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CircleBath
Quality Account
2013/14
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CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Contents
About the Quality Account
Chapter one
Statement on quality from the leadership team
Chapter two
The Circle ethos
CircleBath
Chapter three
Reviewing our quality improvement objectives from 2013/14
1. To develop a suite of theatre audits to reduce harm in the
peri-operative environment
2. Implement the safety initiative ‘Stop the Line’
3. Our Oncology Service to develop links with Dorothy House
4. To develop visitor and patient facilities further
Chapter four
Setting out new quality improvement objectives for 2014/15
1. Development of the Circle Operating System
2. Development of patient hours in all departments
3. Healthcare Assistant Training Programme
Chapter five
Review of quality performance 2013
• Review of services
• Clinical audit
• Clinical research • Clinical Outcomes Steering Committee
• Patient safety
• Infection prevention and control
• Pressure ulcers
• VTE risk assessments
• Safety thermometer
• Returns to theatre
• Patient readmissions
• Patient transfers
• CQUIN
• Patient Safety Awareness Month
• Patient experience
• Staff engagement
• The CQC
• Data quality
• NHS number validity
• Information governance attainment levels
• Clinical coding error rate
• Involvement in local networks
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About the
Quality Account
What are the required elements of the Quality Account?
The Health Act 2009 requires all healthcare providers to produce a Quality Account, and
the National Health Service (Quality Accounts) Regulations 2010 specifies the requirements
for the reports produced. We have used the requirements as a template around which our
account has been written.
What are the key requirements?
1.
2.
3.
A statement by the leadership team.
Priorities for improvement – these are commitments that CircleBath makes
to improve the level of quality within the hospital.
Review of quality improvement – this demonstrates how the hospital has
performed so far.
How did we produce our Quality Account?
We have used the Department of Health’s Quality Accounts Toolkit as a guide for our
Quality Account.
To supplement all the mandatory elements of the account, we have also worked closely
with our patients, consultants and other partners to ensure that this account truly reflects
the quality measures in place and provides readers with an accurate and comprehensive
insight into the organisation.
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Patient, CircleBath
“Everything from the care
to the food – everything
was fantastic.”
Chapter
one
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CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Statement on quality
from the leadership team
It is with great pleasure that we welcome you to the
2013/14 Quality Account produced by CircleBath, which
has been written in accordance with the Department of
Health’s policy document High Quality Care for All.
It is hence a statutory requirement; however we are pleased to report on the quality
of our services, patient experience and assurance procedures in place. We hope you
find our reflections on 2013 of interest, as well as our plans for the coming year. During 2013, CircleBath has taken every step to ensure the quality of the patient
experience is at its very best. This encompasses the medical treatment received, the
quality of accommodation and facilities, food and hospitality, which are all centred
around the individuals’ personal needs. We, therefore, pay meticulous attention to the
whole patient pathway, from making an enquiry, booking an appointment, the treatment,
and aftercare.
We have developed a number of methods of measuring and benchmarking the quality of
our services, therefore, with the primary aim of continuous improvement for our patients.
Many such measures are made available to our partners (staff and consultants), as well as
patients, through our ethos of transparency. We have presented some of these measures
in this report.
CircleBath is committed to providing the very highest quality services for patients, and
working environment for our clinicians and partners. We strive to provide choice, innovation,
safe and personalised care for our patients, whom we fully welcome feedback from. As all
our staff are partners in CircleBath, everyone has a voice on how to ensure and improve
the quality of our services, and we promote a culture that advocates ‘we are the agents
of our patients’, in line with our credo. We are proud of all our achievements to date.
Consequently, the purpose of this report is to present our successes and outline qualityrelated improvements which may still be required. Furthermore, we aim to explain our main
priorities over the next year, including a delineation of those to be involved; how we aim to
measure their effectiveness; and the inclusion of reflective learning from previous initiatives.
Patient, CircleBath
“The operation
was explained in
great clarity, most
helpful in putting
aside any concerns.
Nursing staff were
very attentive.”
Information provided in the Quality Account is trustworthy and reflects a true picture,
which aims to be meaningful and relevant. Comparisons can be made with other organisations
and within CircleBath over time. Access to the report will be enhanced through its publication
on the Circle website and internally to patients and partners. The Registered Manager and Clinical Chairman have reviewed the content of this Quality
Account and confirm that we are accountable for the report’s content. We are confident
that it provides a balanced view and that to the best of our knowledge, the information
contained within this document is accurate.
Shelagh Meldrum
Registered Manager
Jonathan Boulton
Clinical Chairman
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CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Chapter
two
Patient, CircleBath
“From the minute I entered the door,
everything was exceptional; everybody
was professional and friendly. Thank you.”
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CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
The Circle ethos
CircleBath
Our credo
Circle was founded on the belief that hospitals should be
dedicated to patients. CircleBath has been designed to offer
21st-century medical technology with an unequivocal focus
on quality of care and customer service.
Our purpose
To build a great company dedicated to our patients.
Our parameters
We focus our efforts exclusively on what we are passionate about.
What we can become best at. What drives our economic sustainability.
Our principles
We are, above all, the agents of our patients. We aim to exceed their expectations every
time so that we earn their trust and loyalty. We strive to continuously improve the quality
and the value of the care we give our patients. We empower our people to do their best.
Our people are our greatest asset. We should select them attentively and invest in them
passionately. As everyone matters, everyone who contributes should be a partner in all that
we do. In return, we expect them to give their patients all that they can. We are unrelenting
in the pursuit of excellence. We embrace innovation and learn from our mistakes. We measure
everything we do and we share the data with all to judge. Pursuing our ambition to be the
best healthcare provider is a never-ending process. ‘Good enough’ never is.
Our values
Passion
We are driven by the needs of our patients.
We believe in our credo and the importance of our mission.
Each of us has a significant contribution to make.
Disruption
We are not afraid to challenge the norm or the vested interest.
We encourage creativity when balanced with discipline and methodology.
We have the courage to call it as it is.
Humanity
We value care, compassion and empathy.
We engage our partners to be their best.
We are straightforward, listen to and respect each other.
Resilience
We learn from setbacks and come back stronger.
We are tenacious and see obstacles as challenges.
Our belief in ourselves underpins our resolve.
Agility
We are always open to new ideas and ways of doing things.
We believe that ‘good enough’ never is.
We keep it simple and make things happen fast.
Partnership
We have a sense of ownership for what we do.
We feel valued and able to make a difference.
We hold each other to account for what we believe in.
Each of our hospitals is co-formed, co-owned and co-run by clinicians. We are the largest
partnership of healthcare professionals in Europe.
CircleBath is wholly committed to delivering clinical excellence and the highest level of
customer service, every step of the way. We embrace innovation and look for ways to
improve what we do every single day. We believe that makes us different to other hospitals.
Our facilities
CircleBath facilities are state-of-the-art and include:
• four operating theatres.
• one endoscopy suite.
• twenty-two day case beds.
• thirty inpatient beds.
• nine consultation rooms.
• four treatment rooms.
• a physiotherapy suite, including hydrotherapy off-site.
• full diagnostic service, including MRI, mammography screening, x-ray, ultrasound, CT,
pathology and cardiac testing.
• satellite first consultation only clinics at a selection of local GP surgeries. These clinics only
consist of a first consultation appointment with no regulated activity being undertaken.
Aims and objectives
• The hospital operates seven days a week on a 24-hour basis.
• We aim to deliver a patient experience characterised by comfort and respect for the
patient’s individual needs and views.
• We aim to provide speedy access to outpatient, inpatient and day case surgery treatments
in a first-class facility.
• We aim to deliver high-quality, evidence-based clinical care that provides patients with
the best outcomes.
Principles
We will therefore exclusively focus our efforts on services where we:
• can be the best provider for our patients in their community.
• have a passion for service delivery.
• realise a sustainable economic drive that allows our services to persist.
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CircleBath Quality Account 2013/14
Patient, CircleBath
“Everyone kept me informed of what
to expect and showed great care for
my recovery.”
Chapter
three
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CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Reviewing our quality
improvement objectives
from 2013/14
Our priorities for improvement in 2013/14 were based on
the value equation:
1 To develop a suite of theatre audits
to reduce harm in the peri-operative
environment
The following audits were undertaken by our Recovery Department, which assessed all
patients on one day per week to ensure that:
• 90% of clinically-appropriate surgical patients receive on time appropriate antibiotics
within 60 minutes of surgical incision.
Audit results – 99.6% of clinically-appropriate surgical patients receive on time
appropriate antibiotics within 60 minutes of surgical incision.
• 95% of all surgical patients maintain normal range temperature during surgery and
in the immediate post-operative phase.
Audit results – The temperature range for this audit has been deemed unrealistic
by a study carried out at the Royal United Hospital by one of the anaesthetists and,
therefore, the audit results have not been published.
• 95% of all known diabetic patients maintain a serum glucose level within the normal
range on the day of surgery.
Best
clinical
outcomes
Most
engaged
staff
Best
patient
experience
Best
value
Audit results – 100% of all known diabetic patients maintain a serum glucose level
within the normal range on the day of surgery.
• 95% of all elective surgical inpatients that require hair removal for their surgery will
have it performed using the recommended method.
Audit results – 99.41% of all elective surgical inpatients that require hair removal for
their surgery will have it performed using the recommended method (one patient removed
hair at home prior to admission and, therefore, we are unable to guarantee that it was
done with the recommended method).
• 95% compliance with the World Health Organisation (WHO) surgical safety checklist
with evidence of changes made to the team brief.
Audit results – 99.5% compliance with the WHO surgical safety checklist with evidence
of changes made to the team brief.
The team brief has recently been amended to ensure that the consultant anaesthetist
and consultant surgeon are aware of the whereabouts of the emergency trolley and how
to activate the emergency bleeps, to ensure that help arrives quickly should it be required.
Our priorities for last year were:
• to develop a suite of theatre audits to reduce harm in the peri-operative environment
• implement the safety initiative ‘Stop the Line’.
• for our Oncology Service to develop links with Dorothy House.
• to develop visitor and patient facilities further.
The details of progress made on our key priorities from last year are outlined within this
Quality Account.
The outcomes of further planned initiatives will be reviewed and analysed over the coming
year. Our successes will be clearly demonstrable and areas for improvement identified.
2 Implement the safety
initiative ‘Stop the Line’
A number of presentations were undertaken to educate the teams about ‘Stop The Line’,
to explain that any member of staff who encounters a situation that may harm a patient
can make an immediate call to stop the line (cease any activity that could cause further
harm). This will empower staff to stop the line when potential sources of mistakes are
discovered, without fear of blame, creating a safety culture throughout the organisation.
We wanted to create a culture of openness, learning and continuous improvement with:
• hospital staff that pledge to stop and act.
• leadership that will support staff who raise a concern (even if they are wrong).
• teams that will act immediately to rectify problems and prevent harm.
This has given our teams the ability to take responsibility for anything that they
consider to be harmful to their patients and be able to act upon it immediately,
therefore, preventing harm.
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CircleBath Quality Account 2013/14
Reviewing our
quality improvement
objectives from 2013/14
Continued
CircleBath Quality Account 2013/14
If staff see a problem they are asked to:
Dorothy House
• stop the line.
• SWARM as a team to find a solution – the team needs to consist of those
relevant to the issue.
• complete an incident form using our online reporting tool, DATIX.
Our connection with Dorothy House and the outreach centre locally, remains firm. Sandra
and Emma updated the palliative care nurse specialists on chemotherapy, and a reciprocal
session was given to some of CircleBath’s non-clinical staff on what palliative care is, and
the role of the Dorothy House staff. Our staff found this invaluable in caring for some of
our patients.
Within one hour, the team involved must:
• notify the Clinical Nurse Lead, Governance Lead and General Manager.
• notify the Chief Executive Officer, Head Office, for information.
• decide on interim action.
Within 24 hours, the team must:
•
•
•
•
organise a SWARM.
organise a review of interim actions.
consider a safe stop.
organise the completion of an incident form.
Respite care
In conjunction with our oncologists, our medical consultants offer respite care for patients
that may want to recuperate in a relaxed environment, but with full nursing care. To date,
two patients have stayed longer than anticipated as they felt comfortable and cared for.
Multi-disciplinary team (MDT) meetings
Weekly attendance at the breast MDT continues with ad hoc attendance at the urology
and gynaecology meetings. Sandra and Emma regularly join the educational events
arranged by the MDTs.
Within 48 hours, the team must ensure that:
Cancer services within Circle
•
•
•
•
•
•
The oncology team at Hinchingbrooke Hospital, touring the unit and working through
pathways with the Acute Oncology Nurse.
a unit lead report is produced and sent to identified staff.
the Stop the Line team reviews and reports on actions taken.
recommendations are made for implementation within 25 days.
a final report is produced by the unit lead with clear root cause analysis.
lessons learnt are shared with relevant staff.
permanent change to practice is fully implemented.
We met with other cancer nurses from Nottingham, Hinchingbrooke and Reading at our
annual Allied Health Professionals conference in October. We all gave a presentation on
our individual services.
• an audit of practice is carried out to ensure implementation.
The Cancer Treatment Nurse Lead has been mentoring the Breast Care Nurse at Reading,
who completed the breast care course in February last year. We also held a Patient Safety Awareness Month across all Circle sites in October 2013.
More details regarding this event can be found on page 45 of this Quality Account.
Liaison with the Acute Oncology Service at the Royal United
Hospital – local NHS hospital
Within 30 days:
3 Our Oncology Service to
develop links with Dorothy House
In 2012, we had 54 chemotherapy patient episodes. In 2013, this increased to 72. We also
had 10 medical patient episodes in 2012, as opposed to 26 in 2013. Macmillan
Our service adoption by Macmillan has been a real bonus for the hospital. Enquiries have
come via the website due to the link with Macmillan.
Our oncology team have attended ‘setting-out’ study days, an end-of-life day and a planning
local cancer services study day with Macmillan. This has fostered links with some of the
local Macmillan initiatives such as the radiotherapy injuries unit at the Mineral Hospital.
Our Macmillan launch and coffee morning not only raised funds for Macmillan, but acted
as an informal meeting for our patients and carers, giving them an opportunity to chat over
any worries with Sandra or Emma.
Sandra and Emma triage their patients using a national triage tool. If appropriate,
these patients attend the Royal United Hospital, and good communication with the
acute oncology nurse there is crucial. They spent a morning shadowing staff to
understand the procedures involved.
Dignicap® scalp cooler
Our patients who have used this system to keep their hair have been so pleased with
the results, being more tolerable than our previous system. Patients say it has made their
chemotherapy journey far easier, claiming they would have felt completely different if they
had lost their hair. We have recently communicated with a centre in Lithuania interested in
Dignitana, giving them practical feedback and comments from our patients.
Out-of-hours service
Our patients find the 24-hour mobile phone service invaluable for queries and, most
importantly, if they become unwell. They are reassured that they will be triaged immediately
and the appropriate treatment obtained without delay.
Laing & Buisson Award
In the summer of 2013, Sandra was nominated for an award.
On 8th October, Sandra won the Laing & Buisson Award for Nursing Practice.
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CircleBath Quality Account 2013/14
Reviewing our
quality improvement
objectives from 2013/14
Continued
CircleBath Quality Account 2013/14
4 To develop visitor and patient
facilities further
During 2013, our patient and visitor experience has been further enhanced by some
significant changes. They include:
Artwork
A new art company has been sourced and we now have a new and varied selection of
artwork in both the atrium and day case areas. This was launched back in the autumn,
with a reception that included the artists and local councillors, as well as staff, patients
and visitors to CircleBath.
The artwork will now be changed half yearly, to further enhance the building and promote
interest for returning patients.
Patient toiletries
New toiletries have been introduced into patients’ rooms after being reviewed by our
patient forum. Feedback was very positive, and so we changed it throughout the hospital;
not only in the patient rooms, but also throughout the patient and staff toilets. We have
received great comments and, during 2014, we hope to be able to offer for sale the
same toiletries in the gift shop.
The deli bar
A deli flyer is in production at the moment, which will be included within admission
paperwork that is sent to patients, as well as a local leaflet drop. This will provide patients
and visitors with an idea that they are able to buy tasty fresh food from our deli between
the hours of 7.30am and 6pm, Monday to Friday. This is something that people would not
necessarily have been aware of before. New tables and chairs are also being purchased
to create more dining space at peak times.
Events calendar
We have a fun events calendar in place on the deli, which includes Easter lunches, nurses’
day celebrations, a summer picnic, Halloween, winter warmer menu and the ever popular
Christmas lunches, to name just a few.
The gift shop
The gift shop and the variety of items on offer continue to go from strength to strength,
being further enhanced by a new and varied range of ‘food gift items’. The seasons are
mirrored beautifully with the range of items that can be purchased. Toys for children
are being introduced throughout 2014, along with a wider range of greetings cards.
Landscaping
We have also introduced newly landscaped window boxes for inpatient bedrooms.
Patient, CircleBath
“Extremely happy from reception to
operation, right down to aftercare.”
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CircleBath Quality Account 2013/14
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Chapter
four
Patient, CircleBath
“Everyone involved in my procedure was
very informative and helpful. The care
afterwards was excellent. Catered really
well for my vegan diet.”
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CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Setting out new quality
improvement objectives
for 2014/15
2 Development of patient hours
in all departments
Our priorities for improvement in 2014/2015 are as follows:
During a Patient Hour, partners should:
• feel that they fully contribute to the running of their unit and are empowered to suggest
better ways of working.
• have a sense of team identity.
• understand their own performance and the performance of the unit, and have the desire
to want to improve it.
• feel involved and know the role they play.
1 Development of the Circle
Operating System (COS)
A dedicated COS lead has recently been appointed, and an objective for 2014 will
see the continued implementation of COS throughout the hospital. It provides
all partners with tools and processes to help bring our credo to life.
This project will entail training all our partners on the COS tools, and building
skills within each department which allow teams to meet their objectives and
create the best hospital for our patients.
Our purpose
To build a great company dedicated to our patients.
Our parameters
We focus our efforts exclusively on:
• what we are passionate about.
• what we can become best at.
• what drives our economic sustainability.
What is Patient Hour?
Patient Hour is a dedicated time for teams to come together to review progress, discuss and
plan improvement initiatives. Patient hours can be a series of huddles, or be part of weekly
or monthly team meetings.
Items that should be covered during a Patient Hour
• Site and local communication.
• Review of departmental quality quartet.
• Plan improvement initiatives.
• Report back on improvement projects.
• Open forum.
What and who are our patient champions?
Our patient champions play a very important role in COS and are currently progressing
through a training programme so they are fully educated in the key elements of COS and
patient hours. The patient champions will be available to help co-ordinate and, if needed,
facilitate a SWARM.
Throughout 2014, continual monitoring will evaluate the progress in embedding Patient
Hours within departments.
Our principles
Project Lead: Nicola Abbott Board Sponsor: Alexandra Buckley
We are, above all, the agents of our patients.
We empower our people to do their best.
We are unrelenting in the pursuit of excellence.
Project Lead: Nicola Abbott Board Sponsor: Alexandra Buckley
3 Healthcare Assistant (HCA)
Training Programme
As part of our credo to develop staff within Circle, we are introducing a new HCA training
programme. This will be progressive, research-based training, delivered by registered nurses
and experienced HCAs with NVQ qualifications. The subject matter will be dependent on
the needs identified by HCAs and registered nurses. The training will be delivered by means
of lectures, skill stations, and simulation/scenario role play.
SWARM the
opportunity
Subject areas
Plan the
solution
Act
Check
the do
Do the
plan
• Simple anatomy and physiology of respiratory and circulatory systems, female
reproductive organs, large joints (hips, knees and shoulders), the spine.
• Simple explanations of common surgeries performed at CircleBath.
• Performing vital signs and simple science behind why we perform them, including
manual blood pressure techniques and neurological assessment/Glasgow Coma Scale.
• The PQRS complex, and performing 12 lead ECG recordings.
• Simulation training using a laerdal mannequin, covering emergency situations that may
occur and the first response treatment, how to call for help, and giving a hand over to
other staff.
• The opportunity to spend time in the operating theatre to observe the operative
procedures through to the recovery stage.
Evaluation of each training session will take place to allow trainers to reflect on how
to continuously improve the HCA programme.
Project Lead: Penny Rutter Board Sponsor: Jane Scott
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CircleBath Quality Account 2013/14
Patient, CircleBath
From the moment I arrived,
the patient care was excellent.”
Chapter
five
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CircleBath Quality Account 2013/14
Review of quality
performance 2013
The law requires evidence of fate of unit in 100% of transfusions. It is the responsibility
of Circle staff to return the tags to the providing blood bank. The RUH will, as part of
the service level agreement (SLA) with Circle, contact the relevant area if tags are not
returned. The RUH will also, as part of the SLA, provide training support to staff.
CircleBath hospital results:
Review of services
Units transfused
% traceability
During 2013/14, CircleBath provided Choose and Book and transferred activity NHS services.
59
98.2%
CircleBath has reviewed all the data available to them on the quality of care in 100% of
these NHS services.
The income generated by the NHS services reviewed in 2013 represents 100% of the
total income generated from the provision of NHS services by CircleBath for 2013.
Clinical audit
National audits
During 2013, two national clinical audits and no national confidential enquiries covered
NHS services that CircleBath provides.
During that period, CircleBath participated in 100% of national clinical audits and 100%
of national confidential enquiries for the national clinical audits and national confidential
enquiries which it was eligible to participate in.
Summary of blood usage:
Blood units issued
Units used
Units wasted
O negative
108
0
0
Patient specific
109
60
1
Summary of training undertaken
All healthcare professionals that are involved with the blood transfusion process will
have their competences assessed every three years to ensure they are safe and competent
to administer blood and blood products to patients. In addition, all healthcare professionals
involved with the blood transfusion process are responsible to undertake e-learning theory
every two years.
The national clinical audits and national confidential enquiries that CircleBath was eligible
to participate in are detailed below.
The records of the completed training will be kept jointly by the Hospital Blood
Transfusion Lead and the Governance Lead. Training is cascaded down to relevant
departments via the link workers.
The national clinical audits and national confidential enquiries that CircleBath participated
in, and for which data collection was completed during 2013, are listed below.
A detailed training matrix is kept on the S-drive (hospital intranet) and updated
monthly by the Blood Transfusion Lead.
The reports of one national clinical audit (National Joint Registry) were reviewed by the
provider in 2013.
CircleBath training and competency record
• Currently 93% of staff have completed specified e-learning programmes and passed.
• Currently 99% of staff have been assessed and passed as competent.
The reports of one local clinical audit (blood transfusions) were reviewed by the provider
in 2013, and CircleBath intends to take the following actions to improve quality of
healthcare provided:
• Continue to build a working relationship with the Royal United Hospital (RUH)
Transfusion Service, to improve efficiency and validation of audit data.
Bloods
CircleBath transfusion team
The hospital transfusion team has wide representation with link workers from all hospital
departments and is chaired by the Hospital Blood Transfusion Lead. More specialised
support is provided by Helen Maria, who is the Blood Transfusion Practitioner at the
RUH. The team has met quarterly during 2013 and all meetings were minuted and
all actions documented. Minutes from the meetings are distributed to all hospital
unit leads, as well as uploaded on the hospital intranet (S-drive).
Return compliance
The Blood Safety and Quality Regulations (BSQR) 2005 require trusts to ensure all
blood components are traceable from donor to recipient in 100% transfusions of blood
and plasma components. The Medicines and Healthcare Products Regulatory Agency
(MHRA) are the inspection body enforcing this law. Non-compliance can result in
prosecution of the responsible officer.
Blood safety audits
The following blood safety audits are undertaken at CircleBath hospital:
1. Monthly blood register audit – to ensure the register is always completed correctly,
all daily checks are carried out and the blood fridge disc has been changed every week.
Currently there is 100% compliance with this audit.
2. Ten per cent of all (transfused) patients’ notes will be audited every three months –
to ensure they have had a blood transfusion, to check all paperwork was completed
correctly and within relevant time scales. Currently, there is 99% compliance with
this audit.
Plans for 2014
1. Continue with quarterly transfusion meetings.
2. Continue with regular monthly and quarterly audits.
3. Run further emergency desk top scenarios.
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Review of quality
performance 2013
Continued
CircleBath Quality Account 2013/14
Internal audits
Audit planning is carried out within the governance and assurance team, and is split
into three categories:
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Audit calendar 2014
Monthly audits
Who has to complete this audit?
1. Centralised audits – Internally collected by designated staff over the course of a
year. All data is inputted into a central audit tool, in line with all other Circle sites.
The data is then collated centrally and reviewed by the Corporate Integrated
Governance Committee, to which all sites provide a representative.
Hand hygiene
Outpatients, inpatients, endoscopy,
radiology, theatre, recovery, day case,
physiotherapy, hospitality
Health and safety
All departments
2. External audits – Within the central audit tool, a number of audits are designated
to be completed by external advisors (corporate employees, with no affiliations
to a specific Circle hospital).
Environmental
hygiene/cleaning
Outpatients, inpatients, endoscopy,
radiology, theatre, recovery, day case,
physiotherapy
3. Internal audit programme – A further series of audits are completed internally at
CircleBath, to enhance clinical safety, patient care and quality of services specifically
for our hospital.
Fire warden
All departments
Clinical records
Physiotherapy, day case, outpatients,
inpatients, theatre (separate tab
for each department)
Controlled drugs
Inpatients, recovery, endoscopy, theatre
Medical gas
Theatres (porters)
Pre-assessment care
Pre-Assessment Department
Medical notes and
tracker system
Lyn Clifford (medical records team)
J
F
M
A
M
J
J
A
S
O
N
D
30 CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Clinical research
Review of quality
performance 2013
The number of patients receiving NHS services provided or sub-contracted by CircleBath in
2013 that were recruited during that period to participate in research approved by a research
ethics committee was zero.
Continued
Governance audits will also take place throughout the year – please see below for a selection
Clinical Outcomes Steering Committee
Confidential waste audit
Governance
Annual
Site-wide privacy and dignity
Governance and Nurse Lead
Annual
Site-wide fire assessments
Fire Officer
Annual
Site-wide health and safety audit
Corporate Health and Safety Lead
Annual
Site-wide infection control audit
Corporate Infection Prevention and Control Lead
Annual
Business impact assessment
Governance and all departments
Annual
Business continuity plan review
Governance, higher leadership team, facilities management
Annual
Site-wide security and information security audit
Governance and Corporate Information Governance Officer
Annual
Laser audit
Ruth Matthews
Annual
Medical gas annual audit
Facilities management
Annual
Evening information security audit
Governance
Twice a year
Variance form audit
Governance
Twice a year
CALMS registration compliance reporting
Governance
Every two months
CALMS information governance training
compliance report
Governance
Every two months
Practising privileges audit
Governance
Every two months
CircleBath still collects patient reported outcome measures (PROMs) for all NHS
patients (four key procedures), as well as in-house PROMs for most of our private patients
(eg. excluding diagnostic procedures, paediatrics, ophthalmology etc.). Quarterly reports
are generated and distributed to the general managers and clinical chairs of each Circle site
for review and action. With regards to NHS patients, there have been some changes since
August last year. We are now able to access and download our patients’ level data from the
NHS Information Centre. As more patients are added to the system each month, we will be
able to monitor and trend our performance.
HR audits
Governance
Every two months
The latest hip and knee outcomes are on the following page.
Resus trolley audit
Penny Rutter and Sarah Blake
Monthly
Resus scenarios
Penny Rutter and Sarah Blake
Monthly
Cancellations
Governance, Nurse Lead, Theatre Lead
Monthly
Returns to theatre
Governance, Nurse Lead, Theatre Lead
Monthly
Emergency transfers
Governance and Nurse Lead
Monthly
WHO compliance
Recovery, Day Surgery Unit, theatre, governance, Nurse Lead
Monthly
CQC outcome quality audit
Governance and Unit Lead (separate outcome allocated
to each unit lead)
Monthly
The vision
The Clinical Outcomes Steering Committee aims to collect and report robust clinical
outcomes and patient satisfaction that will raise the benchmark of excellence in clinical
care delivery in the independent healthcare sector.
•
•
•
•
•
Best at collecting clinical outcomes and patient satisfaction.
Best achievement in clinical outcomes and patient satisfaction.
Open and consistent publication of unfiltered patient feedback.
Best at translating what we learn to create positive impact on patient care.
Become a centre of excellence and a beacon for other organisations for
clinical outcomes.
31
32
CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Patient safety
Review of quality
performance 2013
Device alerts
Continued
A plethora of safety measures are in place at CircleBath, to ensure the highest standards
are adhered to. The following medical safety checks are made:
Hip April 2012 to March 2013
Circle
Target
UK
best
UK
average
UK
worst
1.
2.
3.
4.
5.
6.
MHRA medical device alerts – recorded electronically
MHRA field safety alerts – recorded electronically
NICE guidance
CAS alert system – recorded electronically
MHRA drug alerts – audited by our pharmacy partners and in house pharmacist
Company field safety alerts (received directly from source)
All alerts are now registered onto an electronic system; DATIX, which staff can access
and record the findings of their investigations. Results are reported on a monthly basis
to the Clinical Governance and Risk Management Committee (CGRMC). Information is
also reported to the Executive Board through assurance reports.
21.31
17.21
24.68
UK
ranking
4th
24.39
24.01
Equipment
Target
UK
best
16.01
UK
worst
12.46
20.37
18.54
Incidents are also reported electronically using the DATIX system. Full details of the
incidents are recorded, with unit leads assigned the role of ‘investigator’. All details
of the review are then recorded on the electronic record, with clear lessons learnt and
actions taken logged. The Governance Lead and Nurse Lead are able to review all records,
as can the Corporate Head of Risk.
On a monthly basis, a full audit is undertaken using the incident reports and actions plans,
to ensure that all incidents, near misses and accidents have been captured and acted upon.
The incident records and any actions logged as a result of an actual incident, near miss
or accident are presented to the CGRMC and the Integrated Governance Committee
corporately.
UK
average
18.57
Incident reporting
Additional resources or procedures stated in the action plans can also be loaded into the
electronic record as evidence.
Knee April 2012 to March 2013
Circle
All equipment is thoroughly checked and maintained either by our facilities team
or on-site engineer.
Accidents are reported to RIDDOR when appropriate. An incident form is also logged for
each accident. There was one RIDDOR reportable incident in 2013 – a member of staff fell
into a door and broke their wrist.
UK
ranking
9th
33
34 CircleBath Quality Account 2013/14
Review of quality
performance 2013
CircleBath Quality Account 2013/14
Summary overview
Patient falls
Continued
J
F
M
A
M
J
J
A
S
O
N
D Total
Accidents
4
2
4
3
3
3
3
3
3
0
8
5
41
Medication
1
5
2
6
3
1
7
7
9
11
3
3
58
Admin
8
14 1
5
1
4
10 9
4
5
7
7
75
Clinical
0
4
4
3
4
3
8
11
4
10 4
4
59
Information/security
0
1
4
4
2
7
3
1
1
0
2
0
25
Building
0
0
0
0
2
0
0
1
1
0
0
0
4
262
All patient falls are logged through our incident management system and reported to the Clinical Governance
and Risk Management Committee.
Day Surgery
Unit (DSU)
29th January
2013
Post knee arthroscopy
patient mobility being
assessed by physiotherapy.
On standing, patient was
unable to bear weight and
fell to knees. Patient claims
no harm caused, no pain
or distress felt
Patient assisted into
sitting position in chair by
physiotherapist and nurse
It is unusual for an arthroscopy
patient to have a spinal, but we
have learned that all therapists
and assistants need training
and agree a procedure of
examination to be written as a
standard operating procedure
Inpatients
21st February
2013
Moving from commode to
bed and patient slowly fell
to the floor while trying to
go to the toilet standing up
Lowered him to the floor
to make sure he did not
hurt himself. Pulled the bell
asap. Help arrived in seconds.
Observations taken by staff
nurse. Resident medical
officer (RMO) informed
of events
Enforced the need to monitor
patients regarding their ability
to mobilise safely
Inpatients
2nd March 2013
Patient found sat on the
floor by the bed. Patient
claimed he slipped when
trying to sit on bed. No
apparent injuries noted
Patient managed to stand up
with help and walk back to his
chair. Baseline observations
done: temperature is 39.3,
oxygen saturation 86% on
air, O2 inhalation given via
nasal cannula. Informed RMO
about the incident. Will review
patient as soon as possible
To ensure the bell is within
reach at all times and that
the patient uses it until safe
to mobilise independently
DSU
7th May 2013
Patient was walking to the
toilet out of pod seven, where
she stated that she thought
the curtain had a hard surface
behind it. She fell directly
onto the bed, and had not
sustained any injuries
from this
Ensured patient was not
harmed. Ensured staff
were present when patient
was mobilising (as patient
explained, she is prone
to falling). Incident form
carried out
Patient is prone to feeling
dizzy and will be supervised
if re-admitted at any stage
Inpatients
18th June 2013
Staff nurse answering
the patient’s call bell found
them kneeling on the floor
in their en-suite bathroom.
Patient had a laceration
to forehead which was
bleeding. Attempted to get
into wheelchair and became
unresponsive, so lowered
them to the floor. Rapidly
recovered consciousness and
was able to answer questions
Emergency bell pulled.
Fifteen litres of O2 given via
re-breathe mask. Patient
made comfortable with
pillow. Observations taken
and were within normal limits.
999 called for emergency
transfer to Royal United
Hospital. Wound cleaned
with normal saline and
dressing applied
Patients to be advised not
to mobilise by themselves
if feeling unwell
Examples of actions taken following incidents/near misses reported:
Outline of incident (September 2013)
• Emergency call bell system within the hospital failed following a power surge
in the local area (only inpatients affected).
Actions taken:
•
•
•
•
•
•
•
•
•
•
Nurse Lead and Operations Lead immediately led a recovery plan.
Protec contacted to attend same day and try to fix the system.
All staff made aware of the issues.
Moved all patients on the ward to the rooms closest to the nurses’ station.
Increased the number of staff on the ward.
All patients informed of the call bell failure.
Increased ward rounds by nursing staff on the ward.
Resident medical officer mobile used for emergency support.
Purchase of a remote call bell system (£8,500) should the incident reoccur.
Mobile call bell system can be used by other sites should it be required.
35
38 CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Infection prevention and control
The Infection Prevention and Control (IPC) Committee
• Infection control advice is sought from the team at Hinchingbrooke hospital – all staff are
aware of how to contact the team. Marlis Emery – infection control nurse specialist visits
CircleBath approximately four times a year for teaching sessions for the link workers and
to carry out an annual environmental audit.
• Each department has an infection control link worker who is trained to Level 3.
• Lead nurse trained to Level 3 in infection control.
• Consultant microbiologist.
The IPC Committee meets every two months throughout the year and reports into the
Clinical Governance and Risk Management Committee which, in turn, reports in to the
Executive Board.
Summary of infections
Zero
MRSA
cases
There have been no cases of bloodstream
MRSA at CircleBath hospital.
Zero
Clostridium
difficile cases
There have been no cases of Clostridium
diffiicile at CircleBath hospital.
Audit
During the course of the year, the following audits have been carried out; the results
of which are reviewed by the Lead Nurse and the unit leads, and action plans are drawn
up as required. The following audits were completed:
Hand hygiene – Carried out monthly in all areas by the link workers.
Patient, CircleBath
“My sincere thanks to the consultant,
their team and all the staff. This has
been an amazing experience and a
superb environment to recover in.”
Review of quality
performance 2013
Continued
39
40 CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Review of quality
performance 2013
Continued
Light box audits – Additional audits are also carried out by link workers using the hospital
light box.
Overall yearly hospital hand hygiene audit data results
100
Environmental cleaning – Carried out monthly in all areas by the link workers. Results
are presented at every IPC meeting.
99.5
Monthly walkaround’s – Carried out by the governance team.
99
98.5
98
97.5
97
96.5
96
J
F
M
A
M
J
J
A
S
O
N
D
Average
98.75%
Jewellery audits – These are carried out on a quarterly basis, looking at the following:
• Bare below the elbow
• One pair of stud earrings
• No stoned rings
• Hair tied back
• Closed appropriate footwear
• No watches
The results of the jewellery and uniform audits are shared with unit leads and presented
at the IPC Committee meetings.
Policies
All policies are accessed via CALMS for all staff to read.
Compliance – Monitored monthly by the governance team, and unit leads informed
of any non-compliance
Outbreaks and incidents
Average hand hygiene audit results by department
100%
Inpatients
97.83%
Day surgery
Any diarrhoea and vomiting involving patients and staff are reported to the Governance
Lead and Nurse Lead on a monthly basis – there were isolated incidents in departments,
mainly with staff throughout 2013; no trends.
100%
Theatre and
recovery
95.25%
Radiology
Education
The IPC link workers are all trained to Level 3 and are responsible for training their
departmental colleagues, and the unit leads monitor mandatory training compliance.
Any ‘mop-up’ sessions will be undertaken by the Lead Nurse on mandatory training days
as allocated.
Environment
Housekeeping has undergone significant change recently to enable the housekeeping team
to have responsibilities for certain areas and report to specified unit leads. This has only
happened in recent weeks; therefore, no data has been collected to report at present.
98.81%
Physiotherapy
99.91%
Endoscopy
100%
Outpatients
97.32%
Hospitality
Plan for 2013/14
• Policies – CircleBath will continue to ensure a good percentage of compliance of reading
the IPC policies on CALMS.
• Audit – Audit programme to continue.
• Education – CircleBath will continue mandatory training and induction for all staff.
• Cross-site communication – Work with the infection control team in Hinchingbrooke
to decide on a clear policy for MRSA screening.
41
© Foster + Partners
42 CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14 43
Pressure ulcers
Between March 2013 and March 2014, we have had one reported incident of a patient
acquiring a pressure ulcer during our care. This was a Grade 2 pressure ulcer located
in the natal cleft.
Actions taken:
Inpatients have devised a new pressure area care plan on the ward, which has helped
us to ensure pressure area sores are consequently not developing.
If they do develop, we are acting on it immediately and putting equipment/dressings,
turning charts in place to ensure they do not break down further.
Training has also been provided to inpatient staff.
VTE risk assessments
A VTE risk assessment is undertaken for all patients while in our care at CircleBath. This is
audited on a monthly basis; which involves reviewing 10% of patient notes for that month.
Any issues raised during the audits are acted upon swiftly by the Clinical Nurse Lead.
Safety thermometer
CircleBath began participating in the safety thermometer scheme in September 2012.
Every month, data is formally submitted. To date (March 2014), no harms have been
recorded.
Returns to theatre
During 2013, nine patients returned to theatre following their procedure, from 5,331
anaesthetic episodes. Patient transfer, therefore, represents 0.17% of total patients
having a surgical procedure.
Patient, CircleBath
“Everything has been brilliant; very, very
comfortable and relaxed. Many thanks.”
Month
Number
January
0
February
0
March
1
April
1
May
0
June
0
July
2
August
1
September
1
October
1
November
2
December
0
Review of quality
performance 2013
Continued
44 CircleBath Quality Account 2013/14
Review of quality
performance 2013
Continued
CircleBath Quality Account 2013/14
Patient readmissions
Patient Safety Awareness Month
During 2013, 15 patients were readmitted to the hospital within 29 days of their procedure,
from 5,331 patient anaesthetic episodes. Patient readmissions, therefore, represent 0.28%
of total patients seen.
During October 2013, every Circle hospital participated in a co-ordinated Patient Safety
Awareness Month. This consisted of the following:
Month
Number
January
1
February
0
March
2
April
1
May
1
June
1
July
1
August
1
September
2
October
1
November
2
December
2
• Noticeboard development to promote patient safety.
• Annual Health and Safety Audit of the hospital.
• Executive Board members visited the hospital and spoke to staff and patients
about their experiences.
• Training sessions for staff
– The six Cs (care, compassion, competence, communication, courage and commitment)
– SBAR – A patient safety communication technique
– How to report near misses and incidents
– Patient feedback and hospitality
– Wound care
– Stop the Line safety initiative
• Patient champion interviews with patients with a focus on safety.
• Safety-related quizzes for all staff.
• A ‘safety superhero’ competition for all staff to promote an initiative they had implemented
in their departments regarding patient safety.
• A one-day patient safety masterclass held at our head office for the winners of the superhero
competitions from all Circle sites.
• Additional governance audits held throughout the month.
Patient experience
Feedback cards
Patient transfers
During 2013, 15 patients were transferred out of the hospital, from 5,331 patient episodes.
Patient transfers therefore represent 0.28% of total patients seen.
All patients are asked to complete a feedback card regarding their experiences at the hospital.
Our patient recommendations percentage for 2013 can be seen below:
Month
Patient recommendations
Month
Number
January
100%
January
2
February
99.6%
February
2
March
99.8%
March
2
April
99.8%
April
2
May
99.7%
May
1
June
99.7%
June
3
July
99.4%
July
0
August
99.9%
August
2
September
100%
September
0
October
99.8%
October
0
November
99.9%
November
1
December
100%
December
0
CQUIN
We were within a national contract for six of our main clinical commissioning groups (CCGs).
Part of this contract requires us to be part of the national Commissioning for Quality and
Innovation (CQUIN), in addition to local ones negotiated with these commissioners.
45
46 CircleBath Quality Account 2013/14
Review of quality
performance 2013
Continued
CircleBath Quality Account 2013/14
About you
Is this your first patient stay?
Your
feedback
is
appreciated
On what basis did you receive treatment?
(Total patient replies)
Please tick the relevant box for your visit
n Physiotherapy
n Radiology n Day case
n Pre-assessment
n Outpatient
n Inpatient
47
67
n NHS n Private
Your consultant’s name Your consultant anaesthetist’s name
What did we do well?
27
What could we have done better?
Would you recommend us to friends or family? n Yes
n No How likely is it that you would recommend us to friends or family?
n Extremely likely n Likely
n Neither likely nor unlikely n Unlikely n Extremely unlikely n Don’t know
9
How did you hear about CircleBath? n Friends or family n TV n Internet search engine, eg. Google n Print advertising, eg. magazine n Other, please specify
Alternatively, or for further comments, please email Shelagh.Meldrum@circlepartnership.co.uk
Email (optional):
Thank you
n
The CircleBath team
Name (optional):
We publish the majority of feedback, anonymised, on our website. Please tick here if you do not wish your comments to be published.
Yes 79%
No 21%
NHS 67
Insurance 27
Self-pay 9
What was the main influence for choosing CircleBath for your treatment?
Inpatient survey
(Total patient replies)
The 2013 inpatient satisfaction survey was conducted over a four-week period from
16th September to 14th October 2013.
Feedback forms were given to inpatients, both private and NHS, to complete prior
to departure.
112 completed forms were received during the survey period; this compares to 28
during the same period in 2012.
36 23 21 17
6
4
1
Consultant 36
Personal
recommendation 23
GP 21
Other 17
Insurance 6
Website 4
Advertisement 1
48 CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14 49
Review of quality
performance 2013
Continued
Pre-admission
Overall, how easy was it to contact
CircleBath when you needed to?
Those who attended a ‘joint school’ prior
to admission for surgery, how useful did
you find the information provided?
Your nursing care
What was your overall impression
of your nursing care?
Cleanliness
How would you rate the cleanliness
of your room? (Total patient replies)
(Total patient replies)
32
89
5
19
2
Very easy 32
Fairly easy 5
Not very easy 2
Not at all easy 0
Your admission
How would you rate the welcome you
received from reception staff on arrival?
Excellent 83%
Very good 13%
Quite good 4%
Very useful 66.7%
Fairly useful 22.2%
Not very useful 11.1%
Your consultant
What was your overall impression
of your consultant care?
Hospital and catering
How would you rate the friendliness and
helpfulness of the hostess? (Total patient replies)
96
Excellent 81%
Very good 15%
Neither/nor 3%
Quite good 1%
Excellent 93%
Very good 7%
13
Excellent 96
Very good 13
1
Excellent 89
Very good 19
Quite good 1
How would you rate
the response to requests?
(Total patient replies)
90
16
Excellent 90
Very good 16
50 CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Review of quality
performance 2013
Continued
Hospital and catering (continued)
How would you rate the variety/choice of food?
Your overall views
How likely are you to recommend
CircleBath in the future?
Overall, how would you rate the
quality of service at CircleBath?
Excellent 86
Very good 16
Quite good 4
Neither/nor 2
86
16
Going home
Did you receive appropriate advice for your care at home?
Yes, completely 93%
Yes, to some extent 6%
Not applicable 1%
No 0%
4
2
Definitely would 91%
Very likely 6%
Quite likely 2%
Neither/nor 1%
Excellent 88%
Very good 10%
Quite good 2%
Neither/nor 0%
51
52
CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Positive feedback
“Just wish I was staying longer!”
“Everyone I had dealings with was excellent and an asset; I would
definitely recommend Circle to anyone.”
“I found all staff very competent, friendly and helpful. It wasn’t
a planned stay, but made very comfortable, and it has been a
good experience.”
“I would like to thank all members of staff for their excellent care and
attentiveness – I felt very well cared for and safe in their care.”
“It would be inappropriate to name individual staff as they were all,
without exception, excellent. Very good service from physiotherapists.
Clearly, hospitality and nursing staff have been well trained in putting
people at ease, and they instil confidence. They have good people skills.”
“Everything was first class and all staff are polite and helpful.”
“CircleBath is an amazing hospital and NHS patients are very fortunate
to be able to use it.”
“Without exception, all staff members, from the surgeon to the theatre
assistant, to the head nurse on the ward to the cleaners, all gave what is
expected of them and more, to ensure all my needs were met. Nothing
was ever too much trouble day or night – a big heartfelt thank you
to all.”
“Treatment and care exceptional, staff caring and friendly;
will certainly recommend CircleBath.”
Patient, CircleBath
“If you have to come into hospital, it’s a
great place to be. Friendly, helpful staff
on each stay. Hostesses could not be
more accommodating.”
53
54 CircleBath Quality Account 2013/14
Review of quality
performance 2013
Continued
CircleBath Quality Account 2013/14
Areas for improvement
•
•
•
•
•
•
•
•
•
•
•
•
1. On arrival at the outpatient reception, were you greeted promptly?
Headphones to listen to TV.
I was not told what to expect from the operation.
A clock and pictures on the walls
IT phones are difficult for the elderly to use.
More attention to the correct fitting of the sling.
Would have been good to see the consultant on day of discharge.
The bathrooms have a motion sensor light that seems to stay on for 25 minutes –
a nuisance at night.
Discharge process – I was told to be ready at 2pm but wasn’t seen until 4pm.
Explain to all staff what a yellow ‘at risk’ armband means.
Tell hostess staff to explain why they cannot fulfil an order (too late etc.),
as it appears very rude to be ignored.
Long wait before surgery was very stressful.
Found the TV controller difficult to understand.
Examples of actions now in place
Yes
Yes to some extent No
N/A
275
3
2
2
2013 97.6%
1
0.70%
0.70%
2012 99.3%
0.7%
2011
1.7%
97.7%
2. On arrival at the outpatient reception, were you greeted courteously?
Yes
Yes to some extent No
N/A
253
2
27
0.70%
9.60%
0.6%
6.1%
2013 89.70%
Action
Responsible
Closed by
2012 100%
Clocks for bedrooms
Hospitality
January 2014
2011
Review of patient entertainment system
remote control
IT
December 2013
Improve the pre-admission room checks
to ensure lights, telephones etc. are in full
working order
Housekeeping
Hospitality
December 2013
Discuss with Artscope the introduction
of art to the inpatient floor
Hospitality
February 2014
Greater communication with hostesses and
patients regarding visitor dining and ordering
‘off menu’
Hospitality
December 2013
Full survey results to be shared with inpatient
nursing team at Patient Hour
Inpatients
93.3%
3. How long did you wait before you were seen by your consultant?
Seen on time
or early
0–15
minutes
15–30
minutes
30–60
minutes
181
83
17
1
2013 64.25%
29.40%
6%
0.35%
2012 59%
26%
12%
8%
2011
27%
8%
4%
60%
Over 60
minutes
December 2013
4. If your appointment was delayed, were you kept informed?
Outpatient questionnaire 2013
Yes
No
N/A
14
41
46
2013 14%
40%
46%
2012 13%
40%
47%
2011
3.7%
94.8%
Number of patients surveyed: 282*
Detailed breakdown of results, showing the number of different responses for each question,
expressed as percentage of all patients and compared to previous year.
1.5%
5. Was your consultant polite?
Domain: Maintaining trust
Attribute: Show respect for patients
*
In 2012, we surveyed 271 patients.
Excellent
Very good
Good
261
20
1
2013 92.65%
7
0.35
2012 91.7%
7.7%
0.6%
2011
9.6%
0.3%
89.5%
Fair
0.3%
Poor
N/A
0.3%
55
56
CircleBath Quality Account 2013/14
Review of quality
performance 2013
Continued
CircleBath Quality Account 2013/14
6. Did your consultant make you feel at ease in his/her presence?
10. Did your consultant involve you in decisions about your treatment?
Domain: Communication partnership and teamwork
Attribute: Establish and maintain partnership with patients
Domain: Communication partnership and teamwork
Attribute: Establish and maintain partnership with patients
Excellent
Very good
Good
256
22
4
2013 90.80%
7.80%
1.40%
2012 89.0%
9.0%
2.0%
2011
11.6%
0.6%
87.5%
Fair
Poor
N/A
0.3%
Excellent
Very good
Good
Fair
235
29
7
1
10
2013 83.39%
10.28%
2.48%
0.35%
3.50%
2012 85.2%
9.2%
4.0%
0.5%
1.1%
2011
12.0%
2.3%
0.6%
3.8%
81.3%
Poor
N/A
7. Did your consultant listen to you and answer your questions?
11. Did you have clarity of arrangements regarding the next stage of treatment?
Domain: Knowledge skills and performance
Attribute: Apply knowledge and experience to practice
Domain: Communication partnership and teamwork
Attribute: Communicate effectively
Excellent
Very good
Good
252
26
2013 89.45%
N/A
Excellent
Very good
Good
Fair
3
1
232
32
9
1
8
9.20%
1%
0.35%
2013 82.35%
11.30%
3.20%
0.35%
2.80%
2012 87.0%
9.0%
4.0%
2012 84.5%
11.0%
2.3%
1.1%
1.1%
2011
11.0%
0.9%
2011
10.5%
3.2%
1.1%
3.2%
87.5%
Fair
Poor
0.3%
0.3%
8. Did you have confidence at your consultant’s ability?
Domain: Maintaining trust
Attribute: Show respect for patients
Excellent
Very good
253
28
1
2013 89.75%
9.90%
0.35
2012 89.0%
9.0%
1.4%
0.6%
2011
10.5%
1.7%
0.3%
87.2%
Fair
N/A
12. Were you confident that your consultant will keep information about you
confidential?
Domain: Communication partnership and teamwork
Attribute: Establish and maintain partnership with patients
Good
82.0%
Poor
Poor
N/A
Strongly
agree
Agree
Neutral
250
22
6
4
2013 88.70%
7.80%
2.10%
1.40%
2012 87.4%
11.4%
0.7%
0.5%
2011
16.0%
1.2%
1.5%
81.3%
Disagree
Strongly
disagree
N/A
9. Did your consultant explain your condition and treatment?
Domain: Communication partnership and teamwork
Attribute: Communicate effectively
13. Were you confident that your consultant was honest and trustworthy?
Excellent
Very good
Good
Fair
247
28
5
1
1
2013 87.60%
9.90%
1.80%
0.35%
0.35%
2012 87.8%
10.0%
1.5%
0.7%
2011
11.6%
2.6%
0.6%
84.0%
Poor
N/A
1.2%
Domain: Communication partnership and teamwork
Attribute: Establish and maintain partnership with patients Strongly
agree
Agree
Neutral
255
20
2
5
2013 90.50%
7%
0.70%
1.80%
2012 88.9%
10.3%
0.8%
2011
15.4%
0.9%
82.5%
Disagree
Strongly
disagree
N/A
1.2%
57
58 CircleBath Quality Account 2013/14
Review of quality
performance 2013
Continued
CircleBath Quality Account 2013/14
Patient choice questionnaire
14. Was your consultant prepared for your appointment?
Domain: Knowledge skills and performance
Attribute: Apply knowledge and experience to practice
In the first few months of 2014, we asked patients attending an outpatient appointment
about why they chose CircleBath as their hospital. Results are shown below:
Strongly
agree
Agree
Neutral
Disagree
253
22
1
2
4
2013 89.75%
7.80%
0.35%
0.70%
1.40%
2012 86.7%
10.7%
1.4%
0.7%
0.5%
2011
15.1%
1.5%
1.5%
0.5%
80.5%
Strongly
disagree
N/A
What was the most important factor when making the decision to choose to be seen
at CircleBath? (Total patient replies)
15. Were you confident about the hospital’s ability to provide care?
Yes
No
280
2
2013 99.30%
2012 99.6%
2011
I wanted to be seen as soon as possible, first appointment was at CircleBath 107
I had heard about CircleBath’s reputation 93
I wanted to see a specific consultant 91
My GP/GP practice recommended CircleBath 80
Family/friend recommendation 65
Other 33
The five-star hotel experience 19
No response
0.70%
0.4%
97%
2.9%
16. Would you be prepared to see this consultant again?
Yes
281
2013 99.65%
No
No response
1
0.35%
2012 100%
2011
98%
1.7%
Complaints and concerns
A complaint is defined as a written communication, detailing dissatisfaction with any
aspect of the patient’s treatment before, during and after their procedure, and includes all
aspects of their experience. These, for example, may include catering, ambience, nursing
care and environment. Concerns, whether verbal or written, are also addressed, recorded
and reported in the same manner as complaints in this report, although clearly defined.
In total, during 2013, we received:
• fourteen formal complaints
• one formal complaint re-opened from 2011
• seven formal concerns
All of the formal complaints were acknowledged within three workings days, with the
exception of one, which was acknowledged within four workings days (awaited confirmation
from legal as complaint required re-opening).
Formal complaints
• 93% of formal complaints acknowledged within three working days
• 100% of formal investigations and subsequent responses sent within 20 working days
Of these 14 formal complaints, four were upheld, one is still under investigation, and one
has failed local resolution and escalated to corporate and legal (originally opened in 2011).
Ten formal complaints were not upheld.
Formal concerns
• 100% of formal concerns acknowledged within three working days
• 100% of formal investigations and subsequent responses sent within 20 working days
Of these seven formal concerns, six were not upheld and one was upheld.
59
60 CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Review of quality
performance 2013
Actions resulting from complaints and concerns
Introduced in 2012 as a result of suggestions made during a review of our complaints
procedure is an action plan. The action plan ensures that, like our patient feedback plan,
all causes of complaints and concerns are not just shared with the team lead investigating
but shared on a broader scale and that they receive, if appropriate, their own action plan.
It is felt that the learning experience of complaints should be shared by unit leads with
their teams during patient hours. Examples of some of these actions include:
Continued
Complaints and concerns
Received by month 2013
1
1
1
1
1
1
2 1 1 1 1 2 1 1 1 1 2 2
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Causes of patient complaint
Sep
Oct
Nov
Complaint
Concern
Dec
Causes of patient concern
Medical treatment 43%
Consultant 14%
Anaesthetist 11%
Administration 7%
Telephony 7%
Environment/design 7%
Insurer 4%
Staffing 4%
Hospitality 3%
Anaesthetist/BAG 33%
Consultant 17%
Environment/design 17%
Insurer 17%
Medical treatment 16%
Complaint/concern
Action
Patient attended for bloods to be taken,
after difficulty getting blood. Resident
medical officer (RMO) held hand under
warm water – patient complained of water
temperature being too high and RMO
forcefully holding hand under water
Outpatients nursing team and RMOs
to be advised that if this process is used,
to check with patient if temperature is
acceptable. Facilities management checked
flow rate and temperature, and recorded
well within guidelines (42 degrees)
Dissatisfaction with cleanliness of
day case toilets and being prescribed
incorrect medication (claimed given
spray when should have had drops)
Hourly toilet checks and sign off reintroduced. Prescription issue raised with
day case team as drops or spray are both
acceptable; however, this was not advised
to patient at the time
Cold call from marketing company
received via the phone in patient’s
room on the inpatients ward
All inpatient direct dial extensions have
since been added as barred telephone
numbers in the Telephony Preference
Service list so no other calls such as
this occur again
Lack of consideration with regards to a
patient’s hearing and balance disability
Patients with hearing difficulties are now
to be offered consultation in day case in
private room. This matter was raised at
CircleBath’s Clinical Governance and Risk
Management Committee. Day Surgery Unit
side room is now in use for this purpose
61
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CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14 63
Patient, CircleBath
Staff engagement
“Made me feel very
welcome. Could
not do enough
for me and my
daughter. Felt
very comfortable.
Many thanks.”
Staff awards
Sarah Jones
Our Hospitality Lead at the hospital recently won the Bath Chronicle South West Business
Award for ‘Best Employee’.
What sets CircleBath apart from other private hospitals is that we constantly strive to
create a better experience in a better environment for our patients. This is achieved on many
levels but, most importantly, Sarah Jones and the hospitality team achieve this by providing
a welcoming and friendly face for all patients from the moment they arrive at the hospital,
to the time they leave and beyond. When you bear in mind that an average of 1,000 private
and NHS patients are seen at CircleBath on a weekly basis, this takes a huge commitment
from everyone. Sarah has, without doubt, enhanced the overall success of CircleBath.
Sarah Jones’ commitment to delighting our patients and inspiring the team she is part of,
has been instrumental in CircleBath’s success over the past three and a half years, since the
hospital opened. She is absolutely committed to helping our patients and their visitors feel
more comfortable and relaxed during their visit to the hospital, whether they are here for a
20-minute consultation or a week-long stay, following an operation. She was instrumental
in the setting-up of Circle’s gift shop concession in the atrium which feels more like a gift
shop in a boutique hotel and has been hugely appreciated by so many visitors. Nothing is
ever too much trouble for Sarah as she continues to lead her team to embrace the ethos
of partnership and transparency, which is so much part of CircleBath hospital. Her constant
smile is enjoyed by all.
Feedback
“From the moment the hospital opened, she has been, for me, the face and the image that has
set the tone on arriving in the building. Her cheerfulness, kindness and willingness to work hard
are known to everybody, but her contribution is greater than this. Her sense of humour and the
rapport she has with all of us who work here genuinely infects the whole team. I do not believe
that the atmosphere would have developed in the way that it has without her. Not only do we
all get the benefit of this, but I am sure the patients do as well.”
Consultant Shoulder Surgeon
“Sarah has the most sincere attitude towards patients. Always warm, kind, funny and, most of
all, empathetic. Nothing is ever too much trouble for patients or staff for Sarah. The gift shop
has been a huge success, distracting patients from quite a stark environment. This has gone
from strength to strength. My own personal view of Sarah is she is the best manager I have
ever known, and every day is a pleasure to be around her. She is more a friend than a manager.
We are always considered with the holiday rota. Sarah would rather go out of her way to make
things possible for us all. Patients comment on how jolly and cheerful we all are, and I believe
this is all down to one person, Sarah. Since Sarah has taken on the role of manager, we as a team
have thrived. We will all go out of our way to help and support Sarah. Sarah recognises patients,
greets them, has a chat, has been offered lunch numerous times, which is a very special treat
for a very special lady. Sarah is just a wonderful lady who deserves the highest credit for all that
she achieves. What would I change about Sarah? Absolutely nothing. She has brought warmth
to all our hearts and has brought out the best in us all.”
Hostess at CircleBath
Review of quality
performance 2013
Continued
64 CircleBath Quality Account 2013/14
Review of quality
performance 2013
Continued
CircleBath Quality Account 2013/14
Sandra Jones
CircleBath is proud to announce that Sandra Jones, Cancer Treatment Nurse Lead, has won
the Nursing Practice award at the Laing & Buisson 2013 Independent Healthcare Awards.
Cancer Treatment Nurse Lead, Sandra Jones, established the Oncology Service at CircleBath
from scratch. Through her dedication to excellence for both clinical standards and patient
experience, she has attracted the highest calibre oncology consultants who were inspired
by Sandra’s vision and Circle’s credo, we are the agents of our patients.
Sandra makes herself available to all her patients 24/7, offering advice, comfort and
encouragement. With many years as a specialist oncology nurse, her knowledge is second
to none and instils confidence in her patients. To allow her patients access to the latest
technology and information, Sandra has forged links with the local trust and Dorothy
House; a local charity hospice. She has also developed links with the London Clinic to
utilise their CyberKnife technology.
Sandra has recruited an additional member of staff who she is mentoring, thus promoting
the continued culture of excellence.
Although Sandra works in a small department, she works across all departments,
supporting patient pathway developments, clinical competency projects and new
standard operating procedures.
Sandra also works tirelessly on cancer charity events at the hospital; from raising
awareness to organising fun events, such as car washes with the Bath Rugby team. She
has raised a significant amount of money to date. As part of the charity events, Sandra
presents awareness seminars to visitors and members of staff, to raise the profile of
oncology and to allow staff to understand key signs and symptoms, and how to carry
out checks.
Patient feedback quote
“Sandra was there in November 2011 when I was diagnosed with breast cancer. She was there
for every meeting with my surgeon, my oncologist, and during my chemotherapy treatment.
Sandra was there for me no matter what day it was, and always had time to answer my questions.
Sandra has a way with you that helps you focus on what you can do to help yourself through
this ordeal and also make you laugh. Her sense of fun is refreshing but, more importantly, her
time and understanding does wonders to help you feel better in yourself. She has a depth of
knowledge she will share with you to get you through each new worry. She won’t answer a
question she does not know the answer to, but would come back to you as soon as she could when
she did have the answer. The truth is, you feel you can trust her to help you navigate between
the emotions and the specialists who are taking great care of you when you feel overwhelmed.
All in all, I met an excellent cancer care nurse back in November 2011, and ended up with a
trusted friend by August 2012.”
Consultant Oncologist at CircleBath
“Sandra has done an amazing job in establishing a new oncology service. Not only has she been
instrumental in setting up a smooth and efficient chemotherapy service, but also provides much
personal support and encouragement for the patients, guiding them through the whole process
of treatment from surgery to palliative oncology support. Her approachable and helpful manner
is much appreciated by the patients.”
Food hygiene inspection
On 11th February 2014, the kitchen
received an unannounced food premises
inspection by our local food safety officer.
The main purpose of the visit was to ensure
that there are no contraventions of food
safety legislation, and to ensure that food
is being prepared, handled, stored and
distributed in a safe and hygienic way.
During the visit, he inspected the
kitchen, deli and inpatient pantry for
general cleanliness and condition. He
also interviewed staff so he could gain
an insight into their level of knowledge
of food handling and cleaning procedures.
Our Head Chef provided all relevant
documentation, eg. the food safety plan,
temperature records, supplier audits,
cleaning schedule, external contractor
visit records, and probe calibration records.
The workflow of the kitchen, from food
arriving to storing, preparation, cooking
serving and cleaning was also discussed.
We are pleased to report we were awarded
a food hygiene rating of five stars, which
means we are compliant with food hygiene
and safety at the highest level and it shows
strong confidence in management and
control procedures.
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66 CircleBath Quality Account 2013/14
Review of quality
performance 2013
Continued
CircleBath Quality Account 2013/14
Staff continued professional development
Our staff are our greatest asset. Hence we invest in their continued professional development.
Mandatory training
A suite of mandatory training courses are attended by all staff; compliance being
monitored by unit leads and our governance team. Training days are provided throughout
the year, by both internal and external trainers.
Clinical training
Examples include: • the deteriorating patient – for adults and paediatrics
• epidurals
• critical care
• male catheterisation
• dignity and privacy
• maintaining records
• consent and the Mental Capacity Act
Resus training provided by a clinical skills nurse
Adult basic life support
• Recognition of cardiac arrest in the adult.
• Adult Basic Life Support as per Resuscitation Council UK Guidelines 2010.
• Recognition and emergency treatment of the choking adult as per Resuscitation
Council UK Guidelines 2010.
• Safe positioning of the adult into the recovery position.
Paediatric basic life support
• Recognition of cardiac arrest in the child.
• Paediatric basic life support as per Resuscitation Council UK Guidelines 2010.
• Recognition and emergency treatment of the choking child as per Resuscitation
Council UK Guidelines 2010.
• Safe positioning of the child into the recovery position.
• Familiarisation and contents of the Broselow system.
Immediate life support (ILS)
Licensed by the Resuscitation Council as an approved ILS training centre from February 2013.
•
•
•
•
•
•
•
Causes and prevention of cardiac arrest lecture.
ABCDE approach to assessing a patient lecture.
Resuscitation Council UK ALS algorithm lecture.
Initial resuscitation and defibrillation demonstration and practical.
Emergency treatment of airway and breathing problems demonstration and practical.
Scenario-based practical.
Candidates are continually assessed throughout the course.
Recognition and treatment of the deteriorating adult (RaToDa)
Following the Resuscitation Council UK Guidelines 2010 and reference to Treating the
Critically Ill Patient by Philip Jevon.
• Identify a variety of likely conditions which cause a deterioration in an adult patient
at CircleBath. Revise and understand the emergency treatment of these conditions –
lecture and group discussion.
• Demonstrate and understand a systematic A–E assessment of an adult patient –
demonstration, lectures and practical.
• Discuss when and how to call for help at CircleBath.
Recognition and treatment of the deteriorating child (RaToDchi)
Following the Resuscitation Council UK Guidelines 2010 and reference to Advanced
Paediatric Life Support Manual by the Advanced Life Support Group (ALSG).
• Pre-course quiz of basic paediatric emergency knowledge.
• Understand basic anatomical differences of a child – lecture and discussion.
• Identify a variety of likely conditions which cause a deterioration in a paediatric patient
at CircleBath. Revise and understand the emergency treatment of these conditions –
lecture and group discussion.
• Demonstrate and understand a systematic A–E assessment of a paediatric patient –
demonstration, lectures and practical.
• Discuss when and how to call for help at CircleBath.
Anaphylaxis
•
•
•
•
Signs and symptoms of anaphylaxis – lecture and discussion.
Basic aetiology of anaphylaxis – lecture and discussion.
Revision of Resuscitation Council UK Anaphylaxis algorithm – lecture and discussion.
Practical scenario of anaphylactic emergency.
Advanced life support algorithm and defibrillator UPDA
Revision of Resuscitation Council UK Advanced Life Support algorithms – lecture
and discussion.
• Tachycardia
• Bradycardia
Practical use of Phillips MRX defibrillator for cardioversion and pacing.
Scenario-based practical.
All staff e-learning courses
We have also provided our staff with online training courses for 2014, to further develop
their knowledge and talents and allow them to train at a time and in a place convenient
to them.
Courses available for all staff
•
•
•
•
•
•
•
•
•
•
•
•
NSPCC Child Protection Awareness in Health
NSPCC Safer Recruitment
NSPCC Child Sexual Abuse
NSPCC Child Neglect
NSPCC Child Protection – Staying Aware
Protecting Vulnerable Adults
Safeguarding Vulnerable Adults
Personal Safety
An Introduction to Equality and Diversity
Health and Safety
Safety in Business – Safeguarding People and Productivity
An Introduction to Effective Team Work
67
68 CircleBath Quality Account 2013/14
Review of quality
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Continued
CircleBath Quality Account 2013/14 69
The CQC
CircleBath has been inspected by the Care Quality Commission (CQC) on two occasions
during 2013/14, as unannounced inspections.
CircleBath is fully compliant with the CQC.
CircleBath is required to register with the Care Quality Commission and its current registration
status is ‘approved’. CircleBath has the following conditions on registration – none.
The Care Quality Commission has not taken enforcement action against CircleBath during
2013 or 2014 to date.
CircleBath has not participated in any special reviews or investigations by the CQC during
the reporting period.
The CQC did perform an unannounced inspection in January 2014, the findings of which
can be located on their website.
Data quality
The quality of our data is very important to us, as it could not only affect patient safety
and outcomes, but also impacts our improvement plans. CircleBath will be taking the following actions to improve data quality:
• Improve the validation process of data
• Increase the auditing of data quality and collection
• Increase training process of staff to ensure accurate data collection
NHS number validity
CircleBath submitted records during 2013 to the Secondary Uses Service for inclusion
in the Hospital Episode Statistics, which are included in the latest published data.
The percentage of records in the published data which included the patient’s valid NHS
number was: • 100% for admitted patient care;
• 100% for outpatient care; and
• Not applicable for accident and emergency care.
The percentage of records in the published data which included the patient’s valid
General Medical Practice Code was:
• 100% for admitted patient care;
• 100% for outpatient care; and
• Not applicable for accident and emergency care
Information governance
attainment levels
CircleBath places great importance on information security (IS) and aims to protect all
patient, organisational and staff data. We also recognise that information is at its most
valuable when accurate, reliable and accessible. IS is a keystone element of clinical and
corporate governance, as well as service planning and patient care.
To ensure the highest standards of compliance, CircleBath has implemented a suite of IS
processes, forums and monitoring systems, as well as instilling a culture of accountability
and always providing the best for our patients with regards to their care and information.
This document aims to clearly demonstrate the robust processes in place with regards
to IS and our plans for the next 12 months. This strategy however, cannot be viewed in
isolation; being closely linked to all aspects of business activity and our responsibilities
towards our patients.
The aims of this strategy
1. To support the provision of high quality care by promoting the correct and safe
use of information in line with legislation.
2. To encourage responsible staff who work together and promote shared learning.
3. To develop a range of monitoring tools which continuously improve compliance.
4. To enable CircleBath to understand its own performance, learn from previous
incidents and implement improvement plans.
5. Reinforce an active IS culture and ethos among the staff.
6. Minimise the risk of information breaches.
7. Minimise the inappropriate use of information.
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CircleBath Quality Account 2013/14
CircleBath Quality Account 2013/14
Review of quality
performance 2013
Continued
CircleBath objectives for 2014
Protocols in place
Objective
Plan
Monitoring
Target date
Owner
Protocol
Current view
Improvements
Target date
Owner
Develop additional audits
relating to information
governance (IG)
Shared learning between
sites regarding audits.
Incorporate higher
leadership team
(HLT) based audits
Audit compliance to
be assessed by General
Manager and Head of
Governance and Risk
(Corporate)
Ongoing
CAM
Business continuity
Business continuity/major
incident plan in place. Available
to all unit leads via the S-Drive
Business continuity
toolkit to be updated
January 2014
CAM
CALMS IG training audits
to be undertaken and
shared with unit leads
Training effectiveness to
be monitored.
January 2014
Business continuity review day
held – CGRMC and Executive
Board Chair as well as HLT. Plans
reviewed and additions made
Monitoring of business
continuity events through
DATIX – and reported
through the CGRMC
and the Executive Board
Fire desktop drills to be
carried out
Further night/evening
desktop drill to be arranged
Annual inspections for fire,
health and safety, and infection,
prevention and control
Compliant
Annual business impact
assessment completed
Compliant
Incidents now reported
through DATIX
Continuous training
Monthly reviews of incidents
Compliant
Quarterly overview report sent
to General Manager for sign-off
Compliant
Security team in place during
the evenings and weekends
Embed security team
who have now been
brought in-house
Renewal of Caldicott
Guardian training
for JS and CAM
Compliance figures to be
reported to the Clinical
Governance and Risk
Management Committee
(CGRMC)
Improve unit lead
data reporting
Ongoing discussions with
unit leads for continuous
data improvements
Ongoing
Successfully complete
the IG toolkit, including
an improvement on last
year’s performance score
IG toolkit initial training
has taken place. Identify
whether further training
needed. Planned approach
to completing the tool –
Circle wide
Ongoing – review of score
achieved in 2013
Encourage to report
on DATIX
Ongoing review
Increase awareness of IG
issues among the staff
Trending of incidents
JS/CAM
Ongoing
March 2014
August 2014
CAM, JS
CAM
Incident
management
CAM
Physical security
Staff leaflets updated
Any incidents raised through
the normal reporting route
Notice board for staff
CAM
March 2014
CAM
SB
CAM
2014
CAM
Ongoing
N/A
Further configurations
completed as and
when necessary
Annual information security (IS)
audit reviews physical security
HLT walkarounds every two months
Risk management
Strategic risk register completed by
Governance Lead on a monthly basis
Register sent to Executive Board
and Integrated Governance Board
and CGRMC
IS risks and incident reported on
corporate governance dashboard
Policies
IS policies in place – available to all
staff electronically through CALMS
CAM
71
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CircleBath Quality Account 2013/14
Review of quality
performance 2013
Continued
CircleBath Quality Account 2013/14
Training
Current training delivery
•
•
•
•
•
Annual IG training pack with payslips
CALMS IG training modules – for all staff
Royal College of Nursing privacy and dignity training (launched December 2011)
Mandatory training – data protection module on EDUCARE
Caldicott Guardian training
Plans for 2014
• Root cause analysis training for Nurse Lead and Governance Lead
• Compliance report writing
• Review of additional e-learning tools for unit leads
Clinical coding error rate
CircleBath was subject to the ‘payment by results’ clinical coding audit in July 2013,
which is an annual assessment.
Capita provided the auditors for the above assessment.
Involvement in local networks
CircleBath hospital works constructively with commissioners and other partners to develop
effective and integrated care pathways that improve the health of the local community.
There is an established Clinical Governance and Risk Management Committee which
monitors and reviews performance, governance and quality standards in line with other
external organisations.
Network partners
•
•
•
•
•
Bath and North East Somerset (BaNES) LINk Network
NHS Wiltshire, Avon and Somerset – controlled drugs compliance
Cancer Networks
Quality Network
ALS Provider Network
Key achievements
• February 2014 – accreditation achieved with ISO 27001 with zero non-conformities
• Passed CQC unannounced inspection in January 2014
• Retained our environmental health hygiene five-star award
Clinical Commissioning Group (CCG) quality visit: December 2013
Undertaken by: Clinical Director, BaNES CCG; Designated Nurse for Safeguarding
Children, BaNES CCG; Lay Member, Chair Audit and Assurance Committee, BaNES CCG.
BaNES CCG undertook a formal assurance visit to CircleBath on 19th December 2013. The CCG were shown around the hospital, including the recovery unit and the inpatient ward,
where they were able to talk to staff and patients. They reported that they were impressed
by the quality of the environment.
A number of topics were discussed, including:
• any patients with dementia are nursed 1:1.
• no cases of Clostridium difficile or MRSA.
• currently 140 consultants work from Circle. Any new consultants are subject to
thorough checks before starting to work from the hospital.
• regular internal audit of patient notes takes place.
• regular resuscitation training takes place in different areas of the hospital, although
an arrest has not yet happened.
• children have their own room and parents remain overnight with children under
16 years. Young people over 16 years remain overnight without their parents.
In summary, the CCG reported that they were impressed by the facilities offered and the
comprehensive processes which underpinned the governance within the organisation.
73
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CircleBath Quality Account 2013/14
Thank you
Thank you for taking the time to read our Quality Account. We hope you
found it interesting and useful in understanding our commitment to quality
for our patients and partners.
Should you have any further questions, we would be pleased to hear
from you.
Please contact our General Manager, Shelagh Meldrum, on 01761 422222
or email shelagh.meldrum@circlepartnership.co.uk
Patient, CircleBath
“Reception was excellent.”
Foxcote Avenue
Peasedown St John
Bath
BA2 8SFU
circlebath.co.uk