0. is a registered charity and expanding organisation providing a seamless service of integrated health and social care to help improve the health and wellbeing of people living in South Norfolk and North Suffolk. The Trust constantly evolves and develops existing services and introduces new ones. There are few parts of the country where such an integrated service as that provided from All Hallows is available: services ranging from daycare, homecare, medical assessment, nursing home care, palliative care, occupational therapy and physiotherapy, rehabilitation, respite care through to specialist long term care. Many communities wish to have what we have got, but they do not have the benefit of a foundation like All Hallows Healthcare Trust to provide it. where care counts…. 1. Our Values All Hallows Healthcare Trust is an independent charity, which aims to deliver quality and compassionate healthcare using skilled and dedicated staff. We value the unique contribution of each member of staff and aim to develop their full potential through a commitment to training and education. Our distinctive philosophy of care, based on Christian values, is reflected in our welcoming environment, understanding patients’ needs and beliefs and respect for the dignity of each individual. Our Mission To promote the relief of persons of either gender without regard to race or creed, while suffering from any terminal or life threatening illness, or from any disability or disease, attributable to old age, or from any other physical or mental infirmity, disability or disease . We place patients’ clients and carers at the centre of what we do and with their consent. Our Aims To provide a seamless service of integrated health and social care for the local population within the ethos of All Hallows Healthcare Trust. To provide facilities and services of the highest quality and best value for money . 2. Contents Page Part 1: Our Commitment to Quality 1.1 1.2 1.3 1.4 1.5 1.6 Statement of Assurance from the Chairman Statement on Quality, a foreword from the Chief Executive Statement from our Matrons Statement from our Head of Therapies Statement from our Head of Homecare Introduction to All Healthcare Trust 4 5 6 7 7-8 8-18 Part 2: Our Priorities for Quality Improvement 2013-2014 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Review of Services Quality Overview Priorities for achievement in 2014-2015 Statement of Assurance from the Board Participation in Clinical Audits Participation in Clinical Research Goals agreed with Commissioners - use of the CQUIN Framework What others say about All Hallows Healthcare Trust Data Quality (Including Information Governance & Clinical Coding) 19 19 20-23 23 23-24 24 24-25 25-30 31 Part 3: Review of Quality Performance 3.1 3.2 3.3 3.4 Achievement of priorities for improvement 2012-2013 Reporting on our top 10 Clinical Governance at All Hallows Healthcare Trust Comments 3. 31-33 33-40 40-42 43-45 Part 1: Our Commitment to Quality: Our Assurance to you 1.1 Statement of Assurance from the Chairman This year we received an award from the Community Hospitals Association for Innovations and Best Practice for our Out of Hospital Care programme. The Association said “the standard of submissions was very high and you have shown excellence”. We recognise the importance of understanding patients’ needs and reflecting these in our values and goals. This Quality Account allows us to: demonstrate our commitment to continuous, evidence-based quality improvement draw your attention to the standards achieved and the progress we have made; and describe the approach we intend to continue improving our services to patients. It enables you to assess the quality of our performance across the healthcare services we offer. For the future, the Trustees will be working closely with our Clinical Commissioning Groups and local GPs to expand upon developing more integrated health and social care services. I am proud to include excellent reviews from the patients and carers using the services and from the Care Quality Commission. I’m equally proud of the care and professionalism of All Hallows’ staff that produce the results that people are so consistently positive about. We say care counts and mean it. Our patients want and deserve excellent clinical care delivered with dignity, compassion and professionalism and these remain our key quality goals. John Chapman Chairman 4. 1.2 Statement on Quality, a foreword from the Chief Executive I am pleased to present our annual Quality Account which demonstrates our continued commitment to delivering high quality patient care. We continually strive to improve the quality and practice of our services, to deliver high standards of care and to safeguard our patients/service users. This report assures our patients/service users and purchasers of care that our services are safe, appropriate and effective, but additionally highlights the excellent quality improvement initiatives undertaken by staff which are monitored through Clinical Audits and monthly Key Performance Indicators (KPIs) Clinical Audit is a process to improve patient care through the regular review of care against clear standards and the implementation of change. Monthly Key Performance Indicators (KPIs) are undertaken to review / monitor clinical quality indicators, and all staff are involved in collecting evidence, such as length of stay, clinical incidents, drug errors, infections, pressure areas, complaints and compliments. Internal and External Mechanisms for Achieving Quality To the best of my knowledge, the information reported in this quality account is accurate and a fair representation of the quality of healthcare services provided by All Hallows Healthcare Trust. Howard Green Chief Executive 5. 1.3 Statement from our Matrons As the Matron of the All Hallows Hospital, along with my dedicated team, we work to ensure patients are given a high quality of care, adopting a holistic and person-centred approach and ensure they are cared for in a safe environment. The hospital continues to care for patients for rehabilitation, post-acute care including bariatric, general, and palliative and end of life care funded by NHS Norfolk and Great Yarmouth and Waveney. Patients are also admitted with long term complex care funded by continuing health care. Quality is monitored continually through patient satisfaction questionnaires, audits, management of incidents and complaints, risk assessments, reviews of key performance indicators, and formal reports to the Commissioners and the Board. Nursing assistants continue to complete QCF level 2&3 (Formally NVQ). Policies and procedures are reviewed regularly. An annual training plan continues and opportunities are available for staff to undertake specific training relevant to their needs to enhance patient care. Training needs are identified at staff appraisals and meetings, to ensure we provide good quality, evidenced based care to our patients. UEA students continue to undertake placements at All Hallows Hospital with positive feedback. Denise Hubbard Matron, All Hallows Hospital All Hallows Nursing Home has undergone a general upgrade in 2013/2014 including nurses’ stations, residents’ rooms, and corridors. A new physiotherapy room was opening in the home for the residents. In November we had a unannounced CQC inspection and we continue to remain compliant with the outcomes. In 2012 we were reaccredited by the Gold Standard Framework for further 3 years. We constantly review, monitor the clinical procedures, carry out monthly audits to help us improve our quality of care in areas where we feel is necessary and that are highlighted by our auditing. Cristiana Predoi Matron, All Hallows Nursing Home 6. 1.4 Statement from our Head of Therapies The Physiotherapy Service aims to provide high quality Inpatient and outpatient care for patients with Musculoskeletal Problem (Conditions involving muscles, bones and joint) within the community setting. The physiotherapy Department strives to offer a comprehensive individualised patient focused care that is evidenced based. We as a team succeeded in managing every patient with dignity, courtesy and with individualised case management and would remain to do so. Patients are empowered to be more in control of their treatment. We aim to ensure the service is easily accessible to patients for treatment by extending the working hours to six days a week. This year, at the Nursing Home, we managed to establish a physiotherapy treatment room for the nursing home patients. It is been proved working magnificently well. As part of the Clinical Effectiveness, every year we review the efficacy of treatment and gather information about experience via audit, PROMS (Patient Reported Outcome Measures) eg. EQ-5D5L & Quick DASH and patient feedback. Information received via PREMS (Patient Reported Experience Measures), audit and Patient Stories indicate that the patients are provided with a high level of care, at a place convenient to them, are treated well, have their therapy well explained and feel engaged and involved in their care and they were very well satisfied with the service. 97% of our patient group suggested that they would recommend our service to their friends and family. As a team this is the greatest achievement and we would like to continue this high standard of care to all our patients. Let me quote one of our patients comment “I believe All Hallows is a great asset to the local community, long may it continue.” Shilu John Head of Therapies 1.5 Statement from our Homecare Manager The Home Care team pride ourselves in delivering a quality service, tailored to every client’s individual needs. We aim to ensure everyone receives the highest standard of care, without compromise, in the comfort of their own homes. Our dedicated team of carers and staff provide support every step of the way, from an initial enquiry through to the delivery of care. We also provide the much needed support for relatives and families, testimony to this is the comments and compliments we regularly receive. We put effort into induction and training of new staff into the quality 7. standards we expect. As head of the department I am now a community QCF assessor and within the team we have 2 community trainers, each covering their own patch to ensure the induction and training process is consistently delivered to new staff. Quality standards are continually being reinforced by us throughout the team. The positive feedback we continue to receive is testament to the services we offer clients and professionals. Myself and the team maintain this thriving department and continue to build on our good rapports and contacts with service providers. Mandy Hart Homecare Manager 1.6 Introduction to All Hallows Healthcare Trust Our Objectives To provide a seamless service of integrated health and social care for the local population within the ethos of All Hallows Healthcare Trust. To provide facilities and services of the highest quality and best value for money. Our Services We are an expanding organisation (Registered Charity No. 1124717) offering a wide range of quality healthcare services with priority for residents of Norfolk & Suffolk. We have two main locations, All Hallows Hospital situated in Ditchingham, South Norfolk, with the Daycare Centre, situated in its grounds and All Hallows Nursing Home in Bungay Suffolk. (about 2.5 miles from the Hospital). Both locations are registered separately with CQC. Current Services provided by the Trust are: Daycare (for adults) Homecare Medical Assessment Nursing Home care Palliative care Physiotherapy / Occupational Therapy Rehabilitation Respite care) Specialised Care Home (for people with physical and sensory disabilities 8. The Trust provides, under contract, a number of bed based and therapeutic services for the National Health Service and has a range of short to medium term, intermediate care and preventative services that aid faster recovery from illness, prevent unnecessary acute hospital admission and support timely discharge. We concentrate on needs based care for people whatever their circumstance: offering people what they need not what we think they need. 9. A seamless care approach that works locally to support patients at home and in the community 10. A closer look at the full range of services available from All Hallows Healthcare Trust: All Hallows Hospital All Hallows is a focal point for healthcare in our locality, and the hospital has 30 in-patient beds Inpatient Services include: Post-acute, e.g. post-operative rehabilitation, orthopaedic patients and stroke patients Palliative / End of life HIV Long term care to individuals with a physical or sensory disability GP assessment Individuals with complex needs Private respite care 11 beds are commissioned with NHS South Norfolk (CCG) and NHS Great Yarmouth and Waveney CCG. The Hospital accepts patients from James Paget University Hospital, Norfolk and Norwich University Hospital, GPs and other health professionals within the area. If a patient wishes to be referred to All Hallows they can express their choice to their doctor, consultant or nurse. Private beds are also available for patients wishing to self-fund and beds are available through NHS Continuing Care arrangements. Currently 8 residents are funded through NHS Continuing Healthcare “When I came I wasn’t eating and losing weight – the kitchen staff took great care and got me eating again (tempting me with Scampi & chips). I would like to thank each one personally – but can’t, so thank you all so much”. Did you know…we have a full range of Bariatric equipment and can accommodate larger clients. 11. All Hallows Physiotherapy Department The Physiotherapy department provides a comprehensive range of diagnostic and rehabilitative physiotherapy in outpatients and inpatients and the Nursing Home. It also provides a palliative care service to St. Elizabeth’s Hospice. We address the physical, psychological, emotional, and social well-being of patients. We are strongly committed to patient focused care, addressing their individual needs. Through health promotion, preventive healthcare, treatment, and rehabilitation we help people and their families and carers to aid the individual to reach their full potential following injury, illness or surgery. Our expert team adhere to the guidelines of the Health Care Professions Council and the Chartered Society of Physiotherapy. We follow best practice in clinical governance and ensure that we keep abreast of the latest evidence based practice. The team continuously monitor and improve the quality of our services to safeguard a high standard of treatment. The service is run by 5 highly skilled Physio-therapists who are State registered and members of the Chartered Society of Physiotherapy and 4 Assistant Physiotherapists. The Physiotherapists may use a combination of manual therapy (mobilisation & manipulation), exercise therapy, electrotherapy (ultrasound, interferential, TENS), moist hot packs and cryotherapy (ice application) for treatment in accordance with the patient’s needs. Acupuncture treatment can also be provided for musculoskeletal conditions. The MSK (Musculoskeletal; involves Muscle, Bone and Joint);) Physiotherapy Service aim to provide Outpatient care for patients with; Neck and shoulder pain including whiplash Back pain Upper and lower limb problems; shoulder, elbow, wrist, hand, pelvis, hip, Knee, Ankle and Foot Post-surgical Rehabilitation, e.g. Joint Replacement, Arthroscopy and Revision Traumatic injuries Arthritis and other degenerative conditions Sports injuries Pre and postnatal problems ( Women’s Health) 12. The department also provide rehabilitation for hospital, nursing home and palliative care patients of the Trust for the following conditions: Respiratory conditions Complex pain syndromes Reduced exercise tolerance Musculoskeletal impairment Neurological impairment Lymphoedema We strive to offer a comprehensive individualised patient focused care that is evidenced based. Every patient is managed with dignity, courtesy, with individualised case management. Initial Assessment appointments are 45 -60 mins and the follow up appointments are 30 min. We aim to ensure the service is easily accessible to patients by offering flexible time for their appointments. During the working days we are open from 8:00am - 18:30 and on Saturday we are open from 8:30am – 16:00pm. The department services are commissioned by NHS Great Yarmouth & Waveney CCG. Patients can be referred to us by their GP (we are on Choose & Book) or they can self-refer by completing our self-referral form. Department also has private patient from other area. The MSK services have a structured audit cycle to review documentation, Health and Safety, Infection Control and audit service outcome measure using condition specific and standardised outcome measures i.e. The Quick DASH (Upper limb) and EQ – 5D – 5L as PROM( Patient reported Outcome Measures). As a Department we also do half yearly Patient Reported Experience Measures (PREMS) by sending questionnaire randomly to discharged patients. Information received via PREMS, audit and Patient Stories indicate that the patients are provided with a high level of care, at a place convenient to them, are treated well, have their therapy well explained and feel engaged and involved in their care. “Excellent treatment I received was effective, pleasant and by continuing the recommended regime has 90% cured the problem. I am well satisfied!” 13. Occupational Therapy The Occupational Therapy department ensures that patients receive an appropriate level of Occupational Therapy to maximise functional ability and independence and facilitate a safe, prompt and effective discharge home. When a patient is admitted to the hospital and is first seen by our GP, it will be decided whether referral to Occupational Therapy is appropriate. If a referral is made the Occupational Therapist (OT) will aim to carry out an initial assessment within 3 working days of admission, with the patient’s consent. Following this assessment, the OT or assistant may require to assess the patient’s home. Arrangements will be made to either take the patient in the OT’s car to visit the home, or for the OT to visit the home in the presence of a relative. The OT will discuss the outcome of the assessment with the patient and a report will be sent to the GP and if appropriate, the Social Worker. The OT will arrange provision of all necessary equipment/adaptation as provided by social services free of charge. The OT can advise on any extra equipment that the patient may wish to purchase independently. The OT works closely with the other members of the hospital team; nurses, physiotherapist, doctor and social worker, as well as services in the community, to devise a treatment programme to increase functional ability and independence and maximise the potential of each patient. The OT will determine that the patient has reached their optimum level of rehabilitation with regard to managing personal care, independence in activities of daily living and mobility and whether the patient will require a package of care. The OT/OTA (Occupational Therapy Assistant) will liaise with the patient and their relatives/carer concerning the home situation. They will consider the preferences and quality of life of each and try to facilitate a plan for discharge which is agreed by all concerned. The OT aims to provide a holistic service to the patient which can involve liaising with family, charities, local authorities etc. to obtain specialist equipment or adaptations for the home and to support patient, family and carers in what is sometimes a stressful time in their lives. The All Hallows Occupational Therapy team is currently only able to care for NHS Great Yarmouth and Waveney inpatients. An external OT visits NHS Norfolk inpatients and provides a very similar service. 14. All Hallows Nursing Home All Hallows Nursing Home is registered to provide 24 hour Nursing Care to 51 residents who require such care by reason of old age and physical disability: it accepts residents from the private sector, Social Services and the National Health Service. We Provide Warm friendly atmosphere A high standard of professional nursing care Long and short stays including respite and postoperative convalescent care Single rooms with en-suite facilities Freshly prepared home cooking Minibus for outings Activities and entertainment programmes Open visiting A multi-denominational chapel on-site Physiotherapy treatment room on-site CQC Registered 3 beds are commissioned with NHS South Norfolk Clinical Commissioning Group (CCG) for postoperative convalescent care (and 3 additional beds are spot purchased). Currently 8 residents are funded through NHS Continuing Healthcare and other beds are funded through Social Services or the resident themselves. “Thank you for looking after Mum. She commented quite often on how enjoyable and peaceful her residence was, considered it her home with Friends around her. We believe we selected the best Home in the area for the care and attention she received. “ Staff education continues with palliative care being part of the mandatory training for all staff. Staff have also undertaken updates such as seminars and training sessions on Palliative Care Pain & Symptom Control/Loss & Bereavement, Communication and Palliative Care Conferences. We have a designated link nurse who attends regular updates. 15. Daycare Day Care provides a range of services designed to deliver social stimulus and a broad base of care that supports care in the community. Daycare helps to improve people’s general well-being; it assists with maintaining skills and independence, and provides an opportunity for people to learn new skills and gives mental and physical stimulation. Essentially it is a great way to meet people, take part in a wide range of activities and is very well equipped with aids for less able and dependent individuals. Services Bathing facilities Tea & Coffee, 3 course lunches with a choice of hot and cold dishes and special diets are catered for. A wide range of therapeutic activities to encourage both physical and mental stimulation Palliative Daycare Daycare is equally beneficial to family members who provide care at home, enabling them to enjoy a well-deserved break. Day opportunities as requested A Hairdresser visits the Centre regularly offering their expert services at a nominal charge Daycare will help individuals to remain living in their own homes with guidance and support in finding appropriate help It has a purposely adapted minibus to transport local people to and from home (subject to availability) and alternative transport can also be arranged if required. A range of activities along with good company and home cooked meals creates a great experience for all. This service does not have any contracts with the NHS and is funded through Social Services or the resident themselves. “I love the company and having people to talk to. I enjoy the entertainment and the meals wonderful.” 16. Homecare Homecare specialises in Needs Based Care for people living at home. The team aim to ensure that each client receives the highest standard of care, and to assist them to live as independently as possible, whilst recognising personal freedom of choice and promote dignity, self-respect, independence and privacy. They consider their clients’ needs and what they would like to achieve from their assistance and then work to deliver the level of support that's right for them. If their needs change, the care adapts. Services Deciding to have Homecare can help people to retain their independence in their own home and is equally beneficial to family members who provide care at home, enabling them to enjoy a welldeserved break for the evening or a week. The Homecare Team is contactable 24 hours per day 365 days per year. Outside office hours all calls are diverted to our dedicated on call team, so you will always be safe in the knowledge of a response whatever time of day. Personal Care Full wash, shower, bath and shave Getting in and out of bed Dressing Day or night sitting Companionship, having someone to talk to Emergency assistance Home Call Services Housework/domestic tasks Laundry and ironing Shopping with or without the client Meal preparation Meals on Wheels This service is for people aged 18 and over, normally older people, who are unable to prepare and cook one hot meal a day. This may be a permanent situation due to sight loss, a physical or learning disability, illness or a temporary situation such as recovering after a stay in hospital or a partner has to go to hospital or away visiting relatives and the meals can help to make the situation easier. The 17. service is available 7 days per week and people can choose to have the meals as little or as often as they like. All produce is locally sourced, freshly prepared and cooked in the kitchens at All Hallows Hospital. Befriending Services Befrienders offer friendship and company on a supportive basis. What they do depends on the needs of the client; they provide the opportunity to have a cup of tea and a chat or play Scrabble and do a crossword. They may join sports activities, such as taking someone out and playing a round of golf. Go shopping, to a garden centre, or just sit and listen. The good thing about this service is that we can provide exactly what the client needs. It is also ideal for family carers to give them a break, either for a few hours in the evening or even a week. Everyone needs other people, but not everyone has someone. For people who become isolated because of poor health, disability or social disadvantage, a Befriender can fill a big gap. Tailor made Homecare Service If you require a service not listed it does not necessarily mean the team cannot help. Care packages can be arranged on either a short term or long term basis, offering flexibility. This service has a small number of NHS clients commissioned by NHS South Norfolk and NHS Great Yarmouth and Waveney CCG. (A registered nurse based at the Hospital is involved with these clients). Other clients are either self-funded or funded through Social Services. “Peace of mind knowing they will be here every morning to help me” 18. Part 2: Our priorities for Quality Improvement (2014/2015) 2.1 Review of Services – Scope of NHS During 2013-2014 All Hallows Healthcare Trust provided 4 principal NHS services on behalf of commissioners: Inpatients beds at two locations, Continuing Healthcare in the community and in/out patient Physiotherapy. For the purposes of the Quality Account All Hallows has reviewed all the data available to them on the quality of care in these NHS services. The income generated by the NHS services reviewed in 2013-2014 represents 51.5 % of the total income generated by All Hallows Healthcare Trust. 2.2 Quality Overview In 2013/2014 All Hallows Healthcare Trust cared for 170 NHS patients and their families within All Hallows Hospital (25 long stay, 65 Norfolk, 78 Gt Yarmouth & Waveney & 2 Suffolk). In 2013/2014 All Hallows Healthcare Trust cared for 95 NHS patients and their families within All Hallows Nursing Home. (16 long stay -continuing healthcare funded) 77 Norfolk & 2 Gt Yarmouth & Waveney). In 2013/2014 All Hallows Healthcare Trust cared for 38 NHS continuing care patients within their own homes. (2 Norfolk & 36 Gt Yarmouth & Waveney). In 2013/2014 a total of 6192 NHS patient attendances were seen by the All Hallows Physiotherapy Department. (The department saw an additional 2386 inpatients from All Hallows Hospital and All Hallows nursing Home). 19. 2.3 Our Priorities for Achievement in 2014-2015 The areas we have chosen as our quality improvement targets for 2014-2015 . Patient Safety Priority 1: To implement and follow a procedure for collectively looking at data on patients who developed pressure sores in both the Hospital and Nursing home. To analyse which area of the body sores developed, which mattress type is used, does turning the patient have any effect and consider other factors such as age, diagnosis and morbidity. How was this priory decided: We would like to reduce the amount of patients/residents that develop pressure sores whilst in our care. How will the priority be achieved: Our Matron at the Hospital has been appointed to implement this for the Hospital and the Nursing Home. How progress will be monitored and recorded: Further questions will be added to the monthly KPI’s and a further analysis will be made at our Clinical Governance Group. Relevant action will be taken and implemented, incorporating a new policy and procedure for pressure sores. _________________________________________________________________________________ Priority 2: To record more information about patient / resident falls looking at the time, location, staffing skills available at any particular time and diagnosis. To analyse the data to see if the amount of falls can be reduced across the Trust. How was this priory decided: We would like to reduce the amount of patients’ residents and staff that fall/trip whist on the premises. How will the priority be achieved: Our Matron at the Hospital, along with the Estates Manager working across the Trust has been appointed to implement this. How progress will be monitored and recorded: Further questions will be added to the reporting falls procedure and a further analysis will be made at our Clinical Governance Group. Relevant action will be taken, current risk assessments will be considered and any changes implemented, incorporating a new policy and procedure for assessing and reducing the risks of falls. _________________________________________________________________________________ Priority 3: To improve communication between All Hallows staff and St. Elizabeth Hospice specialist palliative care team. How was this priory decided: Poor feedback was received from patients (and their families) receiving specialist palliative care within the Hospital. We want to ensure a continuous high standard of care is received. How will the priority be achieved: We hope to achieve this by reviewing the rotas to ensure the specialist team have an opportunity to liaise directly with each shift change, allowing time for discussion. Any training need in specialist palliative care would be identified and addressed as required, this will enhance continuity of care for the patient. How progress will be monitored and recorded: Staff meetings / group discussions, patient satisfaction surveys, and feedback from the St. Elizabeth specialist palliative care team. 20. Patient Experience Priority 1: To help patients understand their condition and how to manage it. How was this priory decided: After seeing patients regularly the Physiotherapy team recognised that patients didn’t fully understand their condition. How will the priority be achieved: Through producing information leaflets for various musculoskeletal and orthopaedic conditions and using the provision of treatment protocols such as Physio Tech including website links, downloads and short videos. How progress will be monitored and recorded: Using the Subjective, Objective, Assessment Protocol used by professionals each time a patient is seen looking at pre, during and post physiotherapy care. A section will be added to the existing patient questionnaires and the outcomes recorded. _________________________________________________________________________________ Priority 2: To create two additional private Physiotherapy treatment rooms and a new waiting area. How was this priory decided: The feedback from Patient questionnaires about the waiting area was poor, cold and nowhere to get a drink. The Physiotherapy team also raised concerns at team meetings about patient privacy. Only curtains separate treatment areas. How will the priority be achieved: A plan has already been produced. The current gym area in the department is big enough to erect internal walls creating two private rooms and a waiting area. The curtain treatment areas will be removed created a nice space for a gym. There are also plans to install a drinks machine in the new waiting area and a television in the new gym. How progress will be monitored and recorded: Patients feedback and patient questionnaires will continue and will be reviewed monthly. _________________________________________________________________________________ Priority 3 To enable Hospital and Nursing Home rehabilitation patients to receive social stimulation as part of their care package. How was this priory decided: This need was identified at Nursing Team meetings, the nursing team feel this would promote independence, give interaction with other people and enable recovery quicker than just sitting within the ward environment alone. How will the priority be achieved: Patients would attend the Daycare Centre situated in the grounds of the Hospital, twice weekly and personal care needs would be met by Daycare staff (they are all trained). This will aid transition between inpatient and returning to home or other domiciliary settings. A leaflet will be produced to inform patients and their families about this service and the range of activities that will be available to them. How progress will be monitored and recorded: Monitoring effective outcomes will be by discussion with patients, patient satisfaction surveys and discharge times. This would be assessed on an individual basis and would be optional. Clinical Effectiveness of Care Priority 1: To create a ‘Physiotherapy Triage Clinic’ not via the telephone but by actually seeing patients which in turn will effectively scrutinise the self-referral system for better management of patient care. How was this priority decided: Looking at data and through Physiotherapy team meetings it was noted that some patients return frequently. 21. How will the priority be achieved: A senior Physiotherapist will take on this clinic and look at treatment protocols, give advice (refer to priority 1 under patient experience), proceed with Physiotherapy treatment or suggest secondary care. How progress will be monitored and recorded: Patients feedback and patient questionnaires will continue and will be reviewed monthly. _________________________________________________________________________________ Priorty 2: To ensure a constant and equitable high standard of care is received across the Trust we will review and aline our policies and procedures. Reshaping our contract bid team across the Trust to ensure corporately sound and clinically robust tender responses are prepared for submission to commissioners. How was this priory decided: It was noted that the Hospital and Nursing Home have slightly different ways of working. The number of staff working across different sites has increased therefore the need for a consistent approach was identified. How will the priority be achieved: The PA to the Chief Executive has been appointed to deal with a complete review of all policies and procedures working closely with all heads of department, the training department and the Clinical Governance Group. How progress will be monitored and recorded: Staff questionnaires and staff appraisals will continue. Our New Services manager leading our contract bidding team should notice a significant improvement with responses for tenders. This will be evaluated at both team meetings and board meetings. _________________________________________________________________________________ Priority 3: Review length of stay for patients in our care (including case conferences where appropriate) and developing a discharge co-ordinator nurse post to facilitate movement of patients through the health and social care system. How was this priority decided: NHS commissioners are keen to ensure that patients are treated ‘closer to home’, thereby minimising lengths of stay in inappropriate locations and by developing patient pathways that facilitate swifter return to their communities. This will enable commissioners to minimise the costs of excessive bed occupancy. Our range of service provision across the health and personal/social care spectrum makes us ideally placed to assist in this. How will the priority be achieved: Those patients requiring rehabilitation will receive support through ‘beds with associated care’ packages, which include daycare, homecare and/or therapeutic care whilst in a community bed or immediately after discharge in order to facilitate that discharge. Elements of this programme can be applied to patients who either have a spell within the hospital or nursing home or directly discharged from the acute sector. Application of this service directly through the Trust can enable quicker transfer to and support in the home environment whilst other services (e.g. social services) are arranged to be put in place. To facilitate this movement of patients, the Trust will employ a senior clinical discharge co-ordinator to monitor patient progression and liaise with all associated agencies to facilitate discharge. Those patients potentially reaching a length of stay in a community bed beyond that which may be considered necessary for a medically fit person, will have a ‘case conference’ instigated for their benefit and facilitated by the Trust to ensure that services are in place. The Trust can therefore put in its own day/home/therapeutic care, as appropriate. Commissioners will then be able to purchase these packages of care rather than discreet ‘bed days’ or ‘hours of domiciliary care’, thereby creating a care pathway and cutting down the bureaucracy of separately arranged and individual written agreements. 22. How progress will be monitored: We will further analyse current lengths of stay in a hospital bed for those patients otherwise ‘medically fit’ to determine a ‘trim point’ beyond which occupation of a bed is deleterious to patient well-being; Understand the ‘pinch points’ inhibiting appropriate discharge; Monitoring the incidence of use of ‘beds with associated care’ packages; Monitoring the frequency of necessity for ‘case conferences’. _________________________________________________________________________________ We also plan to review our visiting times to assist in-patient recovery and rest to allow nursing interventions to take place undisturbed. 2.4 Statement of Assurance from the Board For us, there’s nothing more important than patient safety and being assured that quality and care are at the heart of every encounter between our staff and those they care for. To do this we focus on the “Checking Standards Are Delivered” box in the image towards the front of this report. We regularly receive full and detailed reports on all aspects of quality as measured in audits, patient satisfaction questionnaires, key performance indicators (KPIs), and compliments and complaints and Commissioning for Quality and Innovation (CQUIN) payments. To strengthen the framework, we are currently conducting a fundamental review of all our policies and procedures to rationalise them and ensure they are up to date and reflect all recent changes in legislation. We are also rationalising the way our many KPIs are gathered and responded to, to make this exercise as efficient as possible and to maximize our response to them for the good of the patient. Our Chairman John Chapman said “At a practical, but equally important level, the Trustees are investing time and energy in the building of closer working relationships with the staff and improved understanding of the day to day challenges involved in meeting the standards we expect.” Board of Trustees 2.5 Participation in Clinical Audits The Trust participated in the 2013/2014 NHS National Audit of Intermediate Care Survey (National Bed Audit): there were no other national clinical audits and national confidential enquiries that All Hallows Healthcare Trust was eligible to participate in during 2013/2014. Local audits All Hallows Healthcare Trust did take part in during 2013/2014 are included below. We also followed and completed the Blue Cross Audit, Information Governance Toolkit, have regular medication audits, regular care plan audits and record keeping audits. 23. All Hallows Healthcare Trust will continue to take part in audits during 2014/2015 and will include the following: Quality Improvement- care plans, medications, Gold Standard Framework, and nutrition survey. Patient Safety- Out of hours calls, pressure areas, medication errors, near misses/incidents/accidents, hand hygiene and annual infection control (external). Health & Safety Management-Staff accidents, sharps injuries and health and safety risk assessments. In order to ensure provision of high quality Physiotherapy Service, we will continue issuing a patient satisfactory survey every 6 months, distributing questionnaires to a sample of 100 patients who have received treatment from the Trust. Patient feedback will be encouraged and questionnaires will continue to be issued, recorded and acted upon. 2.6 Participation in Clinical research There were no patients receiving NHS services provided or subcontracted by All Hallows Healthcare Trust in 2013-2014 recruited to participate in research approved by a research ethics committee. There has not been any national research projects in which our patients or the Trust were asked to participate. 2.7 Goals agreed with Commissioners, following commissioning for Quality and Innovation (CQUIN) principles. A proportion of All Hallows Healthcare Trust income in 2013-2014 was conditional on achieving quality improvement and innovation goals agreed between All Hallows Healthcare Trust and the local commissioning bodies for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. The CQUIN Scheme Indicators for 2013/2014 for both Great Yarmouth & Waveney CCG and South Norfolk CCG (worth 2.5% of contract value) are listed below and are all under the quality domain Patient Safety. The agreed goals for NHS South Norfolk CCG for 2013/2014 are: 1. NHS Safety Thermometer – To reduce harm. The power of the NHS Safety Thermometer lies in allowing frontline teams to measure how safe their services are and to deliver improvement locally. 2. Pressure Ulcer Care – Reduce incidence of grade 2, 3 & 4 pressure ulcers. 3. Dementia – Clinical Leadership – named lead clinician for dementia and appropriate training for staff 4. Dignity Champions – identify dignity champions and appropriate training for staff 24. The agreed goals for NHS Great Yarmouth and Waveney CCG for 2013/2014 are: NHS Safety Thermometer – Reduction in the prevalence of pressure ulcers – 25% Dementia – The proportion of patients aged 75 and over to whom case finding is applied following emergency admission the proportion of those identified as potentially having dementia who are appropriately assessed and the number referred on to specialist services 10% Dementia – Clinical Leadership – named lead clinician for dementia and appropriate training for staff – 5% Dementia – supporting Carers of People with Dementia – Ensuring carers feel supported – 10% Developing best practice admission and discharge processes to reduce delayed transfers of care and excess bed days - 25% Review of Physiotherapy outcomes 25%. Outcomes are monitored quarterly using the MYMOP2 and visual analogue scale and will be reported bi-annually. Family and friends surveys (We as a Trust added this). The outcome: “All HealthEast CQUIN targets for 2013/2014 were achieved” The agreed goal for NHS Great Yarmouth and Waveney CCG for 2014/2015 is the reduction of delayed transfers of care. 2.8 What others say about All Hallows Healthcare Trust Statements from the Care Quality Commission (CQC) All Hallows Hospital is required to register with the Care Quality Commission and is regulated for the following activities: Hospital, Hospice, Rehabilitation (illness or injury) Accommodation for persons who require nursing or personal care, Diagnostic and/or screening services, Eating disorders, Nursing care, Personal care, Physical disabilities, Sensory impairments, Treatment of disease, disorder or injury, Caring for adults under 65 yrs, Caring for adults over 65 yrs. (This includes Physiotherapy and Continuing Healthcare.) The Care Quality Commission did not have cause to take enforcement action against All Hallows Healthcare Trust during the period April 2013-March 2014. On 7th March 2014 the CQC carried out an unannounced inspection. The inspection included: Care and welfare of people who use services Supporting workers All Hallows Hospital was found to be compliant with both of the Outcomes. Summary of their report: “We carried out this inspection in response to concerns that were raised with us anonymously. We were told that people were not cared for properly and that staff were not supported in their work. We spoke with four people who used the service and one person’s relative. We observed how staff worked with people and spoke with four members of staff, the acting matron, the operational 25. administrator and the interim chief executive. There had recently been changes to the senior staff at the service after a period of uncertainty. The long term matron, who was also the registered manager, resigned in August 2013 and since then there had been a number of matrons appointed who had not remained in post. There were also disciplinary issues that resulted in staff leaving the service. People told us that they received a good service. One person told us, “I have been cared for well.” Another person told us that staff, “… always help me if I need it.” We saw that care and treatment was delivered in a way that was intended to ensure people's safety and welfare. We found that staff had not been supported properly through supervision since the changes to management, but that since the appointment of the acting matron the staff we spoke with told us that they felt that things were improving. One staff member said, “It has been a difficult time, but things are getting better now.” All of the staff said that they received training essential for caring for the people they supported.” 17th September 2013 the CQC carried out a review as part of their routine schedule of planned reviews. The inspection included: Care and welfare of people who use services Safeguarding people who use services from abuse Requirements relating to workers Supporting workers Assessing and monitoring the quality of service provision Complaints All Hallows Hospital was found to be compliant with all of the Outcomes; they stated: Care Quality Commission – good standards maintained. Summary of their report: “This inspection was conducted in respect of the home care service run by the provider, All Hallows Healthcare Trust. During this inspection, we spoke with five people who used the service, five relatives of people who used the service, three staff members and the manager of the service. The people we spoke with were happy with the care they received from the service. One person told us, “They are great, I couldn’t manage without them, they provide you with anything you need.” Another person said, “You just have to ask if you want any help and they will help.” A further person said, “I am very thankful for the service.” One relative told us, “The staff have gone beyond what we would expect.” A further relative told us, “I am jolly glad that they are there, nothing is too much trouble.” We saw that people had received an assessment of their needs before they started using the service. The care was planned and delivered in line with their individual care record. People told us that they felt safe when staff were providing care within their homes. We saw that the service had taken the appropriate steps to ensure that people who used the service were protected from the risk of abuse. The required recruitments checks were being undertaken by the service before staff commenced their employment. The staff told us that they felt well supported and trained. We saw that a variety of training was available to the staff to ensure that they had the necessary skills and experience to provide care safely. The service regularly assessed the quality of the care they provided and responded to any complaints or concerns that were made.” 26. All Hallows Nursing Home is required to register with the Care Quality Commission and is regulated for the following activities: Care home with nursing, Rehabilitation (illness or injury) Accommodation for persons who require nursing or personal care, Diagnostic and/or screening services, Physical disabilities, Sensory impairments, Treatment of disease, disorder or injury, Caring for adults under 65 yrs, Caring for adults over 65 yrs The Care Quality Commission did not have cause to take enforcement action against All Hallows Nursing Home during the period April 2013-March 2014. On 22nd November 2013 the CQC carried out a review as part of their routine schedule of planned reviews. The inspection included: Care and welfare of people who use services Cooperating with other providers Requirements relating to workers Records All Hallows Nursing Home was found to be compliant with all of the Outcomes; they stated: Care Quality Commission – good standards maintained. Summary of latest Care Quality Commission report for All Hallows Nursing Home “Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We spoke with four people and they were generally pleased with the service they received. One person told us, “I’m well looked after. It is very nice and I like being here.” Another person described the service as, “Very good, but no one’s got time to just chat so it’s rather lonely.” People’s health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others. People were cared for, and supported by, suitably qualified, skilled and experienced staff. There were effective recruitment and selection processes in place with appropriate checks undertaken before new staff took up their appointments. People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. However, insufficient action had been taken to ensure that personal notes were securely held, posing a threat to people's privacy. The service undertook to tackle this issue immediately. Records and checks relating to the management of the service helped ensure that a safe environment was maintained.” We have recruited more volunteers at the Nursing Home to chat to our patients and residents, make a jigsaw, or play a game with them, whatever is reasonably requested. Volunteers have, and continue to help us fill this gap. The long term care unit within the Hospital and Daycare centre also have a group of volunteers that provide social interaction. In the Hospital they make afternoon and evening drinks and take the tuck shop trolley around. We are truly grateful for the time that all our volunteers give us, they really are the icing on the cake and hope to continue to recruit more in the year. 27. What our physiotherapy patients say The department patient questionnaire focus was over 4 distinct areas; Dignity & respect, communication, care & treatment, administration & location. Overall the results were very pleasing showing a minimum of 80% of patients either agree or strongly agree. Under administration & location the results did highlight that patients travelling from Lowestoft frequently requested a drink after travelling, and under care & treatment the results identified a need to better inform and educate patients about their condition, how to manage it and about exercises to assist them. Following the questionnaire results two priorities for achievement in 20142015 were identified under patient experience, see page 21. Other questions included were: Quality of Life Improved 4% 6% 16% Yes No Unanswered 74% Level of Satisfaction 5 1% 2% 2% 1% 12% 6 7% 7 8 75% 9 10 28. N/A Patient and Carer Comments Physiotherapy “I have had excellent treatment at All Hallows – thank you. The physiotherapist was courteous, friendly, so helpful and very kind.” “Louise was excellent and as I am rarely ill found it all very reassuring.” “All good! Thank you. Appreciated weekend appointments for workers” “All round good experience.” “The treatment by Val Johnson was first class.” “Very satisfied with the treatment I received.” “Overall it is an excellent and convenient facility to use and I would have no hesitation in recommending it to others and using it in the future.” “Shilu & Caroline were brilliant, many thanks.” “I believe All Hallows is a great asset to the local community. Long may it continue!” “The experience was absolutely excellent, thank you to all.” “Everybody was very helpful with everything and all very kind and helpful. I was thoroughly satisfied with my treatment and will be happy to have more treatment here when necessary. Thank you.” 97% of the patients said, they would recommend our service to their friends and family. Hospital In-patients “I would like to thank all you girls as my Dad called you my girls, you‘ve done a splendid job looking after him, you will remain special to me and my lovely dad Stan. Thank you.” “Thank you all for taking good care of our mother and nanny, the care she received was absolutely fantastic.” “I have enjoyed my stay at All Hallows and everyone has been wonderfully helpful and professional.” “I would like to say thank you to all the staff for their excellent care and kindness that they have given to me on my stay All Hallows.” “You have looked after me with great care and compassion, you have wonderful staff and I do thank you for your kindness from the bottom of my heart.” 29. “Loud TV noise from other patients rooms.” “Relaxed atmosphere.” “I didn’t like the cutlery.” “Would like to bring my mother here again for respite care.” Continuing Healthcare “Without Mandy and her teams support over the last 7 or 8 years the following would not have been possible: Mum and Dad to remain in their home of 50+ years. From the detection of dementia related medical problems All Hallows were involved in the care plan. At times it seemed we would have to find a place in a residential home. However with support, utterly wonderful attention and a calm approach we achieved the impossible- Thank you to you all for all you have done and for your good humor when it seemed impossible.” “I thought the care that my late mother got was excellent, they were all so lovely very caring, and very good to all of us, and we were very involved with her care in the last 10 days of her life.” “Waveney was so lovely, very caring excellent with our mum, she was a great support to us as they all were, anything we wanted or needed for Mum it was sorted. Thank you all again.” Nursing Home “I stayed at All Hallows Nursing Home from 6th March to 15th March convalescing after having bilateral hip replacements in The Spire Hospital, Norwich. The care I received was superb from all members of staff and helped me on the road to complete recovery. My consultant Surgeon was impressed by my progress – I recommended All Hallows to him for any of his patients who might need a bit of extra care after major surgery. With thanks and love to all.” “One NHS patient said “This was the best hotel she had stayed in and the staff are marvelous.” “We are delighted with dignified nursing care provided for mum at the end of her life and appreciate the marvelous and excellent skills of all the staff involved.” Did you know… “We prepare cook and provide meals on site.” 30. 2.9 Data Quality Data referencing at All Hallows Hospital includes inpatient services within the hospital, Physiotherapy and Continuing Healthcare. Data referencing at All Hallows Nursing Home includes inpatient services within the home. All Hallows Healthcare Trust did not submit records during 2013 -2014 to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics which are included in the latest published data. We have not been required to submit data to this system: however, in negotiation with our principal commissioners, we anticipate being part of the SUS during the next 12 months and have everything in place so to do. Information Governance All Hallows Hospital Information Governance Assessment Report score for 2013-2014 was graded level 3. All Hallows Nursing Home Information Governance Assessment Report score for 2013-2014 was graded level 3. (To sustain robust Information Governance (IG), the expectation nationally is that all NHS organisations should achieve Level 2 attainment on all applicable requirements as detailed in version 11 of the Information Governance Toolkit (IGT) by 31st March 2014. Each requirement has a number of elements and detailed scoring guidance. The scores (attainment levels) range from 0 (little or no compliance with the requirement) to 3 (full compliance). Clinical Coding All Hallows Healthcare Trust was not subject to the Payment by Results clinical coding audit during 2013-2014 by the Audit Commission. Part 3: Review of Quality Performance 3.1 Achievement of Priorities for Improvement 2012-2013 What We Have Done Patient Safety Priority 1: Refurbish or replace the Call Bell System within the Hospital: Outcome: The new replacement system is a definite improvement allowing pressure alert mats to be incorporated within the alarm system which alerts staff and ensures the safety of patients that have a tendency to wander. We continue to monitor response times monthly. No issues have been reported, we monitor time responses, record completed patients’ surveys and any faults are repaired by the maintenance team immediately. There have been positive responses to this system and no complaints. _________________________________________________________________________________ 31. Priority 2: To implement an internal training matrix offering more diverse training to improve quality of care for our residents and patients. Outcome: The implementation of a mandatory annual training plan has taken place in February 2014 with the intention to ensure that all clinical and non-clinical mandatory training is completed by 100% of all staff and management. In addition, efficient monitoring and review processes have been designed and applied Trust wide in order to target any non-attendances or out-of-date training; this included the new appraisal review systems designed to encourage two-way dialogue between manager and employee in order to full discuss all areas of employment and is concluded with a thorough training needs assessment. Results from regular staff surveys have been reviewed and actioned with regard to improving the levels of qualifications and external training requests so that all staff have the opportunity to work towards their Continuing Professional Development across all services and departments. Patient Experience Priority 1: To create a family area and sensory room within the Hospital. Outcome: The room itself has lots of colourful moving objects and touchy feely items specifically designed to aid individuals with low level awareness. On the floor there are colourful liquid tiles to touch and to the side a Responsive Bubble Tube which is interactive allowing the user to change colour and play games like ‘Simon Says’. There is a raised platform designed to accommodate a hoist to assist people in and out of their wheelchairs and it has a sofa which folds down into a soft mat for people to lay on allowing them to move freely without harming themselves. On the opposite wall there is a very large screen with a DVD / IPod facility. It is a sensory room and a family room. Photographs can also be brought in on a memory stick sharing those special occasions. The Sensory/family room is now used regularly by long term patients and their families. We also promote availability to local individuals via outside organisations, but to date we have had no uptake. Future plans include encouraging the use of sensory room for patients attending daycare. We will continue to record the usage and include this in our patient and family and friends questionnaires. ___________________________________________________________________________ 32. Priority 2: To review our patient questionnaires and produce a single, simple form. Outcome: Following a review of our questionnaire we have produced a simple but effective questionnaire that is now used by all of the Trust. All Heads of departments were involved in ensuring the correct questions for their relevant departments were included whilst keeping them straightforward and easy to understand. We also included in the questionnaire the family and friends question which is part of our monthly CQUIN and a requirement from our commissioners. Since doing this we have found we have a higher rate of returns with the questions answered correctly which enables us to create a comprehensive analysis which is presented to the board of trustees on a 6 monthly basis. Clinical Effectiveness of care Priority 1: To ensure that we identify Dementia Champions within the organisation to ensure we have a knowledgeable and competent workforce. Outcome: The Head of Homecare and Training Co-ordinator have commenced the Dementia Alliance Framework course and are in the process of holding one-to-one coaching sessions to members of staff in support of their roles and working with dementia patients. Both Dignity and Dementia training is provided with 100% of all staff completing this course to reach the Dignity and Dementia Champion status. All staff are required to log-on to the relevant website to register and hold their Dignity and Dementia pins in support of this campaign. ___________________________________________________________________________ Priority 2: Look at Discharge Arrangements, named social worker and reduce delayed transfer of care. Outcome: Evidence shows delays often result in social workers not accepting referrals unless “medically fit discharge date has been documented” Discussions continue with the social workers to improve this. The acute hospital community liaison teams have also highlighted this problem county wide and are also addressing it. Current monitoring of discharge delays are ongoing, and issues identified at multi-disciplinary weekly meetings. We will work better on this through the establishment of a Clinical Discharge Coordinator post. _________________________________________________________________________ 3.2 Reporting on our top 10 1: Patient Feedback We are very keen to know what our patients, residents, clients and their families think about us to ensure that we provide high quality, individualised care in a safe, friendly environment where privacy and personal dignity are of the highest importance. Handbooks are given to all patients, residents and clients when they join us (except in Physiotherapy and a questionnaire is given) we also have an Information for Visitors leaflet available in each reception all detailing how to complain and how to leave a compliment. They also list a step by step guide of how to leave a comment on three different websites. CQC, NHS choices and All Hallows Healthcare Trust. 33. Completion and return of patients’ questionnaires Questionnaires are given out to all patients as part of their discharge pack. Nursing Home residents and Homecare clients are asked to complete a questionnaire every 6 months. Poor results / comments are acted upon and investigated as required. Feedback from patients/public surveys are reported and will continue to be so. We continued to: Undertake in April and October (6 monthly) Reply to poor performances as questionnaires received/returned To achieve response rate of 80% across both sites. In 2013/2014 51% of inpatient questionnaires where completed and returned in All Hallows Hospital In 2013/2014 84% of inpatient questionnaires where completed and returned in All Hallows Nursing Home On the agenda for the next clinical governance group meeting is what do we need to do to increase the amount of questionnaires that are returned to us? A suggestion is to change the KPI’s and appoint a single person in charge for recording and monitoring these. The team will also look at how the Trust can improve on following up bereavement (page 48) too. It is a priority for improvement. Complaints There were 7 complaints during 2013/2014, compared with 3 complaints during 2012/2013 and 7 complaints during 2011/2012 for All Hallows Hospital. There were 2 complaints during 2013/2014 compared with 1 complaint during 2012/2013 and 4 complaints during 2011/2012 for All Hallows Nursing Home. All complaints were acted upon and resolved in line with our policies and procedures. All complaints are acknowledged in writing and a full and proportionate investigation undertaken with a conclusion and any learning outcomes identified. Compliments Compliments continue to be received from patients and relatives; 60 were recorded during 2013/2014, 65 were recorded during 2012/2013 compared with 79 during 2011/2012 for All Hallows Hospital Compliments continue to be received from patients and relatives, 42 were recorded during 2013/2014, 63 were recorded during 2012/2013 compared with 57 during 2011/2012 for All Hallows Nursing Home. 34. 2: Needle stick related injuries, together with correct reporting, documentation, together with presentation and reflection In 2013/2014 there were no needle stick injuries in All Hallows Hospital In 2013/2014 there was 1 needle stick injuries in All Hallows Nursing Home We continue to: Maintain our zero record of needle stick injuries at the Hospital by sharps training for all departments as mandatory training and staff to be aware of policies and procedures. At the Nursing Home we would like to reduce this to zero too. Identify ongoing risk assessment Adequate sharps bins available Identify and introduce self-retractable needles Continue monthly audits on KPIs Continue to report in annual clinical governance report Continue with Occupational Health services/advice. 3: Infection control audits are carried out to ascertain that correct infection control procedures were being adhered to. The results are as follows: 2013/2014 for All Hallows Hospital, by NHS Gt Yarmouth & Waveney – an excellent report received High standards are maintained in infection control with staff uniforms continuing to be laundered on-site and no staff travelling in uniforms. Also, All Hallows Hospital infection control link nurse maintained. 2013/2014 (August 2013) for All Hallows Nursing Home by NHS Norfolk infection, prevention and control team – an excellent report received with some minor recommendations which have all been successfully completed. High standards are maintained in infection control Also, All Hallows Nursing Home infection control link nurse maintained. Both link nurses attend regular meetings and training sessions to ensure they are continually up to date with infection control. The minor recommendations identified were areas in the kitchen requiring some updating. Rather than just doing the few bits mentioned the housekeeping manager decided to replace and redecorate the entire kitchen with funds raised from the Friends of All Hallows. The opening for this is scheduled for the 1st May. MRSA In All Hallows Hospital during 2013/2014 there were 2 cases admitted and no cases developed of MRSA bacteraemia. In All Nursing Home during 2013/2014 there were 6 cases admitted and no cases developed of MRSA bacteraemia. 35. Clostridium Difficile In All Hallows Hospital during 2013/2014 there were no cases admitted and no cases developed of Clostridium Difficile. In All Hallows Nursing Home during 2013/2014 there was 1 case admitted and no cases developed of Clostridium Difficile. Urinary Tract Infections The following figures are number of patients with urinary tract infections during the 12 month period: In All Hallows Hospital during 2013/2014 there were 14 patients from NHS Norfolk, 12 patients from NHS Gt Yarmouth & Waveney and 3 long stay patients (continuing healthcare) 12 with catheters and 17 without catheters. In All Hallows Hospital during 2012/2013 there were 5 patients from NHS Norfolk, 8 patients from NHS Gt Yarmouth & Waveney and 5 long stay patients (continuing healthcare) 9 with catheters and 9 without catheters. In All Hallows Nursing Home during 2013/2014 there were 16 patients from NHS Norfolk, and 13 NHS continuing care funded patients. 8 with catheters and 21 without catheters. 4: Monitoring and reducing the incidence of pressure sores (NHS Safety Thermometer) Monitoring of pressure ulcers, where admitted from, treatment given and outcome, together with grading, will benefit patient-centred care and the use of appropriate pressure relieving equipment e.g. electric mattresses, relating to patient’s individual Waterlow scores, together with evaluation. We continued to: Monitor grades using European Pressure Ulcer Advisory Panel (EPUAP) grading and Waterlow scores Monitor all patients admitted with and developed at All Hallows Hospital & All Hallows Nursing Home Measure performance against the Essence of Care benchmark Monitor outcomes, treatment, equipment used Monitor monthly KPIs Be aware of National Institute of Clinical Excellence (NICE) guidelines Continue monthly audits and report in annual clinical governance report Wound care guideline procedure adhered to Procedure AHH/NUR/29, Skin care/pressure ulcer risk assessment and prevention management 2013/2014 In All Hallows Hospital 1 person was admitted with pressure sores (1 NHS Norfolk, 0 NHS Gt Yarmouth & Waveney, 0 continuing healthcare, 0 specialist palliative care); 2 grade 1 were developed, 2 grade 2 were developed and no grade 3 or 4 were developed. Our actions and reporting is monitored through CQUINS (see page 24-25) 36. 2013/2014 In All Hallows Nursing Home 16 people were admitted with pressure sores (14 NHS Norfolk, 0 NHS Gt Yarmouth & Waveney, 2 continuing healthcare, 0 specialist palliative care); 7 grade 1 were developed, 8 grade 2 were developed and 1 grade 3 was developed Our actions and reporting is monitored through CQUINS (see page 24-25) 5: Follow up bereavement with family We continued to: Telephone next of kin of RIP patients for feedback (after funeral) Undertake After Death Analysis (ADA) with All Hallows Healthcare Trust medical team Commence GSF community hospitals for accreditation when released EOL questionnaires to be developed and undertaken Ensure relevant clinical and medical organisations are informed 6: Risk Management Incident summaries and trend analysis for the Trust’s significant risks were maintained. This includes risk assessment overview and staff/patient accident reports. Clinical risk assessments are also carried out on all our patients, which include manual handling, pressure ulcers, falls, use of bed rails, MUST screening (nutritional assessment) and self-medication. The Hospital and Nursing Home has undertaken risk assessments for its clinical activities. It is our policy to manage those risks to a level that is as low as can reasonably be expected. We cannot eliminate all risks and when incidents occur they are reported, investigated and actions taken to prevent the incident from recurring. Recognising and sharing lessons learnt when things have gone wrong is critical to ensuring the highest standards of clinical and housekeeping services for patients and staff. 2013/2014 there was 162 risk assessments undertaken – 123 were assessed as low, 38 medium and 1 high. 7: Staff & Patient Accidents The aim is to continue correct reporting of accidents, monitoring and reflection to prevent accidents: All Hallows Hospital: Staff 2013/2014 4 accidents, no needle stick injuries Patients 2013/2014 30 accidents – 100% due to falls Staff 2013/2014 4 accidents, 1 needle stick injuries Patients 2013/2014 9 accidents – 88.88% due to falls All Hallows Nursing Home: 37. All patients have a fall risk assessment and individual care plan, and manual handling assessment. Our falls reduction service has been implemented internally to reduce incidents and will be closely monitored. 8: RIDDOR The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995) require we report certain incidents to the Healthcare Commission. These include accidents that result in death or major injury, including the requirement to stay in hospital for more than 24 hours or absence from work for more than 3 days. During 2013/2014 there was 1 occurrence at the Nursing Home involving a Norfolk patient who fell and fractured their hip: these form part of our falls review and monitored through the falls reduction programme. 9: Our Medical Advisors Medical Care at All Hallows Hospital is provided by Dr A Self, Dr M Elisson and Dr H Amarawickrama as Medical Advisors through our subcontracted arrangements with doctors at Bungay Medical Centre. Out of hours medical cover is provided by IC24 Ltd & the East Anglian Ambulance Service. 16 hours a week is contracted for medical cover at the hospital site. This consists of: i) daily rounds ii) extended time provided on Mondays iii) weekly case conference on Wednesdays iv) emergency care and cover as necessary Medical Care at All Hallows Nursing Home is provided by Dr A Emerson and also by the doctors at Bungay Medical Centre. Out of hours medical cover is provided by IC24 Ltd & the East Anglian Ambulance Service. 6 hours a week is contracted for medical cover at the nursing home site. This composes of: i) 2 weekly rounds every Monday and Thursday morning ii) Emergency care and cover as necessary Responsibilities include covering all aspects of in-patient care, clerking, assessment and discharge plans. Decisions are also made regarding cardio pulmonary resuscitation/do not resuscitate status achieved for all patients. 10: How we support our staff: A dedicated HR function is a new development to the Trust. Its aim is to continuously improve everything we do through supported and managed change. A crucial element of this process is a strategy for people, where we aim to develop their full potential through commitment to training and education. We have annual appraisals for all staff and encourage them to enhance their Qualifications through Diplomas/Apprenticeships. We monitor recruitment and retention, the sickness rate, and undertake return to work interviews to highlight any significant variations and understand reasons for them. 38. During 2014/2015 we will be presenting an HR and Training Strategy to the Board for approval. It will provide a framework for improvement and success to be delivered through our employees with appropriate support and encouragement. Through discussions and feedback involving Heads of Departments, the Chief Executive, and employees at all levels, a range of issues have been identified and these will help shape the strategy and the development of the key improvement programmes. Training & Development We systematically manage the training of 310 staff in sometimes a high-risk environment where exacting and standards are expected of them by our patients, our funders, and the public. A training plan is produced for each department at the beginning of the financial year to enable us to budget for staff requiring non-mandatory training. Staff are entitled to 21 hours paid training per year. The Training Co-ordinator undertakes Mandatory Training and Skills for Care. Literature from study days is disseminated with other staff through a structured leaving programme and reported back to clinical supervision meetings and staff meetings. During 2014/2015 the Training Department we will be presenting an HR and Training Strategy to the Board for approval. It will provide a framework for providing ‘excellence and innovation’ in all that we do, focusing on high quality provisions which will enable us to consolidate our position in the changing health and social care ‘market place’. It will cover: How training and development will support the organisation Expectations of line management Expectations of our employees Training provided in line with Care Quality Commission standards The structure of training and the training coordinators Our HR development for 2014/2015 will: Provide all Heads of Department a full Training List of Mandatory training, identifying which trainer is responsible for specific topics Include highlighted sections on the 6 weekly training matrix of all mandatory training Roll out the training matrix two weeks prior to its commencement date for planning needs Ensure that all new starters undertake an Induction within four weeks of the start date Provide all new starters with an Employee Handbook upon Induction Ensure that all new starters, clinical and non-clinical, receive mandatory training in: Manual Handling, Fire Safety, Health and Safety in their first week shadowing shifts Provide department relevant training i.e. Infection Control, COSHH, Food Hygiene. Update Heads of Department as and when QCF funding becomes available for Health and Social Care among additional options, e.g. End of Life, Infection Control. Develop monitoring tools to ensure that all records of completed QCF qualifications are up to date Assist Heads of Department in ensuring staff are qualified to the level at which they are working Maintain an 85% QCF level across the Trust Utilise the new six-weekly training matrix that includes training for those working unsociable hours in order to provide a proactive training service 39. Incorporate training across the three sites, Hospital, Nursing Home and Lowestoft office in order to ensure a fair training plan. Monitor attendances to Dignity and Dementia training for 100% attendees by April 2015 Continue to deliver Norfolk’s Harwood Care and Support Charter which provides an assurance of what people can expect of their care provider and what to do if things go wrong or if they have concerns. 3.3 Clinical Governance at All Hallows Healthcare Trust Clinical governance is the process we use to maintain and improve effectiveness, and practice of what we do through clinical audits, complaints management, clinical leadership and development, continuing education and professional development, clinical supervision and clinical risk management. It is a framework which helps all clinicians to continuously improve quality and safeguards standards of care and monitor the kind of care we deliver. Clinical governance procedures are used to review progress against all aspects of improving patient care and act as learning points for the future. Aims: To ensure safety and quality of care to patients. To ensure staff continually strive to improve their practice and delivery of high quality care. Roles and Responsibilities: Matron (Hospital) is the named responsible person for: i) overseeing clinical governance across All Hallows Healthcare Trust for delivering, reporting, monitoring and evaluating the policy and producing an annual report, which is widely available for staff, patients and other stakeholders; ii) ensuring that the principle of clinical governance underpins the work of our service and is monitored in our annual business plan and quality account; iii) overseeing clinical risk management and that clinical risk assessments are undertaken for each patient to include manual handling, pressure area care, nutrition using ‘MUST’, fall and use of bed rails, incident / near misses, medication. Through Clinical Audit the process of improving patient care through the regular review of care against clear standards and the implementation of change is maintained. Changes in practice can be introduced as a result of findings from clinical audits. Evidence Based Practice: Clinical practice and effectiveness upon which care is planned is delivered through staff having access to up-to-date information by access to internet, health journals, NICE guidance. This information is disseminated throughout the organisation through Heads of Department meetings, staff meetings, feedback from training days, a comprehensive learning and training programme, and other specialists from multi-disciplinary teams as well as from clinical guidance and care pathways such as the Gold Standard Framework for end of life care, infection control guidelines and other professional bodies including Care Quality Commission, Royal College of Nursing, Nursing & Midwifery Council, General Social Care Council, and commissioner clinical governance teams. All Hallows Healthcare Trust uses the Royal Marsden Manual 7 th Edition guidelines on routine clinical procedures. “Quality is the focal point of our service” 40. Clinical Governance Group Clinical Governance Group Board Community Hospital Medical Officer Chief Executive Matron Hospital Matron Nursing Home Heads of Departments 0.41 Head of Daycare and Medicines Management Reporting Structure and Constitution and Reporting Structures Board of Trustees Trust Advisory Group (TAG) Chief Executive Community reps/Friends of All Hallows Healthcare Trust Clinical Governance Operational Norfolk and Waveney Therapeutic Advisory Committee Heads of Departments Policy and Procedure Admin Management HR Estates Housekeeping Nursing Home Hospital 1. 42 Homecare Daycare Finance Physiotherapy 3.4 Comments Statement from the Cath Gorman, Director of Quality and Safety, Great Yarmouth and Waveney Clinical Commissioning Group “Great Yarmouth & Waveney Clinical Commissioning Group as a commissioning organisation of All Hallows Healthcare Trust supports the organisation in its publication of a Quality Account for 2013/14. We are satisfied that the Quality Account incorporates the mandated elements required based on available data. The information contained within the Quality Account is reflective of the Trust over the previous 12 month period. In our review, we have taken account and support the clinical quality improvement priorities identified for 2014/15 and support the identified improvement objectives in the quality and safety of care provided to Great Yarmouth & Waveney residents. The Trust will do this by: Improving patient safety by undertaking focused work on preventing the development of pressure ulcers. The CCG supports this and would encourage the Trust to participate in the system wide pressure ulcer prevention improvement plan. Another patient safety priority for 2014/15 identified by the Trust align with the system wide analysis and aspiration to improve the care of people at risk of falling and to those that have fallen. Improving patient and staff experience by providing patient information to improve their understanding of their conditions. We welcome this aspiration to increase the knowledge of patients and where appropriate how they can contribute to their health improvement. The Trust will also improve the environment and facilities within the physiotherapy department. Patient comfort but also increased privacy will improve the overall experience of their treatment with the Trust. We are pleased to note that the Trust have identified opportunities to improve the experience for patients who receive rehabilitation at home through using day care facilities to improve transition from hospital to home. Improving clinical outcomes and effectiveness by ensuring that the Trust review all policies and procedures within a robust governance framework to ensure that the patients and service users receive clinically effective care. The Trust will also focus on the reduction of length of stay and arrangement of a patient focussed and safe discharge for in-patients through the development of a case conference process. The CCG supports this initiative through CQUIN funding as 43 0. we recognise that people who stay in hospital for longer than necessary are at a higher risk of safety incidents. Great Yarmouth and Waveney CCG also notes the quality priorities identified for 2013/14. We recognise the progress made on these priorities and are particularly impressed with the sensory room for use by patients and their families. . We note the comprehensive section within the report about the Care Quality Commission inspections undertaken and are pleased to note the full compliance with the regulatory requirements. The CCG is pleased to see the inclusion of comprehensive section on how the Trust supports their staff along with a clear plan for 2014/15. In terms of suggested improvements we note that the following would enhance the quality account: Examples of staff members or teams that have been recognised for their contribution to enhancing care and support to patients, relatives or their colleagues Overall the Great Yarmouth & Waveney Clinical Commissioning Group commends the Trust for the quality of this publication and looks forward to working with the AHH Trust during 2014/15.” Statement from Healthwatch Norfolk Healthwatch Norfolk is pleased to have the opportunity to comment on the Quality Report. The report is well laid out, provides a comprehensive explanation as to the areas of work undertaken by the Trust and is a good example of a reader friendly approach to presenting Quality Account information. We note that the report provides details on both the outcome of the priorities identified in the Quality Report for 2012-13 and clearly defines the priorities for the forthcoming year. The establishment of a Clinical Discharge Co-ordinator post reflects our involvement elsewhere across the health and social care sector on delayed discharges. We are particularly pleased to note the emphasis on obtaining patient feedback and where this has been used to help identify priorities for achievement in 2014-15. We also note and endorse the significant amount of effort being put into staff training. We support the priority relating to analysis of patient/resident falls with the aim to reduce the risk. We only have one minor suggestion in terms of format and that is to provide an explanation as to the attainment of Level 3 on Information Governance Assessment 1. 44 reporting (page 31). Finally, Healthwatch Norfolk confirms that we will ensure that any feedback we receive from patients, carers and their families’ forms part of a developing relationship with all commissioners and providers of healthcare in Norfolk, including All Hallows Healthcare Trust. Alex Stewart Chief Executive Please note following the statement from Healthwatch an explanation on the attainment levels on the Information Governance Assessment have been added to page 31. Station Road, Ditchingham, Bungay, Suffolk. NR35 2QL T: 01986 8927278 [email protected] www.all-hallows.org.uk Daycare I Homecare I Hospital I Nursing Home I Occupational Therapy & Physiotherapy I Specialist Care Home 45 2.