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….
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
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 .
Part 1: Our Commitment to Quality
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
Part 2: Our Priorities for Quality Improvement 2013-2014
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)
Part 3: Review of Quality Performance
Achievement of priorities for improvement 2012-2013
Reporting on our top 10
Clinical Governance at All Hallows Healthcare Trust
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
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
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
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
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
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
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)
Medical Assessment
Nursing Home care
Palliative care
Physiotherapy / Occupational Therapy
Respite care)
Specialised Care Home (for people with physical and sensory
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.
A seamless care approach that works locally to support patients at home and in the
A closer look at the full range of services available from All Hallows Healthcare
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
 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
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
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)
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
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
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.
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.
 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
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
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
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
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”
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 &
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).
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.
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.
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
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
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
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
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
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.
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
 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
 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
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
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
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
(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
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
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.”
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
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
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
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
Quality of Life Improved
Level of Satisfaction
2% 2% 1%
Patient and Carer Comments
“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
“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.”
“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
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
“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.”
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.
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
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
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
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.
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
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.
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 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.
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
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.
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.
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
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
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)
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
All Hallows Hospital:
4 accidents, no needle stick injuries
30 accidents – 100% due to falls
4 accidents, 1 needle stick injuries
9 accidents – 88.88% due to falls
All Hallows Nursing Home:
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
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:
daily rounds
extended time provided on Mondays
weekly case conference on Wednesdays
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.
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
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
Assist Heads of Department in ensuring staff are qualified to the level at which they are
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
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”
Clinical Governance Group
Clinical Governance Group
Chief Executive
Matron Nursing
Heads of Departments
Head of Daycare and Medicines
Reporting Structure and
Constitution and Reporting Structures
Board of Trustees
Trust Advisory Group (TAG)
Chief Executive
Community reps/Friends of All
Hallows Healthcare Trust
Norfolk and Waveney
Advisory Committee
Heads of Departments
Policy and Procedure
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
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
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
 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
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
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
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 info@all-hallows.org.uk www.all-hallows.org.uk
Daycare I Homecare I Hospital I Nursing Home I Occupational Therapy & Physiotherapy I Specialist Care Home