Quality Account 2013-14 More information about the services we offer can be www.sirona-cic.org.uk

More information about the services we offer can be
found on our website www.sirona-cic.org.uk
or telephone us on 01225 831403
Quality Account
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Date of publication: June 2014
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Sirona Care & Health Quality Account 2013-14
Your Feedback
We want our Quality Account to be a dialogue between Sirona Care & Health
and the communities we serve.
To let us know what you think of the account, or to tell us what you think we
should be prioritising, please contact us in one of the following ways:
By post:
Sirona Care & Health Quality Account 2013-14
About our Quality Account.................................................................................................................... 00
About Sirona Care & Health CIC.......................................................................................................... 00
Statement from our Chief Executive..................................................................................................... 00
Statement from the Chair of the Quality Committee............................................................................. 00
Customer Care Service Headquarters
St Martins Hospital, Clara Cross Lane, Bath BA2 5RP
A review of our Quality Priorities 2013-14............................................................................................ 00
Performance against National and Local Targets................................................................................. 00
01225 831403
Our Aims............................................................................................................................................... 00
Quality Priorities 2014-15..................................................................................................................... 00
Statements of Assurance from the Board............................................................................................. 00
Statement of Directors’ responsibilities in respect of our quality account............................................. 00
Statement of performance in response to the Care Quality Commission............................................. 00
Statements from Commissioners, OSC and Healthwatch.................................................................... 00
Independent Auditors Limited Assurance report................................................................................... 00
Appendix A
National and local clinical audits: actions to improve quality................................................................ 00
Appendix B
Care Quality Commission Routine Inspections 2013-14...................................................................... 00
Appendix C
Commissioning for quality and innovation payment framework 2013-14............................................. 00
Sirona Care & Health Quality Account 2013-14
Sirona Care & Health Quality Account 2013-14
About our Quality Account
About Sirona Care and Health CIC
What is a Quality Account?
Sirona Care and Health CIC exists for the sole purpose of
providing high quality community based health and social
care. Continuous improvement of quality lies at the heart
of everything we do and is the golden thread that links our
strategy and our plans to the way we deliver care day to
day. We want every service user to feel safe and cared for,
and every member of staff to feel proud of the work they do
in Sirona.
A quality account is an annual report produced for the
public by providers of NHS healthcare services in relation
to the quality of services they deliver. All providers of NHS
services strive to achieve high quality care for all, and
the quality account provides us with an opportunity to
demonstrate our commitment to quality improvement and
show what progress we have made in 2013-14.
What does the Sirona Quality Account include?
Over the course of this year we have collected information
on the quality of all of our services to inform our
understanding of how safe our services are; whether the
care being provided is delivering the best outcomes for
service users and how service users, their families and
carers have experienced the care and support provided.
As an integrated health and social care provider our quality
account makes reference to both health and social care,
reflecting the interdependencies inherent within their
We have used the information to look at how well we have
performed over the past year and to identify where we
could improve in 2014/15.
Developing the Quality Priorities 2014/15
The development of our Quality Account and Quality
priorities has been done via consultation with a variety
of internal and external stakeholders. When developing
priorities for the coming year, a number of factors have
been considered:
l Feedback from Service Users, Commissioners and
other stakeholders
l Data and service metrics
l Evidence based practice and national guidance
How can I get involved now and in future?
At the end of this document in the appendices, entitled
‘Feedback and useful contact details’ you will find details of
how to let us know what you think of our Quality Account,
what we can improve on and how you would like to be
involved in developing the report for next year.
How do I request a hard copy or different
formats of the Sirona Quality Account?
To request a hard copy or a different format of the Sirona
Quality Account, contact the Customer Service Team by
phone on 01225 831403 or by email to
What if I want to talk to someone about
Sirona’s services or my experiences?
If you would like to talk to someone about your experiences
of Sirona services or need to know how to find a service,
you can contact our Customer Services Team in confidence
on 01225 831403
Or email: customercare@sirona-cic.org.uk
You will also find these and other contact details in our
‘Feedback and useful contact details’ section within the
Sirona was created in October 2011 as an independent
not-for-profit organisation providing publicly-funded health
and social care services. Sirona is responsible for the
delivery of the community healthcare and adult social
care services previously provided by Bath and North East
Somerset Primary Care Trust (PCT) and Bath & North East
Somerset Council respectively.
We employ over 1700 community health and social care
professionals who provide community based services for
nearly 500,000 people living or working in the areas of Bath
and North East Somerset. We also provide some services
to people in Wiltshire, South Gloucestershire and North
To improve access to our services, we provide healthcare
from our two community hospitals and a number of locally
based sites. We also treat and support people in their own
Our key levels of governance and assurance are provided
through our Quality Committee a sub Committee of the
Board, Chaired by Dusty Walker, our Non-Executive
Director. It has delegated responsibility for quality and
assurance in relation to services and staffing and provides
co-ordinating structures, governance systems and
relationships across the organisation which are essential to
‘joined up’ quality outcomes.
The full range of Sirona
Services includes:
l Clinics and Treatments:
e.g. community neurology and stroke rehabilitation,
audiology and continence services
l Care in Hospital:
e.g. Paulton and St Martin’s Hospital
l Residential care:
e.g. community resource centres and extra care
l Learning disabilities services:
e.g. community learning difficulties teams in South
Gloucestershire, the Autistic Spectrum Condition
Case Management Service and Supported Living
l Children and younger adults:
e.g. child health and hearing services, children’s
continence services and school nursing
l Mental Health:
e.g. Mental Health Reablement Service, Mental
Health Floating Support Service, Mental Health
Community Options and Building Bridges.
Sirona Care & Health Quality Account 2013-14
Sirona Care & Health Quality Account 2013-14
Statement from
our Chief Executive
I am pleased to be introducing this second Quality
Account on behalf of Sirona Care & Health. During
the past two years we have come so far as an
organisation – we have embraced the culture
and ethos of public and community service and
for me, the essence of Sirona is about “taking
it personally”. I ask all staff who work for us to
take personal responsibility for the commitment
we make to deliver care with compassion; to
understand that every contact we have with people
– those who use our services, their carers, our
colleagues and our partners – makes a difference
and to make that difference a positive one.
Statement from the Chair
of the Quality Committee
I hope that through this account you can see
reflected the care and support given by our staff
with skill, compassion and respect. We know
we still have lots to do and we will continually
strive to make things even better – we aim to
provide services to a standard that we wish
to receive ourselves or for those we love. By
working together with service users, our staff, our
commissioners and our partners in care we can
achieve this and attain excellence in all that we do.
We know, however, that we can only truly judge
our success by listening to the views of those
using our services. Over the coming year we will
be giving even higher priority to meeting with and
listening to their experiences and working with
users to help develop and redesign services to
make sure they continue to meet the needs of
Janet Rowse
Chief Executive
Within Sirona Care and Health we know that we
must always strive to deliver the highest standards
of care to deserve the continued support of our
service users, staff and commissioners. Looking back over the past twelve months I
believe that our performance in many areas
justifies that confidence and support. Look for
example at the impressive performance of our
District nursing services in implementing the
Community Productive Series. Implementation
of this programme has delivered measurable
outcomes that benefit staff wellbeing and the
effectiveness of teams, but ultimately ensure an
improved experience for service users.
We have also established new teams and services
in response to the health and social care needs
of local communities, including health visiting for
the actively ageing. This exciting new initiative, the
first of its kind in the United Kingdom, sees health
visitors supporting people aged 80-85 years to
manage their health and wellbeing, get better and
stay at home for longer.
We continue to work closely with our partners and
statutory agencies to reduce risks and encourage
staff to report incidents and near misses. We have
reviewed the recommendations from the Francis
Inquiry that were published early last year and
have begun implementation of a set of actions
arising from this report.
We are very grateful to the work of our Service
User Panel in supporting our work over the past
year - providing a ‘critical friend’ perspective and
sound comment on our thinking and ideas. The
role of the Service User Panel will be developing
over the course of 2014-15, as we welcome
members from South Gloucestershire.
Now we look forward to 2014-15 with confidence –
determined to deliver the six quality priority areas
identified through feedback received from service
users, staff, commissioners of services, and
partner organisations.
As Chair of the Quality Committee I am particularly
determined to see continued progress towards
reducing the number of preventable pressure
ulcers across our community and inpatient
services and the further implementation of
the Friends and Family Test across all of our
community health services.
We will be reviewing our quality goals over the
course of the year to ensure the best outcomes for
service users.
Dusty Walker
Non-Executive Director and Chair of the Quality
Committee Sirona Care and Health CIC
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Service User Safety
Service user safety is the foundation of good care. In 2013-14 we had four quality priorities which
focused on improving service user safety. These had the aim of improving compliance with reporting
standards and the recording of information, whilst also ensuring a reduction in the prevalence of
specific harms.
Staff from within Sirona are engaged in work across the seven key work streams of:
l Pressure ulcer care
l Falls management
l Catheter acquired urinary tract infections
l Venous thromboembolism (VTE)
l Medicines management
l Managing the deteriorating patient
l Leadership
Within Sirona we are dedicated to building a culture in which all staff work together towards delivery of
zero tolerance to avoidable harm.
❖ What: Service Users will be free from falls,
pressure ulcers, CA-UTI and VTE
❖ How much: 95% ❖ By When: March 2015
Outcome: 92% of Service Users received harm
free care ❖ Progress: Close to target
Pressure ulcers are areas of localised damage to the skin
and underlying tissue caused by pressure, shear or friction,
or a combination of these. We believe that all pressure
ulcers can be prevented by frequently changing a person’s
position, providing special mattresses and chair cushions,
and by paying special attention to hydration and nutrition.
We strive to keep every service user free from harm. One
method we are using to gauge how much harm our service
users come to is called the Safety Thermometer. The
Safety Thermometer is a tool that records how many of our
service users suffer from four types of harm:
l Pressure Ulcers
l Falls
l Urinary Tract Infections in people who are
catheterised (CA-UTI)
l Venous Thromboembolism (VTE)
The safety thermometer was developed by the Department
of Health with the aim of understanding how often the four
types of harm occur in the NHS. Within Sirona Care and
Health we collect data using the Safety Thermometer from
across inpatient units and community teams.
Each of the harms measured by the Safety Thermometer
is also looked at in more depth by dedicated project teams;
their work on improvement can be seen over the following
❖ What: To reduce healthcare acquired pressure ulcers
across inpatient and community based health services.
❖ How much: 30% ❖ By When: March 2014
❖ Outcome: 30% reduction in grade 3 & 4 pressure ulcers
(new & old) ❖ Progress: Target achieved
Improvements Achieved:
l 18% reduction in grade 3 and 4 pressure ulcers (new)
38% reduction in grade 3 and 4 pressure ulcers (old)
l The tissue viability team have reviewed and updated the
list of pressure relieving equipment.
l Internal educational courses have been reviewed and
update d in response to the outcomes of learning from
across services.
l Improved identification and grading of pressure ulcers
by staff.
l A newsletter has been developed and circulated to all
staff in respect of the management of skin care.
l A new set of assessment documentation has been
developed and implemented across community teams.
Further Improvements identified:
l Continue to work towards our goal of eliminating grade 3
and 4 pressure ulcers
l Develop a collaborative across the health system
within Bath and North East Somerset and South
Graph: % numbers of service users
receiving harm free care
Harm Free
Graph: % number of service users
with a Grade 3 and 4 Pressure Ulcer
PU (new)
PU (old)
*As measured by the safety thermometer
Our quality priorities reflect the three domains of:
l Service User Safety
l Service User Experience
l Effectiveness of Care
Pressure Ulcer Reduction
30% reduction in grade 3 and 4
pressure ulcers
This part of the report describes the quality of our services and how we have
performed across the eight areas identified for improvement in 2013-14. These areas
for improvement are called our quality priorities and were identified through feedback
received from service users, staff, commissioners of services, and partner organisations.
Delivering Harm Free Care
92% of our service users received
harm free care*
A review of our Quality Improvement
Priorities 2013/14
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
❖ What: Reduce the number of service user falls occurring
within bedded units resulting in harm
❖ How much: Reduction ❖ By When: March 2014
Outcome: Overall the rate of falls resulting in harm
remains stable ❖ Progress: Not Achieved
Improvements Achieved
l Continued active involvement with the Patient Safety
Collaboration, hosted by the Academic Health Science
l Podiatry has audited footwear on the inpatient units, and
wards will now have a stock of non-slip socks for use
with people at risk of falling.
l Bed sensors have been installed on the inpatient units
to alert staff to the possible risk of falling of service users
l A number of events were held across services during
falls awareness week.
Further Improvement Identified
l On-going support is being provided to the Community
Resource Centre’s & Extra Care Facilities
l The falls clinic will be piloting the use of Tai Chi to
promote balance and movement
l An ongoing training and education programme is to be
delivered throughout the year
l The completion of risk assessments will be audited
across bedded facilities
Graph: % Number of Falls causing
harm to a service user
Falls resulting in harm
❖ What: To risk assess all inpatient service users admitted
to hospital for their risk of developing a VTE within 24hours
of admission ❖ How much: 95% ❖ By When: Ongoing
Outcome: 99% of inpatient service users had a VTE risk
assessment completed within 24 hours of admission to
hospital ❖ Progress: Achieved
Improvements Achieved
l Inpatient services have continued to review actions
in relation to VTE and updated local policy to reflect
national guidance
l VTE has now been included within the prescription chart
ensuring ease of access to information regarding a
person’s status in relation to VTE
Further Improvement Identified
l Continued active involvement with the Patient Safety
Collaborative, hosted by the Academic Health Science
l Improvements are required in delivering prophylaxis
treatment to people identified at risk of VTE.
Graph: % numbers of people who have
had a VTE risk assessment within 24
hours of admission
VTE assessment
Catheter Associated Urinary Tract Infections (CaUTI)
Sometimes when people are unwell it becomes necessary
to use a urinary catheter. While catheters are used to
help patients, they can sometimes lead to a urinary tract
infection. The chance of infection can be reduced by
reducing the length of time the catheter is in place. Within
Sirona Care and Health we have continued to work to
reduce the length of time people have catheters in place
and prevent catheters from being used when it is not strictly
Sirona has been involved with the work of the West of
England academic Health Science Network and the Patient
Safety Collaborative. Since 2011 we have achieved over a
50% reduction in the incidence of catheter acquired urinary
tract infections.
❖ What: To reduce catheter acquired urinary tract
infections ❖ How much: To continue the downwards
trend in CaUTI ❖ By When: March 2014
❖ Outcome: Continued reduction in the incidence
of CaUTI ❖ Progress: Achieved
Improvements Achieved
l Delivery of mandatory catheter education updates:
ensuring the use of best practice guidance across
Sirona services.
l Publication of a leaflet for service users with an
indwelling catheter
l A significant reduction in the use of antibiotics to treat
catheter acquired urinary tract infection in 2013-14: 2%
compared with 9% in 2012-13.
Further Improvement Identified
l Continued active involvement with the Patient Safety
Collaboration, hosted by the Academic Health Science
l Catheter training updates will continue to be offered to
l A survey on the quality of life of people with indwelling
catheters will inform further developments and
Graph: number of service users with an
indwelling catheter who were treated for
a urinary tract infection (UTI)
Service Profile: The Family Nurse Partnership
Sirona Care & Health was one of the first organisations in
the South West to have dedicated family nurses working
with people aged under 20s. The aim of the Family Nurse
Partnership is to support a young parents desire to be
the best parents they can be by gaining confidence and
building on their strengths.
The initiative was part of Sirona’s work to increase the
number of Health Visitors helping families across Bath
and North East Somerset which has seen the workforce
increase by a third.
Sirona has also been awarded the prestigious UNICEF
Baby Friendly Award, and was selected by the
Department of Health in 2011 to be one of the national
sites for the Health Visitor Implementation plan.
Venous thromboembolism (VTE) is a term that covers
both deep vein thrombosis and its possible consequence:
pulmonary embolism (PE). A deep vein thrombosis (DVT)
is a blood clot that develops in the deep veins of the legs.
If the blood clot becomes mobile in the blood stream it can
travel to the lungs and cause a blockage (PE) that could
lead to death. In 2005 the House of Commons Health
Committee reported than estimated 25,000 people die from
preventable hospital acquired VTE in the UK every year.
The risk of hospital-acquired VTE can be greatly reduced
by risk assessing and prescribing appropriate measures
that prevent a VTE from occurring.
The impact of a fall can affect a person’s confidence,
increase anxiety and lead to a reduction in mobility even
following the healing of any physical injury suffered. It is
important to understand why people fall and put plans in
place to reduce falls from occurring and any harm resulting
from a fall.
Venous Thromboembolism (VTE)
99% of inpatient service users had
a VTE risk assessment completed
Reduction in Falls
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Chrissie Hardman, Head of Children’s Services, said:
“The great thing about the implementation plan is that it
is not just about numbers; of greater importance is the
shift in practice to the “new“ health visiting focussed on
inequalities, integrated working with children’s centres,
and really listening to what the families say they need to
keep well and for their children to thrive”.
“Two key areas of focus have transformed practice.
Firstly, the increased contact in pregnancy promoting
the evidence from the world of neuroscience on the
development of the baby brain, and how a greater
awareness from mums and dads can change the life
chances of their new baby. Secondly, an individual health
review at the age of two with a 96 per cent take up allows
early identification of concerns which will affect the health
and educational outcomes for the child”.
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Service User Experience
Implementation of the 15-Steps Challenge
Service users tell us that they care about their experience of services as much as clinical
effectiveness and safety. They want to feel informed, supported and listened to so that they can make
meaningful decisions and choices about their care and treatment.
The 15 Steps Challenge is a tool to help staff, service users
and others to work together to identify improvements that
can be made to enhance the service user experience.
Listening to service users and our local communities is fundamental to our values, not only as a
provider of health and social care services, but also as a community interest company. Our philosophy
is to deliver care that is truly personal and centred on the needs of each individual.
Produced with service users, carers and staff, the
challenge uses a series of questions and prompts to
guide users through their impressions of a service. The
information can be developed into a score which can be
used to develop an understanding of how services are
viewed by service users, whilst qualitative data supports
the development of improvements to benefit the service
user’s experience of the service.
In 2012-13 we had two priorities that focused upon service user experience.
l Implementation of the 15 Steps Challenge
l Introduction of the Friends and Family Test
These had the aim of improving the content and methods of communicating with service users;
involving service users in the development of services.
❖ What: Implementation of the 15-Steps Challenge
in the Reablement Service
❖ How much: Evidence of the service either improving
or maintaining scores in relation to three of the four survey
areas when the exercise is repeated.
❖ By When: March 2014
❖ Outcome: Improvement across three areas
❖ Progress: Achieved
Strategic Context
The 15 Steps Challenge:
l Matches the CQC’s core quality standards and can be
used to prepare for visits or as part of the development
of a Quality Account
l Supports the National Institute for Health and Clinical
Excellence quality standards especially around patient
experience in adult NHS Services
l Helps us to deliver the Carers Trust ‘Triangle of Care’
programme in our acute inpatient wards
l Fits the Government’s priority to introduce the ‘friends
and family test’ in all care settings
Further improvements identified:
l Implementation of the 15-Step Challenge across
identified services, to support service redesign and
service user involvement and engagement.
Improvements achieved:
l Launch of the 15 Step Challenge within the
Reablement Services
l During the first phase of implementation 48 interviews
took place and 142 completed questionnaires were
returned; during the second phase 16 interviews took
place and 83 completed questionnaires returned.
l Board members, frontline staff, clinical leaders and
service user representatives were involved in the
l Findings from the work will be used to develop
continuous improvement plans.
l The communication’s team has supported the sharing
of key messages emerging from the initiative with staff,
service users and other stakeholders.
Table: Response results to
the 15-Step challenge
Was the reablement team
staff member well prepared?
Did the staff member make
you to feel safe and cared for?
Did the Staff member make
you feel involved in the care
you received?
Did you feel the staff
member communicated
with you in a manner
you could understand?
% number responding
‘yes definitely’
Phase 1
Phase 2
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Implementation of the Friends and Family Test
The Friends and Family Test aims to provide a simple,
headline metric which, when combined with follow-up
questions, can be used to drive cultural change and
continuous improvements in the quality of the care received
by service users.
Service User comments on our services, F&F test:
“Friendly, happy, helpful and caring”
Service User, Minor Injuries Unit, Paulton
The Friends and Family Test (FTT) is collected in the MIU
and Inpatient services, with the information available at
ward, site and trust level.
“Friendly, quick, professional service! Excellent thank you.”
Service User, Minor Injuries Unit, Paulton
The Friends and Family score identifies the proportion of
patients who would strongly recommend minus those who
would not recommend, or who are indifferent.
“The staff has been extremely helpful and kind.”
❖ What: Implementation of the Friends and Family Test
within the MIU and inpatient units
❖ How much: Improving response rates above a national
threshold of 15% ❖ By When: March 2014
❖ Outcome: 29%
❖ Progress: Achieved
“Foods good, nurses are good, it’s nice and clean. Can’t fault it.”
Service User, Paulton Hospital inpatients unit
Service User, Paulton Hospital, inpatients unit
“Nobody wants to be in hospital but I have received good
help from nursing staff OT and Physio.”
Service User, Sulis Unit, St Martin’s Hospital, inpatients
Improvements Achieved
l The Friends and Family Test was introduced on 1st April
within the Minor Injuries Unit and inpatient wards.
l There has been an overall improvement in the number
of responses collected over the course of the year.
l Qualitative responses have been used to inform service
improvements aimed at enhancing the service user
experience and outcomes following treatment.
Responding to Service User Feedback
In this section of the report we describe to you other
improvements we have made in 2012/13 in response to
feedback or contacts made with the Customer Care team.
Further Improvement Identified
l implementation of the Friends and Family test across
community Services in line with the timetable for the
National Programme
Complaints and Compliments
Graph: % score from the Friends
and family Test
M r
Au l
Response rate
We have received 49 health related complaints; 25
complaints regarding social care, and 1 complaint that
related to both health and social care; this compares with
33 health related, and 18 social care related complaints
reported in 2012-13.
M r
Au l
Graph: Response rates for the Friends
and Family Test in 2013-14
Providing a high quality service for both our service users
and those who commission our services is a central
objective for Sirona Care and Health. As such we take
all complaints very seriously and utilise feedback as part
of an overall ethos to drive service development through
continuous improvement. Over the course of 2013-14 we
have implemented a more thorough and effective reporting
mechanism in order to ensure that the management and
resolution of complaints is handled with greater efficiency
and transparency.
Of the complaints received in 2013-14:
l 33 were upheld
l 14 were upheld in part
l 27 were not upheld
l 1 complaint is continuing to be reviewed.
Two complaints have been referred on to the Parliamentary
and Health Ombudsman during the year.
Due to improved publicising of our customer services
team and the inclusion of new teams and services within
Sirona there has been an increase noted in the number of
complaints received.
The most frequently reported categories of complaints in
2013-14 were in relation to:
l Staff Attitude
l Communication
l Unwelcome decisions
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Annual Organisational Service User Survey
In September 2013 we conducted our annual organisational service user survey, aimed at
determining the extent to which our services have been meeting the identified needs of the local
community and service users.
The results of the survey were generally positive, most significantly showing a dramatically increased
score on the number of service users who would recommend our services to friends and family.
Table: Comparison of Service User feedback in response to the Organisational Survey
Service users are happy with the length, frequency and
convenience of appointments
Care meets service user needs
Service users feel sufficiently involved in decisions about their care
Service users were treated with care and compassion
Service users know where to seek advice if they need more support
Service users are satisfied with the service they received
Service users say there is nothing we could do better
Service users would recommend the service to friends and family
Service User reported Measures
Feedback from these many and varied engagement
programmes has provided a better understanding of how
people experience the services we provide. The feedback
has been overwhelmingly positive. Key themes identified
from the comments made are:
Several of our services have established or continued their
work with service user groups and partnership forums
l Diabetes
l Health Improvement
l Health Visiting
l Learning Disabilities
l Audiology
l Positive attitude of staff. Positive descriptors
included: professional, competent, kind, caring, cheerful,
friendly, encouraging, gentle, lovely, thoughtful, helpful,
considerate and excellent.
Creative Engagement
Many of our services have implemented creative and
innovative activities to capture feedback from their service
users. For example:
l Social Return on Investment
l Friends and Family Test
l 15-Step Challenge
l Focus Groups
l Surveys
l Social media, including Twitter and You Tube.
“They are kind and caring. They give
me all the help I need.”
Teams and services have received many comments
and feedback from service users, their family and carers
through formal measures and more informal discussions.
Service User forums
3352 questionnaires were sent out to service users in receipt of care from our services. 52% of
service users responded an increase of 4% on last year.
Following the results of the organisational survey we will be seeking to ensure that service users know
who to contact should they need more support or advice, and have set in motion plans to develop our
customer services team to enable easier access to information about our services.
l Service User outcomes: people talked about the
positive difference that the service has made to their lives.
“We are safe so I don’t need to worry.
If I worry or am unhappy I would talk
to the staff. I have not been unhappy
about anything. The staff are kind.”
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Effectiveness of Care
Sirona is committed to delivering excellence in the
provision of health and social care services, with a
persistent focus on the effectiveness of the care we provide
for patients and the outcomes our services achieve.
Improvements achieved:
In 2013-14 we had three priorities that focused upon
clinical effectiveness. These had the aim of improving the
outcomes for service users by improving access to care
and treatment across services.
l Knowing how we are doing?
Implementation of the Community
Productive Series
The Productive Series “Releasing Time to Care” is an
initiative developed by the NHS Institute for Innovation
and Improvement. The aim of the series is to release more
time for staff to spend on delivering direct care with service
The most important aspect of the programme is that its
overall value is in delivering improved outcomes for service
The Community Productive Series provides a structured,
effective and supported framework to empower staff in the
improved delivery of quality focused, safe clinical patient
care. The programmes are in a modular format and aim to
put both clinical and non-clinical staff back in control of their
clinical areas, making the decisions that affect them and
their patients on a daily basis.
Using the modules District Nursing Teams have decided on
the best way of achieving efficiencies and productivities in
their services.
❖ What: Implementation of the foundation modules of
the Community Productive Series across District
Nursing Services
❖ How much: Implementation of the Foundation modules
❖ By When: March 2014 ❖ Outcome: Achieved
l Fully implemented the foundation modules:
l Well organised learning environment
l Patient Status at a Glance
l Developed a working environment that has improved
efficiency with staff able to easily access necessary
equipment and resources when required
l Improved understanding of the population needs across
Bath& North East Somerset and how this affects team
working arrangements
l Improved understanding of caseload weighting and the
allocation of resources
Further improvements identified:
l The District Nursing Teams will continue to implement
the evidence based Productive Community Services.
Achievement will be measured by the full introduction of
the planning modules within the Community Productive
Improved access to Telecare for service users
Telecare and telehealth services use technology to help
people live more independently at home. They include
personal alarms and health-monitoring devices.
Telecare and telehealth services are especially helpful for
people with long-term conditions, as they can reassure the
service user and their family that their health is stable. They
can also help people to live independently in their own
home for longer, avoiding a hospital stay or putting off a
move into a residential care home.
❖ What: Improve the experience and outcomes of people
with chronic obstructive pulmonary disease (COPD) or
heart failure by increasing access to telecare.
❖ How much: 30 people with heart failure and 6 people
with chronic obstructive pulmonary disease will have
access to telecare devices over the course of the year
❖ By When: March 2014 ❖ Outcome: Achieved
Improvements Achieved:
l Over 40 people have been supported in accessing
health monitoring devices over the course of the year.
l Access to equipment has clearly benefited people’s
experience of services and ensured improved health
l Staff have developed a clearer understanding of
the health benefits possible from the use of telecare
equipment and clearer profile of the service users
telecare is best able to support.
l A strategy group has been set-up and a strategy
document developed to ensure improved access
to service users of equipment available to support
improved levels of health and wellbeing for people living
with a long term condition.
Further improvements identified:
l Continue developing access to service users of
telehealth and telecare devices
l Continue the development and implementation of the
telecare and telehealth strategy
Service Profile:
Children’s Audiology Services
Within Sirona Children’s Hearing Services are provided
by a specialist team of audiometricians and paediatric
doctors across 15 clinic sites in Bath and North East
Somerset, and Wiltshire. Referrals are received from
Health Visitors, GPs, School Nurses and Speech
Newborn babies are given a hearing screening test to
check for any hearing loss. One to two babies in every
1,000 are born with hearing loss in one or both of their
ears. The screening of all new babies’ hearing means
that those with hearing loss can be identified early. The
earlier any hearing loss can be identified the better, as
any loss could affect a baby or child’s development. If a
problem is found, support and information can then be
provided to the family.
The newborn screening programme has been running
in Bath and North East Somerset since 2002 with the
district one of the original trial areas for the community
service. The newborn hearing screening programme
operated by Sirona is one of the best in the South West
with figures showing a 99.8 per cent coverage rate.
There are three stages to the screening – with only
a small percentage of babies needing the diagnostic
tests which can lead to a diagnosis of permanent loss.
Vicky Mainstone is the manager of the Newborn
Hearing Screening Programme for Sirona and trains
health visitors.
She said: “We are one of the top performing sites in
terms of the proportion of babies we screen. Our health
visitors are fantastic at ensuring the screens are carried
out within the first couple of weeks and then referred
into audiology in a timely manner.”
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
National and Local Performance Targets
Infection Prevention and Control
During 2013-14 we have maintained a focus on reducing healthcare associated infection (HCAI) through
continued investment in infection prevention and control measures. Considerable steps have been taken to
enhance our response to the infection prevention and control and clean environments agenda.
Sirona continues to aspire to zero tolerance of any preventable infection, encouraging everyone to take
responsibility for their individual practice.
Methicillin Resistant Staphylococcus
Aureus (MRSA)
Methicillin resistant staphylococcus aureus (MRSA) is a
well-known health care associated infection. It is estimated
that 3% of people carry MRSA harmlessly on their skin but
for hospital or community patients the risk of infection may
be increased due to wounds, or invasive treatments which
make them more vulnerable.
To sustain a reduction in preventable MRSA blood
stream infections (bacteraemia)
Within Sirona we have continued to improve our infection
control procedures, sustaining low infection rates within
our two community hospitals. We screen all admissions
to our hospitals for MRSA within 24 hours, and conduct a
root cause analysis on any case of MRSA notified to the
All staff within the community hospitals are aware of the
number of infections acquired within their service areas,
have knowledge of their local reduction targets and their
performance against these.
At the end of March 2014 we have been 864 days without
an MRSA bacteraemia infection. This has meant that
across the year service users have had improved access
to inpatient services, and have been able to return home
more quickly.
Clostridium difficile (C-diff)
Clostridium difficile is a common cause of healthcare
associated diarrhoea. It is a bacterium that is harmlessly
present in the bowel of about 3% of healthy adults, and up
to 30% of elderly patients. When certain antibiotics disturb
the balance of the bacteria within the gut, Clostridium
difficile can multiply rapidly and produce toxins which cause
diarrhoea and illness.
To sustain a reduction in preventable Clostridium
difficile infections
The number of Clostridium difficile infections occurring
within our two community hospitals was the same this year
as the rate recorded in 2012/13: 5 cases. Whilst this is
above our target of 3 cases, the overall rate of infection is
similar to the national average.
All infections with Clostridium difficile undergo a root cause
analysis to determine whether the case is attributable to
any practices occurring within the two community hospitals
E-coli Bacteraemia
E-coli bacteraemia is one of the most frequent causes of
many common bacterial infections, including urinary tract
infection (UTI), travellers’ diarrhoea, and other clinical
infections such as pneumonia.
2012-13 was the first full year of mandatory reporting
for E-coli bacteraemia. There were 2 cases within our
community hospitals during 2012/13 and I case recorded
for this year, 2013/14. In all cases the cause of infection
was investigated and identified, with service users being
successfully treated and discharged home.
Delivering same-sex accommodation can dramatically
improve how patients feel about their care and help ensure
that everyone is treated with the privacy and dignity they
deserve. Sirona is committed to delivering same-sex
accommodation standards across services believing this
will safeguard people’s privacy and dignity when they are at
their most vulnerable.
What are the Same-Sex
Accommodation Standards?
Same-sex accommodation means patients and service
users only share sleeping accommodation, bathroom and
toilet facilities with people of the same sex. It applies to all
areas of hospitals and mental health units.
It is delivered by providing:
l Same-sex wards (i.e. the whole ward is occupied by
either men or women but not both)
l Single (bed)rooms with adjacent same-sex toilet and
washing facilities (preferably en-suite)
l Same-sex bed bays or (bed)rooms, with designated
same-sex toilet and washing facilities, preferably within
or adjacent to the bay or room.
Service users should not need to pass through
accommodation or toilet/washing facilities used by the
opposite sex to gain access to their own facilities. These
requirements apply to organisations providing NHS funded
care whether in the acute or mental health and learning
disability sectors.
Sirona Care and Health is compliant with the same-sex
accommodation standards.
In line with national standards, other than in exceptional
circumstances (such as in an emergency where the ‘right
bed’ cannot immediately be found), service users admitted
to inpatient wards within our Community Hospitals can
expect to be nursed in single sex environment. During
2013-14 there were no exceptional circumstances
when patients could not be cared for in an appropriate
Within our residential homes, and Extra Care flats, all
service users have single rooms and access to same-sex
washing facilities.
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Patient Led Assessments of the
Care Environment (PLACE)
Performance against National Targets
and selected local metrics
The Patient-Led Assessments of the Care Environment (PLACE) programme replaced the Patient
Environment Action Team (PEAT) programme from April 2013.
Below is a list of National and local Quality Targets and Sirona’s performance against these:
The self-assessments were undertaken by teams of staff and members of the public, known as
patient assessors. They focused on the environment in which care is provided, as well as supporting
non-clinical services such as cleanliness, food, hydration, and the extent to which the provision of
care with privacy and dignity is supported.
Table: PLACE Scores 2013
Sirona Care and
Health CIC
Food and Hydration Privacy, dignity and wellbeing
Condition, appearance
and maintenance
A comprehensive action plan has been developed and implemented to address the concerns raised
and improve the experience for service users.
Service Profile:
Learning Disabilities Services in South Gloucestershire
On the 1st October 2013 colleagues from the Learning
Disabilities Service within South Gloucestershire joined
Sirona Care and Health.
“The new service will continue to be shaped from the
views and experiences of people with learning difficulties,
and their carers, and aims to give patients choice and
control in planning their care and ensuring that decisions
are taken with and not for them.”
The service comprises of two Community Learning
Disability teams based at Kingswood and Thornbury. The
teams provide specialist health services for people with
Learning Disabilities and complex needs whose needs
cannot be met in mainstream services.
Working with Social Services, and alongside other
agencies, the Community Learning Disabilities Service
provides a wide range of support to people in their
National and local Targets and Minimum Standard
Infection Control
Number of hospital acquired clostridium difficile cases
Number of bed days lost to clostridium difficile
Number of hospital acquired MRSA blood stream infection cases
Number of E-coli bacteraemias hospital acquired Hand hygiene compliance
Patient Safety Number of grade 2 hospital acquired pressure ulcers
Incident reporting
Number of grade 3 and 4 hospital acquired pressure ulcers
% of adults who have had a VTE risk assessment % of people assessed as at risk of VTE receiving the
appropriate prophylaxis Number of falls in Community hospitals per 1000 bed days
Number of service users with an indwelling catheter
being treated for a UTI
Complaints Number of complaints received (Health)
Number of complaints received (Social care)
Number of new concerns (health and social care)
Effectiveness of Care % of service users waiting a maximum of 4 hours in MIU
from arrival to admission, transfer or discharge
% number of people readmitted to inpatient services
within 28 days of being discharged
Reduction in Community Hospital length of stay for
Fractured neck of Femur
Reduction in Community Hospital Length of Stay for Stroke
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Sirona Care & Health Quality Account 2013-14
Our Quality Achievements
Service Profile:
Memory Technology Library
The Memory Technology Library is an initiative which has
been set up as a direct result of the Dementia Challenge
in a partnership between the Bath Institute of Medical
Engineering and Sirona Care & Health.
The Memory Technology Library holds a collection of five
key products which people in the Bath and North East
Somerset area can try out at home or in a care setting for
l Day Clock
l Talking Photo Album
l Talking Tile
l Talking Card
l Day/Night Orientation Clock (for use in hospitals
and care homes)
The aims of the service are to:
l Make a difference to the lives of people with
dementia and their families and carers, as part of the
government’s Dementia Challenge.
l Raise awareness of these simple technology products
and assess whether they are of real benefit.
l Inform and familiarise people with available market
products that might help them.
Service users and their carers are able to contact the
library who will assess needs and help you find the best
product(s) to support their needs.
People are able to access the equipment from Sirona
Care and Health and a number of partner centres
l Bath Carers Centre
l Bath Ethnic Minority Senior Citizens Association
l Bridge Care – Supporting Older People
For more information visit the memory technology
Accolades for our
Staff and Services
during 2013-14
Sirona Care and Health’s staff have been presented with
a number of awards during 2013/-14 and we have shared
some examples here:
Stella Wainwright
District Nurse Stella Wainwright was named Public Sector
Hero of the Year at the Bath Pride Awards 2014..
The Bath Pride awards aim was to acknowledge people
who have made a difference in their community, or who
have shown great bravery, compassion or commitment.
Stella won the Sirona Award for Excellence 2013 after she
was nominated by a service user who felt that the care she
provided for his late wife should be recognised.
Service User Story:
“This has confirmed my faith that if
we all work together and are prepared
to explore all options for our service
users, even if this means going outside
of the boxes, then we truly can find
wonderful solutions for people.”
Social Worker, Sirona Care and Health.
Peggy’s life changed when she was moved to live in a
nursing home aged 65 years of age where there just
weren’t the facilities to aid her recovery following a
stroke; the nursing home did all they could for Peggy
and cared for her but the environment did not lend itself
to support her rehabilitation.
The Social work team worked alongside Peggy to
understand Peggy’s needs and hopes for her future,
reviewing the various alternative choices for support
within the community.
Peggy is now benefitting from the “Living with Extra
Care” service, an alternative to residential care that has
enabled Peggy to live as independently as possible
and provided new opportunities.
She says “For the first time since my stroke over 2
years ago now, I feel I have somewhere to live that
offers me a future”.
“Living with Extra Care” provides people who have
some care and housing needs, with an assured
tenancy in a self-contained flat in a purpose built or
adapted scheme based on the person’s assessed
needs. Sirona Care and Health provide five such
schemes within Bath and North East Somerset.
Sirona Care & Health Quality Account 2013-14
Looking Ahead to 2014-15
Sirona Care & Health Quality Account 2013-14
Looking Ahead to 2014-15
3. Looking Ahead to 2014-15
In this part of the Quality Account we describe the areas for improvement during the
next year in relation to the quality of our services and how we intend to achieve these
priorities. There are a number of projects we will be taking forward during 2014-15
of which some are highlighted as key priorities and described in greater detail below.
These priorities have been determined in accordance with national guidance to ensure a
transparent and consistent approach to our quality reporting.
Our priorities will be measured via the Quality committee and fall under the three
domains of:
l Service User Safety
l Service User Experience
l Effectiveness of Care
We aim to provide the highest quality community based
l Reduced levels of harm
health and social care services. We want every service
user to feel safe and cared for, and every member of staff
to feel proud of the work they do for Sirona Care and
Health CIC.
l Improved care experience through building stronger
coordination, communication, and compassion
l Delivery of reliable, evidence based care
We will focus our attention on projects that will reduce
harm, improve people’s experience of the services we
provide and ensure that the care we provide to our
service users is reliable and grounded in the foundations
of evidence based practice.
Quality Priorities 2014-15
Service User Safety
Aim: 95% of Service Users, as
surveyed through the safety
thermometer will receive harm free
care as measured by the following
four harms:
l Pressure Ulcers
l Catheter acquired Urinary tract
Infections (CaUTI)
l Venous Thromboembolism
l Harm from falls
We will continue to use the safety thermometer developed
with the Department of Health to detect and monitor harms
occurring within our services. Audits are conducted within
community services and bedded facilities; during these
audits the four specific harms listed are monitored.
In 2014-15 we will continue to focus our attention on
reducing harm by continuing to work on many of the
projects profiled in this account including: pressure
ulcers; catheter acquired urinary tract infections; venous
thromboembolism; harm resulting from a fall, and hospital
associated infection.
Service User
It is our ambition that we will deliver s series of projects that
will ensure service users, carers and their families have a
positive experience of the services they receive from Sirona
Care and Health. The projects we select will be based on
the principles of the Institute for Health Improvement White
Paper on delivering Patient Centred Care and the National
Carers Strategy, and include:
l Developing care pathways that are co-designed and coproduced with individuals and their families;
l Ensuring that people’s care preferences are understood
and honored, including at the end of life;
l Collaborating with partners on programs designed to
improve engagement, shared decision making, and
compassionate, empathic care; and
l Working with partners to ensure that communities are
supported to stay healthy and to provide care for their
loved ones closer to home.
Aim: To develop and implement the
Experience Based Co-Design toolkit
developed across our Services
Experience-based co-design is an approach that enables
staff and service users to co-design services and/or care
pathways, together in partnership. The approach is different
to other service improvement techniques.
Experience based co-design involves gathering
experiences from service users and staff through indepth interviewing, observations and group discussions,
identifying key ‘touch points’ (emotionally significant points)
and assigning positive or negative feelings. A short edited
film is created from the interviews. This is shown to staff
and service users, conveying in an impactful way how
people experience the service. Staff and service users are
then brought together to explore the findings and to work
in small groups to identify and implement activities that will
improve the service or the care pathway.
Within Sirona we are developing plans for the
implementation of this across our services, adapting the
process where required to meet the needs of service
users and the services. An initial pilot project is proposed
commencing in June 2014.
Sirona Care & Health Quality Account 2013-14
Looking Ahead to 2014-15
Sirona Care & Health Quality Account 2013-14
Looking Ahead to 2014-15
Quality Priorities 2014-15
Aim: Implement a system-wide
review of the carer experience of
services that aim to support people at
the end of life, and develop a service
improvement plan for delivery in
End of life care is about caring for people who have an
advanced, progressive and incurable illness so they can
live as well as possible until they die. It is about providing
support that meets the needs of both the person who is
dying and the people close to them.
This care has a strong focus on managing symptoms to
keep a person comfortable, helping them to adapt to the
changes in lifestyle and cope with the emotional impact of
their illness.
End of life means different thing to different people but
generally refers to the last weeks and days in life when
the person’s illness becomes too much for their body to
cope with and death can no longer be postponed through
Within Sirona care and Health we are planning to
implement and develop a programme with other health
and care providers to ensure delivery of a pathway that will
benefit service users and their carers ensuring people have
a positive experience of what is a very emotional time for
all concerned.
Effectiveness of Care
Aim: To increase the time allocated
to the provision of direct care
by removing inefficient ways of
The Productive Community Series is a programme that
supports District Nursing teams to spend more time on
delivering care, reduce waste and improve efficiency.
Originally developed by the NHS Institute for Innovation
and Improvement, the Productive Series methodologies
are used by staff to:
l Increase contact time with service users
l Reduce inefficient work practices
l Improve the quality and safety of care
l Put staff at the forefront of redesigning their services.
It is a practical application of lean based techniques
that will vastly increase the organisation’s capacity and
capability for continuous improvement.
Over the course of 2013-14 District Nursing teams
implemented the foundation modules of the programme.
During 2014-15 teams are proposing to implement the
planning modules:
l Managing caseload and staffing
l Planning our workload
l Working better with our key partners.
Aim: To reduce the number of service
users who are readmitted to our
inpatient units within 28 days of
Service users can be readmitted to hospital within 28 days
of discharge for a variety of reasons. These readmissions
are not always avoidable but it is possible we could
improve on the overall rate of readmission to our services.
Examples of action that can be taken to prevent an
unnecessary readmission and the distress this can cause
service users includes:
l Clearly explaining medication.
l Ensuring follow-up by a professional or care worker
post-discharge, so that any questions can be asked or
discuss any worries they may have in a timely manner.
l The development of ‘hot clinics’ for service users who
require medical input and who may otherwise present
for readmission or to local emergency departments.
Within Sirona Care and Health the readmission rate for
this year was 10%. We are planning to review data relating
to readmissions within our services, obtain benchmarking
data for comparison and implement plans to improve this
are of care delivery.
Measurement is a vital part of improvement; quantifying the
effect of changes or intended improvements that we are
making and enabling understanding of any impacts.
As an organisation we expect that data is presented on
run and control charts so that we can better understand
changes occurring over time. We have also continued to
develop our quality improvement dashboard throughout
2013-14. The measures on this dashboard support
understanding of the quality of care that we are providing
to service users, this is reviewed frequently by the Quality
Committee. Measures within the Dashboard include:
l Measures of harm, such as falls, pressure ulcers,
hospital associated infections and results from both the
safety thermometer and global trigger tool.
l Length of stay and readmission rates
l Service user satisfaction indicators.
In 2014-15 we will continue to develop the quality
dashboard as new measures are developed and new
areas of focus are agreed in line with implementation of the
Company Quality Governance Strategy.
In addition members of the Service Improvement Team will
be working with teams and services to develop the use of
data metrics that will enable clearer understanding of the
progress teams are making with improvement programmes
and projects.
Service Developments:
Medical Equipment
Service Developments: Medical Equipment
Sirona has progressed a number of projects in 2013/14
to improve access to appropriate equipment ensuring
improved outcomes for service users by ensuring
needs can be met in a number of varied environments.
This has included:
l Adopting new types of equipment such as needle
safe equipment to reduce the incidence of needle
stick injuries to staff and service users.
l Our Tissue Viability Nurses have undertaken an
exercise a review of the equipment we supply to
people at home to minimise their risk of developing
a pressure ulcer. This has required them to
review a large number of products on the market
and undertake a “lie in“ when they literally used
products themselves to ensure they were effective
and comfortable. The nurses then advised our
procurement team on the preferred products to be
purchased in the future. We now have a standard
mattress that is being issued to service users for
use at home.
l The types of hospital beds we have in our two
Community hospitals has been reviewed and
agreement secured from our Board to invest
£180,000 to replace them with new hi-low beds to
minimise the risk of people falling in our hospital
l Expanding our telecare service to improve the
range of equipment to support older people to
remain independent in their own homes.
Sirona Care & Health Quality Account 2013-14
formal statements
Sirona Care & Health Quality Account 2012-13
formal statements
4. Formal Statements
Statements of Assurance from the Board
Review of Services
During 2013-14 Sirona Care and Health provided 56 health
and social care services. Sirona Care and Health has
reviewed all the data available to it on the quality of care in
all 56 of these services.
The income generated by the NHS services reviewed in
2013-14represents 100% of the total income generated
from the provision of NHS services by Sirona Care &
The numbers of contacts made with service users in 201314 were as follows:
Table: The Number of Contacts with Service
Users in 2013/14
Service Area
Adult Services (inclusive of
inpatient and specialist services)
Children and Families
Learning Disabilities
Number of first and
follow-up contacts
Participation in Audits and National
Confidential Enquiries
Care audit forms an integral part of the governance
arrangements for Sirona Care and Health. Sirona has a
comprehensive local care audit programme, covering both
health and social care services.
During 2013-14 three national clinical audits were
applicable to the NHS services provided by Sirona Care
and Health. Participation in this audit accounted for 100%
of the national clinical audits for which the company was
eligible. There were no national confidential enquiries
applicable to Sirona services.
Table: National audits in which Sirona
participated during 2013/14
National Intermediate Care Audit
National Sentinel Stroke audit
The National Parkinson’s Audit
Health and social care services also undertook 117 local
care audits; 88 were completed and 27 are ongoing.
Participation in Research
The number of service users in receipt of services either
provided or sub-contracted by Sirona Care and Health in
2013-14 that were recruited during that period to participate
in research approved by a research ethics committee was
Commissioning for Quality and Innovation
Payment Framework (CQUIN)
A proportion of Sirona Care and Health’s income in
2013/14 was conditional on achieving quality improvement
and innovation goals agreed between Sirona Care and
Health and Bath and North East Somerset CCG, through
the Commissioning for Quality and Innovation payment
framework (CQUIN).
For 2013/14 the baseline value of the CQUIN was
£515,939 (i.e. 2.5% of the contract value). If the agreed
quality indicators were not met during the year then a
proportion of the monies would be withheld.
For 2013/14 Sirona Care and Health has received
provisional sign-off by Bath and North East Somerset CCG
that 97% of CQUIN monies has been achieved. This is a
provisional sign-off based on achievement to date, as for a
few indicators, the final results will not be known until later
in the year.
Appendix C provides details of individual CQUINs and the
percentage baseline contract value which each CQUIN
Data Quality
NHS number and General Medical Practice
Code Validity
Sirona Care and Health submitted769 records during
2013/14 to the Secondary User Service (SUS) for inclusion
in the Hospital Episode Statistics (HES), which are included
in the latest published data.
Table: Secondary Uses System Data Quality
Dashboard, April 2013 to February 2014
Total Inpatient General Episodes
Data Item
NHS Number
Treatment Function
Main Specialty
Reg GP Practice
Org of Residence
Primary Diagnosis
Primary Procedure
Ethnic Category
Site of Treatment
Sirona - % Valid
Data Source: Health & Social Care Information Centre
Information Governance Toolkit
Sirona submitted an Information Governance
Assessment in March 2013.
Overall the Company achieved a total score of 57%
against all 39 requirements assessed. 28 requirements
were assessed at level 2 (adequate assurance).
10 requirements were assessed at level 1 and 1
requirement was assessed as not relevant.
The three specific requirements highlighted as needing
improvement were:
l Information governance awareness and mandatory
training procedures are in place and all staff are
appropriately trained.
l All transfers of hardcopy and digital person
identifiable and sensitive information have been
identified, mapped, and risk assessed; technical and
organisational measures adequately secure these
l Business continuity plans are up to date and tested for
all critical information assets (data processing facilities,
communications services and data) and service specific
measures are in place.
These areas are being addressed in the information
governance work programme for 2014/15.
Clinical Coding Error Rate
Sirona Care and Health was not subject to the Payment by
Results clinical coding audit during 2013/14 by the Audit
Action to Improve Data Quality
Good quality information underpins the effective delivery of
improvements to the quality of services and service user
outcomes. Improving data quality will therefore improve
our ability to deliver effective care for service users and
improve cost effectiveness.
Within Sirona Care and Health we have commenced
implementation of TPP SystmOne.
SystmOne is a clinical computer system used by
healthcare professionals. The system is being deployed
as one of the accredited systems in the government’s
programme of revolutionising IT in the NHS and fully
supports the NHS vision for a ‘one patient, one record’
model of healthcare.
SystmOne is available as a number of different modules
designed for different care settings. Modules for GP,
prisons, child health, community units and palliative care
are currently widely used throughout the NHS. In the last
year, a number of secondary care modules have been
announced and have begun to rolled out. These include
modules for community and acute hospitals, accident and
emergency, maternity, mental health and social services.
Sirona Care & Health Quality Account 2013-14
formal statements
Sirona Care & Health Quality Account 2013-14
formal statements
Statement of performance in response
to the Care Quality Commission
Statements from Commissioners, Oversight
and Scrutiny Committees and Healthwatch
Sirona Care and Health is required to register with the Care
Quality Commission and its current registration status is
‘registered without conditions.’
Bath and North East Somerset
clinical Commissioning Group
The Care Quality Commission has not taken enforcement
action against the Company during 2013/14.
Sirona Care and Health have participated in 2 thematic
reviews of Children Services conducted by the Care Quality
Commission in relation to the following areas:
l A thematic review of transitional care for children and
young people with continuing care needs;
l A review of health services for looked after children and
safeguarding in Wiltshire.
The services were assessed as compliant with only minor
areas of being raised. A comprehensive action plan has
been developed and implemented to address the concerns
In addition, the Care Quality Commission reviewed 8
services as part of its routine inspection programme
during 2013/14, with two areas of moderate concern
being raised within the Community Nursing Service and
the Contraceptive and Sexual Health Service (CASH).
The concerns raised related to outcome 16- assessing
and monitoring the quality of service provision. A
comprehensive action plan has been developed and is
currently being implemented to address the concerns
Further details of the outcomes inspected by the Care
Quality Commission during their visits are contained within
the appendices.
Statement of Director’s Responsibilities
in respect of our Quality Account
The directors are required under the Health Act 2009 and
the National Health Service (Quality
Accounts) Regulations 2010 as amended to prepare
Quality Accounts for each financial year.
Guidance has been issued to providers of NHS services
on the form and content of annual quality reports (which
incorporate the above legal requirements) and on the
arrangements that
Boards should put in place to support the data quality for
the preparation of the quality report.
In preparing the quality report, directors are required to take
steps to satisfy themselves that:
l The content of the Quality Report meets the
requirements for reporting;
l The content of the Quality Report is not inconsistent with
internal and external sources of information including:
l Board minutes and papers for the period April 2013 to
May 2014.
l Papers relating to Quality reported to the Board over the
period April 2013 to May 2014.
l Feedback from the commissioners dated May 2014.
l Feedback from Healthwatch dated May 2013.
l The Company’s complaints report published under
regulation 18 of the Local Authority Social Services and
NHS Complaints Regulations 2009.
l The latest staff survey.
l CQC quality and risk profiles.
l The Quality Report presents a balanced picture of the
Company’s performance over the period covered.
l The performance information reported in the Quality
Report is reliable and accurate.
l There are proper internal controls over the collection
and reporting of the measures of performance included
in the Quality Report, and these controls are subject
to review to confirm that they are working effectively in
l The data underpinning the measures of performance
reported in the Quality Report is robust and reliable,
conforms to specified data quality standards and
prescribed definitions, is subject to appropriate scrutiny
and review.
The director’s confirm to the best of their knowledge and
belief they have complied with the above requirements in
preparing the Quality Report.
Janet Rowse, Chief Executive
Simon Kighton, Chairman
Bath and North East Somerset clinical Commissioning
Group is pleased to have had the opportunity to review
the Quality Account prepared by Sirona for 2013-14. In
preparing this statement, key intelligence regarding quality,
safety and patient experience has been reviewed to test
the accuracy of the information reported within the Quality
Account. The CCG can confirm that the information
presented in the Quality Account appears to be accurate
and fairly interpreted. The Quality Account demonstrates a
high level commitment to quality in the broadest sense and
is commended.
The report reflects some of the good work undertaken
by the organisation and sets out the quality ambitions
and achievements of 2013/14 and sets direction for
2014/15 (building upon elements of the 2013/14 priorities).
Commissioners support objectives which have clear
outcomes for patients describing how this intervention has
made a difference to them. The Quality Account provides
information across a wide range of quality measures in
relation to patient experience, clinical effectiveness and
patient safety.
In a joint vision to maintain and continually improve
the quality of services, the CCG have worked in
collaboration with the Provider to establish and maintain a
comprehensive quality framework that includes nationally
mandated quality indicators alongside locally agreed quality
improvement targets. There are robust arrangements
in place with Sirona to agree, monitor and review the
quality of services. These cover the domains of safety,
effectiveness, and experience of care. We meet senior
quality leads for Sirona on at least a quarterly basis to
review information and patient outcomes. We triangulate
this information by visiting clinical areas within the
hospital and by talking with staff and patients about their
experiences of working for, and receiving care from, Sirona.
The national NHS Contract and Commissioning for Quality
and Innovation Scheme (CQUIN) provide us with additional
evidence that local quality improvements are made during
the year. Sirona signed up to a number of national and
local schemes and we are in the process of reviewing
achievement of these schemes.
In conclusion the CCG can confirm that we believe the
Quality Accounts contains accurate information in relation
to the services they provide to residents of Bath and North
East Somerset and beyond.
Sirona Care & Health Quality Account 2013-14
formal statements
Healthwatch Bath and North East Somerset
comments on the Sirona Quality Account
Sirona Care & Health Quality Account 2013-14
formal statements
Sirona Quality
Account 2013-14
General Observations
Healthwatch Bath and North East Somerset welcome the
opportunity to comment on the Sirona Quality Account.
The Quality Account is a well laid out document explaining
the services provided by Sirona. Healthwatch would
have liked the opportunity to have read the statement
from the Chief Executive. Healthwatch were pleased to
read about the quality achievements and the review of
quality improvements for 2013/ 2014 that was well laid
out and illustrated with graphs. The service profiles gave
an interesting perspective to highlight the family nurse
Healthwatch were interested to read about the
implementation of the 15 Step Challenge, the Friends
and Family Test and the section on compliments and
complaints. It would have been nice to have seen some
compliments documented alongside the information on
Healthwatch was also interested in reading about the
improvements achieved through Telecare in the quality
account and welcome the priorities planned for 2014/
2015 and look forward to seeing the development of the
Experienced based Co Design toolkit with staff and service
users together in partnership.
The Quality Account is well laid out and easy to read by a
lay person, or member of the public.
Healthwatch Bristol and Healthwatch South
Gloucestershire have found the report to be interesting
and comprehensive, and generally made easy reading.
It would have been helpful if the list of sections or parts
had shown the corresponding page numbers, however
this criticism is far from unique to you! Additionally, and
again as with most other quality accounts seen this year, a
glossary would have proved useful, although it is noted that
in this report in the majority of cases, if not all, acronyms
and abbreviations have been defined/explained in the
text. A recommendation that we will be circulating to all
those that submitted reports is that they should contain an
executive summary off the whole report, preferably in no
more than 4 sides of A4, and that this summary be written
totally in a way that is accessible to the layman. None of
the reports that we have seen have done so.
Part 1 – Introduction
This section, although incomplete, was perfectly adequate,
however, as with ALL other sections, it would be improved
had the sub-sections each been separately numbered.
Whilst this is less important in this short section, in the two
longer sections that follow, sub-section numbering would
have considerably facilitated referencing.
Part 2 – Our Quality Achievements
This section was well written, logically ordered and
clear. Among the specific points for this section were the
1. The Service profile on p14 was a positive inclusion,
however its position within the section, and particularly its
adjacency to the preceding parts on safety was not thought
optimal. Maybe it could be formatted to its own page, with a
few words of introduction.
2. The use of the 15-Steps challenge (p15) is very good
but it is not clear whether it only applied to the reablement
service, or was, or is to be, implemented more widely.
3. The Service User comments on p18 were possibly
understandably, all positive, and it was noted that 4 of the 5
were from Paulton. Possibly the inclusion of a less positive
comment, and the subsequent actions taken, would give a
more balanced picture.
Part 3 – Looking Ahead
This section was clear and sensible. It is good that the
importance of measurement is recognised, as is the use of
the quality dashboard. The aspirations regarding end of life
care are admirable
4. The Complaints and compliments section on p19 could
have been clearer. Were the 75 complaints listed the
total number received? How many ‘complements’ were
received? What is the process/mechanism for managing
and investigating complaints? It was noted that the
majority of complaints were around ‘staff attitude and
communications’. This would appear to be an issue where
training may have a part to play. Has this been considered?
Part 4 – Formal Statements
This section is as expected.
5. The figures in the table on p20 are assumed to be % if
total replies (assumed to be approx. 1600). Almost all the
parameters seem to be going in the right direction, And it
is to your organisation’s credit that you have picked up and
are acting on the low figures for ‘further advice’.
6. The statement on p21 that a key theme of feedback was
the positive attitude of staff seems at odds with the fact that
the majority of complaints (p19) appear to be staff-related.
7. The implementation of the Community Productive Series
(p22) is a very positive step. Are there any plans to use
it across the different services? The implementation of
telecare (p23) is similarly positive.
8. The Service Profile on p24 would benefit from a short
introduction to precede it.
9. The explanations and introduction to infections (pp25-26)
are good, but could have been referenced to the table on
10. The Service profiles on pp28 & 30, whilst good, seem
out of place and not linked to anything adjacent.
11. The table on p29 is comprehensive, but the various
areas brought together in the one table might better have
been shown adjacent to their corresponding preceding
text, and the table should have been referred to in that
preceding text. It is assumed that where no target is given
the target is zero.
Part 5 – Appendices
The tables on p49 &50 could and should have been better
referenced in the text. It is not immediately clear that the
moderate non-compliances in Feb 2014 are the same as
those in the separate table on p50, which did cause some
initial confusion.
Sirona Care & Health Quality Account 2013-14
formal statements
Sirona Care & Health Quality Account 2013-14
Service Profile:
Health Visiting for the Active Ageing
The Active Aging Service is a new initiative that was
set-up to support older people aged between 80 and 84
years of age. The team of Health Visitors and Health
Visitor Support workers aim to enable older people to
maintain independence, to promote dignity and quality of
life by offering health advice and access to services.
The active aging service works in partnership with
service users to help identify specific needs and to
support people in accessing a variety of services that can
help to maintain their independence.
The Service offers:
l Falls and accident prevention
l Advice on memory loss and dementia
l Support for those who have been recently bereaved
l Advice on managing long term health conditions
l Health education
l Signposting to local and national support services
The service commenced in September 2013 and has
started to make a real difference to the lives of people
from across Bath and North East Somerset.
Appendix A: Care Quality Commission Routine Inspections 2013-14
Compliant with
CQC standards?
What CQC said?
What service users said?
Cleeve Court
Resource Centre
Fully compliant
Re-inspection of minor noncompliance: Outcome 21
Supported Living
Fully compliant
Staff understood the care and
support needs of the service
users they were caring for.
“They are kind and caring.
They give me all the help I
Charlton House
Resource Centre
Fully compliant
Everyone the inspectors spoke
with confirmed they were happy
with the service.
Extra Care
Fully compliant
There were systems in place to
promote the welfare and safe
care of people who used the
“Staff are very kind and caring.”
“I have jolly good care from
Coombe Lea
Resource Centre
Fully Compliant
Service users felt involved in
their care and treatment and felt
respected by staff
Support plans detailed the care
needs of service users.
“I am so well looked after”.
People said they felt staff
treated them respectfully;
everyone said they felt safe in
the home.
Staff developed positive
relationships with Service
users and were observed to be
observed kind and caring.
Service users and their
relatives said they were highly
satisfied with the service
and valued the support they
Sirona Care & Health Quality Account 2013-14
Sirona Care & Health Quality Account 2013-14
Appendix A: Care Quality Commission Routine Inspections 2013-14
Appendix B: Commissioning for Quality and Innovation payment framework
Compliant with
CQC standards?
What CQC said?
What service users said?
Reference Title
Target 2013/14
and Sexual
Health Service
The provider provided training
opportunities to support staff
to undertake their role safely
and effectively. There was a
comprehensive staff induction
which one member of staff
described as “the best induction
they had ever had”.
Service users and their
relatives said they were highly
satisfied with the service
and valued the support they
Friends and
Family Implementation
Implementation across Sulis, Paulton and MIU and maintained
throughout the year
Friends and
Family - Patient
Q1 - Collect baseline data, minimum 15% response rate
Q2 - minimum response rate of 15% and increase on Q1
Q3 - minimum response rate of 15% and increase on Q2
Q4 - minimum response rate of 20% and increase on Q3
Paulton Minor
Injuries Unit
Patients received treatment
from competent staff. Staff
prioritised patients according to
need. We observed treatment
and support was responsive to
patient’s needs.
“They have been very kind,
very good.”
Improved % rate to the staff friends and family test annual
100% payment for maintaining or improving 72% or top quartile
of NHS responses.
50% payment for a score between 65% and 72%
0% payment for less than 65%
Thermometer Data submissions
Maintain the submission of data on time.
Latest dates for submission: 26th April, 24th May, 28th June,
26th July, 23rd August, 27th September, 25th October, 22nd
November, 27th December, 24th January, 28th February, 28th
Thermometer improvement
To achieve full payment, there must be 62 or fewer new
pressure ulcers recorded in Q3 and Q4.
15 Step
Q1 - Project plan and team put together (25% payment)
Q2 - 1st round of visits carried out with patient surveys (25%)
Q3 - Commence implementation of action plans for
improvement (25%)
Q4 - 2nd round of visits carried out and increased patient
scored satisfaction in 3 out of the 4 questions (25%)
Productive Series 36.0%
Q1 - Putting together full and agreed project plan (10% of
Q2 - full introduction of 1st module across all District Nursing
Teams (30%)
Q3 - full introduction of 2nd module ... (30%)
Q4 - full introduction of 3rd module ... (30%)
- Clinical
To have a lead named clinician, plus:
85% of all relevant staff to be trained in Level 1 Dementia
Training (100% of payment)
80% of all relevant staff ... (90%)
70% of all relevant staff ... (80%)
50-69% of all relevant staff ... (50%)
Fully compliant
Areas of non-compliance, for improvement
Areas of non-compliance
Issues addressed?
Community Nursing
Outcome 16 (assessing and monitoring the
quality of service provision): Support in the
form of supervision is not consistently provided.
Quality monitoring systems did not identify or
act upon all key risks to service users or staff
at all levels of the organisation. This meant
that the service did not have a comprehensive
system in place to monitor the quality of the
A remedial action plan has been submitted
to the CQC to address this issue and has
been accepted. Designated timescales for
completion are on track to be met.
Outcome 16 (assessing and monitoring the
quality of service provision): Support in the
form of supervision is not consistently provided.
Quality monitoring systems did not identify or
act upon all key risks to service users or staff
at all levels of the organisation. This meant
that the service did not have a comprehensive
system in place to monitor the quality of the
A remedial action plan is due to be submitted
to the CQC to address this issue.
Contraceptive and
Sexual Health
Service (CASH)