St. Helens
Quality Accounts
2013/2014
Contents Page
Table of Contents
Page
1.
Statement from CEO
3
2.
Purpose and values
5
3.
Governance
6
4.
Review of NHS Services
6
4.1
4.2
4.3
4.4
4.5
4.6
Participation in Clinical Audits
7
Research
Goals agreed with NHS Commissioners (CQUIN)
Regulation
Data Quality
Information Governance
8
8
8
9
9
5.
Key Achievements 2013/2014
9
6.
Regularly Reported Indicators
20
7.
Prescribed Information
21
8.
Priorities for 2014/2015
23
23
25
8.1
8.2
9.
Key Development Areas
Key Business Objectives
Conclusion
39
Schedule 1 CQUIN
40
Statements from External Bodies
42
Chief Executive’s statement
Welcome to the Quality Account for 2013/2014 for Fairfield
Independent Hospital. With difficult economic conditions that have
characterised
the
business
environment
the
charity
has
nevertheless continued to provide high quality healthcare, invest in
its services, infrastructure and staff in pursuit of its overall
strategic objectives.
The difficult financial situation has served to emphasise the
importance of values and integrity. Our not-for-profit model is
particularly suited to healthcare as it enable us to remain
independent, to offer choice and puts the patient at the heart of
everything we do.
The Hospital has been delivering high quality health care to the
local community for 40 years. We are extremely proud of our
record of service as an independent health charity.
The Quality Report is designed to provide a transparent look at
our organisation and to give confidence to our patients, partners
and commissioners. We can improve our services by listening and
acting on what our patients tell us, ensuring that all patients
receive a personalised service.
As an organisation we depend on our staff for their skills and
expertise. They can only do their jobs effectively if we listen to
them and learn from their experience and ideas. We continue to
have a stable, motivated workforce with low levels of staff
turnover.
Our staff team is committed to providing excellent
standards of care at all levels across the organisation. We also
value staff development and we have strong commitment to staff
training and skill improvement.
“May I take this
opportunity to
thank the
Consultant for
performing the
operation, the
anaesthetist and
nursing staff for
making my stay
so pleasant; I
could have
stayed longer.
No hustle or
bustle. A
beautiful place;
food excellent
5*.”
Quality matters to all of us working at Fairfield and we know that
it is key to the success of our organisation. Our reputation is
based on the provision of high quality, personalised care and our
core values as a charitable organisation means we stand out from
other private providers in the area.
We monitor the views of our patients and I am pleased to report
that we have maintained the very high levels of satisfaction that
they have experienced for yet another year.
We value the
feedback, comments and suggestions that our patients and
commissioners make about our services. Our services are open to
all via the insured, self-pay or NHS funding routes.
03
Fairfield Independent Hospital Quality Accounts 2013/2014
April 2013
Chief Executive’s statement
“The care and
professionalism
of staff is
exemplary. The
friendliness and
approachability
of the staff
helped to make
my stay in
hospital much
easier. Thank
you.”
May 2013
Our core business is health and optimising outcomes for patients
and we have created an integrated governance framework for
delivering excellence and the best possible clinical results. We work
in partnership with our consultants to ensure optimum care for our
patients.
During 2013/2014, we reinvested financial resources to enhance
the infrastructure of the hospital and we have some exciting
developments planned for future years.
2013/2014 was challenging economically for us all, our finances
remained on a path of improvement with improved cash flow which
we used to continue to invest in the infrastructure of our
organisation.
As always, any surplus generated is reinvested in
health care and better services in the following years.
The senior team at the Hospital and the Board have welcomed the
opportunity through these Quality Accounts to clearly state our
commitment to quality and making sure that we continue to
improve. It sets out facts and information about the quality of our
services which I hope you will find useful and easy to read and
understand. If you have any queries or comments on our quality
account
then
please
let
us
know
by
emailing
k.roche@fairfield.org.uk.
At Fairfield, we actively promote a culture of openness and
transparency, respecting complaints, learning lessons and being
open and honest about any mistakes we have made and seeking
to make improvements.
These opportunities have helped us
establish a positive culture and enabling the provision of safe care
which permeates throughout the organisation.
The Quality Accounts have been compiled by members of the
senior team and Board and have also drawn upon the feedback
information we get from our patients. We are all working together
to provide the best possible care for our patients and we believe
we have demonstrated this in our Quality Accounts. Therefore, I
am able to state to the best of my knowledge that the information
contained in this document is accurate at the time of publication.
Cheryl Nolan, Chief Executive
Fairfield Independent Hospital Quality Accounts 2013/2014
04
Chief Executive’s statement
2.
PURPOSE AND VALUES
Fairfield Independent Hospital’s charitable purpose is to relieve
sickness, injury and poor health and to promote and preserve good
physical and mental health.
Our vision, as the leading charitable hospital in the area, is
delivering the highest possible standards of safe and effective care
that is accessible and affordable to all, delivered by a highly
committed workforce.
This means that we are the hospital of
choice for many patients.
At all times we act with integrity and through the professional level
of service we provide, we create an atmosphere of warmth and
friendliness. Everyone who comes into the Hospital is treated with
dignity and respect and made to feel ‘special’. We pride ourselves
on the fact that throughout the hospital we put the patient at the
heart of everything we do. We are a fair employer and supportive
of our staff.
“I only had a
short stay but first
class all around;
lovely staff and
was well looked
after. Thank
you.”
May 2013
The aims of our organisation are focused around quality and
putting patients at the heart of everything we do. We have the
following objective:

continuous improvement of our services

evidencing outcomes within a robust governance framework
providing high quality value for money services that are
accessible to all

providing a patient-focused service
ensuring we are the hospital of choice for patients and their
GPs


We monitor the views of our patients and are delighted at the
continued high levels of patient satisfaction with our services and
our facilities.
Our staff turnover is low and we have found that this aids continuity
of care for all our patients. Our focus on continuous improvement
is reflected in our commitment to clinical governance, audit and to
partnership working. Our consultants, many of whom are recognised
leaders in their field, are crucial to how the Hospital performs.
05
Fairfield Independent Hospital Quality Accounts 2013/2014
Patients First
3.
“I cannot
commend your
staff highly
enough. They
were wonderful
from the moment
I entered the
hospital.
Thank you.”
June 2013
GOVERNANCE
The Board sets the strategic direction of the organisation and
oversees the delivery of planned results by monitoring
performance against objectives.
Its role is also to ensure
effective stewardship and to ensure high standards of corporate
governance and personal behaviour. The Board is led by the
Chairman of the Trustees. It is important that the Hospital has
a highly effective and efficient Board that has the skills,
competence and business acumen to drive the strategic agenda.
As a registered charity and a company limited by guarantee
without share capital we have to balance the requirements of
running a not-for-profit business with the need to achieve our
charitable aims and objectives, to demonstrate public benefit;
adhere to the values of our charity; adopt best practices and
act with integrity at all times.
The Chief Executive is responsible for ensuring that effective
processes are in place so that the Hospital can discharge its
legal duty for all aspects of governance and quality, and for the
health and safety of patients, staff visitors and contractors. The
Chief Nurse has executive responsibility for the effective and
safe delivery of clinical services. The Head of Patient Quality
and Safety supports the Chief Nurse in her role and in
implementation of the clinical governance agenda. They work
with staff to ensure that systems and processes are in place to
enable improvements in the delivery of safe effective patient
care.
4.
REVIEW OF NHS SERVICES
During 2013/2014 Fairfield Independent Hospital provided advice
and treatment to 7,658 NHS patients.
Fairfield Independent Hospital has reviewed all data available to
it on the quality of care for those services.
The income
generated by the NHS services in 2013/2014 represents 100
per cent of the total income generated for the provision of
NHS services by Fairfield Independent Hospital.
Fairfield Independent Hospital Quality Accounts 2013/2014
06
Patients First
Participation in clinical audits
4.1
During 2013/2014, 2 national clinical audits covered NHS services
that Fairfield Independent Hospital provides.
During that period Fairfield Independent Hospital participated in
6.2% national clinical audits and 0% confidential enquiries of the
national clinical audits and national confidential enquiries, which it
was eligible to participate in.
Fairfield Independent Hospital was eligible to participate in only one
National Comparative Enquiry into Patient Outcome and Death
(NCEPOD) audit. This was The Cardiac Arrest Audit. However, during
the period of the study there were no cardiac arrests thus making
the audit void.
The national clinical audits that Fairfield Independent Hospital were
eligible to participate in during 2013/2014 were as follows:
National elective surgery
- Patient reported outcome measures
(PROMS)
- Hip and knee replacements
- Hernia
- Varicose veins
National Joint registry (NJR) - hip, knee and shoulder replacements.
The reports of 2 national clinical audits were reviewed by the
Hospital in 2013/2014 and we intend to take the following actions
to improve the quality of healthcare provided:

Patient Reported Outcome Measures - we have improved our
results for PROMS data capture, however there is still work to
do on two particular areas and work in maintaining the
participation and response rates in both hip and knee data.

National joint registry for hip and knee replacements – we have
achieved 100% compliance for 2013/14. Shoulder replacement
compliance commenced in November 2013 to date; a 100%
compliance has been achieved.
“It has been a
privilege attending this hospital.
The doctors,
nurses and other
staff were
absolutely
brilliant; I
cannot praise
them enough.
It has been the
best hospital
experience
that I have
had.”
June 2013
Re-audits for the Quality Accounts for 2013/2014 audit categories
showed the following:
07
Fairfield Independent Hospital Quality Accounts 2013/2014
Patients first
“Excellent
service once
again; very
dedicated staff
all round and
nothing was too
much trouble.
It was very
reassuring all
the way.”
Correct Surgical
Site marking
Audit tool introduced February 2013. Re-audit
December 2013. Changes to care pathways
to include surgical site marking have been
implemented across all specialities with
second re-audit scheduled for April 2014.
Record keeping
within pre-operative
assessment clinics.
Final audit Jan
compliance.
Monitoring and
response to
patients’ oxygen
saturation levels.
Audit showed 100% compliance with
procedures for monitoring oxygen saturation
levels to ensure safe care.
4.2
Research
The Hospital does not participate in clinical research.
4.3
July 2013
– March 2013 showed 100%
Goals agreed with NHS Commissioners (CQUIN)
Use of Commissioning Quality and Innovation (CQUIN) framework
During 2013/2014 we entered into an agreement with the NHS to
provide services for the local population.
A percentage of the Hospital’s NHS income was dependent on achievement of the CQUIN
targets agreed with the NHS commissioners. I am pleased to report
that the CQUIN targets were achieved.
Details of CQUIN targets and achievements are shown in Schedule 1.
4.4
Regulation
Fairfield Independent Hospital is regulated by the Care Quality
Commission to provide the activities detailed below in accordance
with Schedule1 of the Health and Social Care Act 2008.
Regulated Activity - Diagnostic and screening procedures
Regulated Activity - Surgical procedures
Regulated Activity - Treatment of disease, disorder or injury
Regulated Activity - Accommodation for persons who require
nursing or personal care.
Additional conditions that apply - the registered provider must only
accommodate a maximum of one service user at the Guy Pilkington
Memorial Home. (This activity is no longer applicable).
Fairfield Independent Hospital Quality Accounts 2013/2014
08
Patients first
We had an unannounced visit from the Care Quality Commission in
December 2013. Whilst the final report was very positive there was
a minor non compliance issue with regard to consent. An action
plan was submitted to CQC and I am pleased to
report that we
are now compliant with the standard. Whilst it was disappointing
not to achieve 100% compliance the organisation welcomed the
visit and the feedback that was given by the
inspectors. A copy
of the full report can be accessed via our website
www.fairfield.org.uk.
We continue to have regular audits via ISO and there have been
no non compliance issues reported.
4.5
Data Quality
Fairfield Independent Hospital submitted records during 2013/2014
to the Secondary Uses Service (SUS) for inclusion in Hospital
Episode Statistics which are included in the latest published data.
The percentage of records in the published data which included the
patient’s valid NHS number was:
100% for admitted patient care
100% for outpatient care
4.6
“The doctors,
nurses and staff
were brilliant.,
well mannered
and courteous;
they do a
wonderful job.
I can’t fault the
staff in any way.
Thank you so
much for making
my stay a warm
and welcoming
one.”
Information Governance
The Hospital is continually reviewing its information governance to
ensure that all information relating to and identifying individuals is
managed, handled, used and disclosed in accordance with the law
and best practice.
Fairfield Independent Hospital’s Information Governance Assessment
report score for the period rose from 88% to 94%.
5. KEY ACHIEVEMENTS 2013/14
Clinical Effectiveness
In our previous set of Quality Accounts we set out three key
development areas. Detailed below is what we achieved against the
specific areas identified. I am delighted to report that we met all
our key targets across all areas.
09
Fairfield Independent Hospital Quality Accounts 2013/2014
July 2013
Key Achievements
Clinical Effectiveness (continued)
“Staff were
wonderful.
I was very
nervous and
they put me at
ease.”
August 2013
Development Area identified
Outcome
Information
We will provide as much
information as required to
outside
organisations/
individuals
including GP
practices and patients via a
secure service. Using information in a more structured way
in order to make better decisions about what we do and
how we do it and ensuring
compliance with our Information Governance standards.
We continue to improve how we
communicate with our stakeholders
and now use the secure NHS net to
transmit discharge information to GPs
in a timely, secure fashion.
Patients are asked how they would
like their information and for those
who choose, it is transferred
electronically. Appointment reminders
can also be sent by text if patients so
wish.
We have cut out unnecessary
duplication of information collection
from patients.
Our information governance framework
has been reviewed and meets all the
necessary requirements with regard to
information management and security.
Clinic utilisation
We will set a base line target
for usage of our outpatient
clinic environment. and
monitor performance against
that target to reduce any
areas of inefficiency
Working with our Consultant body we
agreed to trial the flexible
scoping
clinic. Changes to working practices
have seen an increase in diagnostic
procedures that can be carried out in
an outpatient environment.
Patients’ feedback to date has been
positive, however, a full audit will be
carried out in 2014. At the time of
writing this report we are doing five to
six clinics per month depending on
demand.
Fairfield Independent Hospital Quality Accounts 2013/2014
10
Key Achievements
Clinical Effectiveness (continued)
Development Area Identified
Outcome
Clinic utilisation (cont.)
Improve clinic efficiency at
peak times and improve
patient experience
The efficiency of the outpatient
consulting rooms and waiting areas have
been reviewed. Staff now run clinics
from two areas, the main reception area
is now utilised as a second outpatient
waiting area. This has seen a reduction
in queues and wait times for patients at
the reception desks.
Increase uptake of Patient
Reported Outcome Measures
(PROMS) .
Working with our consultants
and patients we will increase
our PROMs uptake in groin
hernia and varicose veins to a
participation rate of at least
80%.
Our Proms unadjusted participation rate
for the four areas that are currently
collected centrally are as follows:
Groin hernia
Hip
Knee
Varicose vein
-
70.9%
102.9%
114.9%
20.3%
“I was treated
very well during
my stay;
everything was
first class.”
August 2013
(50%)
(101.3%)
(96.9%)
(no data)
Figures in brackets are those for 12/13
Staff and consultants have made a
concerted effort to increase uptake and
this is evidenced in the figures.
However, it should be noted that the
data available for PROMS at the time of
writing this report shows figures from
April 2013 - September 2013.
Development of enhanced
radiology and scanning
facilities
To implement a radiology
information system across the
organisation that allows
images to be exchanged via a
secure portal, allows GPs to
book directly and have results
transmitted via a secure
portal to provide statistics for
onward transmission to
commissioners.
11
In 2013 we entered into an agreement
with a new MR radiology provider. MR
provision has been increased from one
day per week to two due to increased
demand. All information requirements
with regard to diagnostic reporting and
waiting times have been met. There have
been some issues with the development
of secure referral portal which have
been out of our control but hopefully
these will be resolved during 14/15 and
we will be in a position to take forward
further developments.
Fairfield Independent Hospital Quality Accounts 2013/2014
Key Achievements
Patient Safety
“Absolutely
amazing.
Customer care
was amazing; I
don’t think you
could improve
on anything.
Excellent care.”
Development Area identified
Implement recommendations of
Francis report
Working with our NHS
Commissioners, ensure that the
relevant recommendations of the
Francis report are embedded into
the culture of the organisation.
Ensuring that the Board of
Trustees are aware of their role
and that there are measures in
place to treat patients in an
open and transparent
environment.
September 2013
Medicines Management.
To further reduce the risks of
medication errors across the
Hospital by promoting the safe
use of injectable medicines. This
will include specific risk assessment for each department and
detailed information on the
correct preparation of individual
drugs.
To review procedures and
process in place to ensure the
safe and effective ordering and
use of medicines
Outcome
The Board have been appraised of the
content of the Francis Report and
Board reports now include progress
on recommendations and their
responsibilities in ensuring that the
Hospital meets all its obligations.
Comments from our patient
questionnaire are discussed and
acted upon as required. Any comments, incidents or complaints are
shared with staff and the Board in
bi-monthly Board meetings, as part of
our process of continuous learning
and improvement, with solutions to
issues coming from our patients and
staff.
Risk assessments have been completed
for all drugs used within the ward and
outpatient’s environments. Theatre drug
risk assessments are ongoing due to
the volume and complex nature of the
drugs used in the theatre environment.
Antibiotic audit has been completed to
ensure the required antibiotics are
prescribed when an appropriate clinical
evaluation of the patient’s condition
has been completed. A review of all
out of date drugs that have been
destroyed has been completed for the
period 1st April 2013 to 31st March
2014. Action from this review will
include a comprehensive evaluation of
all medicines and stock levels held
within the Hospital this will be
completed in July 2014.
Fairfield Independent Hospital Quality Accounts 2013/2014
12
Key Achievements
Patient Safety (continued)
Development Area identified
Outcome
“Patient
handling, care
and treatment
is perfect and
exceptional. I
would
recommend
Fairfield to
anyone.”
Decontamination.
A new state of the art scope washer
To replace the existing facility for facility has been installed. The new
processing and cleaning all
facility provides a faster turnaround
scopes within the hospital.
and more efficient service whilst
reducing running costs. We now have
the capacity to store clean scopes in
a sterile environment for up to seven
days.
Workforce
We will strengthen our leadership
across the organisation that it is
not just fit for today but also for
tomorrow. We will, via our recruitment process, ensure that are
workforce are competent,
motivated and effective and that
they are patient focussed.
We will ensure that all staff
within the hospital have training
and development plans that are
specific to their job role to
include continued professional
development (CPD) .
Leadership modules have been
completed by supervisory staff and all
mandatory and statutory training has
been completed.
All staff have clearly identified training
and CPD requirements as part of their
appraisal.
September 2013
Patient Experience
Development Area identified
Outcome
Friends and Family test
A large element of the Hospitals
CQUIN for 13/14 focuses on the
Friends and Family Test. Via the
test, regular real time feedback
from patients will be consistent,
monitored and reported in a far
more structured way than
previous.
The Hospital to date has had a very
positive result for the Friends and
Family Test, with over 45% of eligible
patients responding. To date no
negative comments have been
recorded and therefore no
improvement action has been required.
We will act on the results of the
test if there are areas identified
that need improvement or further
action.
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Fairfield Independent Hospital Quality Accounts 2013/2014
Key Achievements
Patient Experience (continued)
“I would just
like to thank
the staff. They
made me feel
settled and
calm and that
everything was
under control,
especially in
surgery.”
September 2013
Development Area Identified
Outcome
Workforce
We will ensure and monitor that
our staff are competent for the
role they have been employed to
do and that they act with kindness, thoughtfulness and
compassion.
All health care assistants are
undertaking a competency assessment relevant to their role within the
various hospital departments.
Compassion runs through all the
core skills alongside specific
practical competencies together with
underpinning knowledge from Skills
for Health. Registered nurses are
awaiting their new code from the
NMC and details of the
revalidation process. In the interim
clinical supervision and the appraisal
system will continue to identify any
issues and action plans can be
drawn up if required
More flexibility built into services.
To ensure that we offer a range of
appointment times to suit patients
and that wherever possible we offer multiple appointments on the
same day to include such as preoperative assessment, scanning etc.
All departments offer patients
appointments after 5pm to reduce
patient’s time out of work. The need
for multiple appointments is reduced
to a minimum as, for example,
pre-operative assessment and
physiotherapy department work
closely with each other to offer a
joined up service at the same
appointment. Staff are now looking
at the length of time patients spend
in pre-operative assessment to
further reduce the impact on
patients’ time and utilise staff more
efficiently in clinics.
Facilities
We will continue to improve and
update our facilities through our
renovation/improvement
programme. We will improve our
access to diagnostics.
We have introduced a rapid access
flexible scope clinic for urology
patients. Feedback so far from
patients has been very positive and
we will look at this model of
provision for other services in the
future.
Fairfield Independent Hospital Quality Accounts 2013/2014
14
Key Achievements
Patient Experience (continued)
Development Area Identified
Outcome
Facilities (continued)
The rapid access environment has
been developed an is now up an
running in a dedicated suite.
We have increased capacity in MR
scanning and also have employed
more radiographers. We invested
over £250K in our new scope
washing facility. Investments such as
these are only possible due to the
fact that any surplus that we
generate goes directly back into
patient care.
5.1
What else did we achieve during the year?
Governance
Our audit programme for 2013/14 was agreed by the Board and
the Medical Advisory Committee. The programme included clinical
and non clinical audits and was be linked into any incidents/
adverse events that may have occurred. We also demonstrated the
learning that took place as a result of a particular incident.
Leadership and training
The executive team headed by the CEO continue to access
Continuing Professional Development and other opportunities
relevant to their roles including membership of other charitable
boards and mentoring opportunities.
Management training has also been undertaken by middle/junior
managers at the Hospital and this will lead during 2014/2015 to
further recognised qualifications via the Institute of Learning and
Management (ILM)
Student nurses continue on placement. A further staff member has
undertaken Mentorship training. As a result of having more mentors,
our partner Universities have asked us if we would place two more
students in our Outpatient Department for a thirteen week
placement. Two newly qualified staff nurses have completed their
preceptorship programme.
15
Fairfield Independent Hospital Quality Accounts 2013/2014
“Lovely staff
throughout the
hospital; very
caring and
reassuring.”
September 2013
Key Achievements
“Service was
excellent; all
staff
respectful,
pleasant and
courteous.
Nothing too
much trouble.”
September 2013
Placements at the Hospital are favoured by the Universities
because the student’s experience is enhanced by the variety of
specialities that the student has access to here. The ward will
continue to take two students on a thirteen week placement with
some time spent in the theatre and recovery ward environment.
The links with the Universities and the education system remains
strong. We have been working with Liverpool University and have
arranged a placement for a marketing intern to join the team.
Apprentices via apprenticeship schemes offered by St Helens
College and St Helens Chamber have also been accessed.
Listening and acting on patients’ views/patient satisfaction
No organisation can stand still and we are continually reviewing
how we provide our services.
Our managers routinely audit how
patients flow through the system by shadowing patients, with their
consent, and ‘walking in their shoes’.
We have made some
changes in how we run our clinics and are seeking real time feedback from patients on how they think the new system is working.
Clinical and non clinical staff have access to a forum in which
comments from patients both positive and negative are discussed
to ensure learning takes place. Incidents (anonymous) that may
have occurred involving patients and staff are discussed at this
forum to assess how or if any changes can be made to improve
the patients and their family/carers
experience. 2014 will see
an audit of dementia carers’ experiences to assess what further
support the Hospital can give. The care environment for dementia
patients has been reviewed and improvements made. Any patient
with a diagnosis of any form of dementia can now be admitted to
a dementia friendly bedroom.
All of our patient questionnaire responses are reviewed by the
CEO on a daily basis which means our results are in real time
and any actions that are needed can be taken quickly. We are
delighted that NHS patients rate our services highly.
A sample of results for 2013/14 are as shown below:




99% of the patients rated the cleanliness of the Hospital as
very good or excellent.
99% of patients rated the overall standard as very good or
excellent.
100% of the patients felt they had been treated with dignity
and
respect during their stay in the Hospital.
98% of the patients felt that the Doctors and Nurses kept
them informed about their condition and progress
Fairfield Independent Hospital Quality Accounts 2012/2013
16
Key Achievements

100% of patients would recommend the Hospital to a friend
or family member.
Stakeholder Engagement
It is very important that we seek out patients’ views in ‘real time’.
As well as our own internal questionnaire we also do ad hoc
audits where members of the team speak with patients, ask
questions about how their experience has been, if we are getting it
right and if there could be any improvements.
We obtain the views of our consultants and discuss areas of good
practice and concerns via the Medical Advisory Group (MAC). The
MAC has a direct line of accountability to the Board and the
Chairman of the Board of Directors attends MAC meetings. The
MAC Chair is also a Board member. The MAC provides input into
how we take specific areas of the business forward and they also
advise on development opportunities for the Hospital and
implementing new initiatives based on best practice.
We have
been fortunate that the numbers of MAC members has increased
during 2013/14 and we have had an increased attendance at
meetings from our consultant body.
Quality
Our core values compliment the increased emphasis from all of
our commissioners on the need to evidence and demonstrate our
commitment to the provision of quality services.
We strongly
believe that the quality of the clinical and non clinical services
that we provide allows us to demonstrate this. Our patients tell
us about how they feel we have treated and cared for them and
the results of this ‘real time‘ feedback is excellent.
Infection Control
Our infection control performance continues to be excellent and
something we are all very proud of. During 2013/14 we have
continued to maintain our average monthly infection rates at
below one percent. Results of all infections reported from April
2013 to March 2014 have shown that the hospital has sustained
its infection rate below 1% of all patients admitted for surgery
We continue to maintain our zero rates for MRSA, MSSA,
C Difficile E- Coli infection organisms. Our hand washing compliance audits continue to show 100% compliance across the
Hospital.
17
Fairfield Independent Hospital Quality Accounts2012/2013
“No improvement
needed.
Everything about
my stay and
treatment was
excellent. The
staff are
marvellous.”
June 2013
Key Achievements
“What an
excellent stay.
Truly
professional
staff all round.
All my nurses
were brilliant.”
Refurbishments/Capital Programme 2012/13
Work to meet the capital programme during the year has been
continuing. The following major works have been completed.
Installation of two double pass through endoscopy washers and
associated plant and equipment- £250k.
General upgrade and replacement of theatre and ward
equipment.
The
Hospital
has
acquired
refurbished
cystoscopes, ultrasound
machine for theatre anaesthetic
procedures and bladder scanners - investment £50k
Upgrade of the ENT consulting room. Purchase of a new
ENT chair, fittings and equipment - £25k.


New ultrasound machine in X-ray purchased - £75k.
Creation of a new orthopaedic consulting room in OPD £10k.


July 2013
Staff Survey
In 2013/14 we carried out a formal staff survey. The overall
response rate for the survey was 47%. A number of reasons
were given for not responding including ‘not enough time to
complete,’ ‘couldn’t be bothered’, ‘nothing would happen with the
results’. However, we were pleased to note that there was a 5%
increase in uptake from the previous years survey and the
actions that we had put in place to address some of the issues
raised by the 2012/13 survey had contributed to increased levels
of satisfaction from staff.
An action plan has been drawn up and will be monitored by the
senior team. We have decided that due to relatively low staff
turnover we will not carry out a further full survey until 2015.
When staff were asked if they would recommend the Hospital to
a family member or a friend, 97% of those who responded said
they would.
Productivity and Efficiency
We have continued to use the tools from the ‘productive
environment’ to eliminate waste from what we do and how we do
it. This has led to a more efficient use of all hospital resources.
Some examples are as follows:


Surgical site marking in line with WHO requirements.
Just in time stock levels and improved systems for stock
control and ordering.
Fairfield Independent Hospital Quality Accounts 2012/2013
18
Key Achievements



Continued effective rostering of staff so that shifts are
more aligned to clinical activity and that time can be allocated more effectively for continuous professional development and other training.
Use of available technology to ensure that patient discharge summaries are with their respective GPs within 24
hours of discharge.
Better use of our patient administration system in order
to provide monitoring and reporting to our Board and
commissioners.
Where there are reductions in the prices paid to us from many of
our commissioners in 2013, we in turn have had to reduce what
we pay out. Working with an evidence based approach, we are
now in a far better position to determine what we can do cost
effectively and what we can not.
We will continue with this
approach as we do need to ensure that we continue to make a
surplus and that all new services that are proposed for
introduction are assessed in terms of what they can bring to the
organisation, unlike many other hospitals both private and NHS we
do not have the backing of any shareholders or NHS England. In
2013/14 based on our Business Plan for the year, we continued
to widen our medical services to include granting practising
privileges to consultants from other hospitals not traditionally
associated with Fairfield Independent Hospital.
The role of pre operative assessment cannot be underestimated
as it is crucial in preparing patients for their surgery, ensuring
that they are fit for surgery and that if there are any problems,
they can be dealt with in a timely fashion. During the pre operative assessment phase we have been providing public health advice, condition specific support tools and signposting patients to
the most appropriate services.
The Hospital maintains strong links with its supply chain stakeholders. In 2013/14 savings of over £40k on consumables and
contracts have been realised. Energy contracts have also been re
-negotiated.
Our theatre utilisation throughout the year was, on average, 90%.
This has given us a good baseline on which to set future targets.
19
Fairfield Independent Hospital Quality Accounts 2012/2013
“Time in
hospital was
made as
comfortable
and enjoyable
as it could be
possible.”
July 2013
Key Achievements
“All staff,
nurse, kitchen,
cleaning, all
superb. Job
well done.
Everything was
excellent,
really
impressed with
my stay.”
August 2013
We continue to ring or text patients directly (depending on their
preference) to agree a date and time for their inpatient procedure. This cuts down on missed appointments, unnecessary paperwork being produced and patients being able to make the
necessary arrangements to cover child care, work absences, etc
well in advance of their procedure date.
We have introduced speciality specific Saturday minor procedure
clinics, which have proved very popular with patients.
These
clinics will continue in 2014/15.
6.
REGULARLY REPORTED INDICATORS
Total nos. in
period 1 Apr
2013 to
31 Mar 2014
%
Inpatient mortality
0
0
Peri-operative mortality
0
0
Unplanned readmissions within 28 days
5
0.06
Unplanned returns to theatre
6
0.06
Unplanned transfers to another hospital
3
0.04
Mortality within 7 days of discharge
0
0
Pulmonary Embolism
0
0
Deep Vein Thrombosis
0
0
Surgical Infection Rate
0
0
MRSA blood cultures
0
0
MRSA positive blood cultures
0
0
Indicator
Fairfield Independent Hospital Quality Accounts 2012/2013
20
Prescribed Information
7.
PRESCRIBED INFORMATION
The indicators detailed below have been included by NHS England
as part of the suite of information that should be included in the
13/14 Quality Accounts.
Some of the information is not yet
routinely available for the independent sector, the source of the
data has therefore been identified in the results column.
NHS Outcomes Framework
Domain
Indicator
1. Preventing people from
dying prematurely
a) Summary hospital-level 0% (in house data)
mortality indicator
*Helping People to recover
from episodes of ill health
or following injury.
*It should be noted that the
data shown is for April - Sept
2013.
Figures shown in brackets are
the previous years figures.
Results
b) The percentage of
patient deaths with
palliative care coded
0% (in house data)
1. Patient reported outcome measures (PROMS)
a) groin hernia
surgery
b) varicose vein
surgery
c) hip replacement
surgery
d) knee replacement
surgery
Participation rate
70.9%
(12.1%)
20.3%
(No data)
102.9%
(101.3%)
114.9%
(96.9%)
2. The percentage of pa- As shown in above
tients aged 15 and over
readmitted to the hospital
within 28 days of being
discharged.
Ensuring that people have a 1. Personal needs data
positive experience of care. from Health and Social
Care Information Centre.
2. The percentage of staff
employed in the reporting
period who recommend
the hospital as a provider
of care to their friends
and family.
21
“Excellent.
Really felt safe
during my
stay.”
table.
National data not
available. In-house
questionnaire results
detailed on Page 16.
97% (in-house staff survey
data)
Fairfield Independent Hospital Quality Accounts 2012/2013
August 2013
Prescribed Information
“Great
service; staff
so lovely.”
August 2013
NHS Outcomes
Framework Domain
Indicator
Results
Treating and caring
for people in a
safe environment
and protecting
them from
avoidable harm
1. Percentage of patients
who were admitted to
hospital and who were risk
assessed for a venous
thromboembolism.
100%
2. Case of C-difficile
reported.
0%
3. Rates of patient safety
incidents and the number
of such incidents that
resulted in severe harm or
death.
0%
Fairfield Independent Hospital Quality Accounts 2012/2013
22
Priorities for 2014/2015
8. PRIORITIES FOR 2014/15
8.1 Key Development Areas 2014/15
Development Area Identified
Clinical Effectiveness
Pre operative assessment
VTE risk assessment
compliance
World Health Organisation
checklist
Clinical training
Patient Safety
Patient Reported Outcome
Measures (PROMS)
ISO 9001:2008 Quality
Management System and
ISO (Information and
Security Management
System)
23
Outcome to be Achieved
To develop the service further to
ensure that we can co ordinate
multiple appointments together,
access any necessary results in a
timely fashion and provide a more
efficient service for patients.
To ensure we benchmark our
compliance through the national
statistical website.
Compliance with the checklist will
continue to remain a priority at
Fairfield. Via audit any areas of
non compliance will be reported to
the Medical Advisory Committee
and Board.
To maintain and develop the skills
of our workforce we will ensure
that we continue to roll out job
rotation for clinical staff. Provide
resources to enable staff to undertake periods of training/education
away from the work place.
To continue to participate in
PROMS and increase the numbers
of initial patient responses in the
four areas. To review PROMs
data to examine poor practice if
and when it exists.
The Hospital has successfully met
the requirements of both standards
in 2013-2014. These systems are
audited by external auditors every
six months.
Fairfield Independent Hospital Quality Accounts 2012/2013
“Improvement
not necessary
as this is a first
class hospital.”
August 2013
Priorities for 2014/2015
“Thank you to all
staff that helped
me today; you
were all lovely
and made me
feel relaxed.
This is a
brilliant hospital.”
Development Area Identified
Outcome to be Achieved
National Joint Register (NJR)
To continue to participate in the
NJR collection of data and
benchmark our compliance.
Safeguarding and Mental
Health Act capacity training
To ensure that all of our staff
receive the right level of training
with regarding to safeguarding
adults and children. Such training
is a mandatory requirement for
staff employed at the Hospital.
To ensure that staff and self
employed consultants and
clinicians
have appropriate mental capacity
training. In order that we discharge our duties with regard to
any patients who present to our
services who are vulnerable or who
lack capacity
Patient experience
Roll out/phased expansion
of friends and family test to
all inpatients and outpatients.
To rollout the Friends and Family
test to patients attending as day
cases and also to those attending
as outpatients.
Refurbishment of patient
areas.
As part of our process of continuous improvement to improve our
patient bedrooms to include, for
example, wet rooms and improved
lighting.
To redesign patient waiting areas
so that they are comfortable, fit
for purpose and provide privacy
and dignity for patients attending
the Hospital.
Communication with patients.
Ensuring that we engage with all of
our patients regarding how they
wish us to communicate with them.
September 2013
Fairfield Independent Hospital Quality Accounts 2012/2013
24
Key Business Objectives 2014/15
8.2 Key Business Objectives for 2014/15
Governance
We will improve our methods of monitoring our performance against
the revised Care Quality standards and inspection regime. We will
update and demonstrate evidence of our compliance. If we identify
areas where we are not compliant, we will ensure that there are
clear action plans in place that enable us to move to compliance
quickly.
We will continue to develop our governance framework by the
introduction of further policies and procedures through the ISO
framework.
“Customer care
was amazing. I
don’t think you
could improve
on anything.
Excellent care.”
We will ensure that all current polices are reviewed and amended in
line with changes in requirements or in accordance with our policy
review timetable.
Our audit programme for 2014/15 will be agreed by the Board and
the MAC.
The programme will include clinical and non clinical
audits and will be linked into any incidents/adverse events that may
have occurred and also demonstrate the learning that we would
expect to see as a result. The Chief Nurse and Director of Hospital
Services will continue to complete six monthly clinical and non
clinical audits across the Hospital.
We will undertake Root Cause Analysis scenarios with senior staff at
least twice yearly.
We will continue to build up our Risk Register, updating the Board bi
annually and reporting incidents bi monthly.
We will complete the risk assessment and management processes
associated with our participation in the NHSLA membership
process.
We will continue to strengthen our Board of Trustees with the
appointment of new Trustees, ensuring that we maintain a breadth
of experience that represents a good cross-section of the
communities we serve.
Nursing in 2014/15
The Nursing strategy has a clear message that within Fairfield
Independent Hospital our staff ‘will put the patient first’ and that
patients ‘be at the heart of everything we do’. The Hospital will
promote a culture rich in these values in order that patients feel
safe and are cared for by staff who work within a supportive team.
25
Fairfield Independent Hospital Quality Accounts 2012/2013
September 2013
Key Business Objectives 2014/15
“No need for
any
improvements;
staff are
brilliant!”
September 2013
The nursing strategy offers a framework within which staff are
empowered to go the extra mile for patients and where there any
areas of concern, staff are encouraged to raise these concerns
appropriately in a responsible manner.
The Hospital is now registered as part of the Dementia Alliance.
To date key staff across the various departments have been
identified and further training will be undertaken to ensure that
patients who have a diagnosis of dementia and require elective
surgery are cared for in a suitable environment. The patient and
their carer will be given the reassurance that whilst the patient is
in our Hospital all measures are in place to care for the patient
holistically.
Staff will be supported to develop areas of expertise within various
specialties, where possible, and the Hospital will endeavour to
‘grow our own’ experts. The appraisal system will identify any training needs.
Alongside this, leadership/management training will
direct individualised action plans offering a skilled, flexible and
empowered workforce who are productive and efficient in the care
of our patients. Management training will help equip the senior
staff with the skills to help identify and address workforce planning
issues and enable them to recognise achievements and build on
successes.
An audit plan has been produced for 2014/15 and a proportion
of the subject areas that were submitted are from listening to our
patients comments and by looking at ways to improve patient
safety, patient care and health outcomes. Staff will be able to
offer evidence to the Care Quality Commission that the Hospital is
compliant with the new system of regulation, which will be
introduced in 2014/15. This new system will focus on patient
outcomes rather than systems and processes. The work required
to meet this new system cannot be underestimated.
A more
rigorous and detailed approach to inspection and monitoring will
be adopted along with specific key indicators, which are both
quantitative and qualitative, and are expected to generate targeted
actions from CQC.
There is no doubt that in order to meet the ever increasing
demands made on us for evidence of quality, robust systems and
processes, etc. we will have to further support the governance
function across the Hospital, especially in clinical areas.
Fairfield Independent Hospital Quality Accounts 2012/2013
26
Key Business Objectives 2014/15
Refurbishments/Capital Programme
The capital programme for 2014/15 has been approved by the
Board. Some significant areas of investment are detailed below:
 Review the air handling and ventilation system in Theatre Two.
This project will include a review of a number of options to
include - replacing “like for like” and replacement by an ultra
clean ventilation system to provide a second orthopaedic class
theatre which would provide extra capacity and a contingency
resource for equipment maintenance or failure in Theatre One £350k.
 Flooring in the ward corridors and ground floor to be replaced £50k.
 Change main entrance doors and automatic door closures to a
more welcoming and prestigious environment. Widen the entrance
into the corridor to make it properly accessible for wheelchairs
£25k.
 Replace boilers in the old theatre plant room and obtain
technical specification for the replacement of boilers in OPD plant
room in 2014 - £60k.
In addition to the above the Hospital will improve a number of ward
bedrooms in 2014/15 and provide extra car parking spaces.
“I can’t say
enough how
fabulous
everyone was.
I was made to
feel completely
at ease and
every member
of staff I came
across was
faultless,
friendly and
amazing. A
big thank you.”
Efficiency

We will continue to renegotiate contracts with our suppliers in
order to get best value and the best deal for the Hospital.

Utilisation across the Ward and Theatre areas will be reported to
the Board and we will set targets, once a baseline has been
established, to improve our utilisation or to redesign specific
areas and services in order to increase throughput and utilisation.
We would be looking to achieve a theatre target of 92%
utilisation during 2014/15.
(This assumption is based on
maintaining the same levels of activity as in 2013/14).

We will consider the best way to utilise our pharmacy provision
and look to explore other options for provision of pharmaceutical
services to Fairfield.
27
Fairfield Independent Hospital Quality Accounts 2012/2013
September 2013
Key Business Objectives 2014/15
Debtors & Debt Collection
“I can’t say
enough how
fabulous every
one was. I was
made to feel
completely at
ease and every
member of staff
I came across
was faultless,
friendly and
amazing. A big
thank you.”
September 2013
The focus for 2014/15 will be on co-ordinating the information
given to patients about the money that they owe to the Hospital or
will owe if they decide to go ahead with the treatment they may
need. The Hospital will also use the advances it has made in
patient communication in 2013/14 – including the use of email and
text to better communicate the cost of treatment and the extent to
which individual patients are responsible for all or part of their
treatment.
Financial Security
The Charity must consider how services are to be provided in the
future to reduce the overall cost of provision and obtain
sustainable long term financial stability. This will be done in a
staged way and will include a number of initiatives that will act as
enablers for cost reduction.
We will look to target specific groups of the population in order to
promote the Hospital and make people aware of the services that
we provide. For example a recent survey from Saga showed that
the 50+ age group are those that are and will see the PMI market
as an attractive option as NHS waiting times rise and their need to
access services becomes greater.
The demand for our services from the NHS, self pay and the PMI
market may well go up and down in the coming year. However, it
is vital that we are flexible enough to respond to these changes.
Where the NHS is actually restricting access to certain services, we
will look to capitalise on these restrictions by working with our
consultants and offering competitively priced packages of affordable
care.
We will consider, by broadening the range of the services we can
offer, how we can make a contribution to improving health in the
area and consolidate our financial position in the local health
economy.
Partnerships
We will look to building and strengthening our existing partnerships.
We will also develop new ones with different providers and enter
into business arrangements/partnerships which will help us develop
and grow our business.
Whilst 2014 is highly unlikely to see
radical changes, the Executive Team will need to ensure that they
Fairfield Independent Hospital Quality Accounts 2012/2013
28
Key Business Objectives 2014/15
are ‘connected’ to what is happening in and around the catchment
areas.
This will involve many different forms of communication both to
and from GP practices and to the public. We will continue to
support the NHS when it requests us to carry out work on a sub
contractual basis. We will respond to ad hoc requests to carry out
extra work when we can but it will be:

at a cost that offers us a realistic margin

when it takes up any spare capacity we may have

not detrimental to the efficiency and high standards of the
Hospital.
We will also respond to Any Qualified Provider tenders that come
from the NHS that are applicable to our organisation working with
some of our new partners in putting in joint bids as and when
required.
We will build on the new partnerships that we have established in
2013/14. The diagnostic providers are keen to work with us to
develop services and new ways of working. The advantages of
having different companies coming into our organisation are that
we get exposure to different aspects of business.
We view all our Consultants as important partners in our business.
During 2014/15 we will work with our consultant body to develop
ideas and plans to feed into the Hospital’s strategic direction.
With the emphasis in nursing being specialisation, consultant
support is crucial in realising different models of care than we
have at present, in some areas.
We will look to work with other charities where possible to
promote the work we do here and to provide a platform whereby
we can engage with the community in taking forward charitable
initiatives thus raising our own profile as a charity.
Marketing and Communication
The Hospital is now established on Facebook and we have
ensured that mobile devices can access our websites. We will
expand on the existing website for Fairfield Future as our
fundraising activities conitnue during 2014/15 and we celebrate
our 40th year in business.
29
Fairfield Independent Hospital Quality Accounts 2012/2013
“The treatment
from my
Consultant and
all nurses who I
came into
contact with
gave excellent
service. I have
only excellent
comments to
make about the
service I
received.”
November 2013
Key Business Objectives 2014/15
“I believe that the
exceptional care
and quality of
food helped aid
my recovery.
Every single
person on the
staff treated me
with the utmost
respect;
everything was
explained clearly
and staff was
always pleasant.
The quality of
food was outstanding; even
better than many
of the hotels I
have stayed in
this year around
the UK.”
October 2013
In 2014/15 we will continue to develop our websites.
Using the
following target groups we will put in place actions against each
area and monitor our success. The four strands are:




The public who are or may become patients – the message for
this group is that we are here as an independent charitable
hospital and so our main target is to raise familiarity with them
and emphasise our cleanliness, location and accessibility.
The GPs who need to know about the clinical services we can
provide, how to access them and the follow-up service we provide for their patients and the way we manage the information
flow.
The commissioners from the public and private sector – who
need to know what we do, how much we charge and how we
can meet their service requirements.
The medical profession more generally – who will provide our
next generation of consultants and the partnerships which will
use our services or refer patients to us as part of their own
treatment plans
Whilst some elements of our service for example our low infection
rates and our standards of cleanliness will be core elements of
our promotion to all these strands, each of the four will require a
different focus, plan and actions.
Our communications activity is key to our plans and is a building
block on which we realise we must do more work. To this end
we will ensure that we:
 produce a quarterly staff newsletter
 produce a quarterly GP/primary care newsletter
 keep the websites regularly updated and refreshed and analyse
the monitoring data that is available on number of people
accessing the site
 continue to monitor and respond to patient comments and
suggestions as appropriate – including more feedback to
patients along the lines of – “you said, we did”
 have a least two joint meetings during 2013 between the staff
and the CEO
 ensure we meet at least once a year with all the major private
commissioners
Fairfield Independent Hospital Quality Accounts 2012/2013
30
Key Business Objectives 2014/15
 develop links with patient groups in the area so we can identify
where we can develop our role as a significant healthcare
provider in the area
 attend CCG meetings as and when required.
Fundraising and alternatives

During 2014/15 we will capitalise on the work that commenced
in 2013 to raise our profile and raise much needed funds for
specific investment for the Hospital. With the 40th anniversary
of the Charity taking place there is an opportunity to capitalise
on our celebrations and make them memorable.

Fairfield Future was launched at the end of September 2013.
Promotional material regarding Fairfield Future has been
produced for a number of patient areas.

At the time of writing this plan we
hundred Trust Funds applications. To
£14,000 in donations. We have also
feedback informing us that our bids will
Trust Fund Board meetings.
have sent off over a
date we have received
received some positive
be considered at future
During 2014/15 we will review how we fundraise and who does
that fundraising for us. We realise that fundraising in the current
economic climate is difficult and we are competing with some very
emotive charitable causes so we need some fresh thinking on
what we need to do to make those who provide funds that we are
a worthwhile cause. We do not currently have in-house expertise
so we need to buy into fundraising support and link this to our
marketing.
Business Intelligence
There will be four main areas of development in 2014/15:

31
Development of the electronic patient record system – whilst
this project is a key internal project, it does have significant
external links.
The healthcare industry and the NHS are
proposing some challenging standards – in terms of the sharing
of health information and opening up of medical records to
patients and Fairfield. If the Hospital wishes to retain its role
in both the public and private sector it will have to be part of
these initiatives. Illustrations of this are, in the private sector,
BUPA and Benenden who plan to make their systems more
available to their customers and the Hellenic project which aims
Fairfield Independent Hospital Quality Accounts 2012/2013
“Very
approachable
and kind. They
were all
welcoming and
kept me
informed of
everything.
Really good,
effective
communication.”
November 2013
Key Business Objectives 2014/15
to make private patient medical information available, in
summary form, across all providers and medical professionals.
In the NHS the Government has set out its plans for the
opening of future medical records. Fairfield’s project will have
to deliver significant benefits for our patients, consultants and
staff as well as assist in us matching the developments in the
wider medical world. A pilot study has been undertaken in
2013/14 and we intend to build on the lessons learnt to
deliver an operation data record in 2014/15.
“The process
works well and
professionally
implemented.”

We will replace the current system for managing and recording
staff time and attendance with a new package which has a
wide range of advantages over the existing system – this will
give us better management information and will reduce the time
it takes managers and staff to record holidays, rota changes
and absences. It will give better sickness reporting and help
managers work with their staff teams to reduce sickness.

Developing our imaging service and Picture Archiving and
Communication System (PACS) to improve the service it
provides and make it a proper tool for managing patient treatment.
This will be combined with the implementation of a
Radiology Information System (RIS) which links the improvement
of the management of the radiography system with better
reporting of scans in detail and activity reports to our
commissioners.

Improvements in the reporting of performance and activity – this
has both an internal and external dimension with the Hospital
wanting to manage and improve its services and analyse how it
performs both over time and against other organisations. The
analysis of information has long been a challenge at this
organisation and it is a key priority for 2014 to make a
significant difference in that area.
November 2013
Financial Environment 2014
Whilst the external financial environment is apparently improving,
there are no particular signs that insured and self pay activity is
increasing. Patients continue to want to come to the Hospital but
there does not appear to be a greater drive to use their own
money to purchase health related services.
Fairfield Independent Hospital Quality Accounts 2012/2013
32
Key Business Objectives 2014/15
On the demand side of the Hospital business, there is a continual
pressure from the private commissioners to hold prices and there
is still a lack of funds available to the general public for private
health care. Our NHS work through the Choose and Book system
continues to be very popular although the restrictions on price
increase makes some services increasingly difficult to provide and
justify further investment. For the 2014/2015 contracting round
with the NHS we will discuss the specialities where we feel we are
not providing an efficient or clinically effective service.
There is therefore no underlying reason why we should not be
successful in 2014, increasing our surplus, investing in the safety,
quality and range of treatments we provide at Fairfield and
increasing our contribution to the healthcare of the area.
A key financial target for 2014/15 is to increase the cash
balances held by the Charity – this will be achieved by increasing
our surplus and by being more efficient and effective in collecting
debt and controlling cost.
Governance
The Board sets the strategic direction of the organisation and
oversees the delivery of planned results by monitoring performance
against objectives. Its role is also to ensure effective stewardship
and to ensure high standards of corporate governance and
personal behaviour. The Board is led by the Chairman of the
Trustees. It is important that the Hospital has a highly effective
and efficient Board that has the skills, competence and business
acumen to drive the strategic agenda.
As a registered charity and a company limited by guarantee
without share capital we have to balance the requirements of
running a not-for-profit business with the need to achieve our
charitable aims and objectives:
to demonstrate public benefit;
adhere to the values of our charity; adopt best practices and act
with integrity at all times.
The Chief Executive is responsible for ensuring that effective
processes are in place so that the Hospital can discharge its legal
duty for all aspects of governance and quality and for the health
and safety of patients, staff, visitors and contractors. The Chief
Nurse has executive responsibility for the effective and safe
delivery of clinical services.
The Head of Patient Quality and
33
Fairfield Independent Hospital Quality Accounts 2012/2013
“This is the
second time I
have been to
Fairfield (one
BUPA and one
NHS). Really
lovely staff,
always smiling,
which is very
important to patients. If I could
choose a hospital
for treatment I’d
always choose
this one.”
December 2013
Key Business Objectives 2014/15
“I had excellent
care, no
complaints
whatsoever.
The hospital
seems to run
like clockwork.”
January 2014
Safety supports the Chief Nurse in her role and in implementation
of the clinical governance agenda. They work with staff to ensure
that systems and processes are in place to enable improvements
in the delivery of safe effective patient care.
To ensure our compliance with our CQC registration, the Executive
Team will ensure that all our evidence portfolios are up-to-date
and that we are ready for an inspection at any time. It is for us
to make sure that all our staff view the inspection as a positive
feature. During 2014/15 the inspection regime will change.
The new approach
inspection:
will
be
registration,
surveillance,
expert
 Registration: A more rigorous test will be applied which will be
legally binding and named leaders will be held accountable.
 Continuous monitoring, gathering local information
smoke alarms and qualitative information from people.

services,
Expert inspection:
Longer inspection, talking to staff and
people, using intelligence to decide where and what to inspect.
Inspectors using professional judgement.
There will be 3 clear standards:

Fundamentals of care – the basics.
 Expected standards of care – standards of care that anyone
can expect as a matter of course.
 High quality care – good practice led by another organisation
for example NICE. By law services must meet the fundamental
and expected standards of care.
Ratings: These will be introduced but this is causing much debate
at the moment so at the time of writing this business plan it is
not clear.
They are likely to be Outstanding, Good, Requires
Improvement and Inadequate.
Frequency of subsequent
inspections will be based on rating.
Timeline:
In April 2014 the new regulations and registration
requirements will become law.
Our audit plan for 2014/15 will clearly differentiate between
clinical and non clinical audits. The source of the audits will be
clearly defined and all audits will be completed in accordance with
Fairfield Independent Hospital Quality Accounts 2012/2013
34
Key Business Objectives 2014/15
best audit practice. Training and learning will be rolled out across
the organisation as appropriate. Results of audits will also be fed
into the revalidation process for consultants.
During 2014/15
the Board of Trustees is looking to further
increase its membership in order to strengthen the knowledge and
skills available to it. It must be noted that all the Trustees are
volunteers and do not receive any remuneration for the time they
give so freely to the organisation.
External Environment 2014/15
The Hospital recognises that all of its services are very susceptible
to market forces. A considerable proportion of our services are
provided to NHS patients.
We are aware that with the new
landscape and commissioning arrangements locally that the
Clinical Commissioning Group (CCG) are looking to provide many
functions and procedures normally associated with hospital
(secondary) care in primary care. It is difficult to assess any
potential impact this may have on Fairfield however we do meet
regularly with the CCG and we have a good working relationship
with CCG colleagues so any issues that either party may have will
be subject to discussion.
There are opportunities for us in attracting the self pay patients
who, for whatever reason, cannot access NHS services.
The
service may no longer be available as it is deemed to be of a
lower clinical priority or patients are referred for long and tortuous
assessments. Such assessments do offer a range of alternatives
to surgery but for some patients they are just delays in their
desire to eliminate pain or achieve a more mobile and enjoyable
lifestyle. We will look to provide affordable and effective packages
of care to try and resolve some of these frustrations for patients
and we will publish our prices on our website so that our pricing
structure is open and transparent.
We will look to establish some commercial partnerships in
2014/15 in order to develop our services in the coming years.
We cannot let the organisation become isolated and its healthcare
services out-of-date. We have a good reputation externally so we
need to capitalise on that to develop, grow and innovate in the
delivery of our services.
35
Fairfield Independent Hospital Quality Accounts 2012/2013
“Please make sure
all the staff I
came into contact
with are informed
that not only are
they professional ,
they were also
very kind and
caring with me.
Thank you so
much.”
January 2014
Key Business Objectives 2014/15
“I have been
here both as a
private patient
and NHS;
I cannot fault
the service,
care and
support this
hospital provides from the
Consultant,
down to the
housekeeping
staff. The level
of care is
second to
none.”
February 2014
We continue to play an important role in the health care of the
community. In the main, our reputation is good with local GPs.
We are a responsive and flexible charity and we put the patient at
the heart of all that we do. We provide a very high standard of
high quality care. The challenge for us in 2014 and beyond is to
reach different markets in terms of the CCG landscape. GPs hold
the key to referrals for both private and NHS patients. We will
respond to all applicable Any Qualified Provider tenders, either as
a stand alone organisation or working in partnership with others.
Our Consultants are key to the success of our organisation.
Whilst they are not employees of Fairfield they have a relationship
based on the granting of practicing privileges here. They offer a
wealth of advice and support to our staff in their daily work and
their input is welcomed. We continue to work with the Medical
Advisory Committee (MAC) to ensure that we can ‘tap’ into the
expertise of the consultant body in developing services, looking at
new products, new techniques and new ways of working and how
we can innovate and develop services beyond those that we
already provide, widening the range of services available at
Fairfield.
The impact of establishment of a new private diagnostic/day case
clinic in close proximity to the Hospital has not yet been
evaluated. A full evaluation will be carried out on the possible
commercial implications as at June 2014 which will also include
possible commercial conflicts of interest for Consultants. We will
monitor our private activity levels
and also monitor our consultants in terms of clinic cancellations, reduced availability here,
redirection of any private work or any other behaviour that may
put this Hospital ‘at risk’ . At the moment Pall Mall Medical are
not offering services to NHS patients. At the time of writing this
plan we are not aware that they have submitted tenders for NHS
Any Qualified Provider services which have been advertised. We will
of course look to see if there are any areas of mutual benefit we
could pursue with Pall Mall Medical.
Quality and Risk 2014/15
The Charity is totally committed to minimising, managing and
preventing risk through a comprehensive, systematic system of
internal controls, whilst maintaining potential for flexibility,
innovation and best practice delivery.
Fairfield Independent Hospital Quality Accounts 2012/2013
36
Key Business Objectives 2014/15
As part of the Hospital’s assurance framework, the risk register
provides the Board with the detail of the high level risks within the
organisation and how those risks are to be effectively managed.
The risk register will be reviewed by the Board bi annually during
2014/15.
The Hospital will continue to produce annual Quality Accounts
which detail the quality of the services that we deliver.
The risk profile for the Charity includes:




Financial
Clinical
Workforce
Infrastructure risks
We will continue to do our utmost in 2014/15 to ensure that the
systems we have in place do not leave us open to criticism,
potential claims or put the organisation at risk. We will ensure
that all claims are fully investigated and where procedures have
not been followed that relevant action is taken. We would expect
our clinical and non clinical audits to structure assessment of
performance and provide mechanisms for incident reporting and
adverse events. All incidents will continue to be monitored by the
Executive and the Board and learning from incidents will be
cascaded throughout the organisation as part of our commitment
to continuous improvement.
Workforce
During 2014/15 we are not envisaging an increase in our workforce. However, the financial constraints that we are facing will
mean that a number of our services may have to be redesigned in
order to make them more competitive and affordable and roles
and responsibilities will need to be reviewed.
There is a shortage a skilled staff and this will be further
exacerbated in future years across all healthcare. We need,
wherever possible, to ‘grow our own’ with regards to staff and
offer career opportunities across the organisation allowing and
promoting nursing specialisation in fields that we have not done
so before.
We will continue to invest in training and ensure that we have a
capable and competent workforce. When possible we will try to
facilitate placements for clinical staff into other clinical providers
37
Fairfield Independent Hospital Quality Accounts 2012/2013
“No improvement
needed; this
facility is first
class with
excellent
qualities to all
duties of care.”
February 2014
Key Business Objectives 2014/15
“This is a
fantastic
hospital with
an excellent
care plan for
patients to help
to make them
feel relaxed and
comfortable.”
March 2014
to broaden their experience and develop new techniques. We will
also ensure that we continue our initiative of staff shadowing
others in different departments to gain a greater understanding of
how the organisation works. Staff will have annual appraisals and
all objectives will be linked to the organisation’s business plan and
overall strategy. We await the Nursing and Midwifery Council’s
deliberations around revalidation of nurses on a three yearly basis
with regard to their fitness to practice to include assessment
competencies specific patients and peer feedback.
We want our staff to be proud to work at the Hospital. We want
them to work with a greater depth of understanding of what is
expected of them and why and how the part they play contributes
to the development and the success of the Hospital for us all.
The majority of our employees are in the over 40 age group.
While this provides an experienced and highly competent workforce, it also has implications for training and ensuring our clinical
staff are competent in the latest medical practice and continue to
be professionally aware.
There are also issues with regard to
succession planning which we need to start addressing .
We are
all aware that in the next few years we are heading for a skills
shortage in healthcare staffing and, as part of our workforce
planning, we will have to consider looking beyond the UK to
secure the right calibre staff.
At the time of writing this plan the average staff sickness rate for
2013/14 is 5.4%. This is higher than in previous years. The
organisation has unfortunately had a number of staff off work who
are quite poorly and may not return to their duties in the
foreseeable future.
During 2014/15 we will look at ways we can
reduce sickness to achieve a figure more in line with previous
years of 4%. In order to achieve this further work is required by
managers and staff across all areas. Staff have access to the
services of an Occupational Health Nurse and managers have a
range of policies and guidelines to enable them to manage
sickness absence robustly.
We will continue to implement the actions from the staff survey to
ensure that our staff do feel that their comments, concerns and
suggestions are taken seriously by management. We will create a
working environment that is professional and business-like but is
also supportive and engaging. Due to the low staff turnover that
we have here the staff survey will not be run again until 2015.
Fairfield Independent Hospital Quality Accounts 2012/2013
38
Key Business Objectives 2014/15
Productivity of staff is of paramount importance and we will
continue the development of key indicators to provide evidence of
improvements in our productivity by a range of measures. These
measures could include changes to contracts, different ways of
working, job rotation and secondment opportunities.
Leadership and training
During 2014/15 we will look to provide more relevant training to
our staff.
For those staff that have management/supervisory
elements to the job role, management training will be sought from
an external provider. Wherever possible we will utilise e-learning for
staff and secure opportunities to visit other organisations and do
some internal programmes such as ‘walk in my shoes’.
For the Registered Manager further specific training may need to
be organised to ensure they meet any new standards that are
part of the new assessment process by CQC.
9. CONCLUSION
Fairfield Independent Hospital has an important role to play in the
local health economy and everyone who works here is proud to
be associated with the Hospital. As well as providing treatment
and care we also have a role in the public health function and
in prevention, advising patients on lifestyle interventions and
providing advice and support as part of the patient pathway.
Delivering high quality care is not a choice we choose to make, its
part of everything we do here at Fairfield. We are an open and
transparent organisation and are pleased to share information
on how our organisation is performing.
The NHS landscape continues to change and that presents us with
both challenges and opportunities, differentiating ourselves as a
not-for-profit organisation offering the best outcomes for those
patients who choose to come here - something we never forget.
We all recognise that the journey is not going to be easy - with
increases in technology, different ways of providing services and
pressure from consumers, regulators and commissioners. We
do feel that we are on the right track and that the culture and
ethos of the organisation that is
already in place provide sound
building blocks on which we can move the organisation forward.
39
Fairfield Independent Hospital Quality Accounts 2012/2013
“I do not think
it is possible to
make any
improvements;
everything was
first class.”
March 2014
Schedule 1 - Overview of NHS CQUIN (Quality)
Targets & Achievements 2013/2014
Quality Indicator
Outcome
Friends & family test
Improved performance of friends & family test
Venous thromboembolism
All eligible patients
Achieved
(VTE)
to receive a VTE risk assessment
Achieved
VTE prophylaxis in accordance with NICE guidance
Achieved
Patients given care and advice on VTE
Achieved
Completion of Root Cause Analysis for patients who
have DVT or Pulmonary Embolism
One patient suffered a DVT and the RCA
was completed
Participation in national safety thermometer monitoring Achieved
Pressure ulcers
Maintain current performance in the prevalence of
pressure ulcers and move towards 0 harms
Achieved
Dementia
Supporting Carers of People with Dementia
We have been accredited with the
Dementia Action Alliance and provide
appropriate advice and support to carers
Quality Care
Quality Care - Review and implementation of strategies, policies and procedures which underpin care delivery
All of our policies and procedures are
regularly audited and updated. We have
been re-accredited via ISO. Nurse to
patient ratios published on the ward every
day.
Leadership
Senior staff have received training in
leadership and supervision
Workforce for safe care delivery
All staff have to complete statutory and
mandatory training. Continued professional
development is identified at appraisal.
Secondments and job rotation across the
organisation have been implemented. All
recruitment processes in line with national
guidance.
Healthcare assistants
Competency framework underway. All
HCAs have a senior nurse ‘buddy’.
Fairfield Independent Hospital Quality Accounts 2012/2013
40
Schedule 1 - Overview of NHS CQUIN (Quality)
Targets & Achievements 2013/2014
Quality Indicator
Outcome
Percentage of patient and carers reporting improved
very satisfied with discharge planning process against
agreed trajectory.
99%
Percentage of patients discharged on expected day of 97%
discharge against agreed trajectory
Percentage of patients and carers full engagement in
the discharge process against agreed trajectory
99%
Percentage of Patients and carers reporting full under- 100%
standing of expectation and arrangements regarding
discharge and future care against agreed trajectory
95% compliance of Effective Discharge Planning
Checklist for all patients against agreed trajectory
Achieved
98% of Discharge Summaries to contain the
recommended minimum data set
Achieved
95% of Discharge Summaries received in GP Practices
within 24 hours
Achieved
98% of discharge letters to be received within general Achieved
practices 2 weeks from the patients discharge date
95% of patients reporting they received a copy of
their discharge summary on day of discharge
Achieved
Communication
Improving Electronic Communications (SMS Text
Messaging, E-mails and encouraging the use of Self
Care Support Tools) for all patients:


All patients will be asked how they would like their All patients are asked on arrival at the
hospital information communicated
reception desk
Text reminders for all patient appointments
Achieved
Encourage the use of Self Care Support Tools
and Knee surgery patients)
41
(Hip
Achieved
Fairfield Independent Hospital Quality Accounts 2012/2013
Statements from external sources
Fairfield Independent Hospital Quality Accounts 2012/2013
42
Statements from external sources
Comments from Healthwatch St Helens
Healthwatch St. Helens is pleased to comment for another year on the Fairfield Quality
Account document. It is encouraging to see positive feedback quotes from patients
and the FFT results also reflect this.
Whilst we don't disagree with the development areas shown and the achievements
made, we feel these are more relevant to the operational running of the Trust, rather
than chosen with evidenced patient or user input.
E.g. the clinical and non-clinical staff forum where patients comments are discussed
and learning takes place, this might benefit from patient representatives being involved
and Healthwatch could assist in this process.
It would also be relevent to engage with Healtwatch regarding the audit of dementia
carers' experiences, given our recent task group which included work on this area, we
can assist with sharing good practice that is local to St. Helens.
We acknowledge the high standards of infection control achieved, and would also
state the screening processes used prior to any procedure is an advantage in trusts
with smaller patient numbers and no emergency admissions, that is not always available to acute trusts.
We are pleased to see attention being paid to the staff survey this year and that
there is an increase in both uptake of the survey and levels of satisfaction due to actions being taken.
We would agree broadly with the priorities for 2014/15, in particular we would reccommend working with neighbouring St. Helens & Knowsley Trust re. VTE risk assessment, as this is a similar area of improvement that the Trust has chosen to focus on.
Emma Rodriguez Dos Santos
Healthwatch St. Helens support manager
43
Fairfield Independent Hospital Quality Accounts 2012/2013
St. Helens
Fairfield Independent Hospital
Crank
St Helens
Merseyside
WA11 7RS
www.fairfield.org.uk