Quality Account
Circle Reading
2013 - 2014
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Patient Comment……
‘Service and food first class. The nursing staff were excellent.
Helpful and cheerful reception. Bedrooms expertly cleaned.
Accommodation first class'.
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Contents
Chapter One
Statement of Quality from the Leadership Team
Chapter Two
The Circle Ethos
Circle Reading
Chapter Three
Reviewing our Quality improvement Objectives from 2013
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To develop patient and visitor information relating to our facilities
further.
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To develop a suite of Theatre Audits to reduce the potential for
harm in the peri-operative environment.
To re-energise the safety initiative ‘Stop the Line’.

Chapter Four
Setting out new Quality Improvement Objectives for 2014 / 2015
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Chapter Five
Fully embed the Circle Operating System into the culture of Circle
Reading to improve patient experience, efficiencies and overall service.
Re-construct the Hospital Quality Audit, to more closely mirror a CQC
inspection, with the aim of creating innovative monitoring solutions for
patient safety and care.
Monitor re-admissions and variances in patient care to review and
improve Clinical Effectiveness.
Further enhance Patient Experience.
Review of Quality Performance in 2013
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National Audits
Internal Audits
Clinical Outcomes
Patient Safety
Infection Prevention and Control
CQUIN
Pharmacy Services
Patient Experience
Staff Engagement
Care Quality Commission
Data Quality
Information Governance
Involvement in Local Networks
New Initiatives
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About the Quality Account
What are the required elements of the Quality Account?
The Health Act 2009 required all healthcare providers to produce a Quality Account and the National
Health Service (Quality Accounts) Regulations 2010 specified 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. A statement by the Leadership Team
2. Priorities for Improvement – these are commitments that Circle Reading makes to improve the
level of quality within the hospital
3. 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 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 Comment……
‘From start to finish, I received 5 star treatment from my
Consultant, Anaesthetist and all the nurses who have cared and
looked after me. I really cannot thank you enough.'
-5-
Statement on Quality from the Leadership Team
It is with great pleasure that we welcome you to the 2013/2014 Quality Account produced by Circle
Reading 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
plans for the coming year of interest.
During 2013 Circle Reading 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 after care.
We have developed a number of methods of measuring and benchmarking the quality of our services
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.
Circle Reading 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 Circle Reading, 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 quality related
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.
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 Circle
Reading 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.
Adrian Peake
Registered Manager
Tony Andrade
Clinical Chairman
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The Circle Ethos
Our Principles
We are above all the agent of our patients. We aim to exceed our patients' expectations every
time, so that we earn their trust and loyalty. We strive to continuously improve the quality and
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. Because everyone matters, everyone who
contributes should be a partner in everything we do. In return we expect partners to give
patients all they can.
We are unrelenting in the pursuit of excellence. We embrace innovation and learn from our
mistakes. We measure everything we do and share the data for all to judge. Pursuing our
ambition to be the best healthcare provider is a never-ending process. Good enough never is.
Our Values
Caring – The natural ability to empathise with others, to understand how they’re feeling, and to
be able to act accordingly. Putting the patient at the centre of everything we do.
Inclusive – The natural inclination to work collaboratively in teams and involve others when
appropriate. The intuitive sense that most times two heads are better than one.
Uncompromising – The desire to strive for excellence – always. The ability to convert ideas and
plans into real actions and progress.
Entrepreneurial – The ability to spot opportunities for improvement and the drive to get on and
realise them. Not being frightened to take appropriate risks.
Delivery focussed – The ability to convert ideas and plans into real action and progress.
Take ownership and make things happen.
Innovation and Learning – A natural desire to learn and improve.
Curiosity is good.
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CircleReading
Circle was founded on the belief that hospitals should be dedicated to patients. CircleReading
has been designed to offer 21st century medical technology with an unequivocal focus on
quality of care and customer service. Each of our hospitals is co-formed, co-owned and co-run
by clinicians. We are the largest partnership of healthcare professionals in Europe.
CircleReading 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
Circle Hospital Reading facilities are state-of-the-art and include:
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Five operating theatres
One endoscopy and audiology suite
20 day case beds
30 in-patient beds
15 consultation rooms and treatment rooms
Physiotherapytherapy suite
Full diagnostic service including MRI, Digital Mammography Screening, X-ray, ultrasound
and pathology testing
Aims and Objectives
 The hospital operates 7 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 out-patient, in-patient 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.
 Based on:
1. Operational Efficiency
2. Clinical Excellence
3. Collaborative Approach
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; and
 Realise a sustainable economic driver that allows our services to persist.
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Patient Comment……
‘Probably my best experience of inpatient hospital
treatment covering 60yrs and some 15 plus inpatient
visits'.
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Reviewing Quality Improvement Objectives
from our last Quality Account:
Our priorities for improvement in 2013 were based on the value equation:
Best Clinical Outcomes
Most Engaged Staff
Best Patient Experience
Best Value
Our priorities for last year were:
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To develop patient and visitor information in relation to our facilities further.
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To develop a suite of Theatre Audits to reduce the potential for harm in the perioperative environment.
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Re-energise the safety initiative ‘Stop the Line’.
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.
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Review of Last Years' Objectives
1. To develop patient and visitor information in
relation to our facilities further
At CircleReading our aim is to provide clinical excellence and a highly positive patient
experience within a calming and relaxing environment. In addition to a wonderful building,
fantastic service and beautiful art and sculpture work we have a deli bar serving our patients
and visitors with a wide variety of beverages and freshly prepared food.
Patient feedback has recognised that these services are beneficial to their experience and we
have adopted and are continuing to enhance the following principles:
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We have further engaged and expanded our patient forum in relation to feedback.
We have increased our facilities to our patients and visitors.
We have reviewed the level of information provided in relation to our facilities to our
patients and visitors and have further developed how this information is presented.
We have reviewed and development our inpatient, daycase and discharge information
guides which we provide to our patients pre and post operatively.
We have reviewed our opening hours to now include weekends for some of our
outpatient clinics.
Patient feedback, both verbal and written, provides enormous guidance on matters relating to
patient experience and accordingly we shall monitor this closely.
Suggestions and comments arising specifically around these services will continue to be
discussed within the departmental teams and proposals will continue to be put forward to the
patient forum for their consideration.
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2. To develop a suite of Theatre Audits to reduce
the potential for harm in the peri-operative
environment
The following audits were undertaken in 2012 / 2013 by our theatre and recovery partners,
assessing all patients on one day per week.
The cumulative analysed results from December 2013 to date are detailed below:
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85% of clinically appropriate surgical patients receive on time appropriate antibiotics
within 60 mins of surgical incision.
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99% of all surgical patients maintain normal range temperature during surgery and in
the immediate post-operative phase.
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100% of all known diabetic patients maintain a serum glucose level within the normal
range on the day of surgery.
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99% of all elective surgical inpatients that require hair removal for their surgery will
have it performed using the recommended method.
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100% compliance with the WHO surgical checklist with evidence of changes made to the
team brief.
Compliance figures will continue to be monitored and action plans highlighting improvements
required in relation to such are and will continue to be discussed further at the bi-weekly
Quality Improvement meetings which are attended by the Lead Nurse and departmental clinical
and non-clinical leads.
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3. Re-energise the safety initiative ‘Stop the Line’.
Staff who encounter 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 empowers staff to "stop the
line" when potential sources of mistakes are discovered, without fear of blame. This also
incorporates our pro-active incident reporting structure and supports any educational learning.
We have created and embedded a safety culture which allows our staff:
• To process manage serious incidents.
• To learn lessons from serious incidents by the implementation of action plans, STL
improvement groups and embedding improvements.
• To further create a culture where safety is paramount and each voice is heard which
under-pins the stop the line process.
We are continuing 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.
Our staff, should they see a problem are empowered to:
- Stop The Line
- SWARM as a team to find a solution (the team needs to consist of those relevant to the
issue and complete an incident form).
Within 1 hour
» Notify Clinical Nurse Lead
» Notify Operations Lead
» Interim action decided
CLINICAL
NON-CLINICAL
Within 24 hours
» SWARM as a team – including the Lead Nurse, Governance
and Assurance Lead, containing members of involved
parties
» Review interim actions
» Notify General Manager or HLT on call
» Complete incident form
Within 48 hours
» Clinical Unit Lead Report produced and sent to identified
staff
» STL Team will review report and actions taken
» Recommendations may be made for implementation
within 25 days
» Final report produced by unit lead with clear Root Cause
Analysis
» Lessons learnt shared with relevant staff
» Permanent change to practice fully implemented
Within 30 days
» Audit of practice to ensure implementation
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New Objectives for 2014
Our priorities for improvement in 2014/2015 are as follows:
1. Continue to embed the Circle Operating System at Circle
Reading to improve patient experience, efficiencies and
overall service.
There is a growing body of evidence that leaders who engage staff and patients deliver better
results in a range of measures (1). Circle values and anticipated this need and therefore
prioritised the engagement of its patients and staff to enhance the quality of care and patient
experience. The Circle Operating System (COS) has been designed to constructively create and
promote a continuous improvement environment at Circle. COS uses a few, simple, proven
quality improvement tools, which underpin Circle’s organisational values and mission
statement.
How COS improved quality
1. Develop staff with the problem solving skills to constructively deliver satisfying, continuous
and sustainable improvement and encourage original thinking.
2. Respond to patients’ needs by viewing the service from a patient’s perspective, and regular
reflection of clinical and non-clinical aspects of patient care and decision making processes
aided this process.
3. Establish a culture of distributed leadership, teamwork and collaboration, where ideas were
listened to and valued.
4. Articulate a shared vision of performance based upon a combination of parameters: patient
experience, clinical outcomes, staff engagement and organisational value.
5. Promote trust, fairness, respect and celebrated success.
COS plan
1. Each clinical unit will be coached in the application of COS. Although COS incorporates
generic improvement tools, the approach for each unit was tailored to their qualities and
challenges.
Project Lead: Antti Kivimaki
The board sponsor: Adrian Peake
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2. Re-construct the Hospital Quality Audit, to more closely
mirror a CQC inspection, with the aim of creating innovative
monitoring solutions for patient safety and care.
The Nurse Lead and Governance and Assurance Lead introduced a new Quality Audit in Quarter
1 of 2013, which has evolved from an earlier version of a Quality Walk-Around. We
reconstructed the initial audit to closely mirror a CQC inspection.
The Plan:
Each quarter four CQC outcomes will be fully investigated throughout all departments of the
hospital. They have been grouped according to theme, as far as possible. Following the audits
on a pre-designed template (utilising the CQC guidance), an action plan of any areas for
improvement will be distributed to all department leads.
Departmental Leads will work to resolve the issues and report their actions to the Lead Nurse
and the Governance and Assurance Lead.
The audit also provides an opportunity to observe departments implementing best practice or
innovative ways of working, which can then be shared.
Quarter 1:
Outcome 7 – Safeguarding of people who use services from abuse
Outcome 8 – Cleanliness and infection control
Outcome 9 – Management of medicines
Outcome 11 – Safety, availability and sustainability of equipment
Quarter 2:
Outcome 1 – Respecting and involving people who use services
Outcome 2 – Consent to care and treatment
Outcome 4 – Care and welfare of people who use services
Outcome 6 – Cooperating with other providers
Quarter 3:
Outcome 10 – Safety and suitability of premises
Outcome 12 – Requirements relating to workers
Outcome 13 – Staffing
Outcome 14 –Supporting workers
Quarter 4:
Outcome 5 – Meeting nutritional needs
Outcome 16 – Assessing and monitoring the quality of service provision
Outcome 17 – Complaints
Outcome 21 – Records
Project Lead: Antti Kivimaki
The board sponsor: Adrian Peake
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3. Monitor patient re-admissions and transfers to review and
improve Clinical Effectiveness
At the beginning of 2012, we undertook a thorough review of the data collected with regards to
patient re-admissions within 30 days of their operative procedure and the flow of emergency
transfers. Following this review, we aimed to increase the robustness of our data collection
processes and analysis. Overall, new forms were produced to ease data capture and
communication channels through which this data is disseminated were also made more
effective. An additional aim was to ensure all data relating to re-admissions and transfers is
delivered to the Executive Board at the earliest possible point, so that actions, which may be
required, are swift as well as consultant and nurse led.
Patient Re-admissions Process:
All patient re-admissions within 30 days of procedure are documented by the inpatient staff.
The patient details, operation type and date, consultant and patient status i.e. private patient,
self-pay patient or NHS patient and reason for re-admission are collected and the Lead Nurse is
informed immediately. All the data is reviewed by the Lead Nurse and Governance and
Assurance Lead to allow trend analysis and an immediate intervention should it be necessary.
Data is then reported to the Executive Board via the ‘Live’ Quality Quartet on a monthly basis by
the Lead Nurse and the Governance and Assurance Lead.
Patient Transfer Process:
All patient transfers are documented by the inpatient, recovery or day surgery staff. The patient
details, operation type and date, consultant and patient status i.e. private patient, self-pay
patient or NHS patient and reason for transfer are collected and the Lead Nurse is informed as
soon as possible.
An investigative report or root cause analysis (where applicable) is undertaken, by reviewing
the patient notes to determine the reason for the transfer. This will then be discussed with the
RMO, Consultant, Anaesthetist and nursing staff involved where relevant to establish that this
was the correct line of treatment for the patient or whether the patient could have received the
relevant treatment safely at Circle Reading.
All transfer data is discussed at the Executive Board meeting via the Assurance Dashboard on a
monthly basis, with an annual report submitted each year. If it is decided that the patient could
have remained at Circle Reading and safely received the treatment required, the Lead Nurse
will establish why the patient was transferred, to ensure that the issues are addressed to
prevent a reoccurrence. Staff training, skill mix, patient / nurse ratio and senior nurse input are
considered to have a very important part to play in these decisions. These factors are reviewed
on a daily basis by the Lead Nurse or a Deputy Lead nurse in their absence. A senior nurse is on
call out of hours and contact details are held by all relevant areas within the hospital.
In quarter four of 2014, The Lead Nurse will re-examine the processes outlined above, to
determine their effectiveness and impact on service quality for our patients. The findings will be
reported in the Quality Account for 2014/2015.
Project Lead: Antti Kivimaki
The board sponsor: Adrian Peake
- 16 -
4. Further enhance Patient Experience
We have a simple, yet effective system which captures patient feedback. Patients are asked to
complete our 3 question feedback card, which is illustrated in subsequent chapters of this
Quality Account. The data collected is collated into a spreadsheet on a weekly basis and
analysed by our Governance and Assurance Lead. This raw feedback is then published on our
website. Comments for improvement are actioned by all departmental leads; to ensure any
issues which may have arisen, do not re-occur.
However, our credo strongly advocates that we are the agents of our patients, hence we wish
to develop new and consolidate current mechanisms of feedback capture, to inform us of
changes which may be needed. This will ensure that we are providing the highest quality service
for our patients, based on needs they have expressed themselves.
Aim of the project:
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Identify common areas of concern for patients
Identify what we do well and maintain consistency
Allocate areas of concern to all departmental leads for further investigation
Provide the correct solution in a timely manner
The Plan:
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Action points to be allocated weekly to all departmental leads
Action Log created to keep abreast of all ‘open’ and ‘closed’ actions
Departmental leads to add updates in ‘real’ time
Involve our Patient Forum on a more regular basis with set agenda project plans
Regular monthly departmental meetings to be maintained and developed
Publish actions taken next to patient concerns so patients can see real change
How will this improve patient experience:
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Areas of concern will be addressed swiftly and consistently
We will actively listen to our patients an improve their experience, aiming to do so
immediately if possible
This enhanced approach will allow us to adapt to our patients’ needs and provide frontline staff to take ownership and empower them to create effective change.
Project Lead: Antti Kivimaki
The board sponsor: Adrian Peake
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Patient Comment……
‘All of the partners are friendly and professional. You are
treated like a person not a number'.
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Review of Services
During 2012/13 Circle Reading provided Choose and Book and transferred activity of NHS
Services.
Circle Reading 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 Circle Reading for 2013.
- 19 -
Quality Indicators
Clinical Audits
National Audits:
CircleReading participates in 100 % of national clinical audits and 100 % of national confidential
enquires for the national clinical audits and national confidential enquires which it was eligible
to participate in.
Blood Audits:
Our Blood Lead, Antti Kivimaki, is responsible for all blood products within the hospital, in
conjunction with a team of blood transfusion link workers. The team have established rigorous
audit procedures, in conjunction with those conducted by external bodies.
The Royal Berkshire NHS Foundation Trust (RBH) supply CircleReading Hospital with all blood
and blood components in compliance with the Blood Safety and Quality Regulations (BSQR)
2005 No.50 (SI 2005/50). All blood components supplied to CircleReading are accompanied by
the appropriate documentation. The RBH supply two units of O Negative blood which after
fourteen days if not used is returned to the RBH and new O Negative blood supplied. Patient
specific blood and blood components are supplied on request.
Circle Reading is subject to all comparative traceability audits which are conducted on a
quarterly basis by the RBH. Since opening in August 2012, Circle Reading has achieved an
excellent level of compliance for every unit. Results for 2013 are shown below:
Units transfused:
% traceability:
38
100 %
Jan 2013 - Dec 2013
Internally a number of audits are completed to ensure the highest quality of blood
management practice is adhered to. Blood fridge temperatures are monitored daily manually,
with blood disc cards being changed weekly. Quarterly audits of the blood register are also
undertaken.
Patient notes are also audited on a quarterly basis (those having had a blood transfusion); to
check all the necessary paperwork was completed correctly and within relevant time scales.
Further details are seen below:
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The following Blood Safety Audits are undertaken at Circle Reading 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. 10% 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 100 % compliance with this audit.
Our last report (January 2013 - December 2013) data:
Total number of blood units issued - 211*
Number of units transfused – 38
Number of blood units wasted - 0
*all unused units were returned to The Royal Berkshire NHS Foundation Trust (RBH) and used
elsewhere.
Training:
All trained staff involved in the blood transfusion process have their blood competencies
assessed every three years. Scenario training exercises are also completed within the Theatre
department, ensuring ODPs understand the most up to date blood procedures.
Comprehensive staff training matrix records the date of training and competency completion.
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Currently 100 % of staff have completed 'face-to-face' training successfully and
deemed competent.
Transfusion Objectives for 2013
1. The transfusion team will meet three times in 2013.
2. Continue with regular monthly and three monthly audits.
3. Run emergency desk top scenarios as planned.
- 21 -
Internal Audits:
Audit planning is carried out within the Governance and Assurance Team and is split into three
categories:
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.
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).
3. Internal Audit Programme – A further series of audits are completed internally in Circle
Reading, to enhance clinical safety, patient care and quality of services specifically for
our Hospital.
- 22 -
Audit Calendar 2014
KEY: Coloured Box
means audit due
J
a
n
MONTHLY AUDITS
Hand Hygiene
Who has to complete this audit?
Outpatients, Inpatients, Endoscopy, Radiology,
Theatre, Recovery, Daycase, Physiotherapy,
Hospitality
Health and Safety
Environmental
Hygiene / Cleaning
ALL DEPARTMENTS
Outpatients, Inpatients, Endoscopy, Radiology,
Theatre, Recovery, Daycase, Physiotherapy
Fire Warden
Clinical Records
ALL DEPARTMENTS
Physiotherapy, Daycase, Outpatients,
Inpatients, Theatre (separate tab for each
department)
Controlled Drugs
Inpatients, Recovery, Endoscopy, Theatre
Medical Gas
Theatres (Porters)
Pre-Assessment Care
Medical Notes and
Tracker System
Pre-Assessment Dept
QUARTERLY AUDITS
Who has to complete this audit?
Endoscopy, Radiology, Physiotherapy,
Outpatients, Recovery, Theatre, Daycase,
Inpatients
Sharps
Laundry
M
ar
ch
A
p
ri
l
M
a
y
J
u
n
e
J
u
ly
A
u
g
S
e
p
t
O
c
t
N
o
v
D
e
c
Medical Records Team
Waste
(departmental)
Stores (Porters)
Endoscopy, Radiology, Physiotherapy, PreAssessment, Outpatients, Recovery, Theatre,
Daycase, Inpatients
Endoscopy, Radiology, Physiotherapy, PreAssessment, Outpatients, Recovery, Theatre,
Daycase, Inpatients
Information Security
ALL DEPARTMENTS
BI - ANNUAL AUDITS
Security Card
Machine
Who has to complete this audit?
Visitors Log Book
Reception spare
swipe cards audit
Reception
ANNUAL AUDITS
Waste Management
(in depth)
Medical Gas (more
detailed Audit)
Who has to complete this audit?
Housekeeping Lead and Facilities Management
Lead (with support from other departments)
Privacy and Dignity
F
e
b
Reception
Reception
Theatre Lead and Facilities Management Lead
Governance Audits will also take place throughout the year - please see below for a selection.
- 23 -
Confidential Waste
Audit
Site Wide Privacy
and Dignity
Site Wide Fire
Assessments
Site Wide Health and
Safety Audit
Site Wide Infection
Control Audit
Business Impact
Assessment
Business Continuity
Plan review
Site Wide Security
and Information
Security Audit
Governance & Assurance Lead
Annual
Governance & Assurance Lead and Nurse Lead
Annual
Fire Officer
Annual
Corporate H&S Lead
Annual
Corporate IPC Lead
Governance & Assurance Lead and All
Departments
Governance & Assurance Lead, SMT, Facilities
Management Lead
Annual
Governance and Corporate IG Officer
Annual
Radiology Lead
Annual
Facilities Management Lead
Annual
Evening Information
Security Audit
Governance & Assurance Lead
Twice a year
Variance Form Audit
Governance & Assurance Lead
Twice a year
HR Lead
Every two months
HR Lead
Every two months
HR Lead
Every two months
HR audits
Governance & Assurance Lead
Every two months
Resus trolley Audit
Lead Nurse
Monthly
Resus Scenarios
Penny Rutter & Sarah Blake
Governance & Assurance Lead, Nurse Lead,
Theatre Lead
Governance & Assurance Lead, Nurse Lead,
Theatre Lead
Monthly
Governance & Assurance Lead and Nurse Lead
Recovery, DSU, Theatre, Governance &
Assurance Lead, Nurse Lead
Governance & Assurance Lead & Unit Lead
(separate outcome allocated to each unit
lead)
Monthly
Laser Audit
Medical Gas Annual
Audit
CALMS registration
compliance reporting
CALMS IG training
compliance report
Practicing Privileges
audit
Cancellations
Returns to theatre
Emergency transfers
WHO Compliance
CQC Outcome
Quality Audit
Annual
Annual
Monthly
Monthly
Monthly
Monthly
- 24 -
Clinical Research
The number of patients receiving NHS services provided or sub contracted by CircleReading in
2013 that were recruited during that period to participate in research approved by a research
ethics committee was 0.
- 25 -
Patient Comment……
‘I always feel that the hospital treats the person as a whole and
not just the condition. Always informative and procedures
explained. Staff are always very pleasant.'
- 26 -
Clinical Outcomes Steering Committee
The vision:
The clinical outcomes steering group 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 aims to be:
•
•
•
•
•
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
A centre of excellence and a beacon for other organisations for clinical outcomes
CircleReading still collects PROMS for all NHS patients (four key procedures) as well as in-house
PROMS for most of our private patients’ procedures. 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 2013. 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.
Since we opened in August 2012, we have been collecting all relevant PROMS and going
forwards we will be in a position to be able to report on all of our health gains from July 2013.
This will include comparisons in relation to the UK Average and the Best UK Performer.
- 27 -
PROMs Summary
Knee Replacement Primary - Average Health Gain per Patient (Private)
Selection: Circle Reading Hospital(s)
Reporting Period: January - 2014 (rolling data) - Comparisons/Rank Based On: Oxford Knee Score
Site Comparisons
- 28 -
PROMs Summary
Knee Replacement Primary - Average Health Gain per Patient (Private)
Selection: Circle Reading Hospital(s)
Reporting Period: January - 2014 (rolling data) - Comparisons/Rank Based On: Oxford Knee Score
Trends For: Circle Site(s)
- 29 -
PROMs Summary
Knee Replacement Primary - Average Health Gain per Patient (Private)
Selection: Circle Reading Hospital(s)
Reporting Period: January - 2014 (rolling data) - Comparisons/Rank Based On: Oxford Knee Score
- 30 -
PROMs Summary
Knee Replacement Primary - Average Health Gain per Patient (Private)
Selection: Circle Reading Hospital(s)
Reporting Period: January - 2014 (rolling data) - Comparisons/Rank Based On: Oxford Knee Score
- 31 -
PROMs Summary
Hip Replacement Primary - Average Health Gain per Patient (Private)
Selection: Circle Reading Hospital(s)
Reporting Period: January - 2014 (rolling data) - Comparisons/Rank Based On: Oxford Hip Score
Site Comparisons
- 32 -
PROMs Summary
Hip Replacement Primary - Average Health Gain per Patient (Private)
Selection: Circle Reading Hospital(s)
Reporting Period: January - 2014 (rolling data) - Comparisons/Rank Based On: Oxford Hip Score
Trends For: Circle Site(s)
- 33 -
PROMs Summary
Hip Replacement Primary - Average Health Gain per Patient (Private)
Selection: Circle Reading Hospital(s)
Reporting Period: January - 2014 (rolling data) - Comparisons/Rank Based On: Oxford Hip Score
- 34 -
PROMs Summary
Hip Replacement Primary - Average Health Gain per Patient (Private)
Selection: Circle Reading Hospital(s)
Reporting Period: January - 2014 (rolling data) - Comparisons/Rank Based On: Oxford Hip Score
- 35 -
Patient Comment……
‘A really pleasant experience. So happy I have come to
Circle. Thank you so much. Spotlessly clean. All staff very
welcoming. Very relaxed atmosphere.'
- 36 -
Patient Safety
Device Alerts
A plethora of safety measures are in place at Circle Reading, to ensure the highest standards are
adhered to. The follow medical safety checks are made:
1.
2.
3.
4.
5.
6.
MHRA Medical Device alerts
MHRA Field Safety alerts
NICE guidance
CAS Alert system
MHRA Drug Alerts
Company field safety alerts (received directly from source)
A database of all alerts and their outcome is kept centrally by our Governance & Assurance
Lead and reported on a monthly basis to the Clinical Governance and Risk Management
Committee. Information is also reported to the Medicines Management Committee and the
Executive Board through monthly reports.
MHRA Alerts:
The hospital is registered for electronic alerts which are reviewed and distributed to the
relevant and responsible member of staff.
69 MHRA Medical Device Alerts were received, of which 2 was relevant to hospital equipment.
Appropriate action and communication with the company involved and relevant departments
took place to resolve any issues.
NICE Guidance:
All NICE guidance is reviewed on a monthly basis. Those which are relevant to the hospital are
distributed to our Lead Nurse and Governance & Assurance Lead. Action plans are drawn up
and added to our NICE Library which is available to all staff.
Drug Alerts
Alerts are received electronically and audited on a monthly basis by our Pharmacy Lead at Circle
Reading.
36 drug related alerts were received, of which 3 were relevant to the hospital. Actions were
taken by the Pharmacy Lead to remove affected stock and communicate related information to
our clinical staff.
Equipment
All equipment is thoroughly checked and maintained either by our facilities team or our visiting
site EBME engineer.
- 37 -
Incident Reporting
Incidents are reported electronically using the DATIX system. Extensive training has been
provided for staff. 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 & Assurance Lead, Inpatients Lead,
the Lead Nurse are able to review all records, as can the Corporate Head of Risk & Assurance
and the General Manager. Additional resources or procedures stated in the action plans can
also be loaded into the electronic record as evidence.
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 Clinical Governance and Risk Management Committee and the
Integrated Governance Committee corporately.
Accidents are reported to RIDDOR when appropriate. An incident form is also logged for each
accident. There were no RIDDOR reportable incidents in 2013.
INCIDENT AND NEAR MISS REPORTING – 2013
January 2013
No. of Incidents
Reported
Investigated
Open / Closed
Clinical
21
Yes
Closed
Administrative
5
Yes
Closed
Facilities Management
3
Yes
Closed
February 2013
No. of Incidents
Reported
Investigated
Open / Closed
Clinical
28
Yes
Closed
Administrative
4
Yes
Closed
Facilities Management
2
Yes
Closed
March 2013
No. of Incidents
Reported
Investigated
Open / Closed
Clinical
38
Yes
Closed
Administrative
5
Yes
Closed
Facilities Management
0
N/A
N/A
- 38 -
April 2013
No. of Incidents
Reported
Investigated
Open / Closed
Clinical
37
Yes
Closed
Administrative
2
Yes
Closed
Facilities Management
0
N/A
N/A
May 2013
No. of Incidents
Reported
Investigated
Open / Closed
Clinical
41
Yes
Closed
Administrative
3
Yes
Closed
Facilities Management
0
N/A
N/A
June 2013
No. of Incidents
Reported
Investigated
Open / Closed
Clinical
49
Yes
Closed
Administrative
1
Yes
Closed
Facilities Management
0
N/A
N/A
July 2013
No. of Incidents
Reported
Investigated
Open / Closed
Clinical
37
Yes
Closed
Administrative
4
Yes
Closed
Facilities Management
1
Yes
Closed
August 2013
No. of Incidents
Reported
Investigated
Open / Closed
Clinical
50
Yes
Closed
Administrative
4
Yes
Closed
Facilities Management
2
Yes
Closed
- 39 -
September 2013
No. of Incidents
Reported
Investigated
Open / Closed
Clinical
43
Yes
Closed
Administrative
3
Yes
Closed
Facilities Management
3
Yes
Closed
October 2013
No. of Incidents
Reported
Investigated
Open / Closed
Clinical
33
Yes
Closed
Administrative
2
Yes
Closed
Facilities Management
0
N/A
N/A
November 2013
No. of Incidents
Reported
Investigated
Open / Closed
Clinical
26
Yes
Closed
Administrative
5
Yes
Closed
Facilities Management
0
N/A
N/A
December 2013
No. of Incidents
Reported
Investigated
Open / Closed
Clinical
38
Yes
Closed
Administrative
4
Yes
Closed
Facilities Management
3
Yes
Closed
Examples of actions taken following incidents reported:

A number of in depth clinical risk assessments were developed to prevent incidents and
near misses.
a.
b.
c.
d.
Nutrition
Falls
Bed Rails
VTE
- 40 -
Patient Falls
All patient falls are logged through our incident management system and reported to the
Clinical Governance and Risk Management Committee.
Date of
Incident /
Departmental
Area
Incident Description
Immediate Action Taken
Incident Investigation /
Action Plan Implemented
04/07/2013
Inpatients
Patient was assessed as
competent and capable of
having a shower. The patient
was informed and
understood that he should
not bend down to put his
shorts on. The nurse was
informed that the patient
was in the shower. The
nurse went in to assess the
patient and heard him fall to
the floor.
The patient was attended
by the nurse and assessed.
No obvious injuries were
noted.
All nurses are to ensure
that patients are fully
aware and understand the
information in relation to
showering unaided.
As I entered room 304 to
take the patient's
observations, the patient
asked if she could use the
toilet. I assisted her in
walking to the toilet and
helped to position her
correctly in front of the
toilet. I asked if she would
like me to stay but she
refused and said that she
would not need assistance in
sitting down. I reassured her
that I would be just outside
the toilet door if she need
me. I then heard her lose her
footing as she was sitting
down but when I ran into
the toilet she was already on
the floor..
The patient attempted to
stand but I asked her to
stay where she was
The patient returned to
theatre for a knee wound
washout and re suturing.
The nurse immediately
pulled the emergency bell.
Two nurses on shift came in
immediately and took over.
One applied pressure to the
patient's bleeding knee.
A new falls risk
assessment was
completed following the
fall.
13/08/2013
Inpatients
The importance of the
above has been reiterated
to all nurses in relation to
patient care.
The Lead Nurse
commenced a Root Cause
The RMO also attended and Analysis (RCA) in relation
changed the dressing to the to the incident and
operation site.
recommendations and
lessons learnt have been
The consultant was
shared with all respective
informed of the incident
nursing teams.
immediately.
- 41 -
Date of
Incident /
Departmental
Area
Incident Description
Immediate Action Taken
Incident Investigation /
Action Plan Implemented
05/09/2013
Inpatients
Patient was walking out to
the bathroom using a
zimmer frame and was
assisted by a nurse. The
patient was standing against
the toilet and went to sit
down. The patient was given
coaching on how to sit down
but the patient did not
follow the instructions and
missed the toilet and fell
backwards towards the wall
of the toilet with her
shoulder and slipped to the
floor.
Patient was assisted back
to the bed and reviewed by
the RMO.
The patient was
reassessed by the
Physiotherapist.
25/09/2013
Day Surgery
The patient sustained no
visible injuries and
confirmed that she did not
hurt herself.
The physiotherapist was
contacted and a raised
toilet with handles was put
in place and a full Falls Risk
Assessment was completed
and documented.
Patient attempted to stand
Patient sustained
to mobilise to toilet when his numbness as a result of the
leg buckled.
block used in surgery. The
feeling had not returned
The nurse gently assisted
adequately prior to the
and guided him to sit on the
nurse mobilising the
floor.
patient.
The Nurse involved
contacted the
physiotherapist in relation
to the patient's care and
the patient was mobilised
safely.
The nurse provided a
reflective account of the
incident. Shared learning
undertaken by all staff
regarding decreased
sensation postoperatively.
Falls prevention in place in
all clinical areas.
Incidents of this nature to
be continually monitored.
Reassurance given to the
patient regarding the block
and the loss of sensation at
the time.
- 42 -
Date of
Incident /
Departmental
Area
Incident Description
Immediate Action Taken
Incident Investigation /
Action Plan Implemented
27/09/2013
Outpatients
Whilst walking past the
Radiology reception desk
towards the atrium, a Nurse
and a Consultant noticed a
patient in the atrium.
The patient was assessed
by the attending nurse and
consultant present at the
time.
All nursing staff and
patients reminded of the
hazard associated with
not having seat belts
fastened whilst using
wheelchairs.
She was in a wheelchair and
had leant so far forward that
she tipped the wheelchair
forward.
No obvious injuries were
noted.
Before we could get to her,
she had slid from the
wheelchair to the floor.
Patient declined on
accepting a seat belt
fastened prior to using the
wheelchair.
03/10/2013
Inpatients
Found patient lying on the
floor after few minutes of
leaving her.
Nurse providing care of
patient fully reviewed the
patient.
Patient said she wanted to
pick up something she had
dropped on the floor and
ended up on the floor
herself.
No signs of injury noted.
The patient was stable and
not distressed.
Both bed rails noted to be
up at the time.
25/01/2014
Inpatients
Patient was with the
physiotherapist for mobility
assessment. The patient was
mobilising well with a
walking stick and stand-by
support.
Falls Risk Assessment
undertaken.
Patient assisted back to bed
and again given the call bell
in ease of reach.
Patient advised to use call
bell as provided.
Physiotherapist was in
front of the patient. Patient
missed the edge of the bed
and slipped onto the floor
and was slowly put into a
seated position by staff.
Falls Risk Assessment
undertaken.
- 43 -
Date of
Incident /
Departmental
Area
Incident Description
Immediate Action Taken
Incident Investigation /
Action Plan Implemented
27/01/2014
Inpatients
Physiotherapist was assisting
in the mobilising of patient
up the stairs on ward 2.
Nursing were staff present.
Patient began to feel faint.
Patient advised to walk back
downstairs. Patient when at
the bottom of the stairs
began to feel better. Patient
suddenly dropped towards
floor and hit both knees on
the bottom step on the way
down.
Patient eased to the floor
by physiotherapist
assistant.
Falls Risk Assessment
undertaken.
06/02/2014
Inpatients
Patient was assisted with
bed pan and given call bell.
Health Care Assistant
reported finding the patient
on the floor. Patient states
she lost balance, her legs
gave way and she sat on the
floor but did not harm
herself.
Patient assessed by nursing
staff. No obvious injuries
noted.
Falls Risk Assessment
undertaken.
14/02/2014
Inpatients
Patient informed nurse that
he had got out of bed
unsupervised and had fallen
over into the armchair. The
fall was not witnessed.
Patient assessed by nursing
staff and informed to press
the call bell if assistance
required.
Falls Risk Assessment
undertaken.
Patient assessed by nursing
staff and physiotherapist.
When the nurse arrived into
the room, the patient was
back in his bed, with both
bed rails up and the call bell
was in ease of reach.
- 44 -
Date of
Incident /
Departmental
Area
Incident Description
Immediate Action Taken
Incident Investigation /
Action Plan Implemented
03/04/2014
Inpatients
Patient rang call bell and
stated that she had fainted
in the bathroom and woke
up on the floor. Patient
managed to return to bed
unaided and hit her head
and bruised her lip with her
teeth. Patient only contacted
the nursing staff after the
incident.
Patient assessed by nursing
staff and RMO and
informed to press the call
bell if assistance required.
Falls Risk Assessment
undertaken.
17/04/2014
Inpatients
Whilst nursing staff were
assisting a patient to
mobilise from the toilet to
the bed, the patient's left leg
gave way and she fell.
Emergency call bell
activated and assistance
arrived. Patient hoisted
back to bed and full
examination carried out.
Noted bruising to bottom
with no other injuries
sustained.
Full physiotherapy input.
Full assistance to mobilise.
Call bell placed in ease of
reach.
Patient lowered to the floor
by nursing staff.
Pressure relieving mattress
ordered to reduce risk of
skin break-down from the
bruising.
Physiotherapy sessions
and exercise increased in
order to improve patient's
mobility and strength.
Consultant and RMO
informed.
Patient's length of stay
increased.
Patient referred for
community physiotherapy
upon discharge.
- 45 -
Actions taken:





All patient falls are reviewed on a monthly basis at the Clinical Governance and Risk Management
Committee, under a separate agenda item.
Patient fall data capture is added to the monthly Governance & Assurance Monthly Reports.
Patient falls are reviewed at the Health and Safety Committee Meeting with specific lessons learnt
for Health & Safety Link Workers, who cascade knowledge to their departments.
A Falls Prevention Committee has been established and meetings are held on a monthly basis.
Patient falls are also addressed during the Pre-Assessment and Admission processes in place using
the Falls Risk Assessment Tool with 100% of NHS patients having been risk assessed on admission.
Recommendations:






Ensure all new staff provided with mandatory training dates on induction.
Health and Safety Link Workers to provide an induction.
Review at Health and Safety Committee to continue.
Ensure all new staff are given the Health and Safety Induction Leaflet.
Further develop the use of the Health and Safety Notice Board outside the staff restaurant.
Further training opportunities for the Health and Safety Link Workers to be investigated.
Patient Comment……
‘Very warm and efficient welcome. Great time keeping. Helpful
and friendly staff. Lovely clean and relaxing surroundings and
facilities. All in all, a very pleasant experience'.
- 47 -
Infection Prevention and Control
Since opening in August 2012, Circle Reading has taken Infection Prevention and Control extremely
seriously and we pride ourselves on our excellent level of cleanliness.
Hand Hygiene
All staff attend mandatory Infection Prevention and Control training. This is completed on an annual
basis. Each department is also assigned an Infection Prevention and Control Link Worker who champions
good practice, provides information to staff and is a point of reference if colleagues have queries. Regular
Infection Prevention and Control Committee Meetings are also held, which all Link Workers attend. Each
Linker Worker completes more in-depth Infection Prevention and Control training and has the
opportunity to undertake on-line e-Learning NVQ studies.
Monthly hand hygiene audits are completed by each Link Worker and are performed on a crossdepartmental triangulation basis to provide assurances in relation to compliances achieved. The monthly
audits are reported to the Corporate Team and the Clinical Governance and Risk Management
Committee.
The average score for Hand Hygiene during 2013 was: 96.70%.
The average score for Hand Hygiene for 2014 to date is: 99.00%
Departments also use the light box to improve Hand Hygiene awareness within their teams. This is
carried out on a rolling monthly schedule and results and audits from such are discussed in detail.
Alert Organisms
The company has had no alert organism infections (MRSA Bacteraemia or Cdiff) to report to the Health
Protection Agency.
We continue to have zero cases of bloodstream alert organisms to report.
- 48 -
Pressure Ulcers
During 2013 we have had 1 reported incident of hospital acquired pressure ulcers during our care.
VTE Risk Assessments
A VTE Risk Assessment is undertaken for all patients whilst in our care at Circle Reading. 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 Lead Nurse.
Safety Thermometer
Circle Reading began participating in the safety thermometer scheme in October 2012. Every month data
is formally submitted. To date no harms have been recorded.
CQUIN
A maximum of 1% of actual annual NHS contract value is available through the achievement of quality
improvement and innovation goals through the Commissioning for Quality and Innovation.
- 49 -
Patient Comment……
‘Made me feel very comfortable and went through everything I
needed to know prior to the operation'.
- 50 -
Virtual Pharmacy
PHARMACY PROVISION:
The pharmacy service at the hospital is currently provided by Pharmaxo under a Contract. The Pharmacy
provision includes:







The management of electronic dispensing cabinets
Stock control and supply for medicines and medical gases
Pharmacy review of all prescriptions
Pharmacy advice 24 hours
Formulary control
Alert review and communication
Audit and Training
Prescriptions are recorded on a paper record medication chart which is scanned directly to Pharmaxo
through a secure line; prescriptions are reviewed by a pharmacist and labelled drugs released through
the electronic drug cabinet.
In order for the nurse to access drugs in the electronic cabinet they are required to use finger print
recognition and a password, they then need to enter the drug and dose as written on the prescription
chart to confirm the drugs being removed.
The cabinet does not replace the normal pre-administration checks which are undertaken at the patient’s
bedside and administration is recorded on the prescription chart.
The cabinet, drug fridge and fluids are remotely monitored by Pharmaxo, including constant temperature
monitoring.
STAFF TRAINING:
All staff receive training on the cabinets and the medicines management policy by Pharmaxo prior to the
granting of a password allowing access to the cabinet. Relevant staff also receive an annual update on
medicines management and a competency assessment.
Additional workstreams are currently creating a new Medicines Training Framework which will be
implemented in 2014.
CONTROLLED DRUGS:
The Authorised Officer for controlled drugs is the Registered Manager. The hospital sits on the Local
Intelligence Network (LIN) Committees, submitting quarterly reports on Controlled Drugs Incidents and
receiving drug alerts through LIN.
Controlled drugs are stored both in the electronic cabinets and in controlled drugs cabinets. Dual finger
prints are required for the removal of controlled drugs from the electronic cabinet. All controlled drug
stock and use is recorded in traditional controlled drug registers which are audited on a monthly basis.
- 51 -
AUDIT:
The electronic cabinets enable regular audit of stock use and dispensing by Pharmaxo who also audit
prescription chart completion and compliance, the findings of audits and spot checks are discussed
through the weekly medicines management meeting and an overall report is submitted to the Clinical
Governance and Risk Management Committee.
An annual Controlled Drugs Audit is also undertaken for submission to external organisations.
Further audits are conducted by unit leads on a monthly basis, and an in-depth audit carried out by the
Lead Nurse on a Quarterly basis, the results of which are submitted to the General Manager (also the
Accountable Officer).
An additional medicines workstream is currently carrying out a full suite of audits to improve the service
further.
MEDICINES MANAGEMENT COMMITTEE MEETINGS:
A Medicines Management Committee has been established, which examines higher level pharmacy
processes and guides changes to ensure the highest quality pharmacy services are delivered.
The Lead Nurse, Departmental Leads, Anaesthetists, Clinicians and a Consultant Clinical Microbiologist
(Royal Berkshire NHS Foundation Trust) are invited to attend these meetings to discuss concerns,
incidents and stock issues. Action points from these meetings are shared with the Clinical Governance
and Risk Management Committee.
FUTURE PLANS AND CHANGES TO THE PHARMACY SERVICE IN 2014:
Our contract with Pharmaxo, our external pharmacy supplier, will come to an end in July 2014 and as of
Monday the 21st July of 2014 there will be an on-site Circle Pharmacy which will provide all clinical and
supply services throughout the entire hospital.
The on-site pharmacy opening hours will be from 8.00am– 4.45pm (Monday to Friday).
Prescriptions may be left for processing outside of these times with the Pharmacy Technician.
For Out-of-Hours take home medications, there will be a small supply of pre-labelled items in the
designated areas.
Our nurses will no longer need to dispense prescriptions as this will all be done via the pharmacy during
opening hours which will directly free up valuable nursing time for all of our patients.
We have a brand new Circle Private Prescription Pad. This will give our patients the freedom to have their
outpatient medication dispensed either at CircleReading or at a chemist of their choice, which is also
ideal for use out of hours.
NHS patients attending evening clinics, who are normally entitled to free medication, may wish to leave
their prescription at CircleReading for collection the next day. Alternatively they can see their GP to
obtain an NHS FP10 prescription.
We are currently in the process of providing information on the New Pharmacy Service available at
CircleReading to all of our patients.
- 52 -
Patient Comment……
'Everything was perfect. Staff were very attentive, friendly and
happy. A very enjoyable experience. The food was excellent,
especially the warm baked biscuits and the lovely pleasant man
who delivered the food'.
- 53 -
Patient Experience
At CircleReading patient feedback is key and our ability to respond to patients’ views and make the care
and experience for our patients better, this is something that sits as a priority in all of our minds.
We encourage feedback from our patients at all stages of their journey through Circle Reading starting
with our meet and greet team and ending with our patient feedback card and encouragement to email
the Registered Manager with feedback.
All feedback is shared with our team on a weekly basis and in the "Patient Hour" which take place within
each of our departments. Patient feedback is reviewed and actions decided to make the required
changes highlighted by our patients, learning and growing every step of the way.
Our recently formed Patient Focus Group has become embedded within our organisation and enables us
to ensure patients continue to be at the heart of every key decision we make.
The first year has proved a great year for CircleReading and the feedback received both through our
formal mechanisms and also through the many letters and cards received, has enabled us to share
pride in what we do well and to act on the areas we have needed to improve upon.
Patients can express their views and provide feedback in the following ways:
Patient Feedback Cards /
iPad Tablets /
CircleReading Website /
Facebook / NHS Choices
Letters of Compliment
or Concern / Telephone
/ In Person
All patient feedback is logged
anonymously
Weekly report
produced
Distributed to:
Executive Board Members
Senior Management Team
Consultants
Departmental Leads
Published on the
CircleReading
website in its raw
format on a
monthly basis
Compliment
letters logged
and
distributed to
all staff
involved with
treating the
patient
Thank you
cards collated
and presented
within the
Ward Areas
Concern letters
logged &
investigated
Actioned
accordingly
Reported to
Clinical
Governance &
Risk
Management
Committee
and Executive
Board
- 54 -
In order to embed the collection process for patient feedback the Lead Nurse, Departmental Leads and
the Governance & Assurance Lead work closely together and disseminate this information throughout all
departmental teams. These members of staff are responsible for ensuring the feedback process is
streamlined. They are also empowered to make changes and recommendations highlighted by patients,
to ensure swift action is taken.
Patient Feedback Cards
During 2013, Circle Reading had 4757 patient feedback cards completed and returned:

Overall, 99.7% of patients would recommend us to friends or family.
- 55 -
Overall breakdown of completed Patient Feedback Cards by Departmental Area:
3 Question Patient Feedback Cards
Over the course of 2013, patients were asked to complete a short three question patient feedback card
following every visit to the hospital. In total, 4757 cards were returned.
The breakdown of returned cards is shown in the table below:
Departmental Area
Inpatients
Outpatients
Pre-Assessment
Daycase
Radiology
Physiotherapy
Total
Total No. of Completed Feedback Cards (2013)
683
1597
555
1487
282
153
4757
Inpatients
Of the 683 responses from Inpatients:


99.4% would recommend us to family or friends
0.6 % would not recommend us to family or friends which is equivalent to 4 feedback cards
Outpatients
Of the 1597 responses from Outpatients:


99.6% would recommend us to family or friends
0.4 % would not recommend us to family or friends which is equivalent to 7 feedback cards
Pre-Assessment
Of the 555 responses from Pre-Assessment:

100% would recommend us to family or friends
Daycase
Of the 1487 responses from Daycase:


99.9% would recommend us to family or friends
0.1 % would not recommend us to family or friends which is equivalent to 1 feedback card
- 56 -
Radiology
Of the 282 responses from Radiology:

99.6% would recommend us to family or friends which is equivalent to 2 feedback cards
Physiotherapy
Of the 153 responses from Physiotherapy:

100% would recommend us to family or friends
The following positive comments are direct quotes from the feedback cards received in 2013 and 2014
to date:

Pre-Assessment thorough. Consultant and operation excellent. Nursing care good, especially as
the continuity of the nurse was maintained. Excellent experience overall. Thank you.

From my operation to my final physiotherapy appointment today, the care, the treatment, the
accommodation and the food were first class. Thank you.

Everyone was extremely friendly. Everything was explained in full detail and options were given.
Feels more like a hotel.

All staff extremely welcoming. The radiographer was excellent at explaining everything to a
nervous fourteen year old having an MRI.

Very attentive and professional. Any questions asked were answered immediately. The night and
day staff were lovely. The doctors were patient and kind. Thanks to all.

Care and treatment throughout. Lots of check-ups to make sure everything was OK. Great food.
Positive experience.

I like the diverse culture of the staff you employ at the hospital. Polite. Respectful. Everything was
good.

Lovely greeting and settings in the lobby area. Very prompt service. Lovely consultant.
Complimentary coffee was a nice thought.

The food was fantastic. Both the sole and the duck dishes were beautifully cooked and presented.

No one likes coming into hospital but it was a real pleasure to be here. Only my second time in
hospital in some 65 years but my assessment is that there is little you could have done better.
Thank you.
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
You looked after me during a difficult time with care and compassion. My pain was well managed
and everyone was extremely nice.

Quick service. Good explanation. Hardworking people to help patients to meet their needs.
Brilliant.

The whole journey from start to finish was ten out of ten. You are all a credit to your profession.
Thanks.
Positive feedback within the Pre-Assessment and Outpatients Area was focussed on the general welcome
received and the staff within the area, in conjunction with the atmosphere and efficient Reception.
Positive feedback within the Inpatient and Day Surgery Areas was heavily focused on staff. Patients
remarked on the friendly and welcoming approach of both clinical and hospitality staff. Patients felt that
staff kept them well informed and calm before their procedure. A large proportion of patients also
commented on how good the food was.
Positive feedback in connection with the Radiology and Physiotherapy Departments focussed heavily on
the practical advice given by the knowledgeable staff in conjunction with their caring and professional
manner.
Areas for improvement
The feedback card requested patients to highlight areas that they thought could be improved. The
hospital welcomes this valuable feedback so that action plans can be implemented to address areas
requiring improvement. This is completed on a weekly basis and all comments and suggestions are
discussed within weekly departmental team updates.
The tables below illustrate the principal comments and suggestions for improvements and the actions
implemented.
Patient Suggestions / Comments
Would be good to see the same nurse
Try to reduce length of stay times
Patient Suggestions / Comments
Actions Implemented
Nurses allocated to patients where possible to
provide continuity
Now encouraging early dressing and mobilisation
for major joint surgery patients which has resulted
in a positive approach to early discharge
Actions Implemented
Lack of communication in relation to delays
Teams encouraged to frequently feedback to
patients if there are any delays
Inconsistency in nursing experience
Increase flexible use of permanent staff, reduce
use of bank staff and zero use of agency staff
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More detailed pre-admission information about
the room facilities
Inpatient and Day Surgery Patient Information
Guides have been implemented and are sent to
our patients prior to admission
Admission needs to be closer to the estimated
operating time
We are currently investigating staggered
admissions in conjunction with our Consultant
Partners
Inside door handles within the Ladies Toilet
(reception area) difficult to use
We have fitted new door handles within the ladies
toilet in order to make the opening of the doors
easier
Less paperwork and duplication of information
requested
We have introduced a new Care Plan Pathway
Booklet which has minimised the duplication of
information
The T.V. System not working properly
We are trialling a new remote control that should
remove the problems that our patients are
experiencing
Richness of food and lighter menu choices
Our Hospitality Team discuss menus in greater
detail with our patients and highlight the option of
ordering 'off the menu options' for more simpler
and lighter dishes. Our Head Chef actively visits
patients to further discuss menu options,
particularly in relation to long stay patients and
children
Continuity of ward rounds
Roll-out of nurse quality ward rounds and ‘time to
care’ initiative
Communication flow between nursing teams and
other departments
Weekly Team Meetings have been implemented
across all departments within the hospital. This
provides the opportunity for all team members to
share information and to be updated on any new
developments within the hospital
Further patient feedback
We were very pleased to receive a wealth of thank you cards, flowers and chocolates from patients who
have wanted to show their appreciation for the care they have received whilst at CircleReading.
These are displayed within the departments received, to ensure that all staff feel appreciated and valued.
When compliment letters are received, copies are distributed to all those involved with the patient’s care
and any patient identifiable information is removed.
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Patient Focus Group
Aim: Circle is an organisation dedicated to its patients and we continuously strive to improve the quality
and value of care that we give. For this reason we initiated the Patient Focus Group to capture patients’
experiences and ideas so that we can address issues and ideas not only from our perspective but also
from that of the patients.
Who: The members of the Focus Group are past and present inpatients and outpatients of Circle Reading
and include both NHS and private patients. We currently have 8 members. They were personally
approached and invited to be members. It was emphasised that they were not committed in any way.
The variety of patients reflects a cross section of personal experiences within the hospital.
How: The first meeting was held on the 10th of May 2013. The agenda included a welcome tour of the
hospital and then a lunch with the Lead Nurse, Hospital Hotel Manager, Governance & Assurance Lead
and other members of staff from a cross section of all departments within the hospital. The meetings are
held every quarter.
Evolving: From the conception of the Patient Focus Group, we have implemented a structured approach
to the meetings. We have agendas, issues, changes and progress which we discuss. An invitation is sent
out to the members with the agenda and they in turn confirm their attendance. We arrange a meeting
followed by lunch. Minutes are taken and circulated to the members for their information and review.
The future: We aim to continue with the current forum as its members represent a real variety in both
personal experiences of Circle but also thoughts regarding the varied topics we discuss.
Key issues discussed in 2013 and 2014 (to date) include: Patient Feedback, Net Promoter Scores for NHS
Inpatients, Patient Suggestion Boxes, Automating the Friends & Family Test, Circle Reading 'Facebook',
'Staying in Touch' Post-Operatively (Newsletters / Promotional Offers), Gift Shop Product Updates, 'Grab
& Go' Menu, Post-Operative Home Service (Patient Nutrition Plan) and Hand Hygiene Alcohol Gel Stands.
Key actions implemented in 2013: As a result of the above discussions, Patient Suggestion Boxes have
been placed in all departmental areas of the hospital for use by our patients. iPad Tablets which
electronically collect patient feedback are now situated in Outpatients, Inpatients and the Daycase areas
within the hospital. Our 'new look' website has been launched which incorporates the suggestions made
by our patient forum members.
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Providing Feedback to Consultants & GP’s
Patient feedback is shared with Consultants in several formats. The monthly analysis of
feedback is distributed to all staff via email prior to publishing on our website. In addition the
Quality Quartet is discussed at the monthly Executive Board meetings and feature the top 3
improvements suggested by patients and the % of recommendations.
Also discussed at this time are any formal complaints that are in progress. Consultants engage very
positively in this process and are actively involved in of the resulting actions.
GP surgeries are informed about Patient Feedback in a variety of ways with the main being a hard copy
delivered during a visit to the Surgery by one of the two GP Partnership team. The feedback is taken
from the website and is therefore unaltered or edited and includes negative as well as positive
comments.
A GP Newsletter is produced every two months and this includes the patient feedback from the website,
the % of patients that have recommended Circle Reading to their friends and family in the previous two
months and is usually accompanied by a selection of patient comments.
On the Circle Partnership website there is an area dedicated to GPs and staff at GP practices and we
ensure that the patient feedback is accessible from this area.
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Complaints and Concerns:
In total during 2013 we received:
 37 formal complaints.
 19 concerns.
Formal Complaints



100% of formal complaints were acknowledged within 3 working days.
100% of formal investigations and subsequent responses were sent within 20 working days.
95% of formal complaints were upheld.
Complaints Received during 2013
Month
No. of Formal Complaints Received
January 2013
February 2013
March 2013
April 2013
May 2013
June 2013
July 2013
August 2013
September 2013
October 2013
November 2013
December 2013
1
0
8
2
0
2
2
4
4
2
7
5
Actions Resulting from Formal Complaints Received in 2013
All complaints, associated investigations and respective responses are shared with not only the staff
members involved and the departmental team members from the respective area(s), but are also shared
on a broader scale. Action plans are implemented in order that there is education, training and feedback
in relation to sharing lessons learnt. This information is shared in a multi-disciplinary approach.
Complaint Overview
Action Implemented
Issues with Pre-Assessment summarised
as a general apparent lack of
organisation and poor communication.
All Pre-Assessment staff instructed to re educate themselves in relation to
screening policies. Further development
and training implemented in relation to
some specific areas of our operation.
New process initiated incorporating
detailed 1/2 hourly and 2 hourly checks
(as a minimum) of patients to ensure
that all relevant information
requirements and clinical needs are
being met.
Greater feedback in relation to theatre
delays and post-operative care nursing.
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Patient Comment……
'The overall care was excellent. The Consultant and the staff
made me feel special. Thank you'.
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Staff Engagement
Staff Survey:
Circle Reading undertake an annual staff survey, as part of the performance management process. We
ask our staff to score the following statements (1= strongly disagree: 5 = strongly agree):







At work I have clear, well understood objectives.
During the last week, I have received praise for my work.
I am consistently free to make ethical decisions.
I feel that my opinions at work are valued.
I have adequate materials and equipment to do my work well.
I have the opportunity at work to do what I do best every day.
My immediate manager is supportive of me.
Average Scores:
In 2013, staff partners (95%) said they would recommend working at Circle to other potential
candidates.
Average Score for the last half of 2012 = 4.2
Average Score for the first half of 2013 = 4.1
Average Score for the second half of 2013 = 3.9*
* The average score decrease is due to the fact that all partners, since the opening of Circle Reading in
August 2012, are fully appreciating the performance management process and are engaging fully and
openly in relation to such.
Listed below is a sample of responses received from our partners in relation to the question below:
"What would be the one thing about working at Circle that you would keep as it is?"
"Our very strong dedication for our patients and our great customer service".
"Going out of our way to make sure we deliver a great experience is the best feeling".
"The new ideas of ways of working and openness of bringing in new ideas and processes".
"Culture of transparency".
"The flexibility of my role and that I am allowed to make decisions on my own".
"Support received from my peer group at times when things are difficult".
"Being part of a company that is dedicated to it's patients and where all partners are continuously striving
to do things better".
"The friendliness and helpfulness that exists between departments".
"The multidisciplinary team, the supportive staff, and how everyone gets involved, without the blame
culture".
"I enjoy working at Circle Reading due to the friendliness and helpfulness of colleagues and the positive
working environment".
"The partners' pride in their working environment".
"The willingness to improve processes to make working here efficient, productive and practical, especially
when it comes to the patients".
"Partners support one another, regardless of hierarchy. I think that is what makes the hospital so
unique".
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Initiatives
Partner Recognition Award:
Every quarter our partners are able to make nominations for
another member of staff, who they believe has gone
‘the extra mile’.
Each quarter, 3 members of staff are recognised for their
contributions.
Staff Forums – The General Manager holds regular staff forums, to allow staff to ask questions and hear
the latest news and business developments. A weekly update report is also produced by the leadership
team, which outlines what we are doing well and areas which may need improvement. This report is sent
to all departmental leads, who then cascade the information through their departmental meetings, to
their respective teams.
A Voice for Change – Staff at all levels of the business are encouraged to share their ideas with the
leadership team and Executive Board. These ideas are then reviewed and implemented if practical and
beneficial to the hospital. Staff are given incentives to strategically review their department and strive for
excellence which enhance the quality of our services wherever possible.
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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
Departmental Leads, the HR Lead and the Governance & Assurance Lead. Training days are provided
throughout the year, and training is provided by both internal and external trainers. A 'new' suite of
mandatory training courses were launched in April 2014 via 'EduCare' to facilitate and improve the
quality and accessibility of 'on-line' mandatory training tools.
Clinical Training:
In conjunction we have also invited expert external speakers to hold training sessions with clinical staff.
Examples include:

The deteriorating patient
– for adults and paediatrics

Epidurals

Critical Care
We believe the preservation of our culture and founding beliefs across the company is vital if we are to
maintain our differential and the high standards our patients have come to expect from us.
New Starters:




We welcome new starters to Circle Reading by introducing them to our General Manager, the
Credo and the principles that drive our business; best patient experience, clinical outcome and
value at all times.
We provide new starters with the support required in their first 12 weeks, giving them every
chance of succeeding to full partnership.
We carefully manage the probationary period.
We coach new starters by a series of 'face to face' sessions on the learning principles we want to
promote and which will give them a better understanding of what working in the partnership
means.
Training Sessions we implement for New Starters:




The Circle Credo.
Tetra-map – (personality analysis and improving communication).
Explaining the Partnership.
Understanding the performance review process.
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Measuring the process:


Feedback and review from all sessions is gathered through evaluation forms. The information is
correlated and fed to all departmental leads for review and change implemented as required.
Regular meetings with departmental leads are less formal and focused more on developing
‘ownership’ encouraging self-awareness, self-appraisal and self-management. This form of
reflection is designed to keep our principles high on our personal agendas so raising quality in our
day to day working practice.
New from April 2013:


Monthly induction sessions for new partners have been set up in a way that enables
departmental leads and individual partners to access and book.
The ‘Introduction to Circle Partnership’ has been included in the formal mandatory sessions
required for all new partners to attend with reference to the new starter’s handbook.
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Resuscitation Training provided by our Hospital Partnership
ADULT BASIC LIFE SUPPORT
1. Recognition of cardiac arrest in the adult.
2. Adult Basic Life Support as per Resuscitation Council UK Guidelines 2010.
3. Recognition and emergency treatment of the choking adult as per Resuscitation Council UK
Guidelines 2010.
4. Safe positioning of the adult into the recovery position.
PAEDIATRIC BASIC LIFE SUPPORT
1. Recognition of cardiac arrest in the child.
2. Paediatric Basic Life Support as per Resuscitation Council UK Guidelines 2010.
3. Recognition and emergency treatment of the choking child as per Resuscitation Council UK
Guidelines 2010.
4. Safe positioning of the child into the recovery position.
5. Familiarisation and contents of the Broselow system.
IMMEDIATE LIFE SUPPORT
1.
2.
3.
4.
5.
6.
7.
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 and reference to “Treating the Critically Ill Patient”
by Philip Jevon.
1. Identify a variety of likely conditions which cause deterioration in an adult patient at Circle
Reading. Revise and understand the emergency treatment of these conditions. Lecture and
group discussion.
2. Demonstrate and understand a systematic A-E assessment of an adult patient. Demonstration,
lectures and practical.
3. Discuss when and how to call for help at Circle Reading.
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RECOGNITION AND TREATMENT OF THE DETERIORATING CHILD (RaToDchi)
Following the Resuscitation Council UK guidelines and reference to “Advanced Paediatric Life
Support Manual” by ALSG (Advanced Life Support Group).
1. Pre-Course quiz of basic paediatric emergency knowledge.
2. Understand basic anatomical differences of a child. Lecture and discussion.
3. Identify a variety of likely conditions which cause deterioration in a paediatric patient at Circle
Reading. Revise and understand the emergency treatment of these conditions. Lecture and
group discussion.
4. Demonstrate and understand a systematic A-E assessment of a paediatric patient.
Demonstration, lectures and practical.
5. Discuss when and how to call for help at Circle Reading.
ANAPHYLAXIS
1.
2.
3.
4.
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.
ALS ALGORITHM AND DEFIBRILLATOR UPDATE
Revision of RCUK ALS algorithms. Lecture and discussion.
1. Tachycardia
2. Bradycardia
Practical use of Zoll R-Series defibrillator for cardioversion and pacing. Scenario based practical.
Circle Reading actively encourages and supports clinical partners to undertake nationally recognised
external UK Resuscitation Courses including:
1. Advanced Life Support (ALS).
2. Emergency Paediatric Life Support (EPLS).
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Patient Comment……
‘Made me feel at ease and less nervous. Took the trouble to
make me comfortable'.
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The Care Quality Commission
Circle Reading has been inspected by the Care Quality Commission (CQC) on two occasions during
2013/14, as responsive inspections.
The Care Quality Commission's role is to independently regulate the quality of all health and social care
services in England.
The inspections took place on the 14th of January 2014 and the 20th of January 2014.
The inspections covered 2 areas under the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009:

Management of Medicines
Assessing and Monitoring the Quality of Service Provision
All assessed outcomes were found compliant.
Below is an extract of some of the comments noted within the report:“We found that the provider ensured safety of people who use the service because there were robust
systems in place for the management of medicines”.
“We found that the provider had an effective system in place to identify, assess and manage risks to
health, safety and welfare of people who use the service”.
Circle Reading is required to register with the Care Quality Commission and its current registration status
is ‘approved’.
Circle Reading has no conditions on registration.
The Care Quality Commission has not taken enforcement action against Circle Reading during 2013 or
2014 to date.
Circle Reading has not participated in any special reviews or investigations by the CQC during the
reporting period.
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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.
Circle Reading 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 for staff to ensure accurate data collection.
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Information Governance Attainment Levels
Information Governance is of vital importance to us at Circle Reading, and as such is placed very highly on
our Governance & Assurance Agenda. All staff are required to undertake Information Governance and
Information Security mandatory training, which is monitored on a quarterly basis. Patient Information
Guides pre and post admission are also available which highlight best practice with regards to
information governance and data protection.
As a supporting business provider for NHS patients, Circle Reading participates in the National
Assessment of information governance compliance called the Information Governance Toolkit. The first
assessment for Circle Reading was undertaken in March 2014. Circle Reading's Information Governance
Assessment Report (IG Toolkit version 11 Assessment) overall score for 2013 / 2014 is 66% and was
graded 'satisfactory' (RAG rated 'Green').
In May 2014, Circle Reading achieved ISO 27001 accreditation with zero-non conformities.
An Information Governance Strategy (Approved February 2013):
Circle Reading 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. Information Security is a keystone element of clinical and corporate governance
as well as service planning and patient care.
To ensure the highest standards of compliance, Circle Reading is in the process of implementing a suite of
Information Security 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.
The aims of the Strategy are:
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 Circle Reading to understand its own performance, learn from previous incidents and
implement improvement plans.
5. Reinforce an active information Security Culture and ethos amongst the staff.
6. Minimise the risk of information breaches.
7. Minimise the inappropriate use of information.
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Current Protocols in Place
Protocol
Current Position
Improvements Required
Business
Continuity
Business Continuity / Major Incident Plan in
place. Available to all Senior Management
Team members and Departmental Leads via
the network.
Business continuity tool kit to be
produced and kept on Reception.
Business continuity review day to be held on
in conjunction with the Clinical Governance &
Risk Management Committee and Executive
Board Chair and the Senior Management
Team.
Monitoring of Business Continuity
events through the Datix Incident
Reporting System and reported
through the Clinical Governance &
Risk Management Committee and the
Executive Board.
Plans to be reviewed.
Fire Desktop drills to be carried out.
Early morning and evening desktop
drill to be arranged.
Annual inspections for Fire, Health and Safety
and Infection Prevention and Control to be
arranged.
Annual Business Impact Assessment to be
completed.
Incident
Management
Reporting
Incidents now reported through the Datix
Incident Reporting System.
Continuous ongoing training
implemented since initial launch of
system in November 2012.
Further configurations completed as
and when required.
Monthly reviews of all incidents.
Physical
Security
Compliant.
Security team in place during the evenings and Review of camera angles to be
weekends.
organised to ensure all areas of the
hospital site are recorded.
Any incidents raised through the normal
reporting route.
Annual IS audit reviews physical security.
Risk
Management
Strategic Risk Register completed by the
Governance & Assurance Lead on a monthly
basis. Register sent and reviewed at the
Executive Board, Integrated Governance
Board and Clinical Governance & Risk
Management Committee.
Information Security Risks and
incidents reported on Corporate
Governance Dashboard.
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Policies
Information Security Policies in place and
available to all staff electronically through the
Content And Learning Management System
(CALMS).
All Information Security Policies have
been loaded onto the Content And
Learning Management System
(CALMS).
Policy Quality Review Team established
previously by the corporate governance team
to review and standardise all corporate
policies.
Training
-
Annual Information Governance and Information Security Training.
Content And Learning Management System (CALMS) and 'EduCare' both incorporate Information
Governance and Information Security training modules which are available for all staff to undertake.
Mandatory Training.
'Face to Face' Training.
Information Asset Ownership Forum to be formed and for training to be made available within this
forum for all members.
Further SIRO and Caldicott Guardian Training.
Plans for 2014
-
Root Cause Analysis training for Lead Nurse, Deputy Lead Nurse, Theatre Lead and the
Governance & Assurance Lead.
Review of e-learning training materials for Departmental Leads.
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Information Security Objectives - 2014
Objective
Plan
Monitoring
Develop additional audits with
IAO forum to build on the
foundation of audits already in
place.
IAO forum to become
established.
Audit compliance to be assessed
by General Manager &
Corporate Head of Governance
and Risk.
Targeted training for key staff
members.
In conjunction with Staff wide
initiatives, to review and
develop more in-depth training
for key personnel.
Training effectiveness to be
monitored and evaluation forms
completed.


Training for IAOs
CALMS / 'EduCare'
e-learning
 Mandatory training
Ensure accurate data
presentation.
Quality review to be undertaken
by Lead Nurse and Governance
& Assurance Lead.
Compliance figures to be
reported to the Clinical
Governance & Risk
Management Committee.
On-going.
On-going review of data quality
to take place with continued
triangulation to ensure highest
accuracy levels of compliance.
Successfully complete the IG
toolkit.
IG toolkit initial training has
taken place. Identify whether
further training needed.
On-going.
Planned approach to completing
the tool kit (Circle wide).
Reduce the number of
information security incidents /
near misses reported.
Monthly review of Information
Security Incidents.
Investigations to identify
changes to processes to be
implemented.
Continue to embed DATIX as the
incident reporting tool.
On-going review of Information
Security Incidents reported.
Further training to be provided
for report creation.
Patient Guide
Information guide to be created
informing patients regarding
Information Security.
Content to be agreed.
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Involvement in Local Networks
Circle Reading 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:
Critical Care Network
ALS Provider Network
Controlled Drugs Compliance
Berkshire MDT Speciality Group
New Initiatives
Patient Enhanced Recovery Post Hip and Knee Surgery
Programme
The objective of the programme is to improve the patients' experience by improving our efficiency and
this is to be measured by length of stay and outcomes achieved.
2014

Revision of the Patient Pathway
Objective:
So all staff are aware of the daily goals not only for their speciality but also in relation to other teams
involved in the patients care. We are working in conjunction with our Circle partners to review and
implement the revision of the patient pathway in line with best practice, using a multi-disciplinary
approach.
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Pain Audit
At Circle Reading we aim to improve pain control and subsequently patients’ recovery and satisfaction
with care given. We use a common tool for pain assessment throughout the hospital to help raise
standards of patient care. A simple numerical rating scale requires the patient to choose a number
between 0-3 to represent their level of pain. Zero indicates that the patient has no pain and 3 means that
their pain is severe (as bad as can be imagined).
Once we have assessed the level of pain we use the 'Who' ladder to help us decide on which analgesia to
use depending on the severity of the pain.
We evaluate the effectiveness after 20-30 minutes and then give further analgesia if needed. This is
charted on a pain and nausea chart to help with continuity of care. This helps us assess and evaluate how
we can improve on pain management.
Objective:
Areas that we are working towards moving forward in 2014:


To re-evaluation of our pain auditing process using a multi-disciplinary approach.
To continue to monitor the compliances and frequencies of our audit programme on a monthly
basis.
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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, Adrian Peake on 0118 922 6888 or email
adrian.peake@circlepartnership.co.uk
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