Quality Account 2012-13: Community Services
delivered in Surrey
Community Services delivered in Surrey by Virgin Care.
Virgin Care Services Limited
Lynton House, 7-12 Tavistock Square, London WC1H 9LT
t: 0845 504 0594 f: 0845 504 0596 e: info@virgincare.co.uk w: www.virgincare.co.uk
Registered office: Virgin Care Limited, Lynton House, 7-12 Tavistock Square, London WC1H 9LT. Registered in England and Wales: Number 5466033
Introduction
Executive Summary
Part 1
1.1 Chief Executive Introduction
1.2 Clinical Director Introduction
1.3 Key Successes and innovation delivered in 2012/13
Part 2
2.1 Priorities for improvement in 2012/13
2.2 Priorities going forward in 2013/14
2.3 National Clinical audit participation: Community Services
2.4 Core service clinical audit programmes
2.5 Research statement
2.6 Statements from CQC
2.7 Safeguarding Statement
2.8 Data Quality
2.9 Information Governance Toolkit attainment levels
2.10 Independent Service Reviews
2.11 Award winning services in Surrey
2.12 Highlights of quality management systems to support staff and services
2.13 Highlights of initiatives to Improve User Experience and Feedback
Part 3
3.1
3.2
3.3
3.4
Review of Quality Performance
Community Services Performance Report
Customer Experience in Surrey 2012/13
Commissioning for Quality and Innovation (CQUIN) Targets 2012/13
3.5 Comments by the Coordinating Clinical Commissioning Group
How to provide feedback on the account?
APPENDIX 1 – Glossary of Terms
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Introduction
The Health Act 2009 requires that from April 2010, all providers of NHS healthcare services in
England covered by the Act produce a Quality Account. This requirement was extended in 2011 to
cover NHS healthcare services (not social care) commissioned by a strategic health authority or a
primary care trust.
In 2012 we won a major contract to provide community services in Surrey and have successfully
provided these services with nearly 3,000 staff across more than 81 sites including the
management of six community hospitals, for the reporting period 2012/13.
The service was commissioned by NHS Surrey and the contract is now overseen by the
coordinating commissioner, North West Surrey Clinical Commissioning Group (CCG).
Executive Summary
Our Quality Account includes:
Part 1
A statement from our Chief Executive
Key quality initiatives delivered by the organisation aimed at improving services, and
seeking the views of Surrey users.
Part 2 sets out the organisation’s priorities for ongoing quality improvement in Surrey for the
coming year 2013/14.
Our statements relating to the quality of the services we provide are consistent with other
community providers.
The Board has received assurance reports in year and has engaged in quality and safety
initiatives
Part 3 contains a review of quality and performance in our community services
Appendix 1 provides a glossary of terms
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PART 1
1.1 Chief Executive
Our philosophy is to continually develop services (and to transform where required) so that every
patient experiences high quality, safe, personalised healthcare in an appropriate setting.
It gives me great pleasure to present the first Virgin Care Surrey Community Services Quality
Account. In putting together this report, we have sought feedback from staff and service users and
I would like to take this opportunity to thank them for their support.
In a year of significant expansion and change I have outlined on page six some of the key
successes and innovation projects delivered last year which were aimed at delivering safe high
quality care and enhance the experience of staff and those using our community services in
Surrey.
I can confirm that to the best of my knowledge the data and information in Parts 2 and 3 of this
report reflect both success and areas that we have identified for improvement going forward in
2013/14.
I look forward to reporting the continued developments in our services in 2013/14
Bart Johnson
CEO
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1.2 Clinical Director
We have well defined systems of governance in place to ensure that our business operates safely
and delivers high quality care to patients. The governance framework ensures that public and
patient confidence is maintained, business is delivered in a financially and legally secure manner,
and all regulatory and contractual requirements are met.
The quality and safety of the care that our teams provide continues to be our highest priority and
the on-going development of our clinical governance and quality systems has supported
practitioners to provide excellence in care at all levels.
I would like to thank the Clinical Quality Team and the Heads of the Surrey community services for
their involvement in providing information for this report, which contains numerous examples
demonstrating our emphasis on quality and safe care, reactive to patient and customer feedback.
We will continue to work closely with our partners, the CQC and other health watchdogs to
demonstrate high standards.
Dr Peter Taylor
Clinical Director
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1.3 Key successes and innovation delivered in 2012/13
Table1
Patient safety/ensuring
consistency in care
Clinical Effectiveness/Promoting
clinical excellence
User Experience
The NHS Outcomes Framework
for 2012/13 “organisation’s
responsiveness to patients’ needs
as a key indication of the quality of
patient experience”.
We continue to invest in reporting systems for use
in all our services to give ‘real time’ reporting.
We launched an online incident reporting system to
improve how we identify and share lessons and
trends across the organisation.
Nursing teams in Surrey won an award for their
work aimed at reducing the risk of patients
developing pressure ulcers and improving
partnership working with other care sectors.
We have been shortlisted for an HSJ Efficiency
Award aimed at improving the care of people with
lower back pain.
We invested in a new clinical system for our walk-in
centres in Surrey aimed at supporting consistency
in patient care.
Our community hospitals demonstrated lower falls
rates over the last quarter compared with the
national prevalence ‘Safety Thermometer Census’
data. We have also introduced innovative initiatives
like ‘slipper amnesties’ to help reduce falls in the
community related to unsuitable footwear.
We delivered our CQUIN community targets
We launched a Patient Reported Outcome
Measures (PROMs) implementation programme
designed to review clinical effectiveness and
consider patient experience across South and West
Physiotherapy services.
Our palliative care service participated in National
Cancer Peer Review Standards and achieved ReQ
status for a specific resource training package for
IV.
We launched a pathfinder tool in an urgent care
centre designed to ensure consistency of patient
care.
We introduced the Net Promoter Score – which is
being adopted nationally as the ‘Friends and Family
Test – improving user feedback from <5% to >48%.
We have implemented a ‘you said we did’ initiative
for managers to look make changes to their
services based upon feedback from patients
Our service triage systems means that patients are
assessed by the most appropriate clinician and
treatment plans meet the clinical needs of the
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Quality Management Systems
to improve capacity and support
to staff
Remote access to care
Listening to patients
patient.
We installed televisions on wards in the community
hospitals
Our community hospitals launched the national
Butterfly scheme to support the tailoring of care for
patients admitted into hospital who have memoryrelated problems. We delivered training to support
staff to better deal with patients’ needs.
Sexual health services introduced confidential text
messaging to seek the views of service users. The
results show a consistently high level of satisfaction
Sexual health services in Surrey achieved ‘You’re
Welcome’ status across all our sites which
demonstrates their commitment for high quality
services focused on young people.
The Learning Enterprise team in Surrey was
awarded a ReQ mark for the work submitted to the
University of Surrey in recognition of quality
education provision.
E-learning programmes have been significantly
extended to ensure all staff have access to training
to meet service and regulatory requirements.
We employed and trained a number of apprentices
all around the country supporting young people in
to work and encouraging young people to think
about a career in healthcare
Surrey Intermediate Care and Community-based
services welcomed a group of Loyola University
nursing students from Chicago. The visitors
experienced how we deliver services in Surrey and
the ethos of working with the NHS.
The virtual ward programme initiated in Surrey is
making a real difference to the lives of patients. It
supports them to be independent and has
significantly cut unplanned admissions as well as
helping patients feel more empowered to manage
their own conditions.
Most of our services now offer text message
reminders for appointments.
We are steadily increasing the level of feedback
received from our Surrey patients and have
introduced touch screen devices into some of our
services
We appointed a PALs manager to support services
and our prison healthcare teams.
We have responded to concerns and complaints
raised in a timely way.
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PART 2
2.1 Priorities for improvement in 2012/13
Our core objective is to be the best community-based provider of care, providing care good enough
for our own families.
Priority 1: Ensuring service quality, safety and enhancing user experience: providing excellent
clinical outcomes, meeting and exceeding relevant standards and regulatory requirements
We have been able to demonstrate the quality and safety of our services successfully
during a number of unannounced CQC inspections throughout 2012 and 2013. (We have
highlighted some of our local service successes in year – Table 1).
We invested in new clinical and patient management systems to support patient care
pathways and have delivered clinical effectiveness programmes.
Services participated in and reported positive outcomes against core and national audit
programmes.
We monitored patient satisfaction throughout the year, and the Executive Team and Board
received user experience reports having successfully extended the Net Promoter Score
(NPS) tool across our services. NPS is a token system which enables services to receive
timely feedback and implement change as a consequence of areas raised by users for
improvement.
Following a pilot of a Patient Reported Outcomes Measures (PROMs) questionnaire across
six services outside of Surrey (dermatology, ENT, ophthalmology and urology), we have
planned development work on patient feedback and outcomes across community services.
We introduced a new management reporting system and further developed our indicators
of service quality and safety management. This supports the Executive and clinical teams
to report, evaluate and monitor the effect of patient care and implement changes where
required to promote best working practices.
We implemented systems and processes to support medical revalidation, and we expect to
achieve a green rating from the DH Revalidation Support Team following our
Organisational Readiness Self-Assessment (ORSA) submission.
Priority 2 Robust governance: fostering standardised safeguarding and quality assurance
processes
We have enhanced our clinical lead model to increase clinical input in to service
mobilisation, development and training.
Our children’s services participate in their local safeguarding board meetings and regular
clinical governance meetings are in existence across all the business units.
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We have successfully recruited to our national professional lead roles to support ongoing
work for professional standards and service development, and have extended our
safeguarding, medicines management and infection control expertise across the wider
organisation.
Our services use a ‘red, amber and green’ (RAG) clinical governance scorecard as a
monitoring tool for key aspects of clinical quality and training, aimed at delivering a
consistent approach to reporting.
Our mobilisation programme tools for new services ensures we standardise service models
and provide a robust process to ensure gaps against quality and safety are identified before
we take on a service.
Priority 3: To be recognised as an outstanding employer
We actively engaged in an apprenticeship scheme to bridge the recruitment gap in some of
our administrative roles. The scheme also actively supports young people into work.
Surrey clinical service team’s contribution to education and training programme
development was recognised by universities in the south, leading to The Learning
Enterprise (a business unit of Virgin Care) being awarded a ‘recognised education quality
mark’ (ReQ) for the production of quality education modules.
The Learning Enterprise provided links to NHS and other external training programmes and
improved access to training for all staff.
A senior management training programme designed to develop management standards
across the organisation was successfully launched.
2.2 Priorities going forward in 2013/14
Demonstrating ongoing service quality and safety remains a top priority going forward in
2013/14.
Priority 1: Ensuring service quality, safety and enhancing user experience:
Providing excellent clinical outcomes, meeting and exceeding relevant standards and regulatory
requirements
Full roll out of web-based reporting tools to support incident and web-based performance
reporting across the organisation.
A revised service audit programme reviewed at clinical governance committees.
Improving waiting times working in close partnership with other providers and ongoing
investment in IT and software reporting systems.
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Community service CQUIN and safety thermometer metric work programmes will continue
to be reported quarterly to the coordinating commissioner.
All services will continue to review innovative ways for patient engagement, for example,
through the development of promotional materials displayed through audio-visual screens
at appropriate service locations
Priority 2: Robust governance: fostering safeguarding and quality assurance processes which are
standardised across the business.
Implementing additional local team leads for safeguarding who have the appropriate
expertise to provide support to their service teams
Enhancing our national professional clinical leadership structure to monitor best practice
professional standards across our Children’s, Dental, Dermatology, Musculoskeletal,
Primary and Urgent Care, and Sexual Health services.
Mobile working initiatives will continue to be rolled out to support community and field
based teams to ensure unified information systems and clinical records. This is being
taken forward through project managed programmes such as the Surrey health visiting
service being involved in a national EIS group and remote working pilot for district nursing
services.
Sharing our response to the Francis Report and implementing any associated
recommendations that come out of our working group.
Priority 3: Continue to be recognised as an outstanding employer
The launch of an organisational-wide staff survey
The development and roll-out of a talent management programme.
The Chief Nurse awards scheme based on the ‘6 Cs’ outlined by the Department of Health
to recognise and value the work of the nursing teams.
To support and empower staff in delivering high quality services, access for training for
front line staff will be continuously developed by The Learning Enterprise based on the
organisation’s training needs analysis driven at local level.
We will continue to invest in electronic performance management reporting tools to enable
the analysis and timely evaluation by service teams and facilitate and development of local
actions for change and/or sustained improvement.
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2.3 National clinical audit participation: Community Services
Audit title
Participation in National Parkinson’s Disease Audit –
Therapies Services
Health Visitor Call to Action – Children’s Services
National Intermediate Care audit – 40% cases
submitted
Bedside transfusion (National Comparative Audit of
Blood Transfusion) – Community Hospitals
2.4
Core service clinical audit programmes
Our core audit programme included:
Infection Control – measures the standards for decontamination, cleaning and
training against Infection Prevention Society (IPS) tools
Medicines Management – inclusive of prescribing using the Quality Assurance
Programme Tool
Peer consultation record reviews and directly observed clinical practice against
Royal College and Professional Standards
Service specific audit programmes reported in year have included:
Children’s Services Section 11 Safeguarding returns and monitoring of actions at
committee level.
Prison healthcare audits included medicines management and pain
management, were reported at prison clinical governance meetings and noted in
CQC inspections and independent reports.
British Association of Sexual Health (BASH) reported at clinical governance
meetings.
Dental and X-Ray department’s quality and IRMER audits – independently
reviewed as part of the annual radiation protection advisory service and CQC
inspections.
Dental sedation peer review audit reported at clinical governance meetings.
Therapy service rehabilitation standards reported at local level.
Falls re-audit in community hospitals reported at local level.
Antibiotic use in community hospitals: “An audit of prescribing in Surrey
Community Health 2012” reported at local level.
Prescribing including opiates and antibiotics reported at local level.
Community Hospital PEAT – environment audits published nationally.
Clinical supervision and peer review reported at local level.
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Central Alerting Systems (CAS) reported at local level.
Hand hygiene reported at local level.
Community nursing safe care audits – pressure damage, venous thromboembolism (VTE) and falls reported to quality contract meetings and local clinical
and regional clinical governance meetings.
Other audits in use to support ongoing regulatory compliance integral to new service
mobilisations are:
Health and Safety
Environment and building controls
Information governance
CQC baseline provider compliance
Infection control, inclusive of HTM 01-05 decontamination audits for specialist
community dental premises
BOC medical gas management in community hospitals and dental and sexual
health premises
2.5 Research statement
Participation in clinical research demonstrates our commitment to improving the quality of care
we offer and to making our contribution to wider health improvement. Our clinical staff stay
abreast with the latest treatment possibilities and active participation in research leads to
successful patient outcomes.
We have set up a Research Governance Committee under the chairmanship of the Clinical
Director, and we have contracted with the Sussex NHS Research Consortium for the provision
of Research Governance support.
Current research activity
We were involved in conducting clinical research studies in several medical and service
specialties during 2012/13.
At 31st March 2013, ten active projects were included on our Research Database, either in
progress or about to commence:
Three projects are being undertaken by the Jarvis Breast Unit in Guildford:
o The TOMMY trial, comparing a new form of imaging with standard
mammograms;
o Extending the age range of the national screening programme, to see if there is
benefit in screening older or younger women; and
o A new project to see if changing the order in which mammograms are
examined affects the number of positive results.
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The Surrey Sexual Health team is participating in two national studies looking at
aspects of AIDS and HIV – seroconversion rates and factors affecting the transmission
of HIV.
Our Surrey community teams looking after patients who have had strokes have four
projects looking at:
o The experiences of patients discharged early with support at home;
o Screening for anxiety in patients with stroke (funded by the Stroke Association);
o Testing of a method to improve limb function (LifeCIT); and
o Measurement of upper limb function in patients with stroke.
The Paediatric Physiotherapy team is studying the effectiveness of postural care
education for parents and education staff looking after children with complex needs.
Our partners in these studies include Oxford, Cambridge, Southampton, Kent and Brunel
Universities, the Royal Free Hospital, and the National Institute for Health Research.
Publications
In the last year, the following publications have resulted from our involvement in service
review/research, which show our commitment to transparency and desire to improve patient
outcomes and experience across the healthcare sector.
In Surrey one of our community pharmacists had an article published on medicines
and the effect they have on patients’ falls risk. The article has been released as a
continuing professional development module by Chemist + Druggist (C+D), a leading
pharmacy news weekly with a circulation of 13,500 pharmacies (and 40,000
individuals each month online).
The following articles in peer-reviewed journals were written by members of our staff and
published during 2012:
Kneebone, I. I., Hull, S., McGurk, R., & Cropley, M. (2012). Reliability and validity of the
Neurorehabilitation Experience Questionnaire for inpatients. Neurorehabilitation and
Neural Repair, 26, 834-841.
Kneebone, I. I., Neffgen, L., & Pettyfer, S. (2012). Screening for depression and
anxiety after stroke: Developing protocols for use in the community. Disability and
Rehabilitation, 34, 1114-1120.
McGurk, R., & Kneebone, I. I. & Pit ten Cate, I. (2012). “Sometimes we get it wrong but
we keep on trying”: Coping with communication problems by informal carers of stroke
survivors with aphasia. Aphasiology, 25, 1507-1522.
The same member of staff also co-authored a book:
Lincoln, N. B., Kneebone, I. I., Macniven, J. A. B., & Morris, R. (2012). Psychological
management of stroke. Wiley: Chichester, UK
Future direction
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We are proud to be participating in research which is helping to improve patient care, and will
continue to develop this area.
2.6 Statements from the CQC
Our services are required to register with the Care Quality Commission (CQC) and our current
registration status is not subject to any conditions.
Table 2: Overview of the whole organisation’s CQC registrations in 2012/13
Condition of registration
VCL Provider Companies new locations successfully registered in year
2012/13
VCL Provider Companies total registered locations
VCL Registered Managers appointed in year
The CQC has not taken enforcement action against any VCL service during
2012/13.
Status at 31 March
2013
40 services
101
22
MET
The following service inspections were conducted by CQC across Surrey
Virgin Care Provider
Organisation
Service
Virgin Care Services Limited
(VCSL)
VCSL
VH Community Services
Limited
Woking Community
Hospital
Jarvis Breast Screening
Buryfields Dental Service
MET
VH Community Services
Limited - Follow up inspection
VCSL
Buryfields Dental Service
MET
Haslemere Community
Hospital
Milford Community
Hospital
MET
Milford Community
Hospital
WiC & MIU
Dental community services
MET
VCSL
VCSL - Follow up inspection
VCSL Weybridge Hospital
VH Community Services
Limited -Goldsworth Park
Full
Compliance
Compliance Action Plan
Fully
Implemented
Outcome 1
Yes
Moderate
Outcome 21
Minor
Yes
Outcome 20
& 21
Minor
Yes
MET
MET
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VCSL
District nursing
VH Community Services
Limited - Emberbrook
VCSL
Dental community services
MET
Farnham Community
Hospital
Lynton House
Walton Community
Hospital
MET
VH Doctors Limited
VCSL
Outcome 21
Minor
Yes
MET
MET
Services that had a compliance action identified during their inspection developed and
implemented action plans to address the areas raised. All have been fully implemented.
Our CQC reports of inspections of can be viewed on their website: www.cqc.org.uk
2.7 Safeguarding statement
We are committed to safeguarding and promoting the welfare of adults, children and young people
and to protect them from the risks of harm. The organisation has in place safeguarding guidance
and practices in line with statutory and national requirements.
Our Clinical Governance, Quality and Safeguarding Committee provides Board assurance
that our services meet statutory requirements.
Named professionals are clear about their roles and have sufficient time and support to
undertake them.
Where appropriate, services have submitted a Section 11 review and action plans are
monitored across the organisation at Committee and Board level.
Safeguarding policies and systems for children and vulnerable adults are up to date and
robust. All appropriate staff have undertaken and are up to date with safeguarding training
at Level 1, 2, 3 and 4. This is included in induction and integral to the organisation’s training
policy.
2.8 Data Quality
The following work was delivered by the Surrey Data Quality Team:
Surrey inpatient data submissions: we received confirmation of a successful submission
of records during 2012/13 to the Secondary Uses Service (SUS) for inclusion in the
Hospital Episode Statistics which are included in the latest published data.
Clinical coding error rates are continuously audited and reports provided to service leads
for action.
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Data Quality on data items that go into Commissioning Data Sets are monitored on a
regular basis. We were within 2% of the national average or above in 17 out of the 18
indicators monitored by the Health and Social Care Information Centre
The data quality team will be taking the following actions to improve data quality in 2013/14:
Workshop sessions for the Community Nurses in north-west Surrey to ensure
caseloads are accurate, discharges are completed on RiO and there are no duplicate
referrals. The aim of this work is to ensure that caseloads are accurate and that
erroneous data is not impacting on the 18 week waits.
The team is currently working closely with Community Nursing to ensure that
bereavement visits are correctly recorded in order that accurate dates of death can be
entered onto RiO. The aim of this is to ensure that all community nursing contacts are
recorded appropriately to capture the activity undertaken by community nursing teams
but also to prevent the possibility of the family of the deceased receiving appointments
due to the death not being recorded accurately.
Revalidation of community service outpatient data for SUS submissions is underway to
ensure ongoing submissions are confirmed as being successful.
Service clinical records audit tools designed to measure service compliance with the
recording of ethnicity and other equality data and NHS numbers to ensure safe and
effective patient care is delivered.
2.9
Information Governance Toolkit attainment levels
Our Information Governance Assessment Report was graded green overall - “Satisfactory”.
This was the organisation’s first submission and the following actions are planned aimed at
improving our score this year:
Further alignment and integration of IG policies and procedures to ensure that they
are fit for all new services.
Development of an in-house IG NHS approved training programme.
Increased confidentiality audits across all services (records access and security –
paper and electronic).
Improved records management.
Privacy notice review.
Improved monitoring of subject access requests (centrally) and improved timeliness
and completeness of responses.
Ongoing development of information risk management processes.
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2.10 Independent Service Reviews
HMP High Down is a Category B male local prison, serving the Crown Courts of Guildford
and Croydon, and the surrounding magistrates’ courts. It holds Category B and C prisoners,
sentenced and on remand. The Independent Monitoring Board report 2011/12 found
inpatient and outpatient healthcare service are meeting expectations and noted the work
done to reduce dental waiting times. The report made reference to Telemedicine as one of
the exciting new plans for High Down. A six-month trial of video-conferenced medical
consultations is due to commence in 2013, reducing the need for prisoners to attend
outside hospital. The Head Pharmacist was commended for the excellent pharmacy
department, run across the four Surrey prisons.
2.11 Award winning services in Surrey
Community Services
The prevention and management of pressure damage: Surrey community teams were the
outstanding entry and winner for the partnership working category in the national Clinical
Audit Awards for 2012 and the only entry which the HQIP panel felt met all criteria and
demonstrated good practice. The team collected their trophy at an awards ceremony held
in London and also presented their work at a national conference. Process and outcome
measures include incidence, prevalence, care planning, review and reduction in Waterlow
risk score following assessment and intervention.
Surrey Sexual Health Intervention and Promotion Team
In response to service user feedback when young people told us that the Chlamydia test
pathology results form was too complicated, the Sexual Health Intervention and Promotion
Team took all feedback on board and redesigned the form so that the text is clearer and
simpler. Feedback from patients has been positive as a result of the changes made.
2.12 Highlights of quality management systems to support staff and
services
The Learning Enterprise and Surrey community nursing teams were recognised by Surrey
and Brighton universities, having been awarded a ReQ mark for the production of quality
education modules in the following areas:
Palliative and end of life care training.
Return to work programme for mammography radiographers.
Falls training sessions.
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Medicines management training.
IV training programme.
Walk-in Centres (WICs) and Minor Injury Units (MIUs) implemented a new clinical and
patient management system in Surrey. The new system was introduced at Woking,
Weybridge and Haslemere at the end of November. The system led to improved patient
waiting times by reducing the time spent on administrative tasks at reception, and provides a
single records system linked to those.
2.13 Highlights of Initiatives to Improve User Experience and
Feedback
The Butterfly Scheme was launched in our Surrey community hospitals early in March. The
scheme concentrates on improvement of the care and management of patients who either
have a diagnosis of dementia or who are presenting with signs or symptoms which may be
temporary in nature but not yet diagnosed. ‘Butterfly Champions’ lead implementation at their
local levels. They are from a variety of services and departments who are in contact patients
on a day-to-day basis. The champions promote an important number of areas, including
dignity and respect for all patients with dementia or confusion. They also support staff to
ensure that patients with dementia are cared for in an appropriate manner that meets their
needs and are proactive in identifying any gaps within a service.
Surrey staff and the League of Friends teamed up to help friends and relatives travel to
Farnham Hospital for visiting during the Haslemere Community Hospital refurbishment in
Surrey. The refurbishment work is part of a major investment to improve and upgrade the
fabric of the building. The service is free to relatives and friends of patients who would
normally have been inpatients at Haslemere Hospital; it picks them up every day from
Haslemere and drops them at Farnham giving them a chance to visit their friends or family
members in hospital.
Family services in Surrey are participating in a programme of work aimed at developing the
engagement of users (children, young people and their families (CYPF)). This is due for
completion in 2014 and includes:
The use of video service users’ stories to enhance staff understanding of the CYPF
journeys and learning in order to improve future experience.
Setting up of a parents and CYP forum to include them in decision making and as a
resource to gather views on service developments.
The rollout of the nationally sponsored ‘Valuing Frontline Feedback’ process.
Further development of NPS to include analysis of comments made in relation to this
and the ‘Families and Friends’ test.
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Involving young people in decisions about communication style, for example, userfriendly leaflets and websites.
To ensure that all patients admitted to our community hospitals in Surrey during the period
that the Olympics were televised did not miss out on this special event, we supplied and
installed televisions in wards and in communal lounge areas so that our patients and their
visitors did not miss out on this special event.
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PART 3
3.1 Review of Quality Performance
In the second half of the year, our web-based performance tool has provided the opportunity to
report performance against the corporate quality and safety objectives across the whole
organisation. This has supported the wealth of quality performance data reviewed by the
management teams on a monthly basis, including the Safety Triangle and Surrey Dashboard, and
has supplemented the data discussed and reviewed at service team clinical governance meetings.
All targets were met and we reported ‘green’ for Regulatory Compliance and Safeguarding.
For 2013/14, our Board approved priorities include:
Ensuring service quality and safety:
o A focus on centrally reporting through the new clinical governance RAG scorecard
that each service has a local lead for safeguarding who has received the
appropriate training and that service safeguarding training for adults and children is
up to date.
o Standardising clinical effectiveness and quality audit programmes, and capturing
and sharing organisational-wide activity and best practice.
o Extending our clinical peer consultation review and audit process across all
practitioner groups to assist teams to identify areas of best practice and share
learning, which also supported the professional development and recertification
process.
Robust governance – strategic project:
o Enhancing our core set of professional standards for the professional lead specialty
areas and establishing organisational-wide professional communication and
knowledge sharing networks.
Customer experience:
o Extending NPS to capture feedback from 60% of our patients and increasing our
overall NPS score.
o Demonstrating in every service that we listen to what our customers say and make
improvements by recording at least one change per month per service as a result of
patient feedback.
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3.2 Community Services Performance Report
Update on the priorities set in the 2011/12 Surrey Community Health Quality
Account
We have completed a significant amount of work on the implementation and embedding of
the Safety Thermometer requirement; we have now 100% compliance across our
community hospital, community nursing and children’s continuing care services.
Our Promoting Clinical Excellence day on 14th May highlighted the extensive work
undertaken by teams on areas of clinical audit and the positive impact it has on service
development, focusing on areas of sexual health, rapid response and children’s special
school nursing.
We have successfully delivered the CQUIN requirements for Stroke and Dementia, Safety
Thermometer and Preferred Place of Death and we will use our clinical audit programme to
measure compliance with the clinical standards that support these pathways.
We aim to develop more patient reported outcome measures into service line reports.
We have had twelve visits from the CQC. No serious compliance breaches have been
identified and the CQC’s feedback has been positive.
Sharing the learning from incidents and across the wider NHS
We actively reported all incidents to the commissioner through the National Reporting and
Learning System and notified the CQC when appropriate.
We have a robust system to manage the Medicines and Healthcare products Regulatory Agency
(MHRA) alerts.
Quality and Safety Metrics in Community Nursing
Pressure Wound Management
We will be looking to the excellent work carried out by our community nursing adult and
children’s services which resulted in our community team being awarded the HQIPP award of
partnership working in the area of pressure wound management for the second time in three
years.
We have developed an effective array of tools to support staff in identifying the risk of pressure
damage to their patients, how to alleviate pressure areas with the appropriate equipment and
how to manage pressure wounds that do occur.
We are looking to work closely with our CCGs to extend our joint working projects to include
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more nursing homes and residential units, providing them with educational packages, expert
advice and support and the tools for early identification and management. We will be looking to
use our links with the University of Surrey to audit our progress and ensure that our work is
based on academic principles.
Services Highly Valued by Customers and Staff
One of our organisational values is ‘providing care good enough for our own families’ and we are
committed in 2013/14 to increasing our feedback from patients, clients and visitors to our sites and
services. We have extended the roll-out of the NPS reporting scheme to most of the services we
provide across Surrey and this year we want to increase the number of people who provide
feedback through this method following an episode of care to 60% of patients. We will also be
looking at more ways to encourage patients to comment on our services so that we can make
changes that will improve their experience.
We have introduced a monthly ‘morale-o-meter’ which encourages staff to comment on
organisational progress and to highlight areas of improvement.
As part of our transformation programme we have developed ‘Service Improvement Lead’ roles
where staff are given the opportunity to identify a transformation project with their line manager and
given a day a week to focus on the project with tutoring, support and a range of tools to assist them
in implementing the project. This is supporting innovation from the front-line and developing the
health care leaders of the future.
Clinical Management Solution
We are focused on delivering a clinical management solution with significant investment in:
Technology to enable staff to have remote access to users and for patients to support them to
manage their conditions.
Portable diagnostic equipment to deliver safe and effective clinical care to patients.
Introducing Telemedicine into prison healthcare services.
The project will deliver mobile working and other clinical management elements to the Surrey
team, allowing the information from multiple systems to be available through a front end system.
The programme has the ability to reduce the need to visit office bases and will allow for more ‘real
time’ reporting of information on patient care. It will provide telehealth based solutions for
consultations in patients’ homes and for clinicians requiring further advice and support. It will also
allow staff to feel more secure because the system will be able to tell which client they are visiting
and highlight if they have remained longer than expected at a visit, so that support can be
provided.
The first trial group will start in September 2013.
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3.3 Customer Experience in Surrey 2012/13
In September 2012 the Patient Advice and Liaison service (PALs) was set up and has been
running successfully, with increasing numbers of patients and carers having access to our PALs
team. This has resulted in far more qualitative feedback from our patients and their families, telling
us about their experiences.
We have carried out proactive face to face interviews with patients on all our community hospital
wards and staff have developed action plans to tackle any issues that patients have brought to our
attention. We plan to continue the scheme in our outpatient areas and eventually in domiciliary
settings. This should ensure that patients feel comfortable about talking to us frankly, with the
knowledge that we will take appropriate action.
We have carried out over 30 complaint meetings with complainants and all have resulted in a
satisfactory outcome for the complainant. We held six workshops with staff in a new training course
called ‘Valuing Frontline Feedback’ which encouraged staff to proactively value and seek out the
views of patients.
We have dealt with all complaints in a timely manner.
3.4 Commissioning for Quality and Innovation (CQUIN) Targets 2012/13
As a result of successfully achieving the following quality improvement targets, and which
complement our priorities for improving quality, we met our contract requirements in 2012/13.
Table 2: CQUIN Targets for the Community Contract
Target
End of life care/Reduction in Hospital
Deaths
(Experience)
Measure / rational
Through the joint whole system plan, we
successfully helped the local acute hospitals with
the delivery of their CQUIN for the reduction of inhospital deaths.
Within the community, of those patients who died
known to community nursing and who in addition
received additional care during the day/night from
our service, 91% achieved their preferred place of
care at home at the time of death.
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Dementia Screening/Dementia Risk
Assessment/Referral for Specialist
Diagnosis
Data collection and submission using the
Safety Thermometer Tool
VTE Risk Assessment
Early
supported
discharge
Feedback about the experience of care has
been extremely positive, with 98% of carers
indicating that care was well planned, co-ordinated
and met their needs.
Targets achieved
Target achieved and information used to review
and improve services
Target exceeded by year end
following
Target achieved
stroke
Community Heart Failure Pathway
Target achieved for personalised care plan,
management and drug dose Beta Blocker.
Drug dose ACE/ARB remained within 5% of target
at year end.
Baby Friendly Initiative
Level 1 / achieved
Surrey community services will continue to work in partnership with the CCG and acute hospitals
going forward in 2013/14 to support delivery of CQUIN targets.
In 2012/13 our community hospitals reported:
No breaches against admissions to single sex accommodation
No reported MRSA Bacteraemia
3.5 Comments by the Coordinating Clinical Commissioning Group
The draft quality account was submitted to the North West Surrey CCG at the end of May.
How to provide feedback on the account?
We welcome feedback on any aspect of our quality report. If you would like to send us your
comments, please email info@virgincare.co.uk putting ‘Quality Account Report’ in the subject line.
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APPENDIX 1
GLOSSARY OF TERMS
Term
Explanation
Care Quality Commission
The Care Quality Commission (CQC) replaced the Healthcare
Commission, Mental Health Act Commission and the Commission
for Social Care Inspection in April 2009. The CQC is the
independent regulator of health and social care in England. It
regulates health and adult social care services, whether provided by
the NHS, local authorities, private companies or voluntary
organisations. Visit: www.cqc.org.uk
Clinical audit is a quality improvement tool that compares current
care with evidence based practice, to identify areas that have the
potential to be improved, for consistently safe, clinically effective
care and positive service user experience.
Visit:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicatio
nsPolicyAndGuidance/DH_091443
Health services provided in the community, for example health
visiting, school nursing community nursing, special dental services,
physiotherapy, podiatry (foot care).
Healthcare includes all forms of healthcare provided for individuals,
whether relating to physical or mental health, and includes
procedures of medical or surgical care.
The National Institute for Health and Clinical Excellence is an
independent organisation responsible for providing national
guidance on promoting good health and preventing and treating ill
health. Visit: www.nice.org.uk
This is a new way of collecting user experience at the time of their
care. A green disc is given to the service user or their carer and
they have the opportunity to drop it into a series of boxes which
best reflects how they felt about the service. At the end of each day
the discs are added up and an overall score is given to that service
in a report.
Is the document which sets out the outcomes and indicators that
will be used to hold all providers of health care to account and
provides the financial planning and business rules that support the
delivery of NHS priorities.
These are self-reports from patients which tell us if they felt
satisfied in terms of treatment and services given
Clinical audit
Commissioning for Quality
and Innovation (CQUIN)
payment framework.
Community services
Healthcare
Institute for Health and
Clinical Excellence
Net Promoter Score
NHS Outcomes Framework
2012/13
Patient reported outcome
PALs
Patient advise and liaison service
Provide you with information about local health services –
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especially our services
Help solve problems with services quickly and informally
Advise you how to make a formal complaint if you want to
Pass on your suggestions for service improvement, and any
comments or compliments you may have
Virtual ward programme
The "virtual ward" programme provides multidisciplinary case
management services to people who have been identified, using a
predictive model, as high risk for future emergency hospitalisation.
Virtual wards use the systems, staffing, and daily routine of a
hospital ward to deliver preventive care to patients in their own
homes.
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