Duchy Hospital
Quality Account
2013/14
No reported MRSA bloodstream
Infections in the past 5 years
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2013/14 (looking back)
2.1.2 Clinical Priorities for 2014/15 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2013/14 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
3.2
Patient Safety
3.3
Clinical Effectiveness
3.4
Patient Experience
3.5
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Consultants and staff data
Appendix 3 – Clinical Audits
Welcome to Ramsay Health Care UK
Duchy Hospital is part of the Ramsay Health Care Group
The Ramsay Health Care Group was established in 1964 and has grown to become a
global hospital group operating over 100 hospitals and day surgery facilities across
Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health
Care is one of the leading providers of independent hospital services in England, with a
network of 31 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the NHS
in the UK. Through a variety of national and local contracts we deliver 1,000s of NHS
patient episodes of care each month working seamlessly with other healthcare providers
in the locality including GPs, Clinical Commissioning Groups.
“As Chief Executive of Ramsay Health Care UK, I am passionate about
ensuring that high quality patient care is our number one goal. This relies not
only on excellent medical and clinical leadership in our hospitals but also upon
an organisation wide commitment to drive year on year improvement in patient
satisfaction and clinical outcomes.
Delivering clinical excellence depends on everyone in the organisation. It is
not about reliance on one person or a small group of people to be responsible
and accountable for our performance. It is essential that we establish an
organisational culture that puts the patient at the centre of everything we do
and as a long standing and major provider of healthcare services across the
world, Ramsay has a very strong track record as a safe and responsible
healthcare provider and we are proud to share our results.
Across Ramsay we nurture the teamwork and professionalism on which
excellence in clinical practice depends. We value our people and with every
year we set our targets higher, working on every aspect of our service to bring
a continuing stream of improvements into our facilities and services.”
Jill Watts, Chief Executive Officer of Ramsay Health Care UK
Introduction to our Quality Account
This Quality Account is Duchy Hospitals’ annual report to the public and other
stakeholders about the quality of the services we provide. It presents our achievements
in terms of clinical excellence, effectiveness, safety and patient experience and
demonstrates that our managers, clinicians and staff are all committed to providing
continuous, evidence based, quality care to those people we treat. It will also show that
we regularly scrutinise every service we provide with a view to improving it and ensuring
that our patient’s treatment outcomes are the best they can be. It will give a balanced
view of what we are good at and what we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment centre
within the Ramsay Health Care UK. It was recognised that this didn’t provide enough in
depth information for the public and commissioners about the quality of services within
each individual hospital and how this relates to the local community it serves.
Therefore, each site within the Ramsay Group now develops its own Quality Account,
which includes some Group wide initiatives, but also describes the many excellent local
achievements and quality plans that we would like to share.
.
Part 1
1.1 Statement on quality from the General Manager
Welcome to Duchy Hospital’s quality account. This report outlines the Hospitals
approach to quality improvement, progress made in 2013-14 and plans for the
forthcoming year.
Duchy Hospital has five key values which underpin everything we do as an
organisation:
Put the patient first
Work as one team
Respect each other
Strive for continual improvement
Respect environmental sustainability
The aim of our Quality Account is to provide information to our patients and
commissioners to assure them we are committed to making progressive
achievements. For example, we participate in the Health Protection agency’s
Surgical Site Surveillance Service and our surgical site infection rates are
significantly lower than the national average.
Our emphasis is on ensuring patients receive safe and effective care, that they
feel valued and respected in decisions about their care and are fully informed
about their treatment at each step of the pathway.
The experience that patients have in our hospital is of the utmost importance
and we are committed to establishing an organizational culture that puts the
patient at the centre of everything we do. As well as being treated quickly and
safely, our patients receive a personalised service, enhanced by good
communication and a commitment to ensuring their privacy and dignity are
respected at all times.
High quality patient care is at the centre of what we do and how we operate our
hospital. To do this we rely on excellent medical and clinical leadership plus an
overall continuing commitment to drive year on year improvement in clinical
outcomes.
We especially value patient’s feedback about their stay, treatment and clinical
outcome. In the last year we have taken part in the NHS Inpatients survey and
received excellent feedback. We have also participated in the NHS Friends and
Family Survey, and have been delighted with the results and comments
received from patients. The Health Gain scores for our joint replacement
continue to be amongst the best in the country.
In 2013-2014 we completed a £6m investment, adding a Cardiac Catheter
Laboratory, an additional Laminar Flow Operating Theatre, dedicated state of
the art facilities for Day Case patients and refurbishing all of our Reception and
Waiting Areas. This has further improved the range of services we can of fer,
and the quality of service we provide.
Chris Sealey
General Manager
Duchy Hospital Truro
1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the publication
of this document, the information in this report is accurate.
Chris Sealey, General Manager
Duchy Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Miss Bates, Consultant Gynaecologist,
Medical Advisory Committee Chair
Mr Kumaravel, Consultant Ophthalmic Surgeon,
Clinical Governance Committee Chairman
Helen White,
Regional Director, Ramsay Health Care UK
Kernow Clinical Commissioning Group
Cornwall Overview and Scrutiny Committee
Cornwall Health Watch
Welcome to Duchy Hospital
Duchy Hospital, one of the South West’s leading independent hospitals, provides
medical and surgical services as outpatient or planned admitted care for adults and
older children; the full range of specialties offered is shown at Appendix 1. Where
clinical need requires it, our team of well trained, competent and experienced staff
provide 1:1 care, Level 2 critical care. In the unlikely event of that a higher level of
care becomes necessary, Level 3 Critical Care; there is a transfer arrangement in
place with Royal Cornwall Hospitals NHS Trust. Paediatric trained nurses are
available to care for those under the age of 18 years.
Additional onsite facilities include cosmetics, radiology, physiotherapy, mobile and
MRI/CT. We work closely with the Royal Cornwall Hospital NHS Trust which
provides our blood transfusion, pathology, and some pharmacy services.
On the 24th April 2014 140 Consultants were registered as approved to practise at
Duchy Hospital. The full list of consultants with practising privileges along with a
comprehensive list of the disciplines and numbers of staff employed as of April 2014
can be found at Appendix 2.
We pride ourselves on the delivery of high quality, safe, effective care in a manner
and environment that respects and protects the privacy and dignity of our patients
be they medically insured, self-funding or referred by the NHS. Our facilities and
clinical and support services are continually monitored to ensure that we are
offering the very best service to our patients.
Our major capital investment in our facilities came to fruition in summer 2013 and
Duchy now has 27 inpatient beds, a purpose built Ambulatory Care facility with 12
patient spaces, 3 laminar flow theatres, a cardiac catheterisation laboratory and
outpatient treatment facilities and 11 outpatient consulting rooms. This has enabled
us to expand the range of services to patients and to provide them from a modern,
well designed environment
During the year from 1st April 2013 to 31st March 2014 7,097 patients received
treatment here as day-cases or inpatients of which 5,222 were NHS patients (73%).
Of the overall total 5041 (71%) were treated as day cases compared to 69% last
year. Only 14% of the day case patients were treated on the inpatient ward
compared to 25% in the previous year. This has had a major impact on how
efficiently the attendance and stay of these patients is managed.
Mrs Miranda Field is our GP Liaison Officer. Miranda has close contact with both
the practice managers and the GPs at our practices throughout Cornwall. She
organises regular “Lunch and Learns”, taking Consultants into GP surgeries to
offer training and latest development awareness as well as running evening GP
training seminars on a regular basis.
We value our contact with GPs as “customers” and strive to ensure we actively
work in partnership with them to enhance patient care. Dr Andrew Craze, local
GP, is a member of the hospital’s Medical Advisory Committee (MAC).
The Duchy management team has worked hard to establish a good relationship
with Kernow Clinical Commissioning Group which commissions health care
services for the people of Cornwall, and looks forward to further developing this
relationship during the coming year
We work closely with the Royal Cornwall Hospital NHS Trust which provides us
with blood transfusion, pharmacy services and access to Level 3 critical care
services.
Part 2
2.1 Quality priorities for 2013/2014
Plan for 2013/14
On an annual cycle, Duchy Hospital develops an operational plan to set objectives for
the year ahead.
We have a clear commitment to our private patients as well as working in partnership
with the NHS ensuring that those services commissioned to us, result in safe, quality
treatment for all NHS patients whilst they are in our care. We constantly strive to
improve clinical safety and standards by a systematic process of governance including
audit and feedback from all those experiencing our services.
To meet these aims, we have various initiatives on going at any one time. The
priorities are determined by the hospitals Senior Management Team taking into
account patient feedback, audit results, national guidance, and the recommendations
from various hospital committees which represent all professional and management
levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
2.1.1 A review of clinical priorities 2013/14 (looking back)
Patient Safety
WHO Surgical safety checklist – this was also one of our Commissioning for
Quality objectives for the year. Compliance with the checklist has been
excellent and all of our audits achieve at least 90% with only the absence
of small details e.g. times impacting on the score; patient safety was at all
times protected
Venous-thromboembolism assessment – we audited our compliance and
results were submitted to UNIFY and national health data base. The results
confirm that more than 96.5% of patients were risk assessed where
indicated.
Never events – sadly one Never Event occurred during 2013/14. This
involved the implantation of the wrong intra-ocular lens during cataract
surgery. The lens was removed as soon as the error was known though
this did require a second admission and operation for the patient. They
have since made a full recovery
JAG accreditation – it was only the requirements relating to IT systems that
was holding us back. This has been addressed during 2013/14 and our
formal accreditation visit will take place in July 2014
National Joint Register – whilst there was a small dip as a result of staff
change over, we have in the main been able to maintain our consistently
good scores for data submission to the National Joint Register.
Clinical and other training – we have continued to achieve good levels of
compliance with mandatory training to ensure that patients are cared for by
well trained, competent staff.
Safeguarding – all staff working within the hospital have the appropriate
level of CRB check appropriate to their role. Safeguarding Adults and Children
E-learning has been completed in accordance with the Ramsay training
programme. In addition staff have received a taught session about
Safeguarding, Mental Capacity Act and Deprivation of Liberty Safeguards
and PREVENT in accordance with the Ramsay timetable; this is to ensure
that staff have the necessary resources available to enable them to manage
any concerns appropriately and in a timely manner.
Staffing – Ramsay invested in an electronic rostering system called Allocate;
which was introduced during late 2013. Clinical managers have put key staffing
requirements and parameters into the system which then produces rotas in
line with patient numbers and specific local skill mix requirements. This
reduces the time spent on producing numerous rotas throughout the
hospital and will be accessible to all staff so they can log in and make
requests for leave, training etc. It also records training hours and reminds
staff when they need to attend mandatory training sessions.
Clinical effectiveness
Ambulatory Day Care – Best practice has shown that by caring for short
stay patients in a day care facility, as opposed to a traditional ward, patient
care will improve as the waiting time and recovery period are reduced and
the Ambulatory Care Unit has demonstrated this; it continues to be an
efficient and effective facility for patients and is a large part of facilitating
better outcomes and improving patient experience for those whose
procedure does not require inpatient admission
Patients appreciate the efficiency of the system which enables them to have
their procedure in modern, comfortable surroundings and only have to
spend a few short hours in hospital.
Pre-operative assessment Clinic (PAC) – The capital development
provided designated, purpose built space for PAC and Duchy’s pre
assessment team have continued to work hard to develop the service to
ensure patient’s fitness for surgery is assessed in advance of their
admission to reduce the chance of their operation being cancelled for safety
reasons. Our cancellation on the day of surgery for issues relating to
patient fitness is very low. During 2014/15 we will continue to improve the
efficiency and effectiveness of this service
Ramsay is a member of PHIN – Private Hospitals Information Network
which will enable private providers to benchmark against other types of
provider for key performance indicators(activity/volumes, mortality, day case
rates, unplanned readmissions, average length of stay, unplanned transfers,
reoperations, etc)
We have continued to benchmark our services against other providers
nationally wherever possible including:
VTE risk assessment compliance – benchmarking through the national stats
website
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsSt
atistics/DH122283
PROMS results – benchmarking through national PROMS website.
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer/siteID=1937&ca
tegoryID-1295
Patient experience
Patient reported outcome studies (PROMS) – we continued to participate in
the national PROMS data collection for Hips, Knees, Varicose Veins and
Hernia surgery. The results, which are very encouraging for Duchy, were
shared with the medical and clinical staff through the Medical Advisory
Committee, Clinical Governance Committee, and Clinical Head of
Department and Departmental meetings. Reviewing this data also provides
the opportunity to identify poor outcomes and examine practice if and when
it exists. Last year we participated in a local Clinical Outcomes tool which
was also being piloted by the Royal Cornwall Hospital for orthopaedic
patients. This project continues into 2014/15
Patient satisfaction survey – Duchy has always achieved a high level of
patient satisfaction even during the recent building work. During 2013 the
paper based survey was replaced by a web-based questionnaire / telephone
survey which allows feedback to be received much more quickly and we
receive weekly free-text comments from the survey so we can act in a more
timely fashion where necessary.
The latest formal report relates to patients discharged during March 2014
and there was a response rate of 65% with a quarterly average response
rate of 52.6%. In response to the question “Overall how would you rate your
experience” Duchy achieved a rolling quarter rating of 94.6% and 95.4% of
patients said they would recommend the hospital.
2.1.2 Clinical Priorities for 2014/15 (looking forward)
For 2014/15 Duchy will strive to continue delivering a safe, high quality experience for
all patients. In particular we will focus on:
Patient Experience
We will continue to work hard to ensure that all those who use our services have
a positive experience. We will monitor this through ratings in the patient survey
and national ‘Friends and Family’ test which is one of our Quality targets in our
agreement with Kernow Clinical Commissioning Group (KCCG) for the coming
year and will be monitored through our monthly report to them.
Develop a pre-optimisation service for patients to enable their complete journey
– sometimes patients are anaemic or have iron levels lower than is ideal when
undergoing major surgery. Currently such patients have to attend other
hospitals to resolve this before surgery at Duchy can proceed. This is disruptive
for the patient and can lead to unnecessary delays.
Increase the number of patients who receive copies of the letter to their GP on
discharge. This is important so that patients are fully informed about their care
and aftercare. This is one of our quality targets with the KCCG and we will
measure it through the patient survey responses.
Clinical Effectiveness
Improving the effectiveness and consistency of the PAC experience – ensuring
all patients are assessed prior to admission either by phone or face-to-face and
that any health issues that could cause their admission to be cancelled are
identified and plans put in place to resolve them so surgery can proceed at the
earliest opportunity. All operations cancelled on the day will be recorded and the
information analysed to identify if the cancellation could have been prevented
Reduce avoidable re-admissions within 30 days of surgery- We will further
develop systems for capturing re-admission data including admissions to other
hospitals to enable proper analysis of themes, commonalities and make any
necessary improvements to practice.
Implement a 3-day stay pathway for patients undergoing total hip replacement
where this is appropriate. Providing they have the right support, patients recover
better in their own homes, and this small reduction in length of stay will help
more people go home sooner.
Patient Safety
We will increase the number of patients who report that staff told them about
medication side effects to watch out for when they went home. This is very
important so that patients understand their medication and do not suffer
unnecessarily from side effects; it is also an area where we rate lower in our
patient survey. We will monitor the monthly patient survey results and put
actions in place to improve the information given to patients to increase the
positive response rate
Progress against all of these priorities will be monitored by the Senior
Management Team and reported to our local Clinical Governance Committee.
Those that are targets agreed with KCCG will also be reported in our monthly
quality report to them.
2.2 Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2013/14 Duchy Hospital provided and/or subcontracted 10 NHS Specialties
through the Chose and Book system and has reviewed all the data available to them
on the quality of care in all of these NHS services.
The income generated by NHS services in the year 1st April 2013 to 31st March 2014
represents 69.7% of the total income generated from the provision of services by the
Duchy Hospital for 1st April 2013 to 31st March 2014.
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard are
reviewed each year. The scorecard is reviewed each quarter by the hospitals senior
managers together with Regional and Corporate Senior Managers and Directors. The
balanced scorecard approach has been an extremely successful tool in helping us
benchmark against other hospitals and identifying key areas for improvement.
In the period for 2013/14, the indicators on the scorecard which affect patient safety
and quality were:
Human Resources
Staff Cost as % Net Revenue
HCA Hours as % of Total Nursing
Agency Cost as % of Total Clinical Staff Cost
Ward Hours PPD
% Staff Turnover rolling 12 months
% Sickness rolling 12 months
% Lost Time
Appraisal %
Staff Satisfaction Score (max possible 7)
Number of Significant Staff Injuries
Patient
Formal Complaints per 1000 HPD's
Patient Satisfaction Score
Clinical Events per 1000 Admissions
Readmission per 1000 Admissions
Quality
Workplace Health & Safety Score
Infection Control Audit Score
24.7
18%
<0.5%
5.67
8.3
4.43
21.0
85%
4.63
0
8.35
94.6%
3.76
3.44
96%
97%
2.2.2 Participation in clinical audit
During 1 April 2013 to 31st March 2014 Duchy Hospital participated in 100% national
clinical audits it was eligible to participate in. The hospital was not eligible to participate
in any of the national confidential enquiries
The national clinical audits that Duchy Hospital participated in, and for which data
collection was completed during 1 April 2013 to 31st March 2014, are listed below
alongside the number of cases submitted to each audit as a percentage of the number
of registered cases required by the terms of that audit or enquiry.
Name of audit / Clinical Outcome Review Programme
National Joint Registry (NJR)
Elective surgery (National PROMs Programme)
% cases
submitted
86%
82%
The reports of two national clinical audits from 1 April 2013 to 31st March 2014 were
reviewed by the Clinical Governance Committee and Duchy Hospital intends to take
the following actions to improve the quality of healthcare provided.
Improve our systems for submitting data to the NJR
Strengthen our systems to ensure all pre-operative PROMS forms are collected
and submitted, and that patients understand the importance of submitting their
post-operative PROMS questionnaire when it is received
Local Audits
The reports of 70 local clinical audits from 1 April 2013 to 31st March 2014 were
reviewed by the Clinical Governance Committee and Duchy Hospital intends to take
the following actions to improve the quality of healthcare provided. The clinical audit
schedule can be found at Appendix 2.
All audit results showed a good degree of compliance and our main priority
for 2014/15 will be to further improve our standards of documentation.
2.2.3 Participation in Research
Duchy Hospital did not recruit any patients receiving NHS services provided or subcontracted by them to participate in research approved by a research ethics committee
in 2013/14.
Duchy is working with other providers and local university to enable us to be part
of appropriate clinical research projects during 2014/15.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Duchy Hospital income in from 1 April 2013 to 31st March 2014 was
conditional on achieving quality improvement and innovation goals agreed Kernow
Clinical Commissioning Group and any person or body they entered into a contract,
agreement or arrangement with for the provision of NHS services, through the
Commissioning for Quality and Innovation payment framework.
Agreed goals for 2013/14
Goal
Goal Name
Description of
Goal
Goal weighting
Quality Domain
(% of CQUIN
scheme
available)
(Safety, Effectiveness,
Patient Experience or
Innovation)
1
National Adapted:
Venousthromboembolism
To reduce
avoidable death,
disability and
chronic ill health
from Venousthromboembolism
(VTE)
20%
Patient Safety
2
National Adapted:
Friends and Family
Implementation of
the Friends and
Family Test in
inpatient wards
20%
Patient Experience
3
National Adapted:
Safety thermometer
Improve collection of
data in relation to
pressure ulcers, falls,
urinary tract infection
in those with a
catheter, and VTE
20%
Patient Safety
4
Local: MEWS Risk
Assessment
Reduce clinical risk to
patients by
undertaking Medical
Early Warning
Assessments
20%
Patient Safety
5
Local: WHO Surgical
checklist
Compliance with
WHO safer surgical
checklists. 90%
target for all day case
and inpatient surgical
procedures
Totals:
20%
Patient Safety
100.00%
With the exception of one element of goal 4, all goals were achieved
Goals for 2014/15
Goal
1
2
3
4
Goal Name
Description of Goal
Goal weighting
Quality Domain
(% of CQUIN
scheme available)
(Safety, Effectiveness,
Patient Experience or
Innovation)
National Friends and
Family Test
Offer all patients
(inpatient,)
Implementation of the
Friends and Family
Test in inpatient
wards, day-case unit
and outpatients
30%
Patient Experience
National Adapted:
Safety thermometer
Improve collection of
data in relation to
pressure ulcers, falls,
urinary tract infection
in those with a
catheter, and VTE
10%
Patient Safety
Local: EWS Risk
Assessment
Reduce clinical risk to
patients by
undertaking Early
Warning Risk
Assessments
10%
Patient Safety
Local: After Care
Deliver improved
performance in the
patient survey in the
area of After Care
50%
Patient Experience
Totals:
100.00%
2.2.5 Statements from the Care Quality Commission (CQC)
The Duchy Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March is registered without conditions.
Duchy Hospital has not participated in any special reviews or investigations by the
CQC during the reporting period.
2.2.6 Data Quality
We regularly use statistical data to monitor clinical services – we are constantly
striving to improve this data by regular quality control initiatives.
Data contained in medical records are audited on a monthly basis and actions
are taken to improve quality as required. This applies to both private and NHS
patient streams.
The hospital has a data quality super user who manages the SUS pathway
processes and continually reviews administration functions to ensure data quality.
Duchy Hospital will be taking the following actions to improve data quality.
NHS Number and General Medical Practice Code Validity
Duchy Hospital submitted records during 2013/14 to the Secondary
Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are
included in the latest published data. The percentage of records in the published data
which included:
The patient’s valid NHS number:
100% for admitted patient care;
100% for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code:
100% for admitted patient care;
100% for outpatient care; and
0% for for accident and emergency care (not undertaken at our hospital).
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall score for
2013/14 was 83% and was graded ‘green’ (satisfactory).
Clinical coding error rate
Duchy Hospital was not subject to the Payment by Results clinical coding audit during
2013/14 by the Audit Commission.
2.2.7 Stakeholders views on 2013/14 Quality Account
Comments on this Quality account were invited from Kernow Clinical Commissioning
Group, Health Watch Cornwall and Cornwall Council Overview and Scrutiny committee
Kernow Clinical Commissioning Group
Kernow Clinical Commissioning Group is pleased to have the opportunity to
comment on the Quality Account 2013/14 for Ramsay Duchy Hospital and
welcomes the approach the Hospital has shown in developing and setting out its
plans for quality improvement. There are routine processes in place with the Duchy
Hospital to agree, monitor and review the quality of services throughout the year
covering the key quality domains of safety, effectiveness and experience of care.
We have reviewed the report and can confirm the information presented in the
Quality Account appears to provide a balanced account which is accurate and
fairly interpreted, from the data collected. In terms of the performance against the
2013/14 CQUIN goals the Early Warning Risk Assessment indicators were not
achieved in full.
The Quality Account presents an overview of a range of quality improvement work
being undertaken. We particularly commend the continued high patient satisfaction
and patient reported outcome measures and are pleased with the results of the
new capital investment which has enabled improvements in the patient pathway
and reductions in the average length of stay. We note the positive achievements at
the Hospital in the past year such as good control of infection outcomes, improving
patient safety by mandating VTE assessments and maintaining high compliance
with the WHO surgical safety checklist.
We are pleased to see that the priorities chosen for 2014/15 are evidence based
and have a continued focus on patient safety and improving the patient pathway.
In particular we welcome the continued work on reducing avoidable re-admissions
and the new work on reducing preventable cancelled operations by making the
pre-operative assessment more efficient.
Kernow CCG looks forward to working with the Hospital throughout the year to
achieve ever more efficient pathways delivering high quality services to patients.
Cornwall Council’s Health and Social Care Scrutiny Committee
Cornwall Council’s Health and Social Care Scrutiny Committee agreed to comment
on the Quality Account 2013 -2014 of Duchy Hospital. All references in this
commentary relate to the period 1 April 2013 to the date of this statement.
Though during the period identified the Committee have not directly scrutinised the
provision of NHS services by the hospital they still wished to comment on the
account.
Committee Members felt that the Quality Account provided a good reflection of the
services provided by the hospital, and provided comprehensive coverage of the
provider’s services.
Heath and Social Care Scrutiny Committee should be made aware of any never
events which happen within the hospital
Welcome pre-optimisation as long as it is easiest route for the patient
The Committee would like to highlight the apparent lack of targets and data for the
future clinical priorities. Generic statements such as ‘increase the number of
patients receiving copies of letters to their GP’ do not provide a robust framework
on which to scrutinise.
The Committee looks forward to future working with Duchy Hospital in 2014-15.
Health Watch Cornwall
Health Watch Cornwall decided not to comment as it had received very little
feedback about your services.
Part 3: Review of quality performance
2013/2014
Statements of quality delivery
Debby Blease, Matron and Head of Clinical Services
Review of quality performance 1st April 2013 - 31st March 2014
Introduction
“This publication marks the fifth successive year since the first edition of Ramsay
Quality Accounts. Through each year, month on month, we analyse our performance
on many levels, we reflect on the valuable feedback we receive from our patients
about the outcomes of their treatment and also reflect on professional opinion received
from our doctors, our clinical staff, regulators and commissioners. We listen where
concerns or suggestions have been raised and, in this account, we have set out our
track record as well as our plan for more improvements in the coming year. This is a
discipline we vigorously support, always driving this cycle of continuous improvement
in our hospitals and addressing public concern about standards in healthcare, be these
about our commitments to providing compassionate patient care, assurance about
patient privacy and dignity, hospital safety and good outcomes of treatment. We
believe in being open and honest where outcomes and experience fail to meet patient
expectation so we take action, learn, improve and implement the change and deliver
great care and optimum experience for our patients.”
Jane Cameron, Director of Safety and Clinical Performance,
Ramsay Health Care UK
Ramsay Clinical Governance Framework 2014
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care, clinicians
are enabled to provide that care and the organisation can satisfy itself that we are
doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance systems in
the organisation and should not be seen as a “stand-alone” activity. All management
systems, clinical, financial, estates etc, are inter-dependent with actions in one area
impacting on others.
Several models have been devised to include all the elements of Clinical Governance
to provide a framework for ensuring that it is embedded, implemented and can be
monitored in an organisation. In developing this framework for Ramsay Health Care
UK we have gone back to the original Scally and Donaldson paper (1998) as we
believe that it is a model that allows coverage and inclusion of all the necessary
strategies, policies, systems and processes for effective Clinical Governance. The
domains of this model are:
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
National Guidance
Ramsay also complies with the recommendations contained in technology appraisals
issued by the National Institute for Health and Clinical Excellence (NICE) and Safety
Alerts as issued by the NHS Commissioning Board Special Health Authority.
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
3.1 The Core Quality Account indicators
Mortality
Period
Best
Worst
Average
Period
Duchy
2012/13
RKE
0.65
RXL
1.17
Eng
1
2012/13
NVC04
0
2013/14
RKE
0.63
RBT
1.15
Eng
1
2013/14
NVC04
0
The Duchy Hospital considers that this data is as described for the following reasons
there are very few patient deaths at, or following treatment at this hospital.
The Duchy Hospital intends to take the following actions to improve this rate and so
the quality of its services
maintain a strong focus on pre-admission assessment, and appropriate and
effective staff education and competence assessment
Re-admission
Period
Best
Worst
Average
Period
Duchy
2010/11
RF4
0.0
RYR
15.8
Eng
11.04
2012/13
NVC04
3.15
2011/12
RF4
0.0
RYR
15.8
Eng
11.08
2013/14
NVC04
3.44
The Duchy Hospital considers that this data is as described for the following reasons
there is a safe discharge policy in place and patients are given good aftercare
instructions
The Duchy Hospital intends to take the following actions to improve this rate and so
the quality of its services
maintain a system of comprehensive patient assessment and information
PROMS
Hernia
Period
Apr12 Mar13
Apr13 Sep13
Best
Worst
Average
NT415
0.157
NVC27
0.015
Eng
0.085
RTG
0.138
RNA
0.019
Eng
0.086
Period
Apr12 Mar13
Apr13 Sep13
Duchy
NVC04
NVC04
Duchy Hospital considers that this data is as described for the following reasons
the number of hernia procedures is too small for the Duchy to participate
Duchy Hospital intends to take the following actions to improve this
it will monitor the amount of hernia procedures and subscribe if the numbers
become sufficient
Veins
Period
Apr12 Mar13
Apr13 Sep13
Best
Worst
RV8
5.14
NT350
-15.92
RTD
-9.74
RLN
-10.52
Average
Eng
8.374
Eng
-9.46
Period
Apr12 Mar13
Apr13 Sep13
Duchy
NVC04
*
NVC04
Duchy Hospital considers that this data is as described for the following reasons
the number of veins procedures is too small for the Duchy to participate
Duchy Hospital intends to take the following actions to improve this
it will monitor the amount of veins procedures and subscribe if the numbers
become sufficient
Hips
Period
Apr12 Mar13
Apr13 Sep13
Best
Worst
Average
NT209
24.68
RKE
17.21
Eng
21.32
NT318
25.44
RHQ
18.34
Eng
21.61
Period
Apr12 Mar13
Apr13 Sep13
Duchy
NVC04
22.726
NVC04
21.779
Duchy Hospital considers that this data is as described for the following reasons
patients report good outcomes when returning for follow-up
we have good systems for ensuring pre-op questionnaires are returned and
patients understand the importance of returning their post-op questionnaire
Duchy Hospital intends to take the following actions to improve this
to continue and further improve return rates
to ensure patients have realistic expectations and appropriate rehab.
Knees
Period
Apr12 Mar13
Apr13 Sep13
Best
Worst
Average
NT219
20.37
RAP
12.46
Eng
16.01
RDE
20.09
RM1
14.32
Eng
16.74
Period
Apr12 Mar13
Apr13 Sep13
Duchy
NVC04
17.614
NVC04
*
Duchy Hospital considers that this data is as described for the following reasons
patients report good outcomes when returning for follow-up
we have good systems for ensuring pre-op questionnaires are returned and
patients understand the importance of returning their post-op questionnaire
Duchy Hospital intends to take the following actions to improve this
to continue and further improve return rates
to ensure patients have realistic expectations and appropriate rehab
Readmissions
Period
Best
Worst
Average
Period
Duchy
2011/12
RYR
73.3
RF4
67.4
Eng
75.6
2012/13
NVC04
92.0
2012/13
RYR
75.9
RJ6
68.0
Eng
76.5
2013/14
NVC04
93.4
Duchy Hospital considers that this data is as described for the following reasons
we have robust clinical pathways which include discharge criteria
discharge planning and the decision to discharge are based on individual needs
and condition
Duchy Hospital intends to take the following actions to improve this
to improve our awareness of readmissions to other hospitals
to continue to ensure patients are only discharged when it is safe and with the
proper advice/back-up
Responsiveness to personal needs
Period
Best
Worst
Average
Period
Duchy
2011/12
RYR
73.3
RF4
67.4
Eng
75.6
2012/13
NVC04
92.0
2012/13
RYR
75.9
RJ6
68.0
Eng
76.5
2013/14
NVC04
93.4
Duchy Hospital considers that this data is as described for the following reasons
we provide excellent customer service as demonstrated by patient surveys
care is planned on an individual basis
Duchy Hospital intends to take the following actions to improve this
to continue to ensure patients remain the focus of all we do
VTE Assessment
Period
Best
Worst
Average
Period
Duchy
13/14 Q3
Several
100%
NT244
63.2%
Eng
95.8%
13/14 Q3
NVC04
96.9%
13/14 Q4
Several
100%
NT205
67.0%
Eng
96.0%
13/14 Q4
NVC04
98.9%
Duchy Hospital considers that this data is as described for the following reasons
our clinical pathway documents direct staff to undertake VTE Risk assessment
staff understand the importance of VTE Risk Assessment
Duchy Hospital intends to take the following actions to improve this
to continue to undertake local audit and ensure risk assessment is completed
where indicated, and patients receive appropriate prophylaxis
C. Diff rate per 100,000 bed days
Period
Best
Worst
Average
Period
Duchy
2012/13
Several
0
RNA
58.2
Eng
22.2
2012/13
NVC04
0.0
2013/14
Several
0
RVW
30.8
Eng
17.3
2013/14
NVC04
0.0
Duchy Hospital considers that this data is as described for the following reasons
the hospital has an excellent record in infection prevention and control
assessment
there is low use of anti-microbials and any prescribing is in line with national
best practice and the CCG Formulary
Duchy Hospital intends to take the following actions to maintain this
to continue to provide staff, patients and visitors with education and information
about good infection prevention and control practice
continue as an active participant in local and national infection control forum
Incident rate, patient safety
Period
Best
Worst
Average
Period
Duchy
2011/12
RP6
2.6
TAJ
84.4
Eng
13.5
2012/13
NVC04
3.76
2012/13
RRF
2.0
RAT
85.6
Eng
14.8
2013/14
NVC04
4.86
Duchy Hospital considers that this data is as described for the following reasons
we provide elective care only and are therefore able to risk assess and provide
patients with an appropriate environment
there are procedures and processes in place to ensure safe practice and care
Duchy Hospital intends to take the following actions to maintain this
to continue to analyse patient safety incidents to identify areas where the
environment or practice can be further improved
ensure that our environment is well maintained and risk assessments are in
place where there is cause for concern
Friends and Family Test
Period
Best
Worst
Average
Period
Duchy
Jan-14
Several
100
RPA02
27
Eng
73
2012/13
NVC04
96
Feb-14
Several
100
RPA02
18
Eng
73
2013/14
NVC04
93
Duchy Hospital considers that this data is as described for the following reasons
actively encourage patients to complete the F&F test, and have systems in
place to facilitate them doing so
the hospital has an established reputation for high quality care and customer
service
Duchy Hospital intends to take the following actions to maintain this
to continue to and facilitate patients in the completion of the test
to extend the test to outpatients and those who attend for day case procedures
3.2 Patient safety
We are a progressive hospital and focussed on stretching our performance every year
and in all performance respects, and certainly in regards to our track record for patient
safety.
Risks to patient safety come to light through a number of routes including routine audit,
complaints, litigation, adverse incident reporting and raising concerns but more
routinely from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of key
indicators as illustrated in the graphs below.
3.2.1 Infection prevention and control
Duchy Hospital has a very low rate of hospital acquired infection and has had no
reported MRSA Bacteraemia in the past 5 years.
We comply with mandatory reporting of all Alert organisms including MSSA/MRSA
Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents
year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital. An
annual strategy is developed by a corporate level Infection Prevention and Control
(IPC) Committee and group policy is revised and re-deployed every two years. Our
IPC programmes are designed to bring about improvements in performance and in
practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:
All staff receive education and training in IPC and Hand-washing. In addition
clinical nurses undertake further training and assessment of competence
assessment in Aseptic No Touch Techniques (ANTT)
The cleanliness of the hospital is audited regularly as part of the Ramsay corporate
clinical audit programme as well as regular monitoring by Matron, the Operations
Manager and other members of the local senior management team
There is a real focus on wearing uniform and protective clothing properly and
appropriately
We have introduced hand gel dispensers on every patient bed and at the entrance
to clinical departments
The Hospital Infection Control Committee meets regularly and reports to the
Clinical Governance Committee as well as the corporate IPC Committee.
All staff take their responsibility for preventing infection seriously
As shown in the graph our already low infection rate has reduced even further during
the year despite the hospital treating more patients and employing more staff year on
year.
3.2.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient-Led Assessments
of the Care Environment (PLACE)
PLACE assessments occur annually at Duchy Hospital, providing us with a patient’s
eye view of the buildings, facilities and food we offer, giving us a clear picture of how
the people who use our hospital see it and how it can be improved.
The main purpose of a PLACE assessment is to get the patient view.
The NHS England chart below shows the four domains of the assessment with Duchy scores
as the thermometer compared to the national average as a green bar by its side
Duchy is very proud that we were above average in all domains but
continue to strive to improve.
3.2.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring our staff have high
awareness of safety has been a foundation for our overall risk management
programme and this awareness then naturally extends to safeguarding patient safety.
Our record in workplace safety as illustrated by Accidents per 1000 Admissions
demonstrates the results of safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every month
and these are sent in a timely way via an electronic system called the Ramsay Central
Alert System (CAS). Safety alerts, medicine / device recalls and new and revised
policies are cascaded in this way to our General Manager which ensures we keep up
to date with all safety issues.
Activities during 2013/14:
All incidents are recorded on our electronic reporting system ‘RiskMan’ and
analysed by our Clinical Governance and Risk and Safety committees to identify
areas for action.
We have replaced all of hydraulic patient beds with electric ones. This provides
greater control for patients and reduces moving and handling for staff
Additional moving and handling equipment has been purchased including patient
slide sheets and straps
Internal floor coverings have been replaced and external paths and car parking
areas have been resurfaced to further reduce Slip, Trip Falls.
Staff continue to receive training in risk assessment, moving and handling and Fire
and Security
3.3 Clinical effectiveness
Duchy Hospital has a Clinical Governance team and committee that meet regularly
through the year to monitor quality and effectiveness of care. Clinical incidents, patient
and staff feedback are systematically reviewed to determine any trend that requires
further analysis or investigation. More importantly, recommendations for action and
improvement are presented to hospital management and medical advisory committees
to ensure results are visible and tied into actions required by the organisation as a
whole.
3.3.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our services
grow. The majority of our patients undergo planned surgical procedures and so
monitoring numbers of patients that require a return to theatre for supplementary
treatment is an important measure. Every surgical intervention carries a risk of
complication so some incidence of returns to theatre is normal. The value of the
measurement is to detect trends that emerge in relation to a specific operation or
specific surgical team. Ramsay’s rate of return is very low consistent with our track
record of successful clinical outcomes.
As can be seen in the above graph our return to theatre rate has increased a little over
the last year but the numbers are still very low. The increase may be a reflection of the
increasing complexity of the procedures we now undertake. Each return to theatre has
been reviewed to see if there are trends or commonalties, and we have not found any;
the returns are attributable to a number of specialties, and various times of day/day of
week but most are accepted risks of the various procedures. In all cases the patient
made a full recovery.
We will continue to monitor all returns to theatre and take any action indicated as
necessary
3.4 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care is
welcomed and informs service development in various ways dependent on the type of
experience (both positive and negative) and action required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and notice
boards. Managers ensure that positive feedback from patients is recognised and any
individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback. All staff are aware of our complaints procedures
should our patients be unhappy with any aspect of their care.
Patient experiences are feedback via the various methods below, and are regular
agenda items on Local Governance Committees for discussion, trend analysis and
further action where necessary. Escalation and further reporting to Ramsay Corporate
and DH bodies occurs as required and according to Ramsay and DH policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
Continuous patient satisfaction feedback via a web based invitation
Hot alerts received within 48hrs of a patient making a comment on their web
survey
Yearly CQC patient surveys
Friends and family questions asked on patient discharge
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan of
care
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently of the
hospital so we receive a true reflection of our patient’s views.
Every patient is asked their consent to receive an electronic survey or phone call
following their discharge from the hospital. The results from the questions asked are
used to influence the way the hospital seeks to improve its services. Any text
comments made by patients on their survey are sent as ‘hot alerts’ to the Hospital
Manager within 48hrs of receiving them so that a response can be made to the patient
as soon as possible.
As can be seen in the above graph our Patient Satisfaction rate has been maintained
over the last year despite significant disruption due to the presence of contractors
onsite and building works.
All staff endeavour to deliver a positive experience for everyone visiting the hospital or
using its services. Now the building work is complete, we hope to see an improvement
in satisfaction during the coming year.
3.5 Duchy Hospital Case Study
Following the completion of our recent investment in facilities we invited a small group
of patients to conduct a Patient Led Assessment of the Care Environment (PLACE).
We spent time with these patients who then carried out their assessment and gave us
comprehensive feedback. As a result of the feedback we were able to make some
changes to our external and internal facilities, such as improving disabled parking,
improving our entrance ramp, minor changes to some of our toilet facilities.
We are committed to continuing to engage with patients, consultants and other
stakeholders to continually improve our facilities, services and patient experience .
Appendix 1
Services covered by this quality account
Duchy Hospital.
Duchy Hospital has 27 beds and an Ambulatory Care Unit with 12 patient spaces.
The Hospital has 3 theatres with laminar flow and a fully equipped endoscopy unit,
plus a Cardiac Catheter Laboratory.
Patients’ requiring level 2 care are treated and
cared for by a well trained team of staff in individual
rooms. All Ramsay Health Care UK Hospitals have
transfer agreements in place either with their local
trust or critical care network.
Duchy Hospital provides NHS consultations for those over the age of 18 but holds
CQC registration for all age groups.
On site facilities include Outpatients, Cosmetics, Radiology, Angiography
Physiotherapy and Mobile MRI/ CT.
Our clinical facilities are continually monitored to ensure that we are offering the
very best service to our patients.
Regulated Activities – Duchy Hospital
Treatment
of Disease,
Disorder
Or injury
Surgical
Procedures
Services Provided
Physiotherapy, Cardiology,
Endocrinology, General medicine,
Haematology, Oncology,
Neurology, Psychiatry,
Psychotherapy, Speech therapy,
Sports medicine, Urology, Medicine
management, Clinical neuro,
physiology, Allergy testing,
Diabetology, Occupational therapy
Cosmetic, Bariatrics,
Dermatological, Ear, Nose and
Throat (ENT), Gastrointestinal,
Colorectal, Breast surgery, General
surgery, Gynaecological,
Ophthalmic (inc laser), Maxillofacial
/ oral, Orthopaedic, Urological,
Peoples Needs Met for:
All adults 18 yrs and over
All children 12 yrs and over
Consultations – from birth
All adults excluding:
Patients with complex blood
disorders (haemophilia, sickle
cell, thalassaemia) •
Patients on
renal
haemodialysis •
Neurological, Ambulatory, Day and
Inpatient Surgery
Patients with history of
malignant hyperpyrexia •
Planned surgery patients
with positive MRSA screen
are deferred until negative •
Patients who are likely to
need ventilatory support post
operatively
Patients who are above a stable
ASA 3.
Any patient who will require
planned admission to ITU post
surgery
Dyspnoea grade 3/4 (marked
dyspnoea on mild exertion e.g.
from kitchen to bathroom or
dyspnoea at rest)
Poorly controlled asthma
(needing oral steroids or has
had frequent hospital
admissions within last 3
months)
MI in last 6 months
Angina classification 3/4
(limitations on normal activity
e.g. 1 flight of stairs or angina at
rest)
CVA in last 6 months
However, all patients will be
individually assessed and we
will only exclude patients if we
are unable to provide an
appropriate and safe clinical
environment.
Diagnostic
and
screening
Cardio physiology, ERCP, GI
All adults 18 yrs and over
physiology, Imaging services,
All children 12 yrs and over
Phlebotomy, Urinary Screening and
Consultations – from birth
Specimen collection
Diagnostic
and
screening
Imaging services, Phlebotomy,
Urinary Screening and Specimen
collection.
All adults 18 yrs and over
Children 3 years and above
Appendix 2 - Consultants and employed staff.
142 Consultants were approved to work from Duchy at 23rd April 2014
Title
Mr
Mr
Mr
Mr
Dr
Mr
Miss
Initital
S
S
A
P
S
G
S
Surname
Adcock
Ahmad
Al-Shawi
Arumugam
Banks
Bartlett
Bates
Specialty
Facio-maxillary Surgeon
General Surgeon
Orthopaedic Surgeon
General Surgeon
Anaesthetist
Orthopaedic Surgeon
Gynaecologist
Title
Dr
Mr
Mr
Dr
Mrs
Mr
Mr
Initital
K
R
S
R
N
C
A
Specialty
Cardiologist
Orthopaedic Surgeon
Ophthalmologist
Anaesthetist
Family Psychotherapist
Facio-maxillary Surgeon
Orthopaedic Surgeon
E
F
TW
F
N
G
J
R
J
P
B
N
K
S
A
R
N
JD
M
P
J
HJ
RG
S
A
P
A
J
R
Surname
Kandasamy
Kincaid
Kumaravel
Langford
Lansley
Lansley
Lee
LloydDavies
Lone
Lucke
Luscombe
Marshall
Maskell
Matthews
Mawer
McDiarmid
McGannity
McLean
Michell
Mitchell
Mohammed
Moore
Morris
Munro
Myers
Norton
Owens
Paddle
Parker
Parry
Parsons
Patwardhan
Peyser
Pickford
Pinkney
Poulter
Dr
Dr
Dr
Dr
Dr
Mr
Dr
Mr
Mr
Dr
Mr
Mr
Dr
Mr
Dr
Dr
Ms
Dr
Mr
Dr
Dr
Mr
Dr
Mr
Dr
Dr
Dr
Dr
Mr
J
J
H
J
CV
C
J
D
I
D
M
D
P
H
T
J
K
P
R
A
D
J
H
J
M
JM
A
P
S
Bebb
Beckly
Belcher
Berry
Blacker
Blake
Boyden
Bracey
Brown
Browne
Butler
Byrne
Carpenter
Chant
Chave
Cheung
Claridge
Cook
Cox
Craze
Creagh
Dainton
Dalton
Davies
Davis
De Beer
Dingwall
Divekar
Dixon
Mr
Miss
Dr
Dr
Dr
Dr
Mr
Dr
Mr
Mr
Dr
Dr
Dr
Dr
Dr
Mr
Mr
Dr
Mr
Dr
Dr
Mr
Dr
Mr
Mr
Mr
Dr
Prof
Mr
Prof
Dr
Dr
Dr
Dr
Dr
Dr
Mr
P
A
D
R
W
S
KD
JW
Drew
Edwards
Elliott
Ellis
English
Evans
Farmer
Faux
Gastroenterologist
Gastroenterologist
Radiologist
Anaesthetist
Psychiatrist
Urologist
Anaesthetist
Orthopaedic Surgeon
Breast Surgeon
Endocrinologist
Orthopaedic Surgeon
Gynaecologist
Anaesthetist
Vascular Surgeon
Dermatologist
Anaesthetist
Ophthalmologist
Radiologist
Urologist
General Practitioner
Haematologist
Orthopaedic Surgeon
Gastroenterologist
Vascular Surgeon
Rheumatologist
Anaesthetist
Anaesthetist
Dermatologist
Orthopaedic Surgeon
Oncoplastic Breast
Surgeon
Radiologist
Anaesthetist
Oncologist
Anaesthetist
Cardiologist
Radiologist
General Surgeon
Dr
Dr
Dr
Mr
Mr
Dr
Mr
Dr
C
M
A
M
T
R
S
DJ
Powell
Proctor
Rajasri
Regan
Scott
Searle
Sexton
Sim
Anaesthetist
General Practitioner
Obstetrics & Gynaecology
Orthopaedic Surgeon
Orthopaedic Surgeon
Anaesthetist
Orthopaedic Surgeon
Anaesthetist
General Surgeon
Gynaecologist
Dermatologist
Anaesthetist
Anaesthetist
Radiologist
Orthopaedic Surgeon
Anaesthetist
Plastic Surgeon
Dentist (Implant)
Neurologist
Gastroenterologist
Anaesthetist
Radiologist
Anaesthetist
Plastic Surgeon
Urologist
Physician
Orthopaedic Surgeon
Cardiologist
Anaesthetist
Oral Surgeon
Physician
Orthopaedic Surgeon
Ophthalmologist
General Surgeon
Anaesthetist
Physician
Orthopaedic Surgeon
Title
Initital
Surname
Specialty
Title
Initital
Surname
Specialty
Mr
Mr
Dr
D
I
W
Fern
Finlay
Fish
Orthopaedic Surgeon
General Surgeon
Anaesthetist
Dr
Dr
Dr
A
T
A
Simaitis
Skinner
Slade
Cardiologist
Anaesthetist
Cardiologist
Neurologist (Medico Legal
Mr
Mr
Dr
Dr
Mr
Dr
Dr
Dr
Dr
Dr
Mr
Dr
Mr
Mr
Dr
Mr
Dr
Dr
Dr
Dr
Dr
Mr
A
P
P
Z
T
S
J
S
A
WR
B
N
R
N
P
M
H
D
J
WE
RT
D
Fitton
Flanagan
Fortun
Freeman
Germon
Gray
Hancock
Hann
Harvey
Harvey
Holland
Hollings
Holmes
Hopper
Hopton
Hotston
Hussaini
Hutchinson
Hyslop
Jewell
Johnston
Jones
Plastic Surgeon
ENT Surgeon
Gastroenterologist
General Practitioner
Surgeon
General Practitioner
Radiologist
Dermatologist
Anaesthetist
Anaesthetist
Optician
Radiologist
Gynaecologist
Vascular Surgeon
Anaesthetist
Urologist
Gastroenterologist
Rheumatologist
Radiologist
Anaesthetist
Cardiologist
Ophthalmologist
Dr
Mr
Dr
Dr
Mr
Dr
Dr
Dr
Dr
Dr
Dr
Dr
Dr
Mr
Mr
Ms
Mr
Mr
Mr
Mr
Mr
Dr
G
I
M
W
N
T
R
H
A
S
M
R
P
D
W
A
D
A
D
N
KR
W
Smith
Smith
Spivey
Stableforth
Sudhakar
Sulkin
Taylor
Thompson
Thomson
Thorogood
Thorpe
Van Lingen
Waterhouse
Weerasirie
Westlake
Wheeler
Whinney
Wilde
Williams
Wilson-Holt
Woodburn
Woodward
Only)
ENT Surgeon
Anaesthetist
Gastroenterologist
Neurosurgeon
Radiologist
Anaesthetist
Anaesthetist
Oncologist
Radiologist
Paediatrician
Cardiologist
Anaesthetist
Dental Surgeon
Ophthalmologist
Dietitian
ENT Surgeon
ENT Surgeon
Orthopaedic Surgeon
Ophthalmologist
Vascular Surgeon
Anaesthetist
Our Total employed staff complement as of April 2014 is 186 made up of:
Physio & Occupational Therapists
16
Porters
8
Nurses/ ODP’s
59
Admin Staff
49
HCA’s
18
Hotel Services
16
Radiographers
4
TSSU
3
Catering
7
Maintenance
4
Supplies
2
Quality Accounts 2013/14
Page 37 of 39
Appendix 3 – Clinical Audit Programme 2013/14. Each arrow links to the audit to be completed in each month.
Quality Accounts 2013/14
Page 38 of 39
Duchy Hospital
Ramsay Health Care UK
We would welcome any comments on the
format, content or purpose of this Quality
Account.
If you would like to comment or make any
suggestions for the content of future reports,
please telephone or write to the General
Manager using the contact details below.
For further information please contact:
Duchy Hospital,
Penventinnie Lane
Truro TR1 3UP
Telephone 01872 226100
or
http//www.duchyhospital.co.uk
Quality Accounts 2013/14
Page 39 of 39