff are assessed by the ward based
transfusion assessors who in turn are assessed by the Transfusion Practitioner. In areas
where there are blood fridges, staff also complete fridge monitoring competencies to
comply with BSQR and MHRA requirements. It is a legal requirement to have 100%
traceability of blood products from donor to recipient and to provide evidence of the cold
chain of the products. Any deviation is reported on Datix as an incident and investigated.
The Transfusion Practitioner submits a quarterly incident report to the clinical quality and
safety committee.
The low level of incidents demonstrates the benefits of all the training and assessment.
There has been a 55% reduction in incidents in year 2012/2013.
The following table illustrates the year on year reduction in incidents
35
30
25
20
2009/10
15
2010/11
10
2011/12
5
2012/13
Ot
he
r
iss
m
ne
ar
n is
tio
ip
SH
OT
su
e
ain
es
cr
ce
ab
ilit
y
tra
/u
ni
t
co
ld
ch
pr
w
as
te
d b
X‐
lo
od
m
at
ch
0
Page 36 of 60
In 2011/12 there were 60 reported incidents (not including fridge incidents). Most of these
were documentation or cold chain errors affecting compliance with MHRA and BSQR
regulations; 6.7% of transfusions involved a minor error. In 2012/12 there were just 25
reported incidents Mostly minor documentation and cold chain errors. Overall 2.7% of
transfusions involved a minor error, a considerable reduction on previous years. The
ultimate aim is to reduce this to 0%.
Any incident involving the wrong blood transfused; special requirements not met:
unnecessary or inappropriate transfusions: handling and storage errors resulting in unsafe
transfusion of products and Right Patient Right Blood administration errors must be
reported nationally to SHOT (Serious Hazards of Transfusion). In 2012/13 only two
incidents were reported to SHOT. One of these was a transfusion reaction rather than an
error and the second was relatively minor with no harm to the patient. A full root cause
analysis is completed with every SHOT report and an action plan and further education
implemented as required.
NPSA SPN14 ‘Right Patient Right Blood’, endorsed by the MHRA, recommended that
electronic blood tracking be implemented to improve traceability and patient safety. The
Transfusion Practitioner has been working closely with the acute Trusts to ensure a
smooth transition into community sites. Currently, relevant staff are being issued with
barcoded ID cards, training is planned and equipment being ordered and installed to
ensure a smooth transition to new procedures and to ensure our patients are not
inconvenienced.
3.8 Safeguarding Adults
Ensuring our patients are safe and able to live free from abuse remains our constant
priority and we strive to ensure that our staff are equipped to recognise and challenge the
signs of abuse and take appropriate steps to safeguard children, young people and
vulnerable adults.
2012/13 witnessed a significant county wide increase in reported safeguarding concerns
and safeguarding alerts requiring multi agency management and intervention. In
recognition and in a robust response to this PCH undertook a review of its existing
safeguarding management and practice arrangements, compiling a safeguarding action
work plan which scoped the issues and identified positive solutions and focus for the
direction of required improvement and change.
During December 2012 PCH formed a Safeguarding Unit in order to address the following
key priorities:
 To improve safeguarding management, leadership, supervision and education
 To develop and align safeguarding alert processes for children, young people and
vulnerable adults ensuring that individual rights are protected and promoted
Page 37 of 60
 To promote patient safety principles and reduce risk through effective management
 To strengthen and improve engagement with multi agency safeguarding processes
improving the quality of safeguarding alert investigation
 To effectively support staff involved in multi agency safeguarding processes,
embedding and sharing the learning identified from these
 To provide statistical and pertinent data relating to safeguarding trends, themes
and concerns to the executive in order to demonstrate compliance and/or
effectively assess and manage risk
The Unit has focussed its efforts on accessibility and the provision of consistent support
and advice to staff via telephone, electronic or face to face contact.
Review of the safeguarding alert reporting procedure was undertaken in recognition of the
need to streamline the expected interventions taken by staff in order to meet both multi
agency and internal governance reporting requirements. This was achieved by adapting
the existing incident reporting system – Datix, which staff were familiar with. It was backed
up with the introduction of a range of supportive tools and protocols developed to enhance,
capture and transfer information both internally and externally in order to facilitate
improved communication and record keeping in support of the multi agency safeguarding
process. In turn this has resulted in an improvement in the quality of the information
contained within the referrals and an increased confidence in staff when reporting their
concerns.
The PCH Safeguarding Adults Policy was also reviewed in order to reflect the
improvements implemented and provides an easy to read resource for staff that ensures
that they are able to recognise their personal and organisational safeguarding
responsibilities.
The Safeguarding Unit monitor, support and provide safeguarding training, reviewing the
content of training and education in order to ensure that it is current and continues to
reflect legislation. There has been widespread investment in delivery of children’s
safeguarding training for many allied therapy services in order to improve compliance and
understanding of professional responsibilities. Whilst in respect of adult services the
requirement to ensure compliance with the Mental Capacity Act 2005 and Deprivation of
Liberty safeguards provides on going challenge.
As part of their review of providers in 2012/13, the Care Quality Commission visited all
registered locations within PCH and found staff to be knowledgeable regarding
safeguarding procedures and consistently knew where to seek advice and what to do if
they had a concern.
Page 38 of 60
3.9 Nursing Metrics and Patient Experience Measurement during 2012/13
The last year has seen a period of very intensive patient experience activity in PCH. It has
been a year of extensive change in the NHS, accompanied by rapidly changing national
and local priorities. New initiatives were announced with very short timelines for
implementation, and other exciting opportunities for innovative development were seized.
This meant some of the work that had been planned to take place during the year had to
be delayed in order to focus on meeting newly imposed deadlines. Two major areas of
patient experience activity during 2012/13 were:
 Winning Department of Health funding in the NHS Institute Patient Feedback
Challenge. The project, ‘Kinda Magic’ aimed to 1) spread the principles of the PCH
methodology of collecting patient experience metrics across the NHS and 2)
develop tools to collect patient experience feedback from patients with cognitive
and communicative impairment
 Implementation of the Friends and Family Test, announced by the Government at
the end of May 2012
Patient Experience Metrics – adding quality to our metrics
We are now starting our 3rd year of collecting Patient Experience Metrics from patients in
our community hospitals. Our ‘metrics’ or ‘indicators’ are a set of questions we ask patients
during unannounced ward visits. ‘We’ are a team of non-clinical managers or members of
our training team who visit wards and talk to patients. We ask them the questions that help
us obtain our regular quantitative metrics, but we also have a conversation around their
answers and capture their comments. We report this information back to the Ward
Manager and Matron. This information helps us all to understand why patients give the
answers they do. This is the qualitative information that helps us to target our actions most
effectively. Depending on the size of the ward, up to 10 patients (and sometimes relatives)
are interviewed.
Reporting back patient views and actual comments is extremely powerful. Often this
feedback is very positive and encouraging to staff, and when there is negative feedback
this motivates immediate attention to issues that arise. During the last year it’s been very
evident that staff have really taken ownership of their feedback. There are many examples
of where they have acted on patient feedback extremely quickly, sometimes before the
end of day.
Consistent good practice – responses to questions about
 patients’ perceptions of cleanliness of their environment
 patients’ confidence in staff hand hygiene
 patients saying they have enough to eat and drink
 patients not sharing their sleeping area with the opposite sex
Page 39 of 60
 privacy
have always scored highly and continue to do so.
Improvements – aggregated results show overall improvement during the year as a result
of improvement in indicators for patients saying they receive enough help to eat their
meals and patients saying they feel involved in decisions about their care and treatment,
the latter being a significant improvement. A review of historic data shows that
performance of questions about
 prompt answering of call bell
 information giving about medications
 finding staff to talk to about worries and concerns
have improved considerably from 2011-12 to 2012-13
Patient Experience Metrics roll out across District Nursing
Last year we said we would implement our metrics process across District Nursing
Services. After testing it during the year it was implemented during February 2013. A small
number of patients from each of the District Nursing caseloads are randomly sampled
each month. Selected patients are sent a short questionnaire to complete and a
questionnaire for their Carer (if they have one) to complete. Both questionnaires contain a
section seeking qualitative comments.
Although results are not yet available (due to technical issues with the data analysis
process) sight of completed questionnaires at data entry suggests that the majority of
patients report high levels of confidence in the service and hold their District Nurses in high
regard.
TB Immunisation Service – Patient Experience questionnaire survey
We said we would measure the experience of people who bring their children for TB
immunisation. This has recently been implemented. The questionnaire has been simplified
to help people whose first language is not English, and will be available for translation on
request.
Dental Services – Patient Experience questionnaire survey
We said we would measure the experience of people accessing PCH Dental Services.
Due to some organisational changes within the service this did not progress as quickly as
we hoped but it remains in the plans to carry out this year.
A separate piece of work targeted towards the care of people with Learning Disability in
Dental Services is also planned.
Page 40 of 60
‘Kinda Magic’
Last year we said we wanted to develop tools to capture patient experience feedback from
patients with cognitive and communicative impairment because our patients with
dementia, learning disability, aphasia etc. were excluded from our process to collect our
Patient Experience Metrics.
We seized the opportunity of the NHS Institute Patient Feedback Challenge, launched in
May 2012, and submitted a bid for a share of the £1million Department of Health funding
to use for the ‘spread and adoption’ of existing good practice in patient experience across
the NHS. After a rigorous selection process involving ‘hot houses’ and ‘crowd sourcing’
methodologies, ‘Kinda Magic’ was one of 9 projects selected from over 40 entered.
The expert panel recognised the strengths and value of PCH’s methodology of collecting
quality patient experience metrics and asked us to ‘spread’ this process to other areas of
the NHS.
‘Kinda Magic’ has 2 main aims or ‘phases’:
 Phase 1 – the spread and ‘adoption’ of the principles of the PCH process of
collecting patient experience metrics to other specialities and to other
organisations
 Phase 2 – the spread and ‘adaptation’ of the tools and process to groups of
patients usually excluded, those with communicative and cognitive impairment
such as dementia, aphasia and learning disability
The project got underway in September 2012. With the NHS Institute’s closure in March
2013, only 6 months after starting, there has been enormous pressure to progress the
work and achieve its main outcomes during that time. ‘Kinda Magic’ is however a lot more
complex in nature than some of the other projects and it has always been acknowledged
that work on Phase 2 would need to extend beyond that time.
The success of ‘Kinda Magic’ has been astonishing but was made achievable in such a
short time because of the work put in by the project participants and spread partners, and
because it has been largely ‘event driven’.
Phase 1 has completed although there is still work to do to produce the Phase 1 section of
a toolkit.
Peninsula Community Health
 Implemented principles of metrics in District Nursing Service
Royal Cornwall Hospitals NHS Trust (RCHT)
 Implemented PCH principles in Eldercare
Coventry and Warwickshire Partnership Trust
 Implemented in mental health inpatient units
 Implementing in District Nursing
Hertfordshire Partnership Foundation Trust
 Implemented in mental health inpatient units
Page 41 of 60
Cornwall Council Adult Care and Support
 Implementing in Care Homes
Interestingly, although each organisation and service is free to decide on their own
question set, it is remarkable how similar each question tool is to each other. The tool
which is currently in use in Care Homes has been changed very little from the one used in
PCH.
Phase 2 is continuing. Work on developing and adapting tools to include patients with
cognitive and communicative impairment has been organised in workstreams across our
spread partners





Dementia – led by Peninsula Community Health
Learning Disability – led by Royal Cornwall Hospitals Trust
Aphasia and Stroke – led by Peninsula Community Health
Children/Young People – led by Royal Cornwall Hospitals Trust
Mental Health – led by Coventry and Warwickshire Partnership Trust
Creative and innovative tools and processes are being further developed. Moving forward,
both the tools and the methods employed will now require wider testing and validation.
National interest in ‘Kinda Magic’ is growing. In this post-Francis period, ‘quality’ metrics
have a value in providing a regular ‘snapshot’ of patient experience across a wide (or full)
range of areas. Furthermore, tools and processes to enable all patients to be included are
widely sought after.
In March 2013, all 9 Patient Feedback Challenge projects were showcased at a national
celebratory event in London. The ‘Kinda Magic’ project team were asked to open the
presentations and talk about the programme as well as the project. Following this event,
other organisations have contacted us for information about our tools and methods. We
have also been invited to present ‘Kinda Magic’ to representatives of all 7 Health Boards in
Wales in a Masterclass in June.
In March, we were invited to showcase ‘Kinda Magic’ on the new NHS Improving Quality
stand at Innovation Expo, which gave it wide exposure.
We anticipate that there will be tangible progress in produced tools by autumn 2013.
Learning Disability
PCH is working to achieve full compliance with the Mencap Charter to ensure our services
are accessible to people with Learning Disability (LD) and that we meet their needs.
Working with us are ‘CHAMPS’. CHAMPS are employees of Health Promotion; they are
people with LD who represent patients with LD.
Last year the CHAMPS undertook assessments of the Minor Injuries Units and Outpatient
Departments in all our Community Hospitals. They wanted to find out:
Page 42 of 60
 Whether staff knew how to contact their LD Liaison Nurse
 Whether staff knew about and use ‘Hospital Passports’
 Whether easy to understand information about health and health procedures was
available
 Whether staff had an understanding of and awareness of ‘reasonable adjustments’,
Mental Capacity laws and advocacy services
 How they were spoken to
 Whether they could find their way around
The CHAMPS have undertaken assessment visits at all but 2 community hospitals so far.
Following the assessment visits, the LD Liaison Nurses together with the CHAMPS have
commenced a programme of training sessions in each hospital (informed by the
assessments) to ensure that staff are informed and better able to meet the needs of
people with Learning Disabilities. When this programme is complete, the CHAMPS will
make a second round of unannounced visits to repeat the assessment.
Information leaflets have been developed for people with LD. These have been developed
together with the CHAMPS. Information leaflets include
 About the Learning Disability Liaison Nurse Service
 Traffic Light Hospital Passport
 How to make a complaint
 Comment Card
 Leaving Hospital
 Consent – Saying Yes or No
 Carer’s Information
These leaflets are due to be printed and will be in use soon.
Friends and Family Test
The Friends and Family test was implemented in all wards and Minor Injury Units (MIUs) in
all our community hospitals in mid-March, 2 weeks ahead of the mandatory
implementation date of 1st April 2013. All patients aged 16 and over must be offered the
opportunity to answer the question ‘How likely are you to recommend our ward [MIU] to
your family and friends if they needed similar care or treatment?’ at or within 48 hours of
discharge.
Page 43 of 60
A response card is given to every patient on discharge from a ward, or on being seen and
sent home from MIU. They can reply on the response card by a Freepost address, or
online via the PCH website using the ward/MIU identifier. Staff are not permitted to assist
patients to complete the response card but they can give them an information leaflet about
it, and remind them on discharge.
Whilst the first complete month’s data is still being collected, the data collected so far is
very encouraging.
Of 223 responses so far entered onto the database:
 209 said ‘Extremely likely’
 10 said ‘Likely’
 1 said ‘Neither likely nor unlikely’
 1 said ‘Unlikely’
 1 said ‘Extremely Unlikely’
 1 said ‘Don’t Know’
Most have written comments that are very complimentary in nature, there are a few
constructive comments and only 2 negative comments. The following are very typical
comments:
“Very quick and jovial nurse. Happy and cheerful. A great change to have a happy
nurse.”
“I received very quick and friendly help when visiting hospital. Very pleased with
service.”
“Lovely staff that meet you with a smile”
“The staff were cheerful, friendly polite and efficient. I was booked in, treated and on
my way in 25 mins. The treatment was explained to me as it was ongoing and I was
given clear instructions as to how to continue in the next days.”
“Everything was efficient, friendly and nothing seemed too much trouble. The care
and being looked after was far above which one would expect. My thanks go all out
to the unit.”
“Very helpful, very professional. Would like to thank the nurses concerned. They
were apologetic for the delay in being seen, but this didn't matter. Couldn't get to
see GP and would have been sent to you anyway. Wonderful service. Please keep
it up!”
“The proficient way in which the staff did their work giving one an immediate sense
of confidence. The kindness, care taken to explain any suggestions as to what I
should do or not do in order to hasten the healing progress. Well done.”
Page 44 of 60
NHS Choices and Patient Opinion – Feedback on public websites
NHS Choices and Patient Opinion are two popular websites for patients and the public to
post feedback on our services ‘Tripadvisor’ style. Use of these websites is on the increase
and ratings and feedback are followed by local media and other national and local
organisations.
Twenty-nine (29) items of feedback were posted during 2012-2013, more than half of
which (17) relates to MIUs.
All but one item of feedback was positive and praiseworthy of the unit visited.
3.10
Eliminating Mixed Sex Accommodation (ESMA)
PCH has remained 100% compliant with eliminating mixed sex accommodation.
3.11
Complaints and Compliments
PCH welcomes comments and suggestions about any aspect of our services. We equally
value any concerns or complaints to be raised with us in order to ensure we improve the
services we provide. During the year 2012-2013 we received a total of 120 complaints
across a range of community services, raising a variety of issues as well as some common
themes. One of these complaints was passed with consent to another organisation to
investigate and 16 were withdrawn or not taken forward by the complainant. The remaining
103 complaints were about community health services and were followed through the
complaints procedure. 42 were made in writing and 61 were made verbally to staff. 111
complaints were received in the previous year.
A total of 295 PALS contacts were received during this year. 87 of these were about other
organisations. The remaining 208 PALS contacts were about community services provided
by Peninsula Community Health. There were 62 requests for interpretation and translation
services during this period. 254 PALS contacts were received during the previous year.
The following charts compare the number of cases received against previous years as
follows:
Complaints Received:
Q1 2009 to Q4 2013
PALS Contacts Received:
Q1 2009 to Q4 2013
40
120
30
100
20
80
10
60
0
Q1
Q2
Q3
Q4
2009-10
17
25
27
33
2010-11
30
33
23
34
2011-12
30
33
21
27
2012-13
27
36
22
35
40
Q1
Q2
Q3
Q4
2009-10
97
119
101
110
2010-11
109
83
104
106
2011-12
60
54
62
78
2012-13
72
52
83
88
Page 45 of 60
The following chart shows the number of complaints and PALS contacts received in each
month of 2012-13
Complaints and PALS Received 2012-2013
40
30
20
10
Complaints Received
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May12
Apr-12
0
PALS Received
We place an emphasis on resolving complaints and PALS concerns as quickly and
effectively as possible, and in a way that is both proportionate and agreed with the
complainant. The investigation of individual complaints identifies actions to be taken to
reduce the risk of the complaint recurring. Work is ongoing across PCH to ensure that
learning from individual complaints is spread across the organisation. Where any part of a
complaint is upheld, the complainant always receives an apology. All issues require a level
of investigation and the same principle applies where the findings agree with any aspect of
an issue. There are also occasions when suggestions are made, for example, to improve
an environment explanation and information about the actions identified and taken to
address the issue.
94.8% of all complaints received were acknowledged within 3 working days. 97% of the
complaints pertaining to PCH received a final response within a timescale agreed with the
complainant, including those where an extension was requested and agreed. The following
charts show the acknowledgement and final response times over the last four years.
% acknowledged within 3 working days
100
2009-10
2010-11
2011-12
2012-13
85
70
Q1
Q2
Q3
Q4
Page 46 of 60
% final response within timescale agreed with complainant:
100
2009-10
2010-11
2011-12
2012-13
85
70
Q1
Q2
Q3
Q4
The Parliamentary and Health Service Ombudsman has responsibility for the second
stage of the NHS Complaints Procedure. There were two referrals made during this year.
One was made regarding dental treatment, which the Ombudsman decided not to
investigate following an initial screening review. The other related to specialist therapy and
we are awaiting the outcome of this initial screening process.
ICAS is a free, independent and confidential service available to anyone who wishes to
make a complaint about their NHS care. This statutory service was launched in 2003 and
provides a national advocacy service delivered to agreed quality standards. The
organisation has recently been restructured to reflect the concentration on health issues.
IHCAS advocates support complainants in making complaints, and assist them to think
about what they would like to achieve from their complaint, such as an apology, an
explanation or an improvement to NHS services. All complainants who contact the
Complaints & PALS Department are given information about their local IHCAS office.
Three complaints were made through ICAS during this year.
No complaints were made based specifically on issues of Equality or Diversity. All
complainants are advised that they should never be discriminated against if they make a
complaint, and to let us know immediately if they believe this has happened to them
Patient Advice and Liaison Service (PALS)
The Patient Advice and Liaison Service (PALS) was introduced by the Department of
Health in 2002 to provide advice and support to users of local health services. The PALS
service is predominantly telephone based, although an increasing amount of people are
using the website to contact PALS. Enquirers raise a wide range of issues; some are
simple requests for information and others are more complex, requiring numerous calls
and sometimes mediation meetings. The service is available to any member of the public,
patients, carers, relatives and staff.
Page 47 of 60
The seven national standards for PALS are being used to develop a framework in which to
work. This will ensure PCH meets the criteria for the core standards. The seven national
standards are:
 The PALS service is identifiable and accessible to the community served by the






organisation;
PALS will be seamless across health and social care;
PALS will be sensitive and provide a confidential service that meets individual needs;
PALS will have systems that make their findings known as part of routine monitoring,
in order to facilitate change;
PALS enables people to access information about services provided by the
organisation, and information about health and social care issues;
PALS plays a key role in bringing about culture change in the NHS placing patients at
the heart of service planning and delivery;
PALS will actively seek the views of service users, carers and the public to ensure
services are effective.
An integral part of the PALS function is to work alongside other NHS organisations, acting
as a liaison between the patients and the service. Calls relating to other providers are
passed to the PALS services of those organisations, or advice is given about how they
can be contacted.
Peninsula Community Health PALS received a total of 295 contacts during 2011-12. The
table below shows a breakdown of the types of issue raised by callers:
Types of Issues raised with PALs
Q1
Q2
Q3
Q4
25
20
15
10
PALS
Referral
Feedback
Interpretation
& Translation
Complaint
PALS
Support
Information
Issue to
Resolve
0
Advice
5
Page 48 of 60
Translation and Interpretation Services
PALS organises translation and interpretation services which provide face-to-face
interpreters and translation of literature for community health staff. This is arranged
through Jobline Staffing, Language Line or Cornwall Deaf Association. 62 requests were
made during this year, compared with 45 in the previous year.
There was a marked rise in Polish interpretation and although requests were made across
a range of services, the requests were predominantly for Physiotherapy and Dental
appointments.
Positive Feedback
Although complaints and concerns are formally monitored, it should not be forgotten that
these are far outweighed by the number of plaudits received. There are many patients who
are very happy with the services provided by the organisation and who appreciate the
professional and caring treatment they receive from staff. An array of praise is regularly
received by staff in a variety of settings, including numerous cards, flowers, biscuits and
chocolates as a mark of thanks for the care staff have provided to patients.
Around 600 plaudits have been brought to the attention of the PALS team, although we
are aware that not all services and locations regularly advise the department. Work is
continuing to encourage services to share these with PALS, to enable this important
aspect to be accurately quantified and logged.
You said, we did
The investigation of individual complaints identifies actions to be taken to reduce the risk of
the complaint recurring. Work is on-going across PCH to ensure that learning from
individual complaints is spread across the organisation.
Where any part of a complaint is upheld, the complainant always receives an apology, an
explanation and information about the actions identified and taken to address the issue.
Some PALS issues require a level of investigation and the same principle applies where
the findings agree with any aspect of an issue. There are also occasions when
suggestions are made, for example to improve an environment or a service procedure
and, where appropriate, these ideas are acted upon.
Page 49 of 60
Below are some examples of the actions taken as a result of complaints and PALS:
You Said…
We Did…
I wasn’t told soon enough that my
appointment had been cancelled.
We revised our answerphone messaging
policy to ensure patients are notified of
cancellations at short notice.
My child’s orthodontic appointment was
cancelled and there’s been a long wait
for another appointment.
We reviewed the child’s clinical need and
arranged an appointment for the following
week.
My father and I are worried about what
will happen next when it’s time for my
mother to be discharged from hospital.
We arranged a meeting with the matron to
discuss the patient’s care in depth, and offer
reassurance that the family would be involved
in making any decisions about the future.
I would like to understand why, when my
We arranged a meeting with the matron to
father died, his case was referred to the
explain how this happened and why.
Coroner.
How do I access podiatry?
We explained and provided the caller with a
self-referral form.
My son is 17 - why did he have to pay
for a prescription from the Minor Injury
Unit?
We explained that charges applied because
he did not meet any of the charging
exemptions.
I’m concerned about my knee brace,
which doesn’t fit properly and is
uncomfortable.
The physiotherapy team arranged a further
appointment to review the knee brace and
make any necessary alterations.
I took my friend to Bodmin Hospital and
we found there were no wheelchairs
with footrests. This made my friend feel
anxious that he was going to fall out,
and compromised his dignity.
We are currently making arrangements to
rectify this and ensure that wheelchairs with
footrests are available to patients and visitors.
There’s been a delay in the orthodontist
fitting my child’s brace.
Having reviewed the child’s clinical needs, we
explained the reason for the wait, and that
this would not have a negative effect on her
child.
Page 50 of 60
3.12
Focus on the Isles of Scilly
PCH provides hospital and community nursing services on the Isles of Scilly. St Mary’s
Hospital continues to provide “in” patient care for a broad variety of conditions and age
groups. We have especially been focusing on the reablement of patients who are elderly
or who have chronic health problems, to enable them to maintain their mobility and
independence. A large number of the staff have received training in this area over recent
months. We work closely with Adult Social Care in this, and provide comprehensive
information to them when a patient is discharged home to help ensure continuity and
progression.
We continue to provide initial care and stabilisation of patients with acute and serious
health problems prior to transferring them to the mainland for on-going care.
Our MIU department is open 24hours a day. All MIU staff have recently completed the
Resuscitation Council Paediatric Immediate Life support training.
The demise of the BIH helicopter service last year has continued to cause us some
logistical problems with getting blood samples, specimens etc. to the mainland & with
obtaining Pharmacy supplies especially over the winter months. However, these have now
largely been resolved.
We are hoping that the “near patient” testing equipment, due to be installed at the hospital
in the near future should mean fewer samples have to be sent to the mainland for analysis
and should speed diagnosis and improve the service to our patients.
In the last 12 months, we have seen the following performance highlights for St Mary’s
Hospital:
 Co-location of health and social care staff at St Mary’s Hospital
 Continued high performance in risk assessing and providing preventative treatment








for venous thrombo-emboli
Continued high performance in medicines reconciliation
Care of the Deteriorating Patient
Implementation of Early Intervention Service
Reducing harm from falls
Nursing and Patient Experience Metrics
Maintaining Essential Standards for Registration with the Care Quality Commission.
St Mary’s Hospital found to be fully compliant when visited unannounced by CQC
Upgrade of x-ray facilities in St Mary’s Hospital
Page 51 of 60
How safe was healthcare on the Isles of Scilly in 2012/13






100% of inpatients received thrombo-emboli risk assessment and treatment
No community or hospital medication errors
8 inpatient falls – 2 sustained minor harm – nil other harm
2 hospital security incidents – no harm to patients
2 blood transfusion incidents – no patient harm
4 patients suffered pressure ulcers (3 patients had sustained these prior to
admission) No pressure ulcers sustained in our care since April 2012.
 100% inpatients at St Mary’s received Medicines reconciliation, reducing the risk of
medication errors and improving patient outcomes
 Patient Experience feedback tells us that in March, patients found their experience
in St Mary’s to be 91% positive
Isles of Scilly 2012/13
In 2012-13, District Nurses on the
Isles of Scilly undertook 3,534 patient
visits
Throughout 2012-13, St Mary’s
Hospital on the Isles of Scilly had a
total of 191 inpatients
In 2012-13, 2,831 appointments
were undertaken by Dentists on the
Isles of Scilly
Throughout 2012-13, 1,075 patients
Were seen by services provided by
Peninsula Community Health on
the Isles of Scilly
Page 52 of 60
3.13
PEATs
The chart below shows the PEATS scores for 2012. PEATS (Patient Environment Action
Team) visits occur on a yearly basis and are an opportunity for members of the public
(Healthwatch) and organisation representatives to visit all the ward and clinical areas to
undertake an inspection of the environment and food. Maximum scores are 100% per area
of inspection.
PEAT
WEIGHTING
ENVIRONMENT
%
PRIVACY &
DIGNITY %
FOOD %
CLEANING %
BODMIN
80.91
84.62
98.36
95
CAMBORNE
REDRUTH
76.42
94.12
95.08
91.6
EDWARD HAIN
77.56
88.89
90.16
83.4
FALMOUTH
80.18
84.29
90.16
88.4
FOWEY
83.81
92.31
91.8
93.3
HELSTON
91.81
86.25
90.16
90.9
ISLES OF SCILLY
91.16
96
90.16
97.1
LAUNCESTON
76.72
73.33
81.97
92.2
LISKEARD
90.83
95.29
95.08
90.1
NEWQUAY
89.77
96
83.61
90.4
POLTAIR
90.13
100
91.8
84.5
ST AUSTELL
90.16
90
91.8
94.6
ST BARNABAS
91.61
98.57
91.8
90.5
STRATTON
C
L
O
S
E
D
89.6
Page 53 of 60
4.0 Response to this report from our stakeholders
4.1 Cornwall Overview and Scrutiny Committee
During the consultation for this Quality Account, Cornwall Council was in a pre-election
period prior to the 2013 local elections. Whilst the election has now taken place there is to
be a new Council governance structure which will include alterations to the health scrutiny
function.
In the period April 2012 to April 2013 the Health and Adults Overview and Scrutiny
Committee has regularly scrutinised Peninsula Community Health. This scrutiny will be
undertaken by the new Health and Social Care Scrutiny Committee in the future municipal
year.
It is expected that Peninsula Community Health will be required to report to the Health and
Social Care Scrutiny Committee, its progress against the stated future priorities for quality
improvement and performance indicators contained within this Quality Account.
4.2 Isles of Scilly Overview and Scrutiny Committee
The Isles of Scilly Health Overview and Scrutiny Committee welcomes the opportunity to
contribute to these Quality Accounts.
We would like to see further development of the integration of health and social care
services on the islands. As part of this we welcome the opportunity to engage with
Peninsula Community Health on how to maximise all the available resources on the
islands, especially the Community Hospital, to provide seamless service provision.
4.3 Kernow Clinical Commissioning Group
Kernow Clinical Commissioning Group (KCCG) welcomes the opportunity to comment on
the Quality Account 2012/13 for Peninsula Community Health (PCH). KCCG recognises
the approach PCH has developed in setting out its plans for quality improvement and we
continue to develop existing processes to agree, monitor and review the quality of services
throughout the year.
The Quality Account presents an overview of a wide range of quality improvement work
being undertaken. We note the continued progress that has been made in: reducing
avoidable harm through Venous Thrombo-embolism risk assessment, understanding why
pressure ulcers occur, the decrease in cases of CDiff, the expansion of specialist
respiratory services in the East and the expansion of Acute Care at Home across
Cornwall. KCCG would further highlight the work PCH have carried out improving access
to services for patients with Dementia.
We have reviewed and can confirm the information presented in the Quality Account
appears to be accurate and fairly interpreted, from the data collected. However in order to
give a balanced view we would wish to see information relating to learning from Serious
Page 54 of 60
Incidents, and will be looking at patient flow and discharge processes through the agreed
CQUINs.
The Clinical Commissioning group looks forward to working with the organisation
throughout the year to achieve more efficient integrated pathways delivering high quality
services to patients, especially with community nursing teams.
We are pleased to see that the priorities chosen for 2013/14 align with those of KCCG. In
addition to those highlighted in the Account we would wish the organisation to also focus
on the following that have not been selected as a priority:


Patient flow through community hospitals, particularly delayed discharges
Ensure relevant recommendations from the Francis report are embedded within the
organisation.
Page 55 of 60
5.0 Glossary
A trust is an NHS organisation responsible
for providing a group of healthcare services.
An acute trust provides emergency and
planned hospital services.
Board of Peninsula Community Health The Board is accountable for setting the
strategic direction of the organisation,
CIC
monitoring performance against objectives,
ensuring high standards of corporate
governance and helping to promote links
between the organisation and the
community. The Board has 10 members
and includes the Chairman, Chief
Executive, four Executive Directors and four
Non-Executive Directors
The Care Quality Commission (CQC) is the
Care Quality Commission
independent regulator of health and social
care in England. It replaced the Healthcare
Commission,
Mental
Health
Act
Commission and the Commission for Social
Care Inspection in April 2009. The CQC
regulates health and adult social care
services provided by the NHS, local
authorities,
independent
healthcare
providers and voluntary organisations. Visit:
www.cqc.org.uk
Clinical audit measures the quality of care
Clinical Audit
and services against agreed standards and
suggests or makes improvements where
necessary
These are organisations that buy services
Commissioners of services
on behalf of people living in a defined
geographical area. They may purchase
services for the population as a whole, or for
individuals who need specific care,
treatment and support. Healthcare services
are commissioned by primary care trusts.
Social services are commissioned by local
authorities
Commissioning
for
Quality
and A report into the future of the NHS, entitles
‘High Quality Care for All’ 2008, included a
Innovation (CQUIN)
commitment to make a proportion of
providers’ income conditional on quality and
innovation. This is achieved through the
Commissioning for Quality and Innovation
Acute Trust
Page 56 of 60
Complaint
Department of Health
Dignity
Discharge
Hospital Episode Statistics (HES)
Information Governance
Kernow Clinical Commissioning Group
Local Involvement Networks (LINks)
(CQUIN) payment framework.
Visit
www.dh.gov.uk
This is an expression of dissatisfaction that
can relate to any aspect of a person’s care,
treatment or support. It can be expressed
orally, through gestures or in writing.
The Department of health is the department
of the UK government responsible for
policies on health, social care and the NHS
(England only).
Dignity is concerned with how people feel,
think and behave in relation to the worth
and value that they place on themselves
and others. To treat someone with dignity is
to respect them as a valued person, taking
into account their individual views and
beliefs.
The point at which a patient leaves hospital
to return home; or is transferred to another
service: or the provision of a service is
formally concluded.
This is a data warehouse containing a vast
amount of information on the NHS, including
details on all admissions to NHS provider
hospitals and outpatient appointments in
England. HES is an authoritative sourced
used for healthcare analysis by the NHS,
government and many other organisations.
Information Governance is concerned with
the structures, policies and practices in
place to ensure the confidentiality and
security of health and social care service
records.
NHS Kernow is the clinical commissioning
group for Cornwall and the Isles of Scilly.
The Group is formed of 69 local practices
who are themselves formed into locality
groups. KCCG principal work is to buy
health services on behalf of local people.
LINks are comprised of individuals and
community groups such as faith groups and
residents associations, working together to
improve local services. Their job is to find
out what the public like and dislike about
local health and social care, and then feed
the views back to the people who plan and
Page 57 of 60
National Confidential Enquiry into
patient Outcome and Death - NCEPOD
National Institute for Health and Clinical
Excellence - NICE
NHS Number
Overview
(OSC)
and
Scrutiny
Committees
Patient
Patient Environment Action Teams PEATs
Privacy and dignity
run these services. They may talk directly
to healthcare professionals about a service
that is not being offered or make
recommendations about an existing facility
NCEPOD is an independent body
concerned with maintaining and improving
standards of medical and surgical care. It
does this by reviewing the management of
patients and undertaking confidential
surveys and research, which are then
published for the public’s benefit.
NICE
is an independent organisation
responsible for providing national guidance
on promoting good health and preventing
and treating ill health
This is the national unique patient identifier
that makes it possible to share patient
information across the whole of the NHS,
safely, efficiently and accurately.
Since January 2003, all local authorities
with responsibilities for social care have had
the power to review and report on local
health services. Overview and Scrutiny
Committees have taken on this role, and
have been instrumental in helping to plan
services and bring about change. They
bring
democratic
accountability
into
healthcare decision-making and make the
NHS more responsive to local communities.
This is a person who receives health or
social care through a regulated activity.
Patients are defined ‘service users’ in the
Health and Social Care Act 2008.
PEAT is an annual inspection of inpatient
facilities at healthcare sites across England
with more than 10 beds. PEAT is selfassessed and inspects standards including
food, cleanliness, infection control and
patient environment.
The scheme was
established in 2000. It acts as a benchmarking tool to ensure that improvements
are made in the non-clinical aspects pf a
patient’s experience.
To respect someone’s privacy involves
recognising when they would like to be
alone (or with family or friends), and
Page 58 of 60
Providers
VTE – Venous- Thromboembolism
showing sensitivity to their wishes for a
private conversation and preventing others
from looking or listening in.
To treat
someone with dignity is to respect them as
a valued person, taking into account their
individual views and beliefs.
Providers are the organisations that provide
NHS services, for example NHS trusts,
community interest companies, voluntary
sector organisations.
A venous thrombosis is a blood clot
(thrombus) that forms within a vein.
Thrombosis is a medical term for a blood
clot occurring inside a blood vessel. A
classical venous thrombosis is deep vein
thrombosis (DVT), which can break off
(embolize), and become a life-threatening
pulmonary embolism (PE). The conditions
of DVT and PE are referred to collectively
with the term venous thromboembolism
Page 59 of 60
6.0 Statement of Directors Responsibilities in Respect of the Quality Account
The Directors are required under the Health Act 2009 to prepare a Quality Account for
each financial year. The Department of Health has issued guidance on the form and
content of annual Quality Accounts (which incorporates the legal requirements in the
Health Act 2009 and the National Health Service (Quality Reports) Regulations 2010 (as
amended by the National Heath Service (Quality Accounts) Amendments Regulations
2011).
In preparing the Quality Account, directors are required to take steps to satisfy themselves
that:
 The Quality Account presents a balanced picture of the Trust’s performance over the
period covered
 The performance information reported in the Quality Account is reliable and accurate
 There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review
to confirm that they are working effectively in practice
 The data underpinning the measures of performance reported in the Quality Account is
robust and reliable, conforms to specified data quality standards and prescribed
definitions, and is subject to appropriate scrutiny and review; and
 The Quality Account has been prepared in accordance with Department of Health
guidance
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Account.
By order of the Board
Michael Williams
Helen Newson
Chairman
Interim Chief Executive
Page 60 of 60