Providing safe, clean and friendly care
Quality Account 2013-14
This account covers
1 April 2013 to 31 March 2014
A précis version of this account will be produced by the Trust
Communications Department in response to requests from
members of the Healthwatch groups. This will be available on
request
from 12th July onwards from the Communications
Department on 01704 704714
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
CONTENTS
PRESCRIBED REQUIREMENTS
PART 1
FOREWORD
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
Statement from the Chief Executive and Chairman
Introduction to the Organisation
Engagement with Stakeholders
Non Executives areas of Responsibility
Overview & Scrutiny
Healthwatch
Introduction to 2013/14 Quality Account
2013/2014 Quality Agenda
Director of Nursing and Medical Director’s Summary of Achievements
Trust Achievements
Workforce Factors Prescribed information
Scope or Change (LIA)
Real Time Staff Feedback
Nurse Recruitment
Production of Quality Account
Statement of directors’ responsibilities in respect of Quality Account
4
5
6
7
8
8
9
10
11
14
15
20
23
25
28
PART 2
2.1
Review of Quality Performance April 2013-March 2014
30
2.2
2.3
2.4
2.5
Personnel Involved in the Quality Agenda 2013-14
Quality Strategy Workplan 2013-2014
Priorities for Improvement and Work Plan 2014-2015
Prescribed Information (Regulation 4)
2.5.1
National Clinical Audits, National Confidential Enquiries
and Local Clinical Audits,
2.5.2
Research
2.5.3
CQUIN
2.5.4
CQC
2.5.5
Trust Information Governance
Additional prescribed information
PART 3
EFFECTIVENESS
DOMAIN 1: Preventing People Dying Prematurely
Hospital Standardised Mortality Rates
Summary Hospital level Mortality (SHIMI) Prescribed information
Advancing Quality
DOMAIN 2: Enhancing quality of life for people with long-term
conditions
National Service Frameworks
Care Closer to Home
34
35
42
50
50
2.6
3.1
3.2
3.3
3.4
3.5
1
52
54
54
56
57
58
59
60
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QUALITY ACCOUNT 2013-14
3.6
3.7
3.8
DOMAIN 3: Helping people recover from episodes of ill health
following injury
Matrons Checklist/Nursing Indicators
Nutrition
Nurse Education
66
68
68
3.9
3.10
3.11
3.12
NICE Quality Standards
Trauma Audit and Research Network (TARN)
Patient Reported Outcome Measures PROMS Prescribed information
Re Admissions Prescribed information
71
73
73
79
PATIENT EXPERIENCE
DOMAIN 4: Ensuring people have a positive experience of care
3.13
3.14
3.15
3.16
Patient Experience
3.13.1
Responsiveness to the Personal Needs of the Patient
Prescribed information
3.13.2
Patient Experience in the Community
3.13.3
Patient Experience Strategy and Group
3.13.4
Patient Experience Events
3.13.5
Customer Service Department :
Compliments
Complaints
PALs
3.13.6
Learning Disabilities
End of Life Care Prescribed information
Delivering Same Sex Accommodation
Feedback 2 Matron & Friends and Family Test
80
80
81
81
81
82
88
89
97
98
SAFETY
3.17
3.18
3.19
3.20
DOMAIN 5: Treating and caring for people in a safe environment and
protecting them from avoidable harm
Medical Revalidation & Performance
Infection Prevention and Control
3.18.1
MRSA Bacteraemias
Clostridium Difficile Infections Prescribed information
3.18.2
3.18.3
Infection Prevention and Control Developments
HEAT and PLACE inspections
Patient Safety
3.20.1 Never Events
3.20.2 Safety Thermometer/Harm Free Care
3.20.3 VTE Venous Thromboembolism Risk Assessment Prescribed
information
3.20.4 Safety Talkabouts
3.20.5 LIPS System level Aim
3.20.6 Recognition of the Deteriorating Patient
3.20.7 Early Warning Score Audits
3.20.8 Fluid Balance Monitoring Audits
3.20.9 Reported Patient Safety Incidents Prescribed information
2
100
102
102
103
104
105
106
106
107
108
111
112
113
113
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.21
3.22
App 1
App 2
App 3
App 4
App 5
App 6
App 7
App 8
App 9
PART 4
4.1
4.2
4.3
4.4
4.5
4.6
3.20.10 Patient Falls
3.20.11 Hospital Acquired Pressure Sores
Quality and Risk Standards
3.21.1 Clinical Negligence Scheme for Trusts CNST
3.21.2 National Health Service Litigation Service NHSLA
3.21.3 Quality and Risk Profile QRP
Safeguarding Adults and Children
3.22.1 Safeguarding Adult Referrals
3.22.2 Safeguarding Children
3.22.3 Dementia
3.22.4 Volunteers
APPENDICES
Glossary
Trust Performance Table
Mandatory professional Standards
National Clinical Audits
National Confidential Enquiries
Local Clinical Audits
Clinical Research Studies
Table to show Publications submitted by Southport and Ormskirk
Hospitals NHS Trust staff and those linked to research
Place Assessments
PART 4
ANNEX
STATEMENTS OF ASSURANCE
Sefton Healthwatch
Lancashire Healthwatch
Sefton Overview & Scrutiny Committee
-Children’s Services
-Health and Social Care
South Sefton CCG and Southport and Formby CCG
Statement from Southport and Ormskirk on changes made after 30/4/13
Draft
Independent Auditors Limited Assurance Report to the Directors of
Southport and Ormskirk Hospitals NHS Trust on the Annual Quality
Account
116
116
119
119
119
121
122
123
126
128
131
132
133
139
141
152
153
156
159
160
161
162
163
164
If you require this document in an alternative format,
please contact our Communications Team on 01704 704714
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QUALITY ACCOUNT 2013-14
PART 1
STATEMENT FROM THE CHIEF EXECUTIVE AND CHAIRMAN
We are pleased to present the Trust’s Quality Account for 2013/14 and we hope that
you find the array of different highlights interesting and informative.
As we have previously said, it is impossible to name check every initiative of which
we are proud, but given the increasing challenge of producing quality and efficiency
projects that reduce spend, meeting our performance and quality targets and working
on a number of cultural change projects, the biggest of which is the embedding of an
Integrated Care ethos throughout the Trust and the local health economy, the
following initiatives spring readily to mind:•
•
•
•
•
•
•
•
Success in the Nurse Technology bid for just short of £1million to
implement Vital PAC, a unique clinical software system that alerts
clinicians to prioritise poorly patients and reduces mortality, cardiac
arrests and length of stay.
Obtaining resources to allow us to move forward on an ambitious
programme of information technology which will revolutionise the
availability of patient data and reduce radically our reliance on paper
systems.
MANDATORY Professional Standards were launched across the Trust,
reducing patient harm and raising standards of basic treatment and
care. (Appendix 3)
Empowering staff to take control and remove barriers to excellent
treatment and care through the engagement process of Listening into
Action.
The changes to process and culture that have flowed from the Francis
Report and other associated reports.
Real time feedback from patients and staff.
Acquisition of winter pressures monies to improve the urgent care pathway.
The short listing of maternity services for a national award for the most
efficient and effective.
We commend this Quality Account to you.
Sir Ron Watson CBE Chairman
Dr Jonathan Parry Chief Executive
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.1
Introduction to the Trust
Southport and Ormskirk Hospital NHS Trust serves a diverse community of some
260,000 people in Southport, Formby and West Lancashire, which includes the
market town of Ormskirk and new town of Skelmersdale.
The two centres for inpatient care are Southport and Formby District General
Hospital and Ormskirk and District General Hospital which were brought together into
one trust in 1999.
The Trust also hosts the North West Regional Spinal Injuries Centre which also
serves North Wales and the Isle of Man.
In April 2011 Trust became an “integrated care organisation” when it took
responsibility for many local adult community healthcare services. The Trust is also
responsible for sexual health services across the whole of the Metropolitan Borough
of Sefton and the Borough of West Lancashire.
The Trust is in the process of applying to become a foundation trust which will give it
more control over its own affairs and local people a bigger say in helping shape local
services.
The foundation trust application is underpinned by a plan to deliver more coordinated
care between hospital, community health services and patients’ homes. This model
aims to:
•
•
•
•
•
•
Provide seamless and comprehensive healthcare to local people
Encourage collaborative redesign of clinical pathways so, that as best practice
and where appropriate, patients are treated in the community or in their home
Place an emphasis on keeping patients with chronic conditions out of hospital
wherever possible
Improve efficiency and effectiveness in hospital and community services
Recognise that there will be insufficient financial resource to fund everything
that could be undertaken in hospital, but …
Mitigate that loss of income to the Trust by shifting clinical treatment and care
closer to home
We currently have around 493 inpatient hospital beds and 66 days case beds,
employ nearly 3,600 substantive staff and have more than 730,000 patient contacts
yearly of which 305,750 are in the community.
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QUALITY ACCOUNT 2013-14
1.2
Engagement with stakeholders
The Trust has worked hard in 2013-14 to improve engagement with patients.
A new patient experience group has been established. The Trust also introduced
new channels for gauging the patient experience such as the questionnaires and
polling made possible by the new bedside entertainment units.
Our Shadow Council of Governors was established in May 2013.
Shadow Governors play a key role in engaging with members of the public, patients
and partnership organisations. During 2013/14 we held a number of membership
engagement events including Patient Experience – Car Parking Forums, Health &
Well Being Fair which included advice on self care and information regarding
services available to patients and the public from across the Trust, Community
Services and the Voluntary Sector.
We also recruited over 30 members of the public/patients/carers to join the Trust
PLACE teams.
During 2013 / 2014 the clinical audit and effectiveness team organised 3 events to
share good practice and quality initiatives within the Trust.
18th June 2013
15th October 2013
4th March 2014
Effectiveness and Innovation Event
Quality, Effectiveness and Improvement Event
Effectiveness and patient safety event.
The events were attended by Trust Staff and Foundation Trust Members.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Non-executive directors’ areas of responsibilities
Sub Committees/
Trust Meetings*
Graham Slee
(Vice-chair)
Rodney
Dykes
Su FowlerJohnson
Jeanette
Newman
Lead NED for
Quality & Safety
Committee
Finance, Performance &
Investment Committee
Remuneration &
Nominations Committee
Safeguarding
Children
Vulnerable
Adults
Charitable Funds
Committee (Chair)
Audit Committee
Quality & Safety
Committee
Workforce Committee
(Chair)
Research and
Innovation
Quality & Safety
Committee (Chair)
Audit Committee
Remuneration &
Nominations Committee
Workforce Committee
Paul
Burns
(Senior
Independent
Director)
Caroline
WhalleyHunter
Audit Committee (Chair)
Finance, Performance &
Investment Committee
Remuneration &
Nominations Committee
Workforce Committee
Clinical Excellence Awards and
Pride Awards Panels (ad hoc)
Chair interview panels grievance/
disciplinary appeals (ad hoc)
Clinical Excellence Awards and
Pride Awards Panels (ad hoc)
Chair interview panels grievance/
disciplinary appeals (ad hoc)
Clinical Excellence Awards and
Pride Awards Panels (ad hoc)
Chair interview panels grievance/
disciplinary appeals (ad hoc)
Organ
Donation
Clinical Excellence Awards and
Pride Awards Panels (ad hoc)
Chair interview panels grievance/
disciplinary appeals (ad hoc)
Governance reviews
Clinical Excellence Awards and
Pride Awards Panels (ad hoc)
Chair interview panels grievance/
disciplinary appeals (ad hoc)
Governance Reviews
Remuneration &
Nominations Committee
(Chair)
Charitable Funds
Committee
Finance, Performance &
Investment Committee
(Chair)
Audit Committee
Complaints/Review
Panels/Other Areas
Security
Management
Procurement
Clinical Excellence Awards and
Pride Awards Panels (ad hoc)
Chair interview panels grievance/
disciplinary appeals (ad hoc)
NEDs also attend Board of Directors meetings, Board development sessions, NED meetings,
back to the floor and talkabouts.
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QUALITY ACCOUNT 2013-14
1.3
Overview and Scrutiny Committee (OSC)
The Deputy Chief Executive of the Trust attends the Overview & Scrutiny Committee
(OSC) of Sefton MBC on a regular basis. He provides the Committee with a
quarterly report updating the Councillors on key strategic issues and their likely
impact on health care provision.
The Trust geographically provides services to the residents of both Merseyside and
Lancashire and as such, as a courtesy, will also send representatives to the
Lancashire County OSC when requested.
During 2013 / 14 the OSC has been kept appraised of the following key issues:
1.4
Service performance, including delivery of A&E services
Quality and mortality
Patient experience issues
Staffing including recruitment, retention and the staff survey
Financial performance
Service developments, for example the proposed pathology partnership
Healthwatch
The Trust has had continued representation from both Sefton Healthwatch and
Lancashire Healthwatch. Through these representatives we receive valuable
feedback from the local communities. We have received reports from both
Healthwatch organisations to Operational Quality Committee and Patient Experience
Group giving us valuable feedback both positive and negative on patient experience
data collected. These reports are monitored through the Patient Experience Group.
Healthwatch Sefton indicated in their comments about the 12/13 Quality Account that
they welcomed the introduction of the patient experience group and would be keen to
get involved, therefore a member from Healthwatch Sefton and Lancashire are
invited to attend the meetings and receive a copy of the papers.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.5
Introduction to 2013/14 Quality Account
Southport and Ormskirk Hospital NHS Trust is pleased to present the Quality
Account for the period 1st April 2013 to 31st March 2014. This document provides an
overview of the progress made during the reporting period, the priorities for the
coming 1st April 2014 to 31st March 2015 and includes the regulated information
prescribed under the National Health Service (Quality Accounts Regulations 2010,
2011, 2012/13 update and 2013/14 updates).
During 2013/14 the Trust implemented and monitored the Trust Quality Strategy
‘Right First Time – Every Time’ the resulting work plan has been monitored
through the Operational Trust Quality Committee, with exception reports being
submitted to Quality and Safety Committee, which is a committee of the Trust Board.
This strategy has focused on the Trust’s commitment to and strategy for reducing
error, reducing harm and ensuring a positive experience of care for our patients and
staff.
The NHS Outcomes Framework is the method by which the NHS, including
commissioning organisations will be held to account. Right First Time – Every Time,
reflects the requirements of the NHS Outcomes Framework and other relevant
national and local priorities.
The Patient Experience Strategy was launched in 2013 and implementation is led by
the Deputy Director of Nursing. The work plan for this strategy is monitored by the
Patient Experience Committee chaired by the Deputy Director of Nursing and
consisting of a number of patient representatives and patient groups. This group also
reviews patient experience data trust wide, reporting in to the Operational Quality
Committee.
In line with the Department of Health’s NHS Outcomes Framework, for 2011/12,
incorporating the 12/13 update, the Trust quality agenda is based on the five
domains described in that publication which also encompass the three-part definition
of quality described by Darzi: safety, effectiveness and experience. The Work plan
for next year’s Quality Agenda will incorporate the updated 2014/15 NHS Outcomes
Framework.
The publication of QC Robert Francis’ Report of the Mid Staffordshire NHS
Foundation Trust Public Inquiry and the subsequent responses has been a major
feature this year. The Trust has developed a “Hard Truths” Action Plan in response
to these major pieces of work and the Quality & Safety Committee monitors progress
to achieve the identified actions as part of its remit.
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QUALITY ACCOUNT 2013-14
1.6
2013/2014 Quality Agenda
DOMAINS
NHS OUTCOMES FRAMEWORK
PURPOSE
1
Preventing people from dying
prematurely
2
Enhancing quality of life for
people with long-term
conditions
3
Helping people to recover from
episodes of ill health or
following injury
To capture how successfully the
NHS prevents conditions
becoming serious and assists
people to recover as quickly and
fully as possible
4
Ensuring that people have a
positive experience of care
5
Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
To capture how successful the
NHS is from the patients
perspective
To capture how well the NHS is
adopting a safety culture and
delivering improvements as a
result
To capture how successfully
the NHS is reducing the
number of avoidable deaths
To capture how successfully the
NHS is supporting people with
Long Term Conditions to lead as
normal a life as possible
DARZI’s QUALITY
DEFINITION
EFFECTIVENESS
PATIENT
EXPERIENCE
SAFETY
We have consistently acted upon the constructive feedback received throughout the
year via our Customer Services department and other sources, to improve the areas
you have highlighted as requiring improvement and we have continued to further
develop those areas you have praised.
We would like to thank our patients for both positive and negative feedback, all of
which is necessary to keep staff focussed whilst maintaining morale.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.7
Director of Nursing and Quality and the Medical Director’s
executive summary of achievements (April 2013- March 2014)
2013 – 2014 saw the retirement, following many years of valuable service of our
medical director Dr Geraldine Boocock. The Trust has been able to welcome Mr.
Rob Gilles as Executive Medical Director from June 2013.
With the support of our Clinical Commissioning Groups the Trust has further
developed the Care Closer to Home model during this year and our patients and we
are beginning to see the benefits of this exciting new model of care both in reducing
and shortening hospital admission and increasing support in the community.
Additional funding received this winter has been implemented well in order to set up
several initiatives to support the Care Closer to Home model and has assisted the
Trust in its provision of services leading to improvement in A&E waiting times when
compared to the previous year.
We are pleased to report continued high performance in relation to the harm Free
Care initiative where the Trust continues to be a positive outlier.
We have seen the introduction of The Children’s Community Nursing Outreach Team
which aims to provide high quality, safe care to children and families in their own
home. The emphasis is on shared care with parents/carers and we empower,
encourage and support parents/carers to look after their child and together meet all
their health care needs.
Children recover much quicker at home in their own environment and by looking after
children at home it reduces stress, anxiety, cost for families and disruption to the
whole family unit.
The Children’s Community Nursing Outreach Team aims to
1) Reduce length of hospital stay
2) Reduce Accident and Emergency admissions
3) Reduce non elective admissions
4) Reduce readmissions
5) Improve patient and family satisfaction. Following the 18 month pilot the
evidence shows we are meeting these aims.
This work has been recognised further by the successful publication of a paper in the
British Journal of Nursing relating to: Paediatric community home nursing: a model of
acute paediatric care (British Journal of Nursing 2014, vol23, No4).
Maternity services who have had higher rates of caesarean sections in comparison to
the national average and maternity units within the region have enabled Obstetricians
and midwives to work closely to reduce these rates and have successfully reduced
the number of women having elective caesarean sections. This has been as a result
of improving pathways of care, multidisciplinary VBAC (vaginal birth after caesarean
section) clinics, reducing our induction of labour rates and reduction of inpatient stay
on the antenatal ward through Triage assessment on an individual basis.
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QUALITY ACCOUNT 2013-14
Work is ongoing to continue to reduce the number of emergency caesarean sections
which includes multidisciplinary review of clinical records and learning from
experience. We have introduced a dashboard to monitor the reasons why women are
having a caesarean section so that we can be assured via audit that women are only
having this procedure when indicated.
The introduction of the 60 hour Consultant labour ward presence is expected to
contribute to the reduction in these rates as a result of enhanced leadership, support
and training for the obstetric team. We are about to launch a new midwifery led case
loading team in April 2014, with a focus on offering one to one care with a named
midwife. This is expected to increase the rates of home birth, reduce intervention and
support women having a vaginal birth after a previous caesarean section
In the last 12 months Ormskirk Maternity unit has made great progress in the
promotion, protection and support of breastfeeding in line with the UNICEF Baby
Friendly Initiative (BFI) Standards.
In October 2013 the Unit was awarded a Certificate of Commitment by UNICEF Baby
Friendly Initiative. This was a very positive step which recognised that the Trust is
committed to working towards the BFI Accreditation process. During the last 12
months a great deal of work has gone into bringing the staff training curriculum into
line with the New BFI Standards. In total 80% of the Maternity and 64% of the
Neonatal staff have completed the BFI 2 day breastfeeding foundation course
allowing staff to implement these standards whilst supporting breastfeeding mothers
and babies.
The unit has taken part in various promotional events to promote and support
breastfeeding including: Sefton Breastfeeding week 13-17th May 2013, Central
Lancashire re-launch of Bump Birth and Beyond programme for pregnancy and
beyond and the hosting of NCT Baby Day on the 12th October 2013. This event
coincided with receiving the Certificate of Commitment and so the opportunity to
utilise local press coverage of both events was made. This was an excellent day for
prospective parents to see the support we give to breastfeeding mums in Southport,
Ormskirk and surrounding areas.
The Unit continues to work closely with local Breastfeeding Peer Support groups
including Knowsley Bosom Buddies, Central Lancashire Families and Babies and
Sefton Breast Start who all provide breastfeeding support within the unit and in the
community on a daily basis.
The increased knowledge and skills in breastfeeding promotion and support can be
seen in the Units’ breastfeeding initiation data. For this last 12 month period a steady
increase in the initiation rate can be seen (from an average of 55.26% in the 12/13
period to 61.35% in the 13/14 period).
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
It is our pleasure to thank all the Trust staff who have once again provided our
patients with the level of care and commitment we would all expect to receive for
ourselves and our families. Our aim is to continue to build on these achievements
over the coming months and so deliver on our commitment of continuous
improvement to the benefit of our patients. Thank you.
Dr Robert Gillies
Executive Medical Director
Liz Yates
Director of Nursing and Quality
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QUALITY ACCOUNT 2013-14
Trust Achievements
No reported MRSA Infections
No reported grade 4 pressure ulcers
Reduction in grade 2, and 3 pressure ulcers across the
Trust
96.2% of patients receive harm free care
96% of patients have VTE risk assessment completed
96.8% of inpatients felt they were treated with dignity and
respect
95.7% of inpatients felt their hospital room was very clean
or fairly clean
95.6% of inpatients reported hand-wash gels being
available for patients and visitors to use.
96.8% of inpatients always / sometimes have confidence
in the doctors treating them.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.8
Workforce factors
The NHS commits to provide all staff with clear roles and responsibilities and
rewarding jobs for teams and individuals that make a difference to patients,
their families and carers and communities.
This Trust values its staff.
We have now been an integrated care organisation for three years on 1st April 2014
and integration of community and acute based health care, is continuing to further
develop integrated care teams through an active case management model. Staff
have been recruited to support Care Closer to Home and work continues to support a
proactive discharge process, working closely with ward staff and consultants in
improving compliance to expected date of discharge . The Trust has been actively
recruiting nursing staff working with the college to support newly qualified nurses into
employment
STAFF PLEDGE 1
To provide all staff with clear roles, responsibilities and rewarding jobs
The PDR system which was introduced during 2012/13 focuses on staff evidencing
that they have conducted themselves in accordance with our values: SCOPE.
(Supportive, Caring, Open and honest, Professional and Efficient). It also ensures
that staff have completed their mandatory training and successfully completed their
set objectives. The Trust has aims for a PDR completion rate of 90% which gives
assurance in terms of performance management and mandatory training. In
addition, a process for linking PDR to incremental progression and developing talent
was introduced in 2013/14.
Our senior medical staff continue to have strengthened appraisals to support the
revalidation process, with completion rates at 96%. The HR team commenced the roll
out of the Team Contracts in 2012/13. This tool enables all teams and individuals to
clearly identify how they fit into the Trust and understand how they contribute towards
us achieving our strategic objectives. This work continues and ensures that
performance is closely linked to the strategic objectives and the Trust Values
We ran our annual Pride Awards event in May 2013 and again had a large number of
worthy nominees (see facing page).
Category
Improving Quality and Cost Efficiency
Inspirational Role Model
Infection Prevention
Patient Award
Winners
Staff flow agency VAT scheme (Medical
Staffing Team)
Jane Mackie, Sister, Accident and
Emergency
Domestic Services
Dr Chris Barker, Ainsdale Centre for Health
and Wellbeing
Carole Barnes, Healthcare Assistant, Ward
15A
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QUALITY ACCOUNT 2013-14
Service Transformation / Innovation
Team of the Year
The Chief Executive’s Award
The Chairman’s Award
Mortuary and Bereavement Team
Theatres, Ormskirk hospital
Dawn Tyrer, PA, Cancer Services
Caron Johnston, PA, Cancer Services
Stanislawa Eccles, Midwife
Sally Rutherford, Pharmacy Technician
Trevor Davies, Volunteer
Vera Wallworth, Volunteer
STAFF PLEDGE 2
To provide staff with personal development, access to appropriate training for
their jobs, and line management to succeed
The Trust believes that staff are a key asset to the organisation and therefore
investment in their education and training is vital to ensure the transformation that will
work across the acute Trust and within the Community.
The previously merged Medical Education and Training and Development
Department ensures an organisational approach to training. The department aims to
provide high quality education and training to develop personal and professional
knowledge and skills to ensure patient safety. Health Education England will provides
national leadership but the local education and training boards will be the vehicle for
us to work to improve quality of education and training outcomes. Leadership
training for Medical Managers was commissioned and Front Line staff have the
opportunity to work towards ILM Qualifications. The Trust supports Apprenticeships
and NVQ training.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Mandatory training and induction procedures ensure that all new starters complete
their mandatory training before commencing in their work area. It is a requirement of
all Trust Employees to keep up to date with Mandatory Training and this can be
achieved by attending face to face training or via e-learning. All students on clinical
placements are supported by a mentor or clinical supervisor during their attachment
within the Trust. Students have structured programmes and access to clinical skills
facilities where they may practice skills in a safe and supervised environment.
Apprenticeships are open to all staff in bands 1-4 and there is opportunity for
progression through the apprenticeship levels. The majority of apprenticeships are
workplace based and supported by a line manager and regular assessment. Those
staff undertaking apprenticeships are offered support in functional skills. There
continues to be robust apprenticeship programmes within the Trust.
All staff are supported with their Continuous Professional Development, through
Personal Development Reviews. Line managers also monitor through the PDR that
mandatory training both core and job specific are up to date.
Clinical teams have the opportunity to undertake patient simulation training within
their teaching programmes along with other specialist training within the clinical skills
facility.
Revalidation for senior medical staff has been undertaken and is currently being
undertaken by junior doctors.
There are opportunities for staff to attend Leadership and Management courses.
All staff and students have access to a 24-hour library service.
There is an Education Governance Committee which provides a network for leaders
and facilitators with responsibility for education and training within the Trust to ensure
that mechanisms are in place to share and promote good practice across the
organisation. This reports to the Trust Education Board.
We continue to build on partnerships and collaborative working with stakeholders to
support caring professionals to provide a high quality service to patients.
STAFF PLEDGE 3
To provide support and opportunities for staff to maintain their health, wellbeing and safety
The Trust invested in staff health and well-being from April 2013. The investment
facilitated the expansion of our staff health and well-being department with health
promotion and rapid access services, along with an Employee Assistance
Programme, which provides 24-hour telephone access to confidential counselling
services to staff. By implementing these schemes and by changing the way we
manage sickness absence sickness absence rate has reduced from over 4.5% to
below 4% in 2013/14. In addition, the Health and Wellbeing team supported the Flu
Fighter Campaign and achieved immunisation of over 80% of employees in 2013/14.
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QUALITY ACCOUNT 2013-14
A number of Health and Wellbeing initiatives are now underway with yoga and circuit
training available to employees on the hospital sites. The Trust was awarded a
bronze level of participation in the NHS sport and Physical Activity Challenge.
The staff health and well-being department is located on the Ormskirk site and is
managed by the Health and Wellbeing Manager who will continue to support and
promote staff Health and Wellbeing initiatives.
STAFF PLEDGE 4
To engage staff in decisions that affect them, the services they provide and
empower them to put forward ways to deliver better and safer services
Prescribed Information: The % of respondent recommending the Trust as a place for
their friends and family to be treated in the National Staff Survey is as follows
Southport National
&
Average
Ormskirk
51%
63%
2012
National
Highest
94%
National
Lowest
35%
Southport National
&
Average
Ormskirk
51%
64%
2013
National
Highest
94%
National
Lowest
40%
Data from the Information Centre
The results are taken from the National Staff Survey.
Southport and Ormskirk Hospital NHS Trust has taken the following actions to improve
this percentage and so the quality of its services.
We have completed a significant amount of work on staff engagement this year,
commencing with ‘SCOPE for Change’, an initiative that has been embedded
throughout the Trust to engage and empower staff to identify and deliver on
improvements to the services that we provide for our patients.
In order to gain feedback on staff engagement in real time, the Trust launched a staff
engagement pulse check survey in January 2014, which seeks out feedback from
staff on a number of elements of staff engagement and includes the staff ‘friends and
family test;’. The results of this survey will be reported to the Trust Workforce
Committee regularly and will be a useful tool in informing improvements at the Trust.
18
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
The Trust has also redesigned its exit questionnaire to gain further insight into how
we are doing, where we can improve and what development opportunities staff are
aware of.
We have continued with the Trust Board “back to the floor” scheme as well as the
DoN Direct system which enables staff to contact the Director of Nursing and Quality
directly and a rumour busting hotline to encourage staff to report any rumours they
hear and ensure they receive timely feedback.
The results of the 2013 staff survey showed that the Trust was in the best 20% of
trusts for staff working extra hours and staff having received equality and diversity
and health and safety training.
The results also showed improvements in staff feeling supported by their managers,
staff suffering work-related stress and staff experiencing discrimination at work in last
12 months.
Our main workforce concern in 2014/15 is the result of our national staff opinion
survey. Whilst overall our responses are pleasing, we were in the lowest 20% of
acute Trusts nationally in relation to key finding 24, which assesses whether our staff
would recommend the Trust as an employer or place for family or friends to receive
treatment. 51% of our respondents stated that they would be happy with the standard
of care provided by the Trust compared with a national average of 64%.
This is of particular concern and the Trust Board has highlighted improvement in this
response as one of our key objectives in 2014/15. We have analysed the responses
in detail and have produced a comprehensive action plan for improvement in this
area, which will be reviewed and updated regularly in line with real time staff
feedback responses. A bi-monthly review of the Trust real time feedback score for
the staff friends and family test will be undertaken along with analysis of qualitative
information provided by staff explaining their reasons for this response; progress will
be reported to the Trust Workforce Committee.
19
QUALITY ACCOUNT 2013-14
Scope for Change (LiA)
Last summer we launched Listening into Action (LiA), a new way of working that
begins to put clinicians and staff at the centre of change in the Trust.
We’ve seen quick wins and some great projects evolve from LiA which all culminated
in a celebratory event where each team showed off what they’d achieved in January.
Scope for Change is our new name for LiA.
1. Web filter blocked
Blocked sites were one of the top gripes from the
Staff Conversations. A new system is now in place
meaning much smoother web browsing. To mark our
first quick win, we invited members of staff to put their
names forward to symbolically destroy the filter.
Jen Unwin, from Clinical Psychology, was the lucky
winner.
2. Chief Executive's blog
A number of staff for additional channels of communication from the Trust. Jonathan
Parry's Chief Executive's Blog is one we're now using and staff can comment and
ask questions.
3. Quadrangles open to staff and visitors
Staff asked that the
quadrangles and open
spaces between buildings
were opened so staff could
sit out during their lunch.
The first is now open at
Ormskirk hospital. Work is
under way to assess
opening a quadrangle on
the Southport hospital site.
20
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Completed Projects
More Volunteers in Clinical Areas
Strapline:
“Come Dine With Me”
Objective:
Increase the numbers of volunteers available across the organisation,
but especially those who assist patients to eat and drink.
Key Achievement: Trained volunteers increased from 4 to 22 with 15 more in
training.
Smarter Working
Strapline:
“E-systems achieve smarter, faster working”
Objective:
Achieve smarter working and enhanced time management by
introducing an electronic system for time claims and mileage
management.
Key Achievement: Potential savings for Community and Continued Care services in
time and mileage of £47,785.20 per annum allowing more patient
contact
Optimise Ward 15A
Strapline:
A diamond standard ward accreditation programme based on the 6Cs.
Objective:
Optimise Ward 15A.
Key Achievement: Accreditation process outlined and to be rolled out across the
wards ensuring better quality of care.
Improve Patient Information
Strapline:
“Keeping Patients in the Know”
Objective:
Improve or develop 2 aspects of information for patients.
Key Achievement: Developed a patient information booklet for each bedside,
approved by infection control; and a Consultant ‘seen by’ clinic
card
Reduce Meetings throughout the Trust
Strapline:
“We Must Stop Meeting Like This”
Objective:
The team will achieve the prioritisation of patient facing time by
reducing meetings and extracting maximum value from meetings
through smarter working practice and tools.
To reduce the number of meetings throughout the Trust, to reduce the
time meetings take and improve the value from meetings held through
smarter planning.
Key Achievement: New standards and alternative methods devised and available for
meetings held around the organisation to free Clinical hands on
time, and enable smarter working.
Improve Medical Availability & Escalation
Strapline:
“RAPID Response – Rapid Action Patient Illness and Deterioration”
Objective:
We set out to maximise medical availability and response to patient
need.
Key Achievement: Compliance with 4 hour A&E target.
Secured domestic support overnight to enable compliance with
targets.
21
QUALITY ACCOUNT 2013-14
Timeliness and Safety in Theatres
Strapline:
“Safety On Time Every Time”
Objectives:
Improve patient safety
Improve efficiency
Improve communication to patients and staff
Decrease cancellations day of operation
Key Achievements: Improved theatre utilisation and throughput; with significantly
reduced
cancellation statistics, improved teamwork and valued
staff.
Community Treatment Areas
Strapline:
“8 ‘til Late - It’s a Date”
Objective:
To offer a more flexible and accessible service for our patients within
community clinics across the ICO.
Key Achievement: Piloted extended treatment clinics on Tuesday and Thursday
evenings until 19:45 with minimal cost
Car Parking
Key Achievement:
5 parent and child spaces are secured at our Ormskirk site
Compassionate Conversations
Strapline:
Let’s expect respect.
Objective:
To affirm and reinforce passion for compassion – for all grades of staff
and in all areas of work.
Key Achievement: 64% of attendees rated the value of Conversations at 9 out of 10
or above.
Mandatory Training
Strapline:
“Breaking down barriers and raising the bar”
Objective:
Huge rise in mandatory training spaces has compliance rates shooting
up.
Key Achievement: Staff compliance rates increased from 81% to 85% between
October 2013 and Dec 2013; with increase of 200% to 500spaces
for training each month; and a reduction of 35% in non-attendees
to mandatory training sessions.
IT Resources
Strapline:
“Make I.T. So”
Objective:
We set out to improve the overall user experience of the I.T.
equipment they use every day. Speed and flexibility was key and once
the planned changes are in place, these will be paramount.
Key Achievement: Modernised and streamlined IT resources, securing capital for
rolling changes out throughout the Organisation over the next 12
months including electronic patient records going live in April
2014
22
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Real time staff feedback
The Public Inquiry into failings at Mid Staffordshire NHS Foundation Trust (Francis
Report) made 290 recommendations and had a strong focus on bilateral
communication between staff and leaders and the development of robust employee
voice mechanisms in order to foster a ‘culture of caring’ throughout the NHS. In
response to these recommendations, ‘Hard Truths’, the Trust Francis, Berwick and
Keogh Action Plan therefore makes a commitment to conduct regular engagement
‘pulse checks’ with staff along with other initiatives to foster a culture of meaningful
bilateral communication between staff and the Trust Board.
The Trusts real time feedback questionnaire includes 6 core engagement baseline
questions, which are taken from the national staff survey:
Staff have the opportunity to complete the questionnaire via the following
mechanisms:
• Kiosks in restaurants at SDGH and ODGH
• Online through a web link (accessible via the Trust intranet and Trust News)
• Via iPad during Team Briefing sessions
The results presented in this report reflect the views of a total of 177 respondents
between January 2014 and March 2014.
How likely are you to recommend this organisation to friends and family if they
needed care or treatment?
The above table shows that 52% of respondents are either “likely” or “very likely” to
recommend the Trust as a place to receive treatment, while 22% of respondents are
“unlikely” or “very unlikely” to recommend the Trust and 22% of respondents are
indifferent with regard to this question.
23
QUALITY ACCOUNT 2013-14
How likely are you to recommend this organisation to friends and family as a place to
work?
The above table shows that 43% of respondents are either “likely” or “very likely” to
recommend the Trust as a place to work, while 38% of respondents are “unlikely” or
“very unlikely” to recommend the Trust and 17% of respondents are indifferent with
regard to this question
An action plan has been developed which will be implemented and monitored
regularly through the workforce committee, alongside the findings from real time
feedback obtained from staff on an ongoing basis.
The success of the action plan will in part be measured by improvements in the real
time staff feedback results, reported to the Workforce Committee on a bi-monthly
basis. A further measure of success is anticipated to be improvements in the
feedback gained from staff as part of the 2014 national staff survey.
24
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.9
Nurse Recruitment
Introduction
The struggle with nurse recruitment has been recognised as a National issue. The
trust encountered issues last year. This led to active overseas recruitment from
Portugal on two occasions. This resulted in the trust employing over twenty qualified
nurses. The retention for this group has been excellent. Only two have since left
and sought employment elsewhere. This has been due to personal issues.
Working closely with local universities
The Director and Deputy Director of Nursing meet monthly with the local universities
to promote closer links with the Trust. This has led to a number of proposals being
put forward to enable nursing students to feel part of the Trust whilst training. This
will increase their sense of ‘belonging’ and hopefully encourage them to come and
work here once their training is completed. These include;
•
Basing the students at the Trust for the majority of their placements rather
than them moving to trusts all over the region. This has been agreed by both
HEIs
•
Putting the students into Trust uniforms. This is under discussion with both
HEIs. UCLAN have agreed in principle.
There is proactive recruitment management of the students with trust representatives
attending recruitment events held by the Universities.
The deputy Director of Nursing and the Asst. Matron for Education attended an
afternoon at Edge Hill University to discuss working at S&O. The aim was to
promote the Trust, answer any questions that the students had and dispel any myths
or false information.
It was agreed that any student that was interested in a post with the Trust could be
interviewed on the day. Occupational health attended to complete the health
questionnaire and checks.
This proved to be very successful with a total number of 32 students recruited on the
day and due to commence at the trust in May 2014. These students will be closely
monitored and supported both prior to commencing in the Trust and once in post.
They will be asked to provide regular updates of their experience so that we can
learn and move forward in the future.
25
QUALITY ACCOUNT 2013-14
Nurse Bank & Agency Costs
Cumulative Costs 10/11
Cumulative Costs 11/12
Cumulative Costs 13/14
£4,600,000
£4,100,000
£3,600,000
£3,100,000
£2,600,000
£2,100,000
£1,600,000
£1,100,000
£600,000
£100,000
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Health Care Assistant Recruitment and NHSP
Health Education England is currently reviewing how the Health Care Assistants are
educated and trained prior to working with patients. Following on from the Cavendish
Review Recommendations, a report is expected in summer 2014 that provides
direction on ensuring all Health care Assistants complete a ‘Basic Fundamentals of
Care’ certificate prior to working unsupervised.
In anticipation of this, the trust has worked closely with NHSP to provide a basic skills
training course prior to HCAs being placed in the Trust.
NHSP recruit (in conjunction with trust staff) thirty HCAs from the local area four
times a year. They are employed by NHSP and work through a six month placement
with the trust. During this placement they are assigned a ‘mentor’ who will work with
them to ensure they develop their skills and demonstrate the right qualities.
Prior to them commencing in the Trust the staff complete a two week induction with
NHSP where they are taught the basic ‘fundamentals’ of care. This is then followed
with the Trust induction of one week.
After the six month period working through NHSP, the Trust can employ the HCAs
into permanent positions or decide to extend their time working with NHSP.
This methodology enables the trust to develop and grow the Health Care Assistants.
It allows us to train them using our own values and behaviours and ensures they are
fully aware of what is expected of them prior to them commencing into a permanent
post.
In future, all HCAs will move through this pathway regardless of whether they where
recruited by NHSP or the trust. This will ensure consistency for all newly recruited
staff.
It is expected that this will provide a framework for the Trust to develop our own
‘Basic Fundamentals Certificate’. There will be a lot of focus on trust values and the
6C’s to ensure that the staff we recruit are compassionate and caring.
26
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Next Steps
The next steps will be to create a ‘career pathway’ for Health care Assistants that
develops their skills and also provides them with a framework to develop a career in
health. It is expected that this framework will lead to nurse training for those that
have the required skill set.
National Inpatient Survey :
Did you have confidence and trust in the nurses treating you?
100
85
85
83
85
86
85
83
2004
2005
2006
2007
2008
2009
2010
80
84
86
85
2011
2012
2013
60
40
20
0
27
QUALITY ACCOUNT 2013-14
1.10 Production of Quality Account
The Quality Account was compiled by the Director of Nursing and Quality and the
Assistant Director of Integrated Governance with the support of the Quality Data
Analyst and Head of Audit and Effectiveness.
A draft index for the Quality Account was circulated to operational Quality Committee
for comments in February and a draft index has been circulated to members of the
Quality and Safety Committee for relevant feedback. Copies of the final draft were
sent to Sefton and Lancashire Healthwatch groups, the OSC (Overview and Scrutiny
Committee) for their comments and Statements of Assurance.
There are representatives from both Healthwatch and Commissioners on the Trust
Operational Quality Committee and therefore the index and draft which were tabled
at Trust Operational Quality Committee in February and April were available for
comments to all these groups so that any feedback could be considered for inclusion.
Statements of Assurance from the above groups who returned comments after
circulation in April can be found, in PART 4, as dictated by the regulations. Following
inclusion of these statements the Final copy was circulated to Trust Board members
and Quality, Operational Quality Committee and Safety Committee members in June
2014.
28
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
29
QUALITY ACCOUNT 2013-14
PART 2
2.1
Review of quality performance April 2013- March 2014
We need to provide a quality healthcare system which is “safe and effective and
where the patient experience is good” (DH Operating Framework 2009-2010) and to
this end we have continued to monitor the Trust’s quality measures monthly, using
the Quality dashboard which is presented to the Operational Quality Committee. The
committee comprises representatives from all clinical business units and other
departments within the Trust, Executive Directors and LINKS/Healthwatch
representatives from Sefton and Lancashire. Each business unit reports to the
committee on their dashboard figures and provides information and assurance on
how they are implementing steps to improve any areas which are not achieving the
Trust’s own or national and local quality targets. The structure of committees at this
level is being reviewed and the plan is to amalgamate the Operational Quality
Committee with the Operational Risk Committee and therefore from March 2013 the
Operational Quality Committee ceased. The new format will be introduced in 2014.
The “Quality and Safety Committee” which is a committee of the Board and is
chaired by a non-executive director provides assurance to Trust Board and in
2013/14 directed the work of the Operational Quality and Operational Risk
Committees leaving them to concentrate on the operational work plan. This
committee shows the importance the Trust places on quality and safety issues and
gives the directors focus and direction in order to provide assurance.
Each ward and department continues to review/monitor their own dashboard which
they discuss with their Head of Nursing and Matron to ensure actions are
implemented where improvements are required. The Associate Medical
Directors/Clinical Directors and Consultants also have a dedicated dashboard to
facilitate and inform discussion with the Medical Director on theirs and their teams’
performance.
During 2013/14 this trust in liaison with the CCG’s (Clinical Commissioning Groups)
decided to concentrate on the four national CQUINs (Commissioning for Quality and
Innovation) indicators this year. The rest of the Quality contract was concentrated
into a new process called an Alternative Quality contract (AQC). In line with the
requirements of the AQC the Trust compiled five action plans which needed to be
50% implemented to obtain funding from the AQC. These five areas are outlined
below. The table below shows the CQUIN Goals and the Alternative Quality Contract
indicators with the balance of finances awarded to each.
30
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
CQUIN Goal
1
VTE
2
Friends and
Family test
Description of Goal-Acute contracts
% of all adult inpatients who have had a VTE risk
assessment on admission to hospital using the
clinical criteria of the national tool
The number of root cause analyses carried out on
cases of hospital associated thrombosis
Phased expansion
Increased Response Rate
Improved performance or remaining in the top
quartile on the staff Friends and Family Test
The proportion of patients aged 75 and over to
whom case finding is applied following emergency
admission, the proportion of those identified as
potentially having dementia who are appropriately
assessed, and the number referred on to
specialist services
Named lead clinician for dementia and
appropriate training for staff
Ensuring carers feel supported
3
Dementia
4
Safety
Thermomet
er
1
2
Fractured
Neck of
Femur
(NOF)
LACE
3
Staffing
4
Electronic
communicat
Audit of electronic communication to show
ion
required standard
Stroke
Assessment of stroke patients by specialist nurse.
Assessment of stroke patients by Therapists
Satisfaction survey offered to stroke patients 6
weeks post discharge
5
Expected
financial value
of goal
697,544
348,772
348,772
To collect data on the following three elements of
the NHS Safety Thermometer: pressure ulcers,
falls and urinary tract infection in patients with a
catheter
The number of patients recorded as having a
category 2-4 pressure ulcer (old or new) as
measured using the NHS Safety Thermometer on
the day of each monthly survey
All Non Elective admitted patients with fractured
NOF (suitable for surgery) to be operated on
within 36 hours of admission
697,544
Implementation of LACE scores in Long term
conditions and follow up telephone calls/visits.
Compilation of staffing reports to be shared with
CCGs
Continued roll out of E-Discharge
£461,408
31
£403,733
£144,190
£922,818
£141,307
QUALITY ACCOUNT 2013-14
6
Outpatients
7
8
Delayed
discharge
COPD
9
Diabetes
10
End of Life
1.
Digital First
2.
Three million
lives
3.
Child in a
chair in a
day
Intraoperative
fluid therapy
Dementia
Care
4.
5.
International
and
commercial
activity
6.
Processes implemented to reduce cancelled
appointments
Monitoring of delayed discharge
£374,895
Increase the number of COPD patients
discharged with a rescue pack.
Improved monitoring and effective reduction of
HBA1C2 in newly diagnosed diabetic patients
Improved care given to patients at end of life
£115,352
£28,838
£115,352
£201,866
Implementation of electronic initiatives in the community and
outpatient clinics.
Development of telemedicine
Addressing independence and mobility needs of children
Improved monitoring of fluids during surgery
Development of dementia information packs and assessment of
patients.
Research, innovation and technical advances
This year the Trust has used CQUIN monies to improve patient care and experience
in the following ways. As in previous years much of this is recurrent funding. The
Trust is pleased to note the recognition within the Operating Framework 2013/14 that
improvements in Quality are sometimes reliant on recurrent funding.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Investment in technology
Infection control
In Your Shoes patient experience events
Development of the Health and Wellbeing service
Matrons Checklist Software
Quality Analyst Assistant post recurring
Assistant Matron for Planned Care
Improving patient experience
Breast Feeding facilities
The wards are responsible for implementing actions to improve the areas where they
are falling behind as can be viewed on their quality dashboards and the Director of
Nursing highlights to each area where she wants them to prioritise their efforts. The
Quality dashboards create competition and highlight areas of excellent performance
in addition to those areas which need to improve.
32
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
These Quality Boards now also show patient feedback that has been received to
each individual area both positive and negative to show that all feedback is noted
and valued. This encourages the frontline staff to concentrate on what is required to
make improvements in negative areas and take pride in what they do well.
The Deputy Director of Nursing produces regular quality reports which are presented
to Trust Board.
33
QUALITY ACCOUNT 2013-14
2.2
Personnel involved in the Quality Agenda 2013-14
The Trust Board continues to scrutinise the Quality reports provided and led
by the Deputy Director of Nursing, as assurance that the quality strategy is
being implemented effectively
A Quality and Safety Committee chaired by a Non-Executive Director
concentrates on providing Trust Board with assurance enabling the
Operational Quality Committee to concentrate on operational detail
The Chief Executive and the Executive team have continued to support and
advise their respective teams
The Trust Operational Quality Committee have monitored the Quality
dashboard throughout the year
The Assistant Director of Integrated Governance has successfully coordinated all aspects of the quality agenda to ensure that deadlines are met
and that relevant data is reported on
The Senior Nursing team led by the Director of Nursing and supported by the
Deputy Director of Nursing, co-ordinates the collection of the nursing quality
metrics data, supplying Trust Board with reports on a regular basis
The Trust Advancing Quality lead has monitored the implementation of
Advancing Quality, working closely with Clinicians to facilitate and improve
upon this trust’s impressive record
Members of both Sefton and Central Lancashire Healthwatch have given
valuable advice and constructive criticism from the patient’s perspective
throughout the year through their involvement on the Operational Quality
committee and pre Board meetings
The Infection Prevention and Control Team have provided data, advice,
support and encouragement to clinical staff to help us with our battle against
infection
The Quality and Integrated Governance Senior Data Analyst and Assistant
have set up and maintained systems throughout the organisation to enable the
collection and presentation of data. Without these valuable posts it would not
be possible to show the degree of detail that we now achieve
All departments and Clinical Business Units within the Trust have contributed
with evidence and data to support the Quality agenda and have been key to
the implementation of action plans to raise the standards where shortcomings
have been noted
34
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
2.3
Quality Strategy Workplan 2013-2014
The following pages show the achievements of the 2013-14 work plan as set out in
the 2012/13 Quality Account.
This Trust is proud of the progress made in the last 12 months and looks forward to
making further improvements in the quality of care in the year ahead.
Key
Target has been achieved
Close to achieving target
Work is still ongoing to achieve target
35
QUALITY ACCOUNT 2013-14
QUALITY STRATEGY WORKPLAN 2013-2014
ISSUE
OBJECTIVE
Target Status
Quality Account
Final 2012/13 Account submitted
Further develop Quality Account for 2013/2014
Maintain and Develop Links
Maintain links between above and CCG quality monitoring
processes
EFFECTIVENESS
DOMAIN
Preventing people from dying prematurely
Advancing Quality
Continue involvement in all aspects of the AQ agenda
HSMR
Further reduce the Mortality ratio to 85 (national average 100) in next 12 months as measured by the
HSMR
Reduce the SHMI to 100
Board to Board
Update Nursing Strategy Workplan
Harm Free Care
CQUIN
Mini CQC Audits
DANI Audits
10 Mandatory Requirements – Implement monitoring and Reporting
Infant and Perinatal Mortality
Review National Perinatal Mortality Data and Implement any actions/recommendations
Implementation of Safety
Thermometer
DOMAIN 2
Enhancing quality of life for people with long-term conditions
Research
Participation in national research and produce mandated data for Quality Account
36
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Long term condition pathways
Continue to improve and develop pathways across acute and community care
Implement Care Closer to Home model
Implement proactive discharge process
Community staff to undertake Care Aims training ensuring a standardised approach in long term
condition management with identified goal setting for individual patients and plan in place for any
outstanding at April 2014.
Re-admissions
Monitor the rate of readmissions through the readmissions group
Undertake audits as required to monitor progress and effectiveness of the group.
Winterbourne View Report
Complete gap analysis
Compile action plan to implement recommendations
Monitor through Learning Disability Liaison team.
NICE Quality Standards
Complete Gap Analysis on all published relevant standards
Draw up action plans for any partial/non compliance
Clinical Audit
Take part in relevant National Audits
Discharge
Improve the use of expected date of discharge to 90% for Urgent Care CBU and
Planned care CBU 50%
Electronic discharge summaries will be rolled out trustwide
DOMAIN 3
Helping people to recover from episodes of ill health or following injury
TARN
Achieve data accreditation targets
Trauma Centre
Collect data required for accreditation
Stroke
Monitor implementation of National Stroke Strategy
Improve Advancing Quality for Stroke compliance
Medical Revalidation
Commence Medical Revalidation and monitor progress
37
QUALITY ACCOUNT 2013-14
Violence against women &
children
Length of stay
Monitor the compliance with MARAC National Guidance
Re-admissions
A&E Quality Indicators
Newly expanded Discharge Team will support a proactive discharge process
Work with Commissioners to ensure appropriate support in community to facilitate reduction in length
of stay where appropriate to the patient’s needs.
Continue to audit the reasons for re-admissions
Monitor and develop support in the community to prevent readmission where it is not in the patient’s
best interest
Monitoring of the A&E indicators on Quality Dashboards and IPR
Communication with GPs
Continue to work with the GP practices to Implement electronic systems across boundaries
Report of the Children and
Young People’s Health
Outcomes Forum (July 12)
Complete Gap analysis
Compile action plan to implement recommendations
Operational Quality Committee
EXPERIENCE
DOMAIN 4
Ensuring that people have a positive experience of care
CQUIN
CQUINS monitored at CCG Quality Review meetings
Include in Quality reports to Trust Quality Committee and Trust Board throughout the year.
Gold Standard Framework
Increase knowledge of Advance Care planning
Implement Amber Care Bundle trustwide.
Communication training for all levels.
Preferred place of care documentation
Rapid End of Life discharges
Maintain exceptional progress against GSF
Dementia
Achieve Dementia CQUIN
Care of the elderly
Achieve the Care of the Elderly CQUIN
Friends and Family
Continue to record the feedback for FF
Achieve the Friends and Family CQUIN
38
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Implementation of the 15 steps Challenge
Have survey questions compiled and implementation commenced
Implementation to be complete in a minimum of 4 teams
Partake in all relevant scheduled National Patient Surveys
National Inpatient survey
National Outpatient survey
National Maternity survey
National A&E survey
Action plans compiled for all surveys
Action plans monitored through Quality committee
Patient Experience Strategy
Patient feedback
Mixed Sex Accommodation
Monitor all patient feedback Trustwide
Present reports to Operational Quality Committee.
Minimum 3 times a year “Secret Shopper” events with feedback to all relevant committees and Trust
Board.
Further develop Feedback 2 Matron using one off pop up questions relating to any current issues.
Extend Hospedia surveys to Outpatient areas and Community areas.
Continue to Improve PROMS feedback rates
Patient Experience Group to monitor all patient feedback and produce reports to Operational Quality
Committee.
Maintain compliance
Report any unavoidable breaches
PROMS
Improve on completion of data for PROMS questionnaires
Maternity
Monitor National Screening KPI’s on Quality dashboards
Community
National Patient Surveys
SAFETY
DOMAIN 5
Treating and caring for people in a safe environment and protecting them from avoidable harm
External Assessment
Venous Thrombo Embolism VTE
Review plans for NHSLA and CNST in the light of current changes to the Assessment process.
Outcome Evidence catalogued on CQC templates
CBU declaration process refined
Achieve VTE CQUIN
Monitor compliance with NICE through annual audit
Monitor processes through VTE working party.
39
QUALITY ACCOUNT 2013-14
Achieve Medicine Management contract requirements
Implement discharge pharmacist project in more areas
Continue medication ward audits post CQC
Monitor MSSA and E-coli.
Reduce hospital acquired pressure sores by 25%
No grade 4 pressure sores
No grade 3 pressure sores
Agree definition of Community Service Acquired
Measure baseline
Implement RCAs for Community Acquired Pressure sores.
Compile action plan to address Francis 2
Develop focus groups to implement recommendations.
Monitor progress as Quality and Safety Committee
Complete Gap analysis
Compile action plan to implement Seville recommendations
Monitor through Safeguarding committee
Continue safety talkabouts to all areas of ICO and maintain database of areas visited.
Aim for further 10% reduction in cardiac arrests
Implementation of recommendations for “A Time to Intervene NCEPOD”
Achieve CQUIN
MRSA
Monitor extended list of never events
Report and investigate any occurrence
Achieve Nationally set target
C.Diff
Achieve Nationally set target
Hand Hygiene
Improve undertaking of hand hygiene audits to 100%
Improve results of hand hygiene audits to 100%
Nurse staffing
Continue to recruit qualified staff in line with business plan agreed with Trust Board.
Audit Nurse team
Recruit Clinical staff to undertake clinical audits including:
Care as Care should be
Dani
Quality contract audits
Medicine Management
MSSA & E-COLI reporting
Hospital Acquired pressure
sores
Francis Report
Saville Report
National Patient Safety and LIPS
NHS safety thermometer
Never Events
40
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Board to floor
CQC
Dementia
CQC requirements
MSA questions
Continue initiative where Board members shadow the Ward and Departmental Managers for a shift to
enable a better understanding of challenges faced on a day to day basis.
Continue Mock CQC inspections to cover all clinical areas of the ICO
Maintain a register of both Mock inspections and CQC inspections for
Feedback to Trust Board
ACHIEVEMENT OF THE TRUST AGAINST NATIONAL PERFORMANCE TARGETS CAN BE FOUND IN APPENDIX 2
41
QUALITY ACCOUNT 2013-14
2.4
Priorities for improvement/ Quality Strategy workplan 2014-15
Taken from National Priorities as described in the Operating Framework alongside
key local issues, the Trust Strategic Quality Aims and Objectives for 2012-15 are
listed in the following table and Southport and Ormskirk Hospital NHS Trust’s
Strategic Quality Aims and Objectives (The Chief Executive’s Big 5) remain
plus key quality improvements:
1. Review mortality process and reduce mortality rate to 85% in next 12
months as measured by HSMR
2. We will reduce the hospital-acquired pressure sores by 25% each year
3. We will improve undertaking of hand hygiene audits to 100% within 12
months and results of the hand hygiene audits to 100% within 24 months
4. We will reduce the number of inpatient falls
5. Eliminate preventable morbidity in maternity care over the next 3 years
6. We will decrease the number of Clostridium Difficile infections.
7. Maintaining an Embedding Mandatory Professional Standards
(Appendix 3)
These priorities are measured and monitored monthly on the Trust Quality and
Safety dashboard. They will be reported through Trust Operation Quality Committee
and Safety Committee and further reviewed by Quality and Safety Committee to
provide assurance to Trust Board.
Organised under the 5 domains of care set out in the NHS Outcomes Framework the
Trust Quality Strategy work plan for 2014-2015 is set out below
42
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
QUALITY STRATEGY WORK-PLAN 2014-2015
AIM
Produce Quality Account
compliant with all requirements
Maintain and Develop Links
OBJECTIVE
Time Frame
Final 2014/15 Account submitted
Further develop Quality Account for 2015/2015
Maintain links between above and CCG quality monitoring
processes
th
June 30 2014
April 2015
On-going through 2014 - 2015
TIMEFRAME
April 2015
On-going throughout 2014 - 2015
On –going throughout 2014-2015
On-going throughout 2014 - 2015
EFFECTIVENESS
DOMAIN 1
Preventing people from dying prematurely
AIM
Reduction in Mortality
Staffing of Wards and
Departments is equal to the care
needs of the patients
Further develop and embed
Mandatory Professional
Standards
OBJECTIVE
Reduce mortality to 95 in next 12
months as measured by the
HSMR
Reduce mortality as measured by
SHMI to 100 in the next 12
months
Maintain or reduce Perinatal
Mortality
Maintain and improve patient level
monitoring at >95%
Nurse Staffing Levels congruent
with Safer Staffing Alliance 1:8
recommendation
Embed Processes
Ensure occurrence of Always
Events
Activate and maintain local and
professional accountability
43
INITIATIVES
Embed revised mortality process
Review National Perinatal
Mortality data and implement any
actions/recommendations.
Enhanced clinical contribution to
coding
Palliative Care Audits
EWS Audit
Fluid Balance Audit
Implementation of VitalPac
6 monthly nurse staffing levels
review
Real-time Staff Monitoring
Monthly Board Reports
Staffing levels expressed outside
ward areas
Supernumerary Ward Managers
Benchmarking
Performance Monitoring
Framework (PMF)
Monthly CEO Review meetings
QUALITY ACCOUNT 2013-14
Achieve C.difficile target
Maintain nil MRSA performance
Proactively relating to CPEs
Checklists
Standardisation of Care
Mandatory 100% compliance with
WHO Checklist
Agree shared care standards
compliant with National and
Professional Guidance
Infection Prevention and Control
On-going throughout 2014 - 2015
Performance Monitoring
Framework
MPS
RCAs
Antibiotic Stewardship
WHO Checklist Audit
On-going throughout 2014 - 2015
Advancing Quality
LTC Pathway Development
On-going throughout 2014 - 2015
TIMEFRAME
On-going throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
DOMAIN 2
Enhancing quality of life for people with long-term conditions
AIM
Provision of appropriate care in
most appropriate setting
OBJECTIVE
Agree shared care standards
compliant with National and
Professional Guidance
Implement relevant NICE
Guidance
Achieve Dementia CQUIN
Improve information sharing
Improve provision of care for
patients with Dementia
Reduction of Readmissions
Minimise unnecessary hospital
admission
Improve Care Provision for
Stroke Patients
Achieve National Stroke Strategy
Indicators
Improve AQ Stroke Compliance
Improve Care Provision for
Diabetic patients
Agree shared care standards
compliant with National and
Professional Guidance
44
INITIATIVES
Advancing Quality
Care Closer to Home Model
LTC Pathway development
NICE Guidance monitoring and
reporting Framework
Dementia passport
Information Packs –lifelines
Dementia environmental changes
and aids
Care Closer to Home Model
Readmissions Audit
Ambulatory Emergency Care
Active Case Management
Rescue packs
Advancing quality standards
Dr Foster data
Review of current stroke bed
provision, admission into identified
stroke bed within 4 hours.
Advancing Quality standards
Care closer to home
Advancing Quality Standards
Care Closer to Home Model
LTC Pathway development
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Improve Care Provision for Heart
Disease.
Implement relevant NICE
Guidance
Achieve Alternative Quality
contract measures.
Implement relevant NICE
Guidance
NICE Guidance monitoring and
reporting Framework
HBA1c target monitoring
Advancing Quality Standards
Care Closer to Home Model
LTC Pathway development
NICE Guidance monitoring and
reporting Framework
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
TIMEFRAME
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
DOMAIN 3
Helping people to recover from episodes of ill health or following injury
AIM
Provision of Patient Centred,
compassionate and responsive
Care
Become exemplar organisation
for care of the elderly
OBJECTIVE
All Patients receive high standard
of care and / or treatment
relevant to their needs
Outcomes of Care and / or
Treatment are compatible or
better than our peers
Further embed culture of 6Cs
throughout the organisation
All Patients receive high standard
of care and / or treatment
relevant to their needs
Outcomes of Care and / or
Treatment are compatible or
better than our peers
Further embed culture of 6Cs
throughout the organisation
45
INITIATIVES
Patients FFT
Feedback 2 Matron
TARN
Harm Free Care
Transparency Project
CQC mock inspections
Southport Ormskirk Proud
Compliments
PROMS
Dr Foster data
Audit practice
Nursing & Care Staff Strategy
Southport Ormskirk Proud
Patients FFT
Feedback 2 Matron
TARN
Harm Free Care
Transparency Project
CQC mock inspections
Southport Ormskirk Proud
Compliments
PROMS
Dr Foster data
Audit practice
Nursing & Care Staff Strategy
Southport Ormskirk Proud
QUALITY ACCOUNT 2013-14
Become an exemplar
organisation for care of the
patient with dementia in the
acute setting
All Patients receive high standard
of care and / or treatment
relevant to their needs
Outcomes of Care and / or
Treatment are compatible or
better than our peers
Further embed culture of 6Cs
throughout the organisation
All Patients receive high standard
of care and / or treatment
relevant to their needs
Become an exemplar
organisation for care of the
rehabilitating patient
Improve Patient Flow throughout
the organisation
Outcomes of Care and / or
Treatment are compatible or
better than our peers
Further embed culture of 6Cs
throughout the organisation
Achievement of 4 hour Target
Achievement of A & E Quality
Indicators
Reduced occupied wards to
provide a decanting area for ward
environment upgrade programme.
EXPERIENCE
DOMAIN 4
Ensuring that people have a positive experience of care
46
Patients FFT
Feedback 2 Matron
TARN
Harm Free Care
Transparency Project
CQC mock inspections
Southport Ormskirk Proud
Compliments
PROMS
Dr Foster data
Audit practice
Nursing & Care Staff Strategy
Southport Ormskirk Proud
Patients FFT
Feedback 2 Matron
TARN
Harm Free Care
Transparency Project
CQC mock inspections
Southport Ormskirk Proud
Compliments
PROMS
Dr Foster data
Audit practice
Nursing & Care Staff Strategy
Southport Ormskirk Proud
Maintain patient flow
management.
?
Care Closer to Home Model
LTC Pathway development
Rapid discharge for end of life
care.
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
AIM
Patient Feedback will be used to
improve the Quality of care and
treatment provision
OBJECTIVE
Implement Patient Experience
Strategy
Participate in all relevant National
Patient Surveys
Identify changes implemented as
a result of patient feedback and
feedback to patients, carers and
the community
Ensure complaints are handled
promptly and effectively
Care Environment
DSSA
Patient flow
Ward environment upgrade
programme
Nurse staffing levels
47
INITIATIVE
Compliments and complaints
review implementation of actions.
Customer Service Training
15 Steps Challenge
National Inpatient survey
National Outpatient survey
National Maternity survey
National A&E survey
Action plans compiled for all
survey results.
Patient Experience Strategy
Customer services training
Secret Shopper Initiative
Compliments and complaints
implemented actions
Ward Sister ward rounds
Performance Monitoring
Framework
Complaints Reporting System
Complaints Review panel
Business Unit dashboards
Sustainability audits
Ward based feedback
Lessons learnt
Ward dashboards for staff/patients
and visitors
Review of specific areas where
DSSA is a problem.
Care closer to home model
Maintain patient flow management
LTC Pathway development
Rapid discharge for end of life
care.
Reduction in occupied beds to
allow for upgrade programme
Investment into nurse staffing at
TIMEFRAME
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
QUALITY ACCOUNT 2013-14
End of Life Care
Transform programme
ward and department level.
Advance Care Planning
Amber Care Bundle
Advanced Communications
Training
Preferred Place of Care
documentation
Rapid End of Life discharges
Gold Standards Framework
Audit of practice
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
SAFETY
DOMAIN 5
Treating and caring for people in a safe environment and protecting them from avoidable harm
Infection Prevention and Control
Reduction in case of C diff
Remain MRSA free
Plan for future
MSSA & E-COLI reporting
Monitor MSSA and E-coli.
External Assessment
Review plans for NHSLA and
CNST in the light of current
changes to the Assessment
process.
Outcome Evidence catalogued on
CQC templates
CBU declaration process refined
Achieve VTE CQUIN
Monitor compliance with NICE
through annual audit
Monitor processes through VTE
working party.
Venous Thrombo Embolism VTE
Implementation of the C Diff
recovery plan
Antibiotic stewardship to be
enhanced.
Hand hygiene audits
Improve current MRSA
documentation completion.
Horizon scanning for possible new
isolation processes and infections.
Best practice implementation
Benchmarking
CQC mock inspections
VTE/ PE RCA process
Audit of uptake of prophylaxis
across the Trust.
48
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Medicine Management
Hospital Acquired pressure sores
Safeguarding adults and
Children
Francis Report
Saville Report
National Patient Safety and LIPS
NHS safety thermometer
Achieve Medicine Management
contract requirements
Implement discharge pharmacist
project in more areas
Continue medication ward audits
post CQC
Reduce hospital acquired
pressure sores by 25%
No grade 4 pressure sores
No grade 3 pressure sores
Agree definition of Community
Service Acquired
Measure baseline
Implement RCAs for Community
Acquired Pressure sores.
Meet national requirements
Quality contract requirements
Compile action plan to address
Francis 2
Develop focus groups to
implement recommendations.
Monitor progress as Quality and
Safety Committee
Complete Gap analysis
Compile action plan to implement
Seville recommendations
Monitor through Safeguarding
committee
Continue safety talkabouts to all
areas of ICO and maintain
database of areas visited.
Aim for further 10% reduction in
cardiac arrests
Implementation of
recommendations for “A Time to
Intervene NCEPOD”
Achieve CQUIN
Implementation of discharge
trolleys
Audits of practice
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
RCA of all pressure sores above
Grade 2
Establish baselines for community
categorisation.
Audit of practice
Intentional rounding
Review internal process.
Ongoing throughout 2014-2015
Ongoing throughout 2014-2015
Test action implementation by
auditing practice
CQC mock inspections.
Await publication
Link to safeguarding processes.
Ongoing throughout 2014-2015
following publication
Implementation of actions
following talkabouts.
Establishment of the SIRR’s
committee
RCA of all cardiac arrests. .
Review current documentation
completed by the resus team.
Ongoing throughout 2014-2015
following publication
Audits of practice
Matrons’ checklist.
Ongoing throughout 2014-2015
following publication
49
QUALITY ACCOUNT 2013-14
MRSA
Achieve Nationally set target
C.Diff
Achieve Nationally set target
As above
Hand Hygiene
Improve undertaking of hand
hygiene audits to 100%
Improve results of hand hygiene
audits to 100%
Maintaining professional
standards
Ward dashboards
Audit of practice
Training
Publication of nurse staffing
reports
PMF
Monitoring at BU and Board level
Southport and Ormskirk Proud
Training of staff
Ward dashboards
Matrons checklist
Never Events
Nurse staffing
Audit Nurse team
Board to floor
CQC
Monitor extended list of never
events
Report and investigate any
occurrence
Continue to recruit qualified staff
in line with business plan agreed
with Trust Board.
Recruit Clinical staff to undertake
clinical audits including:
Care as Care should be
Dani
Quality contract audits
Dementia
CQC requirements
MSA questions
Continue initiative where Board
members shadow the Ward and
Departmental Managers for a shift
to enable a better understanding
of challenges faced on a day to
day basis.
Continue Mock CQC inspections
to cover all clinical areas of the
ICO
Maintain a register of both Mock
inspections and CQC inspections
for
Feedback to Trust Board
50
RCA training
Training events
Lessons learnt
Consultant radar
Audit practice
As above
Ongoing throughout 2014-2015
following publication
Ongoing throughout 2014-2015
following publication
Ongoing throughout 2014-2015
following publication
Ongoing throughout 2014-2015
following publication
Ongoing throughout 2014-2015
following publication
Ongoing throughout 2014-2015
Back to floor
Ongoing throughout 2014-2015
Ward dashboards
Schedule of audits
Ongoing throughout 2014-2015
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
2.5 Prescribed Information (Regulation 4)
Between April 2013 and March 2014 the Trust provided acute hospital and
community NHS services made up of the following regulated activities, for which
the Trust became registered with the Care Quality Commission (CQC) without
conditions from April 2010;
1. Treatment of diseases, disorder or injury
2. Surgical procedures
3. Diagnostic and screening procedures
4. Management of supply of blood and blood derived products
5. Maternity and Midwifery services
6. Termination of pregnancies
7. Assessment or medical treatment for persons detained under 1983
Mental Health Act
8. Family planning
Southport and Ormskirk Hospital NHS Trust has reviewed all the data
available to them on the quality of care in all of these NHS Services
The income generated by the NHS services reviewed in the period April 2013March 2014 represents 93.62% of the total income generated from the
provision of NHS services by the Trust for April 2013-March 2014.
2.5.1 National Clinical Audits, Confidential Enquiries and
Local Clinical Audits
During April 2013-March 2014 31National Clinical Audits and 4 National
Confidential Enquires covered services that the Trust provides
During that period the Trust participated in 100% of the National Clinical
Audits and 100% of the National Confidential Enquiries which it was eligible to
participate in
The National Clinical Audits and National Confidential Enquiries that the Trust
was eligible to participate in during April 2013-March 2014 can be found in
Appendix 4 & 5
The National Clinical Audits and National Confidential Enquiries that the Trust
participated in during April 2013-March 2014 can be found in Appendix 4 & 5
The National Clinical Audits and National Confidential Enquiries that the Trust
participated in and for which data collection was completed during April 2013March 2014 are listed in Appendix 4 & 5 alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or enquiry
51
QUALITY ACCOUNT 2013-14
The report for the two completed confidential enquiries which were reviewed
by the Trust in the period April 2013-March 2014 and the Trust intends to take
the actions described in Appendix 5 to improve the quality of healthcare
provided
The reports of 31 national clinical audits were reviewed by the Trust in the
period April 2013-March 2014 and the Trust intends to take the actions
described in Appendix 4 to improve the quality of healthcare provided
The reports of 198 local clinical audits were reviewed by the provider in the
period April 2013-March 2014 and the Trust intends to take the actions
outlined in Appendix 6 to improve the quality of healthcare provided
2.5.2 Research
The number of patients receiving NHS services provided or sub-contracted by
the Trust in the period April 2013-March 2014 that were recruited during that
period to participate in research approved by a research ethics committee was
386. (This figure does not include studies in which the Trust is a Participant
Identification Centre (PIC) only. Such studies are signposted to patients who
approach the study centre directly. A PIC is any organisation responsible for
identifying and/or informing potential participants about a study taking place in
another organisation. The other organisation is responsible for the subsequent
assessment, possible recruitment and informed consent into the study.)
Participation in clinical research demonstrates the Trust’s commitment to
improving the quality of care we offer and to making our contribution to wider
health improvement. Our clinical staff stay abreast of the latest possible
treatment possibilities and active participation in research leads to successful
patient outcomes.
The Trust was involved in conducting 131 clinical research studies, this
excludes those studies closed throughout the year and no longer active at 31st
March 2014.
There were 51 clinical staff, leading studies approved by a research ethics
committee at Southport and Ormskirk Hospital NHS Trust during 2013-14 and
taking the role of Principal Investigator. They were supported by 9 dedicated
research nurses and a large number of other staff who supported these
studies either directly e.g. co-investigators, specialist nurses or support
services e.g. pathology, pharmacy, radiology. These staff participated in
research covering 32 medical specialties. The specialities involved in these
studies are listed in Appendix 7
Research evidence shows mortality amenable to healthcare/mortality rate
from causes considered preventable in oncology continues to reduce
nationally. During this period the Trust was collaborating in oncology research
studies in sub-specialities of melanoma, breast, urology, lung, and
haematology and colorectal.
52
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
One such oncology study is the leukaemia lymphoma study which aims to
evaluate several relevant therapeutic questions in Acute Myeloid Leukaemia
(AML), and High Risk Myelodysplastic Syndrome. The trial is primarily
designed for patients over 60 years for whom conventional chemotherapy is
not considered suitable. The outcome measures of this study are mainly
complete remission, relapse and overall survival.
Commitment to clinical research leads to better treatments for patients and the
Trust is committed to encouraging participation in high quality national and
multinational studies recognising that research is vital in providing the new
knowledge needed to improve health outcomes and our engagement with
clinical research also demonstrates our commitment to testing and offering the
latest treatments and techniques.
For example:
1. TABLET A randomised trial on the efficacy of Levothyroxine treatment on
pregnant women with thyroid antibodies, the primary aim of the study being
to increase the proportion of women who attain a live birth beyond 34
completed weeks of gestation by at least 10%.
2. CGLOVES :the effectiveness of compression gloves in arthritis. This is a
collaborative study including 11 Occupational therapy units from across the
North West and the aim is to determine whether compression gloves are
effective in easing the symptoms of pain in patients with arthritis and to
determine if changes are needed to assessment and treatment of this
group of patients.
3. Clinically meaningful QoL changes in neuropathic pain. Approximately
1 in 7 (13%) of the UK population suffer from chronic pain (pain which lasts
for more than 3 months). The presence of ongoing pain affects not just the
physical aspect of the person, but can also lead to psychological
distress such as depression and anxiety. The need for effective
multidisciplinary treatment which addresses all aspects of the pain
experience is vital. The Ainsdale Community Pain Service offer patients
individualised care, taking into account the complex nature of pain
conditions. We identify what the patients' best hopes for their treatment
are, in line with our Solution Focused ethos. It is our aim to evaluate the
effectiveness of this type of treatment, that is, examining whether
increased patient choice and involvement with regard to their care impacts
positively on their wellbeing and satisfaction, (as measured by the
questionnaires and qualitative interviews).
4. AIM: Ankle Injury Management Comparison of close contact cast (CCC)
technique to open surgical reduction and internal fixation (ORIF) in the
treatment of unstable ankle fractures in patients over 60 years
53
QUALITY ACCOUNT 2013-14
5. Natural History Study of the Development Type 1 Diabetes. The aim of
this study is to learn more about how type 1 diabetes occurs. The study
will be open to close relatives of people with Type 1 diabetes within the
age range most at risk of developing the disease. This large international
collaborative study will provide information about which autoantibodies and
genetic factors are present in close relatives of people with diabetes and
should leave to a more complete overview of the factors that lead to the
development of type 1 diabetes than has been possible to obtain from
studies in individual centres. This knowledge will contribute to the
development of and implementation of prevent studies. TRIALNET
The NIHR research sponsors do not inform the Trust of any publications which
have resulted from Trust involvement in NIHR research. However, our
involvement in NIHR research shows our commitment to transparency and
desire to improve patient outcomes and experience across the NHS. Details
of publications by Trust staff can be found in Appendix 8.
2.5.3 Commissioning for Quality and Innovation Payment
Framework (CQUIN)
A proportion of Trust income in the period April 2014-March 2015 (2.5%) was
conditional in achieving quality improvement and innovation goals agreed between
the Trust and NHS Sefton (Lead Commissioner) and any person or body they
entered into a contract, agreement or arrangement with for the provision of NHS
services, through Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for April 2013-March 2014 shall be made
available electronically at www.southportandormskirk.nhs.uk before August 2013,
once full national results are received and agreement between provider and
commissioner is complete. This process ensures that a part of our income is
dependent on locally agreed quality and innovation goals which make a solid lever
with which to ensure that local quality improvement priorities are discussed and
agreed at board level within and between relevant organisations.
2.5.4 Care Quality Commission (CQC)
The Trust is required to register with the Care Quality Commission and
registration status on 31st March 2014 is without condition
The Care Quality Commission has not taken enforcement action against
Southport and Ormskirk Hospitals NHS Trust between April 2013 – March
2014
The Trust participated in an unannounced, routine inspection by the Care
Quality Commission in August 2013 to ensure that the following Essential
Standards were being met. The CQC inspected the Southport site on 29th
August and the Ormskirk Site on 30th August. The Trust was assessed for the
following outcomes and the results are detailed below:
54
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
CQC
Outcome
1
Respecting and
involving people
who use services
2
Consent to Care
and Treatment
4
Care and Welfare
of people who use
services
6
Co-operating with
other providers
8
Cleanliness and
Infection Control
13
Staffing
Southport
29.08.2013
Compliance Ormiskirk
Compliance
30.08.2013
Full
Full
Full
Full
Moderate
concern
Full
Not assessed
Full
Full
Not assessed
Moderate
concern
Full
The official report for this assessment was received in October 2013. Following this,
the Trust complied with CQC requirements and submitted an action plan on 28th
November 2013 outlining the actions being implemented to address the issues
raised. The action plan once fully implemented will be re-presented to the CQC.
During the period April 2013 – March 2014, Southport and Ormskirk Hospitals NHS
Trust has participated in an announced visit by the CQC to monitor compliance with
the Mental Health Act (MHA). This review of services took place on 17th December
2013.
Southport and Ormskirk Hospitals NHS Trust received the MHA inspection report in
January 2014 and complied with the requirements to submit and action plan to
address the issues highlighted by 11th February 2014
Southport and Ormskirk Hospitals NHS Trust’s resulting action plan show how the
Trust intends to take the following actions to address the requirements of the report:
o Improved training of Trust staff in compliance with the MHA.
o Partnership working with neighbouring Mental Health Trusts.
o Administration and detention monitoring logs.
o Improved Trust documentation for MHA.
o Clear guidance for staff relating to the MHA.
o Clarity of staff roles in relation to implementation of MHA
o Availability of MHA information for patients
o Joint working multi agency policies to be compiled
The Trust has embraced this opportunity to work more closely with the Mental Health
Trusts and sees it as a positive way forward to improve the services that can be
accessed by patients within the Trust. The action plan is due for completion of
implementation by October 2014.
55
QUALITY ACCOUNT 2013-14
2.5.5 Trust Information Governance
The Trust submitted a fully complaint IG Toolkit for 2013/14, as all individual
requirements achieved at least level 2.
Assessment
Level
0
Level
1
Level
2
Level
3
Not
Relevant
Total
Req'ts
Overall
Score
Grade
Version 11
(2013-14)
0
0
37
7
1
45
71%
95 / 132
Satisfactory
Grade
Not
Not achieved Attainment Level 2 or above on all requirements
Satisfactory
Achieved Attainment Level 2 or above on all requirements
Satisfactory
The Trust’s benchmarking position against regional NHS organisations has
strengthened with the satisfactory return. A comprehensive work programme is being
developed which will incorporate any changes in version 12 of the Toolkit to ensure
that a compliant IG Toolkit is maintained for 2014/15 and more of the standards
progress to Level 3.
The annual IG Toolkit clinical coding audit was measured against the IG Toolkit
requirement and found a good standard of coding accuracy, a summary of the result
is shown below:
Coding Field
PERCENTAGE
CORRECT 2013/2014
Primary Diagnosis
91.0%
IG TOOLKIT
REQUIREMENT
505 LEVEL 2
>=90%
Secondary Diagnosis
94.2%
>=80%
Primary Procedure
95.2%
>=90%
Secondary Procedure
88.9%
>=80%
Seven recommendations have been made following the coding audit to improve the
general standard of clinical record keeping and the coding derived from this:
•
The Trust highlights to all users of case notes the importance of filing all paper
work in the correct sections and that all sections are filed in a chronological
order in accordance with the Trusts policy;
•
Haematology pro-forma’s to be discussed in the Clinical Haematology
Meetings with examples of issues being made available. To work with Clinical
Haematology in developing a pro forma that can be used by the coding team
to ensure they capture all relevant information;
The Trust should implement a process to ensure that any Sign or Symptom is
signed off as been correct – Furthermore No patient is discharged without the
•
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
•
•
•
recording of primary diagnosis and co-morbidities signed off by the Consultant
lead;
The Trust needs to ensure that all medical staff, who are responsible for
writing in the main body of the case notes, are aware that a Primary Diagnosis
being recorded in the case notes should be verified by the consultant
responsible for the patients care. This will aid the coder in having the correct
information to code accurately and will improve data quality and aid patient
care. Patient’s Primary Diagnosis should be documented consistently on all
paperwork;
The Auditor has been told that Ward Clerks report to Ward managers - Ward
managers need to emphasise the need for accuracy when ward clerks are
entering data onto the Trusts PAS System;
Adherence to National Coding Standards needs to be emphasised. Coding
Errors need to be raised with individual coders
The Trust submitted records during the period January 2013 – December 2013 to the
Secondary Users Services (SUS) for inclusion in the Hospital Episode Statistics
which are included in the latest published data. The percentage of records in the
published data:
Which included the patient’s valid NHS number was:
o 99.0% for admitted patient care
o 99.3% for outpatient care
o 97.5% for accident & emergency care
Which included the patient’s valid general medical practice code was:
o 99.9% for admitted patient care
o 100% for outpatient care
o 99.9% for accident and emergency care
Calendar year as financial year is not available. This will also allow us to use 12 months data
consistently going forward.
•
A Payment by Results audit was deemed by the Audit Commission to be not
necessary in 2013/14.
2.6 Additional prescribed information required for 2013 / 2014
This data is presented throughout the document within the relevant domains. Up to
date data for the reporting period 2013 / 2014 was not available in all cases from the
Health and Social Care Information Centre for some indicators, and therefore where
other data sources have been used which do provide data for 2013 – 2014 the data
source is indicated.
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QUALITY ACCOUNT 2013-14
PART 3
Presented in the previous pages have been headlines of the Trust’s Quality
achievements during the reporting period. The following section gives further details
regarding quality improvement activities and achievements during the reporting
period April 2013-March 2014.
EFFECTIVENESS (measured by clinical outcome)
DOMAIN 1:
Preventing people dying prematurely
3.1
Hospital Standardised Mortality Rates (HSMR)
The HSMR only reflects deaths which occur in hospital and focuses on 80% of these
deaths. A monthly update of the HSMR is published on the Quality dashboard
highlighting any diagnosis or procedure where we are falling outside the expected
mortality rate (based on national benchmarks). Reports are submitted to Trust
Operational Quality Committee for discussion and assurance and this work is
reflected in the steadily decreasing Trust HSMR figures:
Apr 2013 – March 2014
Southport and Ormskirk Hospital
NHS Trust HSMR
2012/13 rebased
England HSMR
2012/13 rebased
99.3
111
90
100
HSMR by month
Month
HSMR
Apr 13
130
May 13
86.4
Jun 13
104.9
July 13
106.2
58
Aug 13
93.2
Sep 13
95.4
Oct 13
97.6
Nov 13
104.7
Dec 13
98.6
Jan 13
83.9
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.2
Summary Hospital Level Mortality (SHIMI)
Dr Foster also publishes data on the SHIMI and this includes those patients dying
within 30 days after discharge from hospital and includes all deaths. If a patient dies
while in hospital or within 30 days of discharge, their death is attributed to the Trust
providing care. If the patient is treated by another Trust within those 30 days, their
death will only be attributed to the last trust to treat them. Unlike the HSMR the
SHIMI makes no allowance for palliative care. This is also being monitored monthly
on the Quality dashboard and Trust progress can be seen below. This is a fairly new
indicator and the Trust is working to achieve a greater understanding, however
pleasingly this is also showing a downward trend.
Prescribed information: Southport and Ormskirk Hospital NHS Trust considers that this
data is as described for the following reasons: All activity data is submitted by the Trust to
Secondary Users Service (SUS) in line with national mandated requirements complying with
data definitions as per the Data Dictionary.
SHIMI
Southport & Ormskirk NHS Trust
Southport & Ormskirk NHS Trust
Banding
England
Highest Performing Trust
Lowest Performing Trust
2011/12
102.88
Oct11 - Sept 12
104.06
As Expected
100
71.02
124.75
As Expected
100
68.49
121.07
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QUALITY ACCOUNT 2013-14
Data from the Information Centre
Southport and Ormskirk Hospital NHS Trust has taken the following actions to improve
this score and so the quality of its services, by the following :
Weekly Mortality Audits are undertaken by a team of senior nurses and doctors from
Integrated Governance and includes coding checks. All deaths are also audited by
the palliative care team. This enables real-time feedback to the clinical staff involved
in the patient’s care and where required information to their clinical/professional
supervisors enabling effective reflection and discussion on the care they have given.
The SHMI makes no adjustments for palliative care. The table below gives a
measure of the palliative care provided by the Trust reported in the SHMI.
Prescribed Information
The percentage of patient deaths with palliative care coded
at either diagnosis or specialty level:
2011/12
23.70%
17.94%
44.20%
0.00%
Southport & Ormskirk NHS Trust
England
Highest Performing Trust
Lowest Performing Trust
Oct11 - Sept 12
21.80%
18.94%
43.30%
0.20%
Data from the Information Centre
3.3
Advancing Quality
The Advancing Quality (AQ) programme commenced in 2008 and is facilitated by
AQuA, Advancing Quality Alliance, and aims to give patients a better experience of
the NHS by ensuring the highest standards of care are consistently delivered. The
programme measures quality across a number of clinical process and outcome
measures which currently focus on: Acute Myocardial Infarction, Heart Failure, Hip
and Knee joint replacement, Community Acquired Pneumonia and Stroke.
The main principle of the programme is to ensure, based on pathways agreed by
upon by experts in each specialty, the best outcome for patients suffering from these
conditions. This is monitored in respect of providing the correct care at the correct
time within their respective clinical pathway.
The programme is a regional scheme and forms a collaboration involving the majority
of NHS Trusts across the NW England. The AQ programme offers the opportunity for
clinical leads to meet on a regular basis and via a virtual network to share best
practice, with the patient at the focus of their discussion and practice.
BEST CLINICAL OUTCOME FOR PATIENTS
Evidence shows that when patients receive all elements of a clinically defined ‘care
bundle’ that they experience a better clinical outcome and a better overall
experience. Each of the focus groups has a number of clearly defined measures /
interventions that are considered as separate entities but together form the care
bundle.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
AQ MEASURES
For this Trust, during the period of 2012/13, overall performance was assessed using
a ‘Composite Process Score’ for each of the following focus area.
• Acute Myocardial Infarction (Heart Attack)
• Heart failure
• Hip & Knee Replacement
• Community Acquired Pneumonia
• Stroke
Each individual intervention within the focus areas is calculated as percentage
compliance based on the number of patients eligible for that intervention and those
patients who correctly received that intervention.
A Composite Process Score (CPS) is an aggregated delivery of several clinical
processes
An Appropriate Care Score (ACS) is all measures passed for an individual patient
Based upon validated available data provided by AQUA, the table below
demonstrates the performance of the Trust in the 5 clinical areas in which it is
currently involved.
Stroke
AMI
Heart Failure
Pneumonia
Hip & Knee
Actual Care Score
11/12
Actual
Target
50.1%
Composite Process Score
Actual Care Score
90.1%
97.8%
85.0%
Composite Process Score
Actual Care Score
98.9%
75.0%
95.0%
Composite Process Score
Actual Care Score
88.7%
65.1%
89.0%
Composite Process Score
Actual Care Score
90.1%
91.4%
95.0%
Composite Process Score
97.7%
95.0%
12/13
Actual
Target
47.7%
88.7%
100.0%
85.0%
100.0%
74.8%
95.0%
88.6%
67.4%
95.0%
89.5%
93.7%
95.0%
98.3%
95.0%
13/14 YTD*
Actual
Target
43.1%
53.6%
86.8%
95.2%
95.0%
96.8%
77.2%
71.0%
89.1%
74.7%
65.4%
90.9%
78.3%
82.1%
91.4%
*Discharges to end November 2013
Areas of non-compliance remain consistent; and in the main, are due to the
increasing capacity within the Acute Trust and subsequent pressures on the system
as a whole and some inconsistencies in clinical management. Increasing numbers of
patients within each data set, along with the new ‘live’ measures introduced in April
2012 within the areas of AMI, Heart Failure and Hip/Knee have been challenging.
The Trust continues to strive for excellence, and in order to maintain a consistently
high level performance, monthly reports of compliance and missed opportunities are
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QUALITY ACCOUNT 2013-14
sent to the respective clinical teams, highlighting areas where standards of practice
or ways of working may need review in order to achieve a higher compliance rate.
Where appropriate, meetings are held on an individual basis with responsible
Clinicians to ensure consistent interpretation of measures and any actual or
proposed changes to measures
It is acknowledged that a single area of failure can have detrimental impact on the
overall scoring against the quality measures; however this should not detract from
the overall experience that the patient has; accounted for by compliance within other
measures. An example of this is that during this time period, the Trust has
consistently struggled with the target of stroke patients reaching the Acute Stroke
Units within 4 hours of arrival at the hospital due to competing pressures for acute
beds; however the Trust scored an equivalent of 93.9% composite process score
across all other measures within that data set, demonstrating that the majority of
patients still received the recommended care pathway albeit in a different areas of
the hospital. In focus areas such as Acute Myocardial Infarction, due to the small
number of patients eligible for inclusion following those transferred to tertiary centres
for Primary PCI, a failure in a single patient can impact negatively on the overall
compliance.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
CHANGES POST APRIL 2013
A number of additional indicators and changes to existing indicators were introduced
with effect from 1st April 2013 into the focus areas of AMI, Heart failure and Hip &
Knee replacement requiring the clinical teams to review their practices and agree
changes and clinical protocols where necessary, this has been particularly evident in
respect of thromboprophylaxis in hips and knee replacement surgery.
With effect from the April 2013 discharges, Trust performance is solely monitored
against the Appropriate Care Score, which requires all individual measures to be
passed, as opposed to previously where the aggregated score was used. This has
been reflected within the Commissioning for Quality & Innovation (CQUIN) threshold.
The data below shows a summary of the performance year to date against each of
the CQUIN Thresholds.
Based on November 2013 discharges the following position applies
Focus Area
Quality Contract
Threshold
Current ACS %
(YTD)
Contract Threshold
Achieved
(Based on YTD ACS)
AMI
HEART FAILURE
PNEUMONIA
STROKE
HIP & KNEE
95%
71%
65.4%
53.64%
82.02%
95.15
77.19
74.71
43.10
78.32
X
X
FUTURE PLANS
During 2014/15 the Trust will continue to circulate monthly ‘missed opportunities’
reports to enable clinicians to review performance and implement changes to
improve the quality of care in a timely manner. This will be complemented by the
planned reduction in reporting timescales from the Advancing Quality Team to enable
provision of more ‘real time’ analysis
Trust Clinicians will utilise data from the recently released performance dashboards
which show a number of indicators for each of the focus areas such as Length of
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QUALITY ACCOUNT 2013-14
stay, mortality, readmission rates etc. to provide a more ‘rounded approach’ to the
outcome analysis
Local ownership and accountability for focus areas is being actively promoted and
lead healthcare professionals are being encouraged to attend the North West
collaborative meetings so that best practice from our own and other organisations
can be shared and adopted across the Region
Continuation of training for all medical staff and amendments / development of
clinical pathways is vital in order for them to adopt the principles of ‘best practice’.
This is encouraged through local induction and formal specialty audit/ teaching.
DEVELOPMENT OF ‘NEW’ CLINICAL FOCUS AREAS
A series of measure sets for new clinical focus areas are due to be introduced during
2014, these include:
• COPD
• Fractured neck of femur (Hip Fracture)
• Acute kidney injury
• Sepsis
• Diabetes
• Alcohol related liver disease
The introduction of these additional measure sets will add to the challenges already
being faced by the Trust, however discussions are underway with relevant clinical
groups in respect of the individual measures and the need for them to review clinical
pathways and provide assurance that they meet the standards. Where there are
deficiencies, the clinical groups are being advised to review and make amendments
to practice as necessary.
AUDIT
The Trust was audited for quarters one and two of 2013/14 by external auditors,
Grant Thornton. The AQ Data Assurance audit assures the Clarity data through a
combination of statistical risk assessment and case note review. The risk rating for
this audit was based on the data accuracy findings from the previous two years of
audit. This confirmed the Trust is in the low risk category for each clinical area and
sample sizes were reduced accordingly.
From 2013/14, Trusts' data accuracy scores include all passed, and failed and
excluded measures which raises the quality standard from previous years when
Trusts public reporting and eligibility for CQUIN payment were based on only the
passed measures.
Grant Thornton testing of Clarity data to the underlying patient case notes identified a
small number of errors which were discussed and agreed during the audit. The
results of the quarter one and two audit confirm that the Trust is on target to meet the
80% data accuracy score for each clinical area for the whole of 2013/14 with an
overall conclusion that
• The data in medical records, underpinning the measures of performance
reported in Clarity Assure System, is robust and reliable
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
•
The data has been prepared in accordance with relevant requirements and
guidance.
DOMAIN 2: Enhancing quality of life for people with
long-term conditions
3.4
National Service Frameworks
National Service Frameworks (NSFs) are long-term strategies for improving specific
areas of care. They set measurable goals within set time frames. They are only
applicable to the NHS in England. National Service Frameworks:
•
•
•
•
Set national standards and identify key interventions for a defined service or
care group
Put in place strategies to support implementation
Establish ways to ensure progress within an agreed time scale
Form one of a range of measures to raise quality and decrease variations in
service
Within the Trust we have an ongoing process for reviewing our progress against the
national service frameworks and monitoring implementation. Any areas of noncompliance are recorded through our risk registers.
3.5
Care Closer to Home
The Community and Continued Care Business Unit have completed a skills audit
within the District Nursing team in order to establish the current level of skill needed
by band 2 to and 7 staff. Also, a workload and dependency audit has been completed
which has provided information relating to the workload of the staff when compared
to regional and national teams. This work will assist workforce planning in the service
and also service and business sustainability plans. Work completed to date also
includes development of District Nursing care plans, community matron management
plans, core assessment documentation which is standardised across the District
Nursing and Community Matron Service.
The Chronic care team have also refreshed their nursing documentation which
enables clinical judgement to be used when undertaking clinical consultations
ensuring patient safety is supported by clinical reasoning and judgement. The chronic
care staff also in reach onto the ward prior to discharge introducing themselves and
the service to patients, identified by the LACE score , for follow up by the chronic
care team
Audit work has been strengthened in the last year including completion of patient
surveys in Stoma , Continence , Diabetes and Intermediate Care . A Service
evaluation audit has been completed in the chronic care team establishing if the
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QUALITY ACCOUNT 2013-14
standards set for the met., providing pleasing results. A representative from
Community & Continued CBU attends regional AQUA events sharing and learning of
examples of good practice relating to the patient experience
Extensive recruitment has taken place in the Community Emergency Response
Team in order to support early supported discharge when patients are medically
optimised for discharge into a range of settings including their home , nursing or
residential care home when discharged from the Frail Elderly Short Stay Unit
During 2013/14 evidence based clinical pathways have been developed or
redesigned to operate across primary and secondary care. These clinical pathways
have been developed in collaboration with partner agencies and designed to ensure
that all patients receive the best quality of care and a consistent seamless
experience. A number of long-term conditions were prioritised for clinical pathway
development, which included the introduction of ‘Rescue Plans’ for when health need
escalates and the skills and competencies required to deliver the new clinical
pathways. For example, the Cardiology pathways require the deployment of
specialist heart nurse practitioners, which have been introduced in West Lancashire.
The clinical pathways that have been developed and are now being implemented,
are listed below.
Cardiology
• Heart Failure
•
Atrial Fibrillation
Frail Elderly
• Nursing Home
•
Crisis
•
Community
End of Life
• Advanced Care
Planning
Dementia
• Diagnosis
Respiratory
• COPD Diagnosis
Diabetes
• Foot Attack!
•
COPD
Exacerbation
•
Management of
Established
COPD
•
Crisis
•
Prevention
•
Primary Care
•
Acute
DOMAIN 3
Helping people recover from episodes of ill health following injury
“Care as Care Should Be”
3.6
Matron’s Checklist/ Nursing Indicators
From June 2013 the “Care As Care Should Be” Audit was superceded by the new
Matrons Checklist that provides realtime feedback on key metrics. These metrics
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
may change over time but the data collection and reporting strcuture has been
streamlined to enable it to be ‘realtime’ and easier to understand.
97.9%
99.3%
98.6%
99.%
97.1%
99.3%
99.4%
99.5%
98.9%
95.9%
99.5%
99.3%
Grand Total
98%
99%
97.9%
Safeguarding and Mental Capacity
99.5%
97.9%
Professional Standards
93.8%
96.9%
Privacy and Dignity
87.1%
95.1%
97.8%
Patient Safety Checks
95.3%
94.6%
Patient Observations
96.8%
Q4
97.1%
Patient Experience and Information
Q3
98.8%
Nutrition and Hydration
93.1%
Medicines Management
End of Life
92.7%
Infection Control
Documentation - Pressure ulcers
97.3%
General Documentation
Documentation - Patient Falls
Q2
Environment
Row Labels
Overall Trust Results
98.1%
97.8%
98.8%
96.8%
97.6%
98.2%
100%
99.8%
98.3%
98.6%
97.8%
99.8%
99.9%
98.1%
98.4%
Matrons Checklist Q2-4
Documentation - Patient Falls
Environment
Medicines Management
Patient Observations
Professional Standards
Documentation - Pressure ulcers
General Documentation
Nutrition and Hydration
Patient Safety Checks
Safeguarding and Mental Capacity
End of Life
Infection Control
Patient Experience and Information
Privacy and Dignity
100%
95%
90%
85%
Q2
Q3
The RAG rating has been set as:
<95% Green >95% Amber > 90% Red.
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Q4
QUALITY ACCOUNT 2013-14
Key Improvements
•
•
•
•
•
•
3.7
The revised Matrons Checklist has been formatted to make it easier to use.
Data is collected onto the Matrons IPADs which enables interpretation quickly
and accurately. Due to the IPADs versatility data collection is more robust.
Matrons checklist results are action planned through each Clinical Business
unit
The questions within the “New” Matrons Checklist have been revised to reflect
changes in key national and local strategies and include key metrics that were
not included in the previous Matrons checklist.
This includes bespoke measures relating to specific areas such as maternity
and Theatres.
Prior to the new checklist, scores for the Matrons checklist were high, however
this did not always reflect other measures of quality of care that were reported
through the trust.
Nutrition and Hydration
• Review of available patient weighing equipment in the trust is underway Jan
2014. This information will be reported to the Director of Nursing’s office to
establish if there are any barriers in place to prevent all patients being
weighed within 24Hrs of admission.
• The Nutrition Group reviews the results of both the Matrons checklist and the
Friends and family Tests and will implement changes across the organisation
using this intelligence.
• Throughout Q4, the information team will continue to develop and strengthen
the reporting process.
• Support will be provided to the clinical business units to drill down to specific
metrics in real-time which will in turn provide the Trust with any trend
information and targets for improvement.
3.8 Nurse Education
Nurse education is currently going through unprecedented changes in light of reports
such as Francis and Keogh.
The Department Of Health published ‘Liberating the NHS: Developing the
Healthcare workforce: From Design to Delivery’
This led to the development of Health Education England (HEE). HEE has regional
groups known as Local Education and Training Boards. (LETB).
The focus is on linking quality improvements in patient care and delivery to education
and learning. This was encompassed in the Education Outcome Framework (EOF).
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
The EOF will directly link education and learning to improvements in patient care and
health outcomes thereby ensuring the health workforce has the right skills,
behaviours and training available in the right numbers to support the delivery of
excellent healthcare and health improvement.
Central to this development are the following 5 domains:
1/ Excellent Education
2/ Competent and capable workforce
3/ Flexible workforce receptive to research and innovation
4/ NHS values and behaviours
5/ Widening Participation
The EOF will apply to the healthcare system as a whole and is intended to measure
progress in improvements in education, training and workforce development. This
will determine how this impacts on the quality and safety of services for patients.
The EOF will act as a catalyst for driving quality improvement and outcome
measurement throughout the NHS by encouraging a change in culture and
behaviour. The outcomes will provide effective, safe and excellent experience for
patients.
The Trust
The Trust has risen to the challenges presented by the above and implemented
supportive programmes to support National Work streams.
There is an 18 month Preceptorship Programme that is aimed at newly qualified
nurses. Nurses with a break in practice of 5 years or more or those who are new to
the Trust and want extra support are also welcome.
A similar programme exists for the existing band 5 workforce.
The Preceptorship Programme has been well received by the local Universities. The
trust is now moving forward to accreditation with one of the local universities and for
endorsement by the Royal College of Nursing.
Registered Nurse Development Study Days
There is a full programme of study sessions aimed at the nursing and health care
workforce.
The RN Acute Care Workshops continue on a monthly basis. These are aimed at
registered nurses of all grades and have been developed to provide a safe
environment for learning and development. They aim to enhance the nurse skills in
managing acutely ill adult patients in a timely manner, incorporating scenarios and
basic simulation.
The feedback from all staff attendees has been extremely positive. Many staff take
the opportunity to discuss their own professional issues.
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QUALITY ACCOUNT 2013-14
The workshops provide each nurse with the opportunity to increase their knowledge
and discuss the most current issues in acute care. This includes reviewing evidence
based care and identifying methodologies that can assist with this.
The practical sessions look at the importance of completing charts correctly, care
planning and prioritising while emphasis is placed on the patient being at the centre
of all care.
The Trusts Quality Strategy ‘Right first time, every time’ has been incorporated into
the opening session. The final session discusses SCOPE and the Professional
mandatory standards. The nurses are encouraged to discuss what this means for
them and the difficulties they face in delivering this. They are encouraged to explore
and identify changes they could make to their area and practice.
The Registered Nurse Annual Updates have been reviewed and modified to include
Professional values, clinical updates and Point of care sessions.
Health Care Assistants
The Cavendish Review was published in 2013. This report reviewed the role of
HCAs and support workers in the NHS. There were over 18 recommendations in the
report. Recruitment, training and education are one of the key themes in the review.
It was suggested that all HCAs and support workers have a career pathway that will
develop and enhance their skills as they progress.
A key recommendation is the development of a ‘Fundamental of care certificate’ and
that all HCAs should have this before they are allowed to work unsupervised.
Employers are also advised to develop recruitment programmes that are based on
values, attitudes and aptitudes towards caring.
This is in development with further action and guidance expected in summer 2014.
In preparation for this the Trust has developed a 2 day PEACH (Patient Emergency
Assessment Course for HCAs) course for Health Care Assistants. This consists of 2
days classroom based training about acute care delivery.
These sessions also include sessions on Learning Disabilities, Professional values,
SCOPE, role definition as well as numeracy and literacy assessments.
The trust is currently in discussion with local Further Education Colleges and
Universities to develop the HCA role with a more practical focused curriculum. This
will result in a Higher National Certificate or a Higher National Diploma. This will be
available alongside the Assistant Practitioner Foundation Degree.
The trust works closely with NHSP recruiting local people who wish to work in the
NHS but do not have experience. They are recruited in line with the 6C’s and Trust
Values. They work through a six month Health Care Support Worker Development
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Programme. They are assigned to a ward/department and have an identified mentor
who works alongside the Support worker as they progress.
We aim to have 3 cohorts of Health Care Support workers throughout the year.
Regular updates are issued in team brief and in the Development of a Health Care
Support Worker quarterly newsletter
3.9
NICE Quality Standards
The National Institute for Health and Care Excellence (NICE) produces concise sets
of statements designed to drive and measure priority quality improvements within a
particular area of care which are titled Quality Standards.
These quality standards are developed independently by NICE (in addition to the
NICE guidance which has been in place for many years), in collaboration with NHS
and social care professionals, their partners and service users with the aim of
assisting health care professionals to make decision about care based on the latest
evidence and best practice. The standards also assist service providers to quickly
and easily examine the performance of their organisation and assess improvement
in standards of care they provide.
Within Southport and Ormskirk Hospitals we have a process of reviewing all quality
standards produced by NICE as they are published and assess our performance
against the standards of care. The outcome of the reviews (gap analysis) is reported
to the Trust Operational Quality Committee. Trust progress is list below:
QS No
Title
Current
Status
QS No
QS001
Dementia
QS30
QS002
Stroke
QS31
QS003
QS006
Venous
Thromboembolism
Specialist Neonatal Care
Chronic Kidney disease
in adults
Diabetes in Adults
QS007
Glaucoma
QS36
QS008
QS009
Depression in Adults
Chronic Heart Failure
QS37
QS38
QS010
Chronic Obstructive
Pulmonary Disease
(COPD)
Alcohol dependence and
QS004
QS005
QS11
Risk Register
Risk Register
Title
QS32
Supporting people to
live well with
dementia
Health and well being
of looked after
children
C-Section
QS33
QS34
Rheumatoid Arthritis
Self Harm
QS35
Hypertension in
pregnancy
Urinary tract infection
in infants, children
and young people
under 16
Postnatal Care
Acute Upper GI
Bleeding
Attention Deficit
Hyperactivity
Disorder
Psoriasis
QS39
QS40
71
Current
Status
QUALITY ACCOUNT 2013-14
QS No
Title
Current
Status
QS No
QS12
harmful alcohol use
Breast Cancer
QS13
End of Life Care in Adults
QS14
Service user experience
in adult mental health
QS15
QS16
Patient experience in
adult NHS services
Hip fracture
QS17
Lung Cancer
QS18
Ovarian Cancer
QS19
QS20
QS21
Bacterial meningitis and
meningococcal
Septicaemia in children
and young people quality
standard
Colorectal Cancer
Stable Angina
QS22
QS23
Antenatal Care
Drug use disorders
QS24
Nutritional Support in
Adults
Asthma
Epilepsy in adults
QS53
Epilepsy in children and
young people
Hypertension
Diagnosis and
management of venous
thromboembolic diseases
QS56
QS25
QS26
QS27
QS28
QS29
QS41
QS42
(Sept)
QS43
(Sept)
Risk Register
QS44
(Sept)
QS45
(Sept)
QS46
(Sept)
QS47 (Oct)
QS48 (Oct)
QS49 (Oct)
QS50
Risk Register
QS51 (Jan)
QS52 (Jan)
QS54
QS55
QS57
Title
Familial
Hypercholesterolaemi
a
Headaches in Young
People and Adults
Smoking Cessation:
Supporting people to
stop smoking
Atopic eczema in
children
Lower urinary tract
symptoms in men
Multiple Pregnancy
Heavy Menstrual
bleeding
Depression in
children and young
people
Surgical Site Infection
Mental Wellbeing of
Older people in care
homes
Autism
Peripheral Arterial
Disease
Anxiety Disorders
Faecal Incontinence
Children and young
people with cancer
Metastatic Spinal
Cord Compression
Neonatal Jaundice
Action Plan in
Progress
Key
Gap Analysis / Action Plan overdue
Action Plan in Progress or Added to Risk Register
Compliant / Await Initial Gap Analysis within timescale
N/A to the trust
72
Current
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.10 Trauma Audit and Research Network (TARN)
Since August 2010 the Trust has been a member of the Trauma Audit and Research
Network and has completed all of the audit information required. The aim of the
project is to collect accurate and relevant information to help doctors, nurses and
managers improve their services in trauma care.
The Trust has a Trauma Care Delivery Group where trauma care within the hospital
is discussed and, as part of this group, action plans are compiled that aim to improve
future trauma care and to aid our hospital’s Accident & Emergency department in
being accredited as a trauma unit. There is also a multidisciplinary trauma audit
group, at this meeting TARN and the other trauma audits being carried out within the
Trust are presented and discussed.
Southport hospital’s Accident and Emergency department has been awarded full
accreditation status to be a trauma unit 24 hours a day seven-days a week with
revalidation being carried out in March 2014. With this comes the responsibility to
care for some patients suffering from a traumatic injury before they are transferred to
the regional trauma centre for more extensive treatment.
In 2013 we set a goal to achieve all our data accreditation targets for data input to
TARN by March 2014. We currently sit at 98.2% for our data accreditation which is a
3.8% improvement on 2012. The requirement for data accreditation is a 0.5%
increase per year and we achieved this target due to the hard work and data quality
initiatives introduced by our TARN team.
Southport & Ormskirk hospital NHS Trust TARN Data Completeness *
Completeness of Data 2011
Completeness of Data 2012
Completeness of Data 2013
72%
94.3%
97.1%*
*As at 30/04/2014 – Data entry completes in June 2014
There is a website for the project www.tarn.ac.uk
3.11 Patient Reported Outcome Measures-PROMS
Patient Reported Outcome Measures (PROMs) are a means of collecting information
on the effectiveness of care delivered to NHS patients as perceived by the patients
themselves.
PROMs comprise of a pair of questionnaires completed by the patient, one before
and one after surgery (at least three months after for groin hernia and varicose vein
operations, or at least six months after for hip and knee replacements). Patients’ selfreported health status (sometimes referred to as health-related quality of life) is
assessed through a mixture of generic and disease or condition-specific questions.
73
QUALITY ACCOUNT 2013-14
EQ-5D-3L: Comprises of 5 qualitative dimensions: mobility, self-care, usual activities,
pain/discomfort and anxiety/depression. Each dimension has 3 levels: no
problems, some problems, extreme problems
The respondent is asked to indicate his/her health state by ticking (or
placing a cross) in the box against the most appropriate statement in each
of the 5 dimensions.
EQ VAS: The EQ VAS records the respondent’s self-rated health on a vertical,
visual analogue scale which can be used as a quantitative measure of
health outcome as judged by the individual patient - ‘Best imaginable
health state’ and ‘worst imaginable health state’.
Using source data available through the NHS Information Centre the following
reports show performance based on four common elective surgical procedures: groin
hernia operations, hip replacements, knee replacements and varicose vein
operations.
The data below shows the position of the Trust against England as a whole.
However, because of the inherent time-delay before post-operative questionnaires
are completed, returned, scanned and processed, many organisations, including this
Trust currently have few or no post-operative questionnaires available for analysis.
Consequently, there is little data available for April 2013 onwards at this time for
analysis. Therefore, as the latest data released in December 2013 contains nothing
for procedures carried out since April 2013, this summary only contains the
‘refreshed and updated’ data for 2012/13.
EQ-5D-3L (April 2012 – March 2013)
Southport & Ormskirk NHS Trust
Groin Hernia
Varicose Vein
Hip replacement
Knee Replacement
England
Groin Hernia
Varicose Vein
Hip replacement
Knee Replacement
Number of
Returned
Responses
92
37
91
113
Number
Reporting
Improvement
39
21
76
89
% Reporting
Improvement
42.4%
56.8%
83.5%
78.8%
Number
Reporting
Same
38
11
6
11
%
Reporting
Same
41.3%
29.7%
6.6%
9.7%
No.
Reporting
Worse
15
5
8
13
%
Reporting
Worse
16.3%
13.5%
8.8%
11.5%
Number of
Returned
Responses
18202
3981
26658
29165
Number
Reporting
Improvement
9154
2104
23892
23544
% Reporting
Improvement
50.3%
52.9%
89.6%
80.7%
Number
Reporting
Same
5831
1220
1444
2800
%
Reporting
Same
32.0%
30.6%
5.4%
9.6%
No.
Reporting
Worse
3217
657
1322
2821
%
Reporting
Worse
17.7%
16.5%
5.0%
9.7%
Graphs below show the response rate for Southport & Ormskirk Hospital NHS Trust
as compared to England for each of the surgical procedures
74
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Hernia (April 2012 – March 2013)
Varicose veins (April 2012 – March 2013)
Hip Replacement (April 2012 – March 2013)
75
QUALITY ACCOUNT 2013-14
Knee Replacement (April 2012 – March 2013 Refreshed)
EQ-5D VAS (April 2012 – March 2013)
Southport & Ormskirk NHS Trust
Groin Hernia
Varicose Vein
Hip replacement
Knee Replacement
Number of
Returned
Responses
99
40
93
118
Number
Reporting
Improvement
36
21
57
60
% Reporting
Improvement
36.4%
52.5%
61.3%
50.8%
Number
Reporting
Same
14
8
12
12
%
Reporting
Same
14.1%
20.0%
12.9%
10.2%
No.
Reporting
Worse
49
11
24
46
%
Reporting
Worse
49.5%
27.5%
25.8%
39.0%
Number of
Returned
Responses
18722
3998
25705
28065
Number
Reporting
Improvement
7064
1662
16900
15479
% Reporting
Improvement
37.7%
41.6%
65.7%
55.2%
Number
Reporting
Same
3417
647
2488
3335
%
Reporting
Same
18.3%
16.2%
9.7%
11.9%
No.
Reporting
Worse
8241
1689
6317
9251
%
Reporting
Worse
44.0%
42.2%
24.6%
33.0%
England
Groin Hernia
Varicose Vein
Hip replacement
Knee Replacement
Graphs below show the response rate for Southport & Ormskirk Hospital NHS Trust as
compared to England for each of the surgical procedures.
Hernia (April 2012 – March 2013)
76
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Varicose Veins (April 2012 – March 2013)
Hip Replacement (April 2012 – March 2013)
Knee Replacement (April 2012 – March 2013)
77
QUALITY ACCOUNT 2013-14
ANALYSIS
The tables below show the % variance from National average for both sets of scores
EQ-5D-3L
Data below indicates that for Groin Hernia and Varicose Veins, taking account the
subjectivity of responses, patients having their surgery through Southport & Ormskirk
Hospital Trust report a more positive outcome than the national average, whereas
those undergoing Hip and Knee replacement surgery show a slightly worse position.
% variance from National average EQ-5D-3L
Reporting Worse
variance
Groin Hernia
Varicose veins
Hip Replacement
Knee replacement
1.4
3.0
-3.8
-1.8
EQ VAS
Data below indicates that for Varicose Veins, taking account the subjectivity of
responses, patients having their surgery through Southport & Ormskirk Hospital Trust
report a more positive outcome than the national average, whereas those undergoing
Groin Hernia surgery and Hip & Knee replacement surgery show a slightly worse
position.
% variance from National average EQ-VAS
Reporting Worse
variance
-5.5
14.7
-1.2
-6.0
Groin Hernia
Varicose veins
Hip Replacement
Knee replacement
Information is circulated to clinical teams for scrutiny. A new online analysis and
reporting system was introduced to Trusts early 2014 to enable a locally focussed
analysis and creation of reports which will form a regular component of the speciality
audit programmes. Whilst it is acknowledged that PROMS outcomes are subjective
and can be influenced by a number of factors including age, socio economic status
etc., it is important for the Teams to determine whether there is any relationship
between outcome and individual surgeons, techniques etc and it is hoped that the
ability to ‘drill down’ further into the statistical results will enable this and identify any
changes to practice that may be required.
Now that processes to collect and interpret proms data have been improved and
embedded the patient experience measures are going to be taken forward by the
patient experience group to ensure that failings/areas for improvement are addressed
and monitored.
78
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.12 Readmissions
Throughout 2013 / 2014 the Integrated Care Organisation has continued to develop
and there is a great deal of work going on with pathways of care for these patients
and the development of a number of new initiatives described throughout this
document.
Prescribed information: Southport and Ormskirk Hospital NHS Trust considers that
this data is as described for the following reasons All activity data is submitted by the
Trust to Secondary Users Service (SUS) in line with national mandated requirements
complying with data definitions as per the Data Dictionary.
Information centre provides only data on 0-15 and 16+ for re admissions
2009/10 2010/11 2011/12
0-15
16 +
Southport & Ormskirk NHS
Trust
England
Highest Performing Trust*
Lowest Performing Trust*
Southport & Ormskirk NHS
Trust
England
Highest Performing Trust*
Lowest Performing Trust*
10.80%
10.01%
6.33%
14.20%
12.41%
10.01%
5.87%
13.78%
11.31%
10.01%
5.10%
13.58%
11.06%
11.18%
7.34%
13.30%
11.17%
11.43%
7.68%
13.00%
11.05%
11.45%
8.96%
13.50%
*Medium Acute Trusts only
*Please note the latest figures from the NHS Information Centre are for 2011/12
Southport and Ormskirk Hospital NHS Trust has taken the following actions to
improve this percentage and so the quality of its services, by the following actions:
•
•
•
•
Implementation of an Admissions Avoidance Group to action plan and
monitor all related issues and projects within Emergency Care and the
Community areas.
Development of the Care Closer to Home model.
Expansion and development of a robust discharge planning team.
Review of Dr Foster data on readmissions and audit where appropriate.
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QUALITY ACCOUNT 2013-14
3.13 PATIENT EXPERIENCE
(Care must be personalised, dignified, respectful and compassionate)
DOMAIN 4:
Ensuring people have a positive experience of care
3.13.1 Responsiveness to the Personal Needs of the Patient
The data below was as a result of the 5 questions below asked through the National
Inpatient Survey and one formed the basis for one of the national CQUINs.
Q32 Were you involved as much as you wanted to be in decisions about your care and
treatment?
Q34 Did you find someone on the hospital staff to talk to about your worries and fears?
Q36 Were you given enough privacy when discussing your condition or treatment?
Q56 Did a member of staff tell you about medication side effects to watch for when you went
home?
Q62 Did hospital staff tell you who to contact if you were worried about your condition or
treatment after you left hospital?
Southport and Ormskirk’s results from the National Patient Survey are as
below and the
2009/10
Southport & Ormskirk NHS Trust 66
England Average
66.7
Highest Performing Trust
81.8
Lowest Performing Trust
58.3
Obtained from the Information Centre
2010/11
63.9
67.3
82.6
56.7
2011/12
63.7
67.4
85
56.5
2012/13
62.2
68.1
84.36
57.43
2013/14
74.8
76.9
Prescribed information: Southport and Ormskirk Hospital NHS Trust considers
that this data is as described for the following reasons: It is co-ordinated centrally
for all trusts by an External source.
Southport and Ormskirk Hospital NHS Trust has taken the following actions to
improve this score and so the quality of its services, by the following actions :
•
Expansion through to the emergency and outpatient areas, of Hospedia real
time feedback systems to enable more timely feedback and action planning.
Plans are in place to extend to community clinics.
•
Implementation and embedding of a Patient Experience Strategy which
concentrates on Patient Feedback Trustwide.
•
The Patient Experience Group monitors the all strands of the Patient’s
Experience and the actions taken to improve. This committee reports to Trust
Board through the “Care as Care should be” reports.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.13.2 Patient Experience in the Community
Community and Continued Care have completed patient surveys in the Continence ,
Intermediate care Stoma and Diabetes service which has provided information
relating to the patients experience including involvement in decisions relating to their
care, treatment received, information shared with them, support and advice regarding
medications, advise on who to contact should they have any worries or fears and if
arrangements were explained to them regarding how to make complaint should this
be necessary. Consistently , the patient surveys revealed that patients were happy
to recommend the individual service to family and friends
The 15 step Challenge is a more in-depth survey for patients receiving home visits
from community teams with the patient having the choice of a home visit , telephone
discussion or email correspondence when gathering information related to their
experience of community health service provision . The information collected focuses
on four themes which included if the patient felt the visiting health professional was
well prepared when undertaking the visit and had an understanding of their health
and social care needs , introducing themselves in a professional way . Theme two
focused upon the patient feeling safe and care , theme three focused upon the
patient being involved in their care with the forth theme focussed upon how well the
staff communicated to the patient and whether they felt listened to. To date pleasing
results have been shared related to care provided by Hants Lane District Nursing
Service within all four domains
A representative from Community and Continued Care is attending Aqua events
relating to the sharing of patient stories and is sharing examples of evidenced based
tools used when attending the events and which are to be implemented when
completing patient experience work
3.13.3 Patient Experience Strategy and Group
2013/14 has seen the embedding of the Patient Experience Strategy which has
been ratified and agreed by Trust Board. This strategy focuses mainly on patient
feedback and is closely linked to the Quality Strategy.
The Patient Experience Group has continued to develop throughout the year and
Trust Shadow Governors are now attending.
3.13.4 Patient Experience Events
During 2013 /14 Southport and Ormskirk organised 4 patient experience events
called “In Your Shoes” where staff listened to patients , carers and families to
understand their current experience and how they want things to be in the future.
The objectives of the project were to:
• Deliver a series of structured, Trust wide engagement activities focused on
listening to patients and their families and carers.
81
QUALITY ACCOUNT 2013-14
•
•
•
Distil outputs from the listening events into clear improvement priorities
developed co-operatively with patients and front line staff.
Establish momentum for on-going listening to patients through, and beyond,
the Trust’s upcoming Foundation Trust Application.
Transfer skills to Trust leaders to enable to the Trust to carry on listening to
and engaging patients beyond this intervention.
From the events priority themes emerged which have been included in an action plan
for improvement which is being monitored through the Trust Patient Experience
Group: The improvement priorities include:
• Appropriate nutrition and hydration
• Timely and adequate pain relief
• Answering call bells and comfort rounds
• Compassionate and appropriate care of patients with dementia and
involvement of their carers
• Involving and informing patients
• Involving families and carers
• Support groups for parents and families of children with particular long term
conditions
• Need for more consistent introductions and welcomes
• Attitudes and behaviours
• Welcoming complaints and concerns
• Weekend cover, particularly access to doctors
• Night staffing arrangement and attitudes of agency staff
3.13.5 Customer Service Department
The last 12 months has seen the workload within Customer Services stabilise with a
slight decrease in both complaints and PALs. Investigation into clinical complaints
continues to be carried out by senior Business Unit Managers with input from
frontline staff to ensure it is thorough and accurate. The Clinical teams are supported
by Governance Officers who co-ordinate the information obtained from different staff
for each complaint and liaise with the Customer Service staff.
The web-based system for clinical incident reporting implemented in 2012 has been
extended in 2013 for complaints, PALs and claims to enable more efficient
collection, interrogation and triangulation of data. This new system has proved
popular with staff trustwide, supplementing the communication and monitoring
systems already in place.
3.13.3.(i) Compliments. Compliments continue to be collected monthly from all
clinical business units and are displayed on the Quality Dashboard alongside
complaints to remind staff of the excellent job they do. The large change in
compliments from 12/13 to 13/14 is due to the training of community staff in the
classification of a compliment (rather than a reduction in actual compliments).
82
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Compliments v Complaints by total patient contacts
1/1/1031/12/10
Total Outpatients
Total Inpatients
Community Contacts
Outpatients Appointments-Community
Total Patient Contacts
Compliments
Complaints
254,836
59,511
1/4/1131/3/12
1/4/1231/3/13
1/4/1331/3/14
314,347
2775
287
253,320
61,049
205,957
108,425
614,066
6708
279
249,415
60,589
230,220
117,025
637,949
13,432
421
266,167
61,416
272,095
130,727
730,405
5,665
369
Compliments as a % of Total Patient
Contacts
0.88%
1.09%
2.10%
0.78%
Complaints as a % of Total Patient
Contacts
0.09%
0.04%
0.07%
0.05%
3.13.3.(ii) Complaints. The following pages give a breakdown of complaints and the
changes made as a result of complaints/concerns. There has been an overall
decrease in the number of complaints from 2012 / 2013 by 47 (11%). From October
2013 the new DATIX webb complaints/concerns/PALs system has been fully
implemented and functional, ensuring improved, more timely communication both
internally and externally in relation to patient contacts through the Customer Service
Department.
83
QUALITY ACCOUNT 2013-14
This table shows the distribution of
complaints through the Clinical
Business Units.
12/13
173
147
36
18
8
3
36
421
Urgent Care
Planned Care
Women & Children's
Service Improvement & Support
Capital & Facilities
Trust Operational
Community Long Term Care
13/14
155
126
50
9
0
2
27
369
%
Change
-10.4%
-14.3%
38.9%
-50.0%
-100.0%
-33.3%
-25.0%
-12.4%
The table below shows why our patients are complaining and the implementation of
DATIX webb has enabled greater recording, breakdown and monitoring of the issues
raised. Although the implementation of this system means that these recent figures
when compared to the data produced from the old system in previous years, is
unable to give accurate, meaningful comparisons, what is does do, is give us
accurate data on which to focus our improvement work.
Discharge is an area where we have focused more resources by appointing a
dedicated team to make improvements to the discharge process. Through 2013 the
team was recruited to and policies compiled and implemented with links to the
community teams being forged. It is hoped that through the work carried out in
2013/14, 2014/15 will show an overall improved discharge process for our patients.
Food Many of these complaints relate to the temperature of the food. The Hotel
facilities Manager has carried out a number of audits in 2013 to ascertain where the
problem is occurring and action is being taken to address the issues highlighted. As
described in more detail elsewhere in the Account we have implemented dining
companions which addresses those complaints relating to dependant patients
requiring increased assistance with nutrition.
Waiting times/Appointments is another area where we have focused a lot of work
over the last 12 months through closer monitoring of the reasons for cancellation of
clinics. All medical staff now have to give a minimum of six weeks notice for their
annual leave to be authorised and this is being more stringently applied by the
Medical Director, partial booking implementation has been further rolled out and
problem clinics have been reviewed and the number of clinics increased where
appropriate.
Medication This continues to be closely monitored trustwide and the trust is
continually striving to find ways of giving patients more information about the
medication that they receive on discharge and also whilst they are an inpatient.
Patients are encouraged to raise any issues that patients have with their medication,
84
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
whilst they are inpatients at the time so that a suitably qualified health care
professional can ensure they are fully briefed and able to make informed decisions.
Any medication errors are treated in line with the trust policy and reported through
the national reporting system, ensuring improvements are made where indicated.
Attitude and Communication is addressed through the Secret Shopper exercises
where actors visit clinical areas and observe staff communication with patients and
visitors. The actors then act the scenarios out and the DVD made is played back to
the relevant staff as a learning exercise. This has been proved to be an effective way
of training. The Customer Service Department also keeps a log of staff who are
named in complaints for attitude/communication so that any trends can be acted
upon. This information also forms part of the Medical appraisal process.
Nursing care As can be seen throughout this document the nursing care is
monitored and reported on in a number of ways such as through the Matron’s
checklist, real-time patient feedback, complaints, national surveys, clinical audit and
incident monitoring. These are reviewed overall by the Director of Nursing and her
senior team, who ensure that where indicated changes are implemented to make
improvements which are reported through to Trust Board. The webb based version of
incident reporting, complaints and claims will now allow better triangulation and
information. With this will come the ability to make more concentrated improvements.
Cleanliness It is good to see that the information received through complaints
supports the trustwide improvements noted through infection control data and
cleanliness audits.
Issue
Cancer
Car Parking
Discharge
11/12
2
2
16
12/13
9
9
54
%
Change
350.0%
350.0%
237.5%
Noise
Food
Waiting
Times/Appointments
Medication
Attitude
3
11
8
29
166.7%
163.6%
42
33
85
105
57
118
150.0%
72.7%
38.8%
85
Issue
11/12
12/13
Communication
Nursing Care
Dementia
Delay/Failure to
Diagnose
End of Life
Medical Care
160
125
12
76
217
158
14
84
%
Change
35.6%
26.4%
16.7%
10.5%
11
154
12
161
9.1%
4.5%
Cleanliness
Other
13
30
8
66
-38.5%
120.0%
QUALITY ACCOUNT 2013-14
Subjects of Complaints Apr-Sept 13/14
1%
2%
5%
2%
20%
9%
6%
1%
16%
1%
1%
12%
2%
4%
18%
Communi ca ti on
Nurs i ng Ca re
Medi ca l Ca re
Medi ca ti on
Food
Atti tude
Tempe ra ture
Cl ea nl i ne s s
Sa fegua rdi ng
Los t Items
Wa i ti ng Ti mes
De l a y/Fa i l ure to Di a gnos e
Confi de nti a l i ty
Lea rni ng Di s a bi l i ty
End of Li fe
E&D
Di s cha rge
Appoi ntments
Specific changes to made as a result of complaints and PALs:
1. Additional training in Fluid Balance monitoring.
2. A new training program for RN Acute Care Workshops and HCA PEACH courses to
run on a monthly basis.
3. Televisions installed in A&E waiting rooms.
4. Dining companions added.
5. Pharmacy discharge trolley has been introduced on EAU and SSU.
6. Matron to identify beds the night before - included with the updated admission
policy, access to include notes on systems & check with Pre-op team.
7. Case management now identified to follow through to admission.
8. All district nurse referrals are to be followed up with a phone call.
9. Change in the recording of audiology visits and imp[lamentation of handovers.
10. Standardisation of discharge information.
11. Twilight shift now embedded.
12. Urgent Care documentation updated
13. Property logging system implemented in certain areas.
14. New patient information booklet implemented.
15. Change of process implemented between day surgery and radiology to improve
communication.
16. Access to ne Bereavement room.
17. Review of fall assessment process.
18. Introduction of Falls link nurses and Nutrition link nurses.
19. Implementation of FESS unit (Frail Elderly Short Stay).
20. Trial planned on the use of falls alarms.
3.13.3. (iii) Patient Advice and Liaison Service (PALS). There has been a
decrease in PALs from last year from 986 to 941. These are now logged on the new
DATIX webb system as concerns and a breakdown in the issues raised can be seen
in the charts below.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
PALS Numbers
1200
1000
986
800
941
759
600
400
397
200
0
PALS 10/11
PALS 11/12
PALS 12/13
PALS 13/14
As can be seen by the chart above the majority of concerns raised are similar to those raised
through complaints and the action taken as a result, has been described earlier in this
chapter. The reduction in complaints and PALs may be in part, effected by the
implementation of real-time feedback which gives patients an alternative method of
feedback.
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QUALITY ACCOUNT 2013-14
3.13.6 Learning Difficulties (LD)
Learning Disability Liaison Service Initiatives 2013/14
Learning Disabilities support has been well established within the Trust for a number
of years. The service works closely with the community LD teams and this has
enhanced the care pathway for all patients.
The success of this model of care has now been expanded to include all adults at
risk. This includes illnesses such as dementia and Parkinson’s. This will be
discussed further in this report.
Comparison of inpatient admissions 2012-2013
35
30
25
20
15
10
5
0
2012
Sept
Oct
Nov
Dec
17
Augus
t
15
3
16
11
11
15
6
17
8
11
13
April
May
June
July
11
12
7
12
6
11
2013
Patients who are admitted with learning disabilities usually access Trust services
through the emergency route or via their GP.
Since October 2013, there has been a high proportion of admissions via the elective
route into planned care and support services i.e. Radiology and anaesthetics to
support CT Scans etc. This is a welcomed increase as it enables the team to
prepare and support the patient and their carers through the admission process. This
alleviates anxieties and promotes better understanding between the hospital staff,
the carers and the patient.
The service continues to see an increase in requirement requests for support to
coordinate and case manage the care pathways of patients with learning disabilities.
Their vulnerability is usually identified prior to their admission. Multi disciplinary
team working is crucial for this to succeed as this group of patients usually have
complex health and social requirements.
Care pathways are continuing to develop. Since the last report, the team have
worked closely with Gastroenterology, the Emergency Department and Mental Health
88
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
services in order to remove any barriers patients may have in accessing services.
One of the benefits of being an Integrated Care Organisation is that this work can
commence prior to admission and post discharge without problem.
There is a clear audit programme for Learning Disability Services and this has led to
changes in how the service is delivered.
Examples of this include significantly strengthening the working relationships with
medical leads in anaesthesia, enabling patients to be prepared for the anaesthetic
and to understand what will happen prior to admission.
3.14 End of Life Care
This year has continued to see End of Life Care in the media across the U.K. with the
publication, in July 2013, of the Neuberger Review ‘More Care: Less Pathway’, which
highlighted the poor care sometimes associated with the last days and hours of life,
and the formation of the Leadership Alliance, the coalition of government and
national bodies, to respond to the forty four recommendations made therein.
Although the Neuberger Review commended the sound ethical principles on which
the Liverpool Care Pathway was based and highlighted the good care provided to
patients and families when it was implemented properly, it also recognised that in
some areas inadequate education, poor implementation and insufficient support had
resulted in misunderstandings, particularly of the word ‘pathway’, and its association
with the poor care that already existed. This combination has resulted in significant
distress and worry for patients, families and health professionals alike.
Southport &Ormskirk Hospital NHS Trust (S&O), as an integrated care organisation
responsible for local community and hospital services, has always understood the
essential nature of the education of all staff in end of life care and communication
skills. The Trust’s continuing recognition of their responsibilities in this regard, despite
many other competing priorities, has helped in coping with this period and enabled
staff to ensure that the concerns of patients and families are addressed wherever
possible. Collaboration between S&O and Queenscourt Hospice, the integration of
Specialist Palliative Care Services across boundaries, close working between
specialist and generalist services and the fact that programmes such as Gold
Standards Framework for Acute Hospitals, the Transform Programme and the
Six Steps to Success for care homes are all intertwined and linked with already
existing programmes working out of the Terence Burgess Education Centre at
Queenscourt, ensures that staff, of all disciplines and in all settings, receive a
consistent educational message, and all services speak with one voice. Development
of simple, effective, workbook based programmes in communication, advance care
planning and spirituality, and the educator development programme, ensure that
these vital topics are easy to facilitate.
Within the local area of West Lancashire, Southport and Formby (WL,S&F), with a
population of about 260,000 inhabitants, approximately 2,500 (almost 1.1%) people
die each year. National figures suggest that two thirds of people would prefer to be
cared for and to die in their own homes. Office of National Statistics annual place of
death figures for WL,S&F in 2011 and 2012 (2013 figures are not yet available) show
that, for the first time in recent history, deaths from ALL causes in the usual place of
residence (home and care home) (47%) have exceeded deaths in hospital (46%) by
1% for two years running. This is excellent, but we have a long way to go to meet the
89
QUALITY ACCOUNT 2013-14
expectations of the public, approximately a quarter of whom still do not achieve their
preferred place of care.
Office for National Statistic figures for 2012.
In 2012 the proportion of people dying with cancer related illnesses who manage to
stay in their usual place of residence was 52% (56% 2011) compared with the
number who died in hospital which had dropped to 28% (30% in 2011).2
Office for National Statistic figures for 2012.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
We are hopeful that 2013 figures, when released in summer 2014, will demonstrate
that the hard work of hospital and community services has maintained this trend.
WL, S&F has more than 3,400 people in registered care homes, more than twice the
national average for the size of population, and not surprisingly, almost 25% of all
those who die are now able to be cared for in care homes until their death.1 This
makes it imperative that we identify and consider this population specifically with
regard to communication, education and clinical support of their employed carers,
regarding end of life care.
S&O understands that the care given to those who are dying is a reflection of the
care given to all patients. Having already introduced the Gold Standards
Framework Acute Hospitals (GSFAH) pilot in 2010/11 and the National
TRANSFORM (Cascade) Hospital Programme (part of the Route to Success in End
of Life Care series) in 2012/13, the Trust became part of the 2nd phase of the
National Transforming Acute Hospitals Programme in 2013/14, each year
building steadily on the work already done. For 2014/15 Network and CCG support
sees this work develop into the exciting challenge of having a Transform Team
which crosses boundaries of hospital, hospice, community and care home to coordinate the care of those with advanced progressive disease, who do not have
specialist palliative care needs. These programmes have introduced improved
systems for patients who may be in the last months of life, and their families, to
ensure that they feel supported, their care is co-ordinated and communication with
them and between their involved health professionals is maximised.
The Transform Programme, headed by Elaine Deeming, Transform Clinical Lead,
ensures that systems are in place to maximize the care and co-ordination of those
towards the end of their lives by use of five key enablers:1) Recognition and co-ordination of the care of this group of people using the
Gold Standards Framework (GSF) and Electronic Palliative Care Coordinating System (EPaCCS) the latter of which is not yet in place across the
area, despite a national drive to do so by Dec 2013. Being recognised as GSF
and holding a ‘gold card’ helps patients to navigate healthcare systems and staff
to be aware of their needs. (393 WL,S&F people have been recognized as being
GSF registered, 31% of whom were recognised by the hospital and the rest by
their GP practice). Two District Nursing (DN) teams have been piloting a
Community Gold Standards Framework Care Plan and an audit of the resulting
differences in care documented is due to be presented shortly, before rolling it out
across all DN teams.
2) Encouraging expression of wishes and preferences by implementing a system
of Future Care Planning, encouraging staff to facilitate conversations about
personal wishes (Advance Care Planning (ACP))and being proactive in
planning for expected clinical situations(Anticipatory Clinical Planning). Having
wishes and preferences documented means that subsequent conversations are
easier and patient’s wishes can be met even when there is loss of capacity to
make decisions. Advance Care Planning as a concept and the associated
1
Office of National Statistics 2012
91
QUALITY ACCOUNT 2013-14
documentation was launched to 100 local GPs at the beginning of 2013/14 in
addition to the education for our own staff outlined below. Formby local area has a
pilot project where one GP is concentrating on introducing Advance Care Planning
to all the local care homes to see what impact that might make. 173WL,S&F people
are known to have had an ACP conversation, 103are known to have made an
Advance Care Plan, 60 have an Advance Decision to Refuse Treatment, 87 have a
recognised Lasting Power of Attorney to act on their behalf in making health
decisions if they are unable. In 2013/14 the number of people with a recorded
preferred place of care (PPC) was 1350(1219 in 2012/13),64%(79% in 2012/13) of
whom chose ‘home’. 917 (83%)(60% in 2012/13)of the 1,111 who died and had
expressed a PPC, achieved their preferred place of care.
2) Recognising and discussing uncertainty of recovery of those who are
seriously ill, develop an acute illness and where treatment may or may not show
benefit(AMBER Care Bundle (ACB)).This involves the documentation of
appropriate care plans, ceilings of treatment, conversations with patients and
families and other health professionals. Early audits demonstrate that the
elements of ACB are increasingly being incorporated into post take ward round
documentation and helping to inform decision making. This work will be audited
further during 2014/15.
3) Respecting patient choices particularly of those who recognise that they are in
the last days and hours of life but are not in their preferred place of care, and
having systems in place to undertake a Rapid End of Life Transfer safely,
efficiently and effectively for them, their families and their health professionals.58
people have had a REoLT during 2013/14(64 in 2012/13). Introduction of the
North West Ambulance Service Community DNACPR (Do Not Attempt
Cardiopulmonary Resuscitation) Policy and form, dovetails with the cross
boundary DNACPR Policy for the local area which already existed. Additionally
agreement was reached that if necessary a private ambulance could be used to
enable a REoLT to take place if the timeliness of the ambulance transport was the
limiting element.
4)
Vigilant care at life’s end for those who are dying and the ‘families’ (relatives,
friends, colleagues, informal carers) who keep vigil with them is crucial along with
the important conversations with senior health professionals who can deal with
the concerns, questions and emotions expressed. 384 (42%)(444 (48%) in
2012/13)dying patients in hospital were supported by the Vigil individualised end
of life care plan, and 334(296 in 2012/13)in the community (including residential
homes). The Vigil will be further developed and personalised in the coming
months to incorporate all the guidance within the Leadership Alliance Response
to the Neuberger Report, due to be published in June 2014.
The adverse media publicity already mentioned has meant that work on the five key
enablers of care at life’s end has been affected. Whilst ensuring that the language
and terminology leaves no room for misunderstanding, much work has gone into
auditing documented conversations with dying patients and their families. It is
imperative that staff avoid euphemisms which can be misunderstood (fading,
deteriorating, passed on), and are clear, without being blunt, about the information
they communicate and the explanations they give (likely to be dying, may not
recover, died).
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Particular effort has been made to visit, on the wards, families of those who are
thought to be dying, to enquire about their concerns and try to address them
immediately. Feedback from patients and families has generally been very positive,
and also grateful for the extraordinary lengths which staff on wards go to, to help
them to cope at this difficult time. Information regarding incidents, concerns and
compliments received by any method has been documented, investigated and fed
back to the Integrated Governance Team to ensure that they are aware of any issues
that transpire.
Coding
Z51.5 coding for those patients seen in hospital by Specialist Palliative Care Services
(SPCS) has been in the news this year. The Trust coding in this respect has been
regularly audited and been shown to be improving over the past 5 years or so as a
result of work between the SPCS and the coding department. However as a result of
external requests both an internal audit and an external audit took place and
demonstrated that coding was 96% correct in both audits.
Audit
Audit of end of life and palliative care is important and two strong audit strands exist.
The cross boundary Specialist Palliative Care Audit programme has been ongoing for
15 years and this year saw the second of our ‘Celebrating Success: Better Together’
mini conferences, chaired by Dr Geraldine Boocock, outgoing Medical Director, at
which many of the ward/department End of Life Audits were presented. Topics such
as Z51.5 coding, mortality, non medical prescribing, AMBER Care Bundle, spiritual
care in the last days, end of life conversations, anticipatory prescribing, district nurse
care in the last months of life, information transfer from care homes, achievement of
preferred place of care, rapid end of life transfers, Quality of Life Feeding, GSF
eligibility on the Short Stay Unit, Heart Failure and Palliative Care have been
presented, some of which have already completed their second cycle, the others of
which are planned for the coming year. Repeat audit cycles have demonstrated the
improvements that interventions have made.
Abstracts were accepted for both the European Palliative Care Congress in Prague
May 2013 and the National Palliative Care Congress Harrogate March 2014 at which
posters and oral presentations took place.
The Trust also took part in the 3rd round of the Royal College of Physicians National
Care of the Dying Audit, the results of which are due in May 2014.
Pharmacy Supplies
Ensuring availability of medications which may be needed at the end of life, is vital if
good care is to take place. Within the hospital, the pharmacy department has a small
stock on each ward, and in the community there was, prior to the formation of the
ICO and the CCGs, a service level agreement with community pharmacies to hold a
small stock of those drugs which might be required. Unfortunately with the changes,
it was unclear where the responsibility for this lay and the system fell down.
Fortunately the CCGs made temporary arrangements for services over the winter
period and new arrangements are due to be in place for the beginning of the new
financial year to avoid the distress caused to families when they are chasing around
93
QUALITY ACCOUNT 2013-14
local pharmacies with a prescription they cannot fill, whilst a loved one is seriously ill
at home.
Care at life’s end is not just about clinical care and great efforts have been made in
three other very important areas which are further to be developed in 2014/15:1) Spiritual Care – at no time in life may spiritual care be more important for patient
or family than as life is thought to be drawing to a close. Rev Martin Abrams,
Trust Chaplain, the clergy team and the new team of chaplaincy volunteers (in
new grey polo shirt uniforms), working with the End of Life Facilitator, have now
developed a much more structured approach to meeting expressed spiritual and
religious needs at this time. However they cannot meet needs which are
unrecognised and currently the ‘Opening the Spiritual Gate’ programme is
ongoing to assist staff to be aware of and discuss spiritual needs with patients
and families, so that chaplaincy or other spiritual services can be enlisted where
patients and families would welcome this support.
The Prayer/Quiet Room at Southport has been very nicely upgraded providing a
quiet space to pray, to think and to escape. Facilities for various faiths have been
accommodated although this can only be regarded as an interim arrangement as
there is still a need to further develop to meet all the needs of all faith groups. At
Ormskirk a room has now been provided next door to the Chapel offering a less
structured space for quiet and reflection.
The chaplaincy team are now having regular meetings and the Spiritual Care
Policy is well on the way to completion.
2) Care for ‘families’ – families who may feel completely isolated, at a loss and out
of place in the hospital environment, feel even more so when they also have to
deal with the impending death of a loved one. As a result of a generous family
donation, a room at the end of 11B has been converted into a ‘Relatives’ Room
for those who ‘keep vigil’ with someone who is likely to be dying. This consists of
sitting and sleeping areas, and gives families an opportunity for a break and a rest
whilst staying close by. This has been much appreciated by families who in the
heightened emotions of this important time for them, rate highly the care and
concern offered to them.
Part of the GSF Care Plan in the community is about developing a care plan for
carers of those who are GSF registered, ensuring that their own needs are
assessed and their concerns listened to and addressed. A similar carers’ care
plan is in development in hospital to provide continuity of this care.
3) Care for the bereaved – care for the family does not stop when the person they
love has died. The mortuary and bereavement team have worked tirelessly to
improve their environment and have a newly refurbished department in which
they can demonstrate appropriate respect and care for the body of the person
who has died. Equally they have been developing their care of the bereaved with
sensitive individual touches. Ben Swift achieved suitable recognition by winning
94
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
the first prize for his poster describing this work at the 2014 National Palliative
Care Congress in Harrogate.
The first change was providing a professional looking uniform and investing in
staff training particularly in communication skills. The entire mortuary and
bereavement suite was rebuilt and modernized (to include colour changing lights)
on one site and money from the hospital League of Friends allowed refurbishment
of a room into a bereavement suite at the other site. Development of a bed cover
allows patient transfer on their bed, rather than a trolley, to enhance dignity and
respect and reduce manual handling. Mortuary and bereavement sessions for all
trust staff improve understanding, reduce fear, improved communication with
families and compliance with care after death procedures. Procedural changes
have resulted in improvements to quality of death certification and the
documentation is now presented to families more professionally and respectfully
in specially designed folders with useful information.
In addition many small touches such as improved quality property bags for
patients’ effects; ‘last thoughts, words and wishes’ cards; ‘forget me not’ seeded
cards; keepsake pebbles; ribbon ties and muslin bags for hair locks and free
parking for those collecting certificates. Bereavement booklets for families have
been redesigned in more user-friendly format, cards created for staff to help them
to remember how to discuss tissue donation and cultural awareness posters
produced for wards and departments to help them to increase their sensitivity to
individual need. Additionally great attempts have been made to support parents
facing the loss of children and those who have miscarried by ensuring burial and
cremation facilities are appropriate.
Education
Education is so crucial to good end of life care for all groups of staff whether engaged
in end of life care routinely, such as district nurses, or occasionally, for example
radiographers, that the End of Life Skill set Challenge was launched to coincide with
the British Olympics and 169 staff are currently engaged on working through this
programme. 13 have already achieved bronze level, one silver and four gold which
includes completion of a case study and an end of life audit. More significantly the
Trust has agreed to develop a Community of Practice of Band 6 staff who will take
responsibility for care of patients in the last months of life throughout the Trust’s
services. As well as the End of Life Skill set Challenge, they are currently working
their way through a 10 month programme of education, discussion, audit and case
study to prepare them for this role.
S&O ICO staff have accessed education at the Terence Burgess Education Centre at
Queenscourt, as well as in their wards and departments from the Transform
Programme. In 2013/14 the number of hospital and community staff who undertook
training in:- Advance Care Planning was 171 (114 in 2012/13)making a total to date
of 743;Gold Standards Framework – 155(105 in2012/13)- total 1082;Rapid End of
Life Transfer 151(136in 2012/13) total 551; care in the last days and hours / Vigil
Care Plan – 284(287in 2012/13)total 1415;Simple Skills Secrets core communication
skills59(64in 2012/13) bringing the total to 447; Advanced Communication Skills
15(12in 2012/13) bringing the total to 139 band 6 & above nurses and senior
doctors;spiritual care - ‘Opening the Spiritual Gate’ course18 (total to date 82) and
short session 32 (total to date 250).
95
QUALITY ACCOUNT 2013-14
During 2013/14 the Micrel Syringe Driver was replaced across the Trust with the
McKinley T34 due to its higher safety profile. This required retraining of 295 qualified
staff in use of the new machine to date.
Specialist Palliative Care Services
Local Specialist Palliative Care Services, have been integrated across hospital and
community, voluntary and NHS services, since their inception. Now fully established
after a period of staffing crisis, an internal programme has been underway this year
to educate new members of staff not only to undertake their own advisory role but
also to educate others. With a full complement of consultant led, specialist services
across the Palliative Care Team and Queenscourt Hospice, patients with specialist
palliative care needs can receive advice and care in a variety of ways and places.
During 2013/14 500(460in 2012/13) patients were seen in hospital and 926(1038in
2012/13) seen at home by palliative care nurse specialists. 24%(25%in 2012/13) had
non malignant disease. 57% (55% in 2012/13) died in their usual place of residence
(home/care home) and 29% in hospital.
Following a piece of work undertaken by Cheshire and Merseyside Palliative and End
of Life Network to benchmark MDTs across the network and identify gaps requiring
development, the network provided the SPCS with an MDT development day in
Autumn 2013, led by Lorna Wellsteed of Wellsteed Associates, following which six
workgroups (presentation skills; caseload management; education; non medical
prescribing; debriefing; research & publication) were created to take forward the work
identified to strengthen the MDT. This work will continue into 2014/15.
The Merseyside and Cheshire Cancer Network End of Life and Palliative Care
Network Group has now been replaced by the Cheshire and Merseyside Palliative
and End of Life Network which is responsible to the Cheshire & Merseyside Steering
Group with the same standing as the other four statutory groups. Members of the
local Specialist Palliative Care Services Groups and the CCGs are represented on
the Network Steering Group and all its sub groups, and of course also relate to all the
Lancashire & South Cumbria Network groups as well.
2014/15
During 2014/15 we hope to see, at least, - the District Nursing Night Service return to
Southport &Ormskirk from Liverpool Community Health in the hope that this will
harmonise the service with other local services; introduction of a needleless system
for use with continuous subcutaneous infusions once the pilots have taken place;
wider use and understanding of the Advance Care Planning processes; introduction
of comfort packs for carers keeping vigil with those who are dying, thanks to the 24
hour ‘Sewathon’ by Burscough Sewing Bee; further development of the Transform
Team, the Band 6 Community of Practice and the End of Life Skill set Challenge;
implementation of the soon to be published national guidance for care of the dying.
Thanks to successful bids for MPET monies via Queenscourt, and support from
Cheshire &Merseyside Palliative and End of Life Network; Greater Manchester,
Cheshire and Lancashire Network; Southport & Formby Clinical Commissioning
Group and West Lancashire Clinical Commissioning Group alongside the positive
96
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Trust commitment to end of life care, at every level from board to ward, it will be
possible to continue to develop the very important good work being undertaken
around specialist and general, palliative and end of life care in all health care settings
into 2014/15. We have only one opportunity to get it right for each individual and their
family – it is crucial that we use that opportunity well and wisely.
3.15 Delivering Same Sex Accommodation
93
95
100
80
81
77
2005
2006
83
86
85
2007
2008
2009
96
92
Hospital: Did you ever share a
sleeping area with patients of
the opposite sex?
60
40
20
0
2004
2010
2011
2012
2013
The Trust places paramount importance on the patients experience during their visit
or stay with us. We aim to treat every patient with dignity and respect. We aim to
place all our patients in areas where they do not share bathroom or sleeping facilities
with members of the opposite sex.
The Trust has declared compliance with Delivering Same sex accommodation since
2009. We are proud to say that we have delivered same sex accommodation in the
majority of our wards and departments for 2013-14.
However, there are occasions when the Trust has to prioritise clinical treatment
above compliance with delivering same sex accommodation. Due to this, there have
been breaches in 2014. These have occurred in the Critical Care department and
on one ward and were all due to clinical prioritisation.
Each breach is subject to a full root cause analysis and review. The patients affected
were kept fully informed and the reasons why it occurred were explained to them.
We will continue to monitor our delivery of same sex accommodation on a monthly
basis.
100
93
92
93
94
92
93
94
94
2004
2005
2006
2007
2008
2009
2010
93
93
National Inpatient
Survey : Were you given
enough privacy when
being examined or
treated?
80
60
40
20
0
97
2011
2012
2013
QUALITY ACCOUNT 2013-14
3.16 Feedback 2 Matron and The National Friends and Family Test
Inpatient feedback is now obtained through the implementation of the Hospedia
system via the bedside screens. This system has been implemented for inpatient
areas and plans are in place to extend this system to outpatient areas, Accident and
Emergency and community locations in 2014/15.
The Friends and Family Test was a Department of Health initiative that was
introduced in April 2013. The Trust was required to ask all patients the following
question:
Would you recommend the hospital wards or accident and emergency unit to a
friend or relative based on your treatment?’
The Net Promoter Score Definition
Net Promoter Score = (% of Promoters) - (% of Detractors)
The equation is therefore capable of delivering a numeric output anywhere in the
range -100 (all detractors) to +100 (all promoters). The nearer to +100 the better!
Encouraging patients to complete the surveys is crucial to ensuring the data is
robust. Low numbers do not provide a wide enough sample for us to act on the
information. This has resulted in poor overall scores for December.
All Business Units are aware of their results and a concerted effort is required to
ensure response rates are improved upon.
Friends and Family – The FFT results remain red for the month and YTD. There is
a correlation between a reduction in responses and a negative score. There were
changes to the Hospedia system that meant patients were not asked for their
response as often as they had been in previous months.
Acute Inpatients
Apr
13
Net Promoter
Response Rate
May
13
June
13
July
13
Aug
13
Sept
13
Oct
13
Nov
13
Dec
13
Jan
14
Feb
14
Mar
14
55
66
59
65
63
50
47
42
37
49
46
58
23.2%
24.5%
27.0%
32.1%
34.3%
40.1%
45.3%
26.1%
21.4%
23.7%
31.0%
38.0%
98
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Net Promoter
Acute Inpatients
Response Rate
70
50.0%
45.0%
60
40.0%
50
35.0%
Net Promoter
score
40
30.0%
25.0%
30
20.0%
20
15.0%
Response
Rate
10.0%
10
5.0%
ch
ar
ua
ua
Month 2013-2014
M
Fe
br
Ja n
De
ce
ve
ry
ry
be
r
m
mb
er
r
No
Oc
to
be
Se
pt
em
Au
gu
be
st
ly
Ju
Ju
ay
M
Ap
r il
r
0.0%
ne
0
Accident and Emergency
Apr
13
Net Promoter
Response
Rate
May
13
June
13
July
13
Aug
13
Sept
13
Oct
13
Nov
13
Dec
13
Jan
14
Feb
14
46
57
50
46
58
55
52
52
52
46
41
40
12.5%
12.1%
12.5%
14.2%
13.5%
10.8%
8.9%
8.8%
15.1%
15.0%
10.5%
8.8%
Net Promoter
A&E
Response Rate
70
16.0%
60
14.0%
12.0%
50
Net Promoter
score
40
10.0%
8.0%
30
Response
Rate
6.0%
20
4.0%
ch
ar
M
ua
Month 2013-2014
Fe
br
J an
ua
ry
ry
r
De
ce
m
be
er
mb
ve
No
Oc
to
be
r
er
Se
pt
em
b
st
Au
gu
Ju
Ju
M
ly
0.0%
ne
0
ay
2.0%
Ap
r il
10
Maternity
Net Promoter
Response Rate
Mar
14
October 13
November 13
December 13
January 14
February 14
March 14
71
62
46
79
76
67
25.2%
13.7%
12.6%
21.7%
15.3%
15.3%
99
QUALITY ACCOUNT 2013-14
Net Promoter
Maternity
Response Rate
90
30.0%
80
25.0%
70
Net Promoter 60
score
50
20.0%
15.0%
40
30
Response
Rate
10.0%
20
5.0%
10
0
0.0%
October
November
December
January
February
March
Month 2013-2014
SAFETY (we must do the patient no harm)
DOMAIN 5
Treating and caring for people in a safe environment and protecting
them from avoidable harm
3.17 Medical Revalidation and Performance
100
87
89
87
88
86
89
87
2004
2005
2006
2007
2008
2009
2010
86
85
86
2012
2013
80
60
National Inpatient Survey:
Did you have confidence and
trust in the doctors treating you?
40
20
0
2011
Appointment of New Responsible Officer
Mr. Robert Gillies was appointed as Executive Medical Director and Responsible
Officer (RO) on 1st June 2013 following Dr Geraldine Boocock’s retirement from the
Trust.
Mr. Gillies received a positive revalidation decision by the GMC on 14th February
2013 and completed an appraisal on 17th February 2014 with an external appraiser
allocated by the NHS England Revalidation team. He has also undertaken the
relevant RO training programme provided by NHS England and regularly attends the
RO Network Groups of which 75% attendance is mandatory.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Revalidation Recommendations
As of March 2014, of the Trust doctors currently employed, 41 have been revalidated
to date with a further 55 scheduled for a revalidation recommendation during 2014
and 53 in 2015.
Two doctors have had a twelve month deferral of their submission date (due to them
not having the opportunity to gather the relevant supporting information in time).
There has been no necessity to report any doctors to the GMC for non-engagement
in the appraisal and revalidation process.
Appraisal systems and clinical governance
The processes and structures are now in place to ensure that all doctors have an
annual appraisal that fulfils the GMC requirements and allows the RO to make
recommendations about each doctor’s revalidation. The revalidation steering group
has therefore been dissolved and the focus of the revalidation team is now
concentrating on the quality of appraisals.
The RO, Associate Medical Director for Revalidation, Clinical Lead and the Appraisal
& Revalidation Support Manager, meet regularly to monitor progress and address
any operational issues. Staff with specific expertise are invited to attend these
meetings when necessary.
Any potential revalidation issues are also discussed at the ‘Professional Standards
and Revalidation Advisory Group’ which meets quarterly. Attendees include the RO,
AMD’s, Medical Staffing Manager, and Appraisal & Revalidation Support Manager.
The RO also holds separate meetings every quarter with the GMC Employer Liaison
Officer and the NCAS Lead Advisor.
NHS England Framework for Quality Assurance
NHS England has drafted a framework designed to help Responsible Officers keep
track of progress and provide evidence of assurance based around implementation
of the RO Regulations. This will feed into an Annual Organisational Audit (AOA) and
an annual report template. This framework has been submitted to various
governance committees including the England Revalidation Implementation Board
(ERIB) and the Revalidation Programme Board (RPB) and was approved in February
2014. The reporting within this is likely to be implemented in April 2014 and will
replace the previous Organisational Readiness Self Assessment (ORSA).
Appraisee and Appraiser Feedback
Doctors are invited to give feedback annually to the Appraisal and Revalidation
Support Manager on the appraisal system, the scope and accuracy of supporting
information provided by the Trust and also the quality of the appraisal discussion.
The information is anonymised before being fed back to the appraiser and any
relevant issues are discussed by the Revalidation Team. This feedback helps to
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QUALITY ACCOUNT 2013-14
identify any process issues and highlight any areas for further training of appraisers
or appraisees.
Appraisers meet annually at the beginning of the appraisal year for a general update
and de-briefing about the previous year’s appraisals. During 2014/2015 it is planned
to hold these meetings every 6 months and to include training and CPD activities in
order to improve appraisal quality.
A more robust and systematic process of reviewing the outputs of appraisals is being
set up, using a suitable scoring template. This information, together with feedback
from appraisees, will form the basis of an annual review for each appraiser, which in
turn will feed into their own appraisals. This should drive up the quality of appraisals
and give the RO more assurance that his recommendations for revalidation are
based on reliable, high-quality evidence.
3.18 Infection Prevention and Control
National Inpatient Survey: How clean were the toilets and bathrooms that you used in hospital?
100
80
80
2004
78
81
79
83
84
84
2005
2006
2007
2008
2009
2010
84
84
86
60
40
20
0
3.18.1
2011
2012
2013
MRSA Bacteraemias
The graph below illustrates that the Trust has maintained its low levels MRSA cases.
Hospital Acquired MRSA Cases
6
5
5
4
3
2
2
1
0
10/11
0
12/13
11/12
Hospital Acquired MRSA Cases
102
0
13/14
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.18.2
Clostridium Difficile Infections
Prescribed information: Southport and Ormskirk Hospital NHS Trust considers
that this data is as described due to the following reasons: All data is collected
and verified by the Infection Prevention and Control Team who fully investigate
each case.
Southport and Ormskirk Hospital NHS Trust has taken the actions described in
the next few pages to improve this rate, and so the quality of its services.
C.diff - rate per 100,000
bed days
Southport & Ormskirk
NHS Trust
England
Highest Trust
Lowest Trust
Information Centre data
2010/11 2011/12
34.1
29.6
0
71.8
22.5
21.8
0
51.6
2012/13
15.6
17.3
0
30.8
Southport & Ormskirk internal data-C. diff Infection by 100,000 bed days
17.72
12.29
17.83
11/12
12/13
13/14
Internal data source
The Trust’s target for 2013/4 was 19 cases, actual figure was 34
As a result of the Trust exceeding the trajectory a comprehensive 26-point action
plan was agreed internally and shared with key stakeholders like the NHS Trust
Development Authority, Public Health England and the local Clinical Commissioning
Groups. Key components of this plan included enhanced cleaning regimes with
sporicidal agents, increasing the hydrogen peroxide decontamination capacity,
raising the thresholds for antibiotic audit compliance and a review of the Antibiotic
Policy. This action plan was supported by all stakeholders.
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QUALITY ACCOUNT 2013-14
Hospital Acquired Clostridium difficile Cases
60
50
50
40
34
33
30
23
20
10
0
10/11
11/12
12/13
13/14
Hospital Acquired Clostridium difficile Cases
All cases of C. difficile infection continue to have a root cause analysis carried out to
ensure that lessons learned are disseminated throughout the Trust to prevent reoccurrence. The root cause analysis of each case of C. difficile is reviewed by the
Medical Director, who is the Director of Infection Prevention and Control.
3.18.3
Infection Prevention and Control Developments
The Trust remains fully compliant with all mandatory reporting for Methicillin-sensitive
Staphylococcus aureus (MSSA), Methicillin-resistant Staphylococcus aureus
(MRSA), Clostridium difficile, Escherichia coli and surgical site infection in
orthopaedics, where data are submitted for the entire year and not just the minimum
requirement of one quarter. At the end of 2013/14 the Trust has reached the
milestone of going more than two years without an MRSA bacteraemia attributable to
the Trust and only seven other acute Trusts in England have achieved this.
Southport and Ormskirk Hospital NHS Trust Infection Prevention and Control Team
has a comprehensive surveillance programme that continues to expand. In 2013/14
blood culture contamination rates, Task Team function (enhanced cleaning
programme) and compliance with care pathways were added into the programme.
During 2013/14 the value of surveillance and feedback of ward-specific data on a
monthly basis had been demonstrated, with the Trust reporting a 28% fall in devicerelated bloodstream infections. Peripherally-inserted Central Catheter (PICC)
infection rates have remained lower than any published infection rates for non-critical
care areas and over the year the rate of infection continued to fall to a new historic
low of 0.42 infections/1000 device days, a 57% reduction on an already low rate.
Infections relating to the use of central lines in Critical Care also fell by 17% during
the year. A small increase in infections in the early part of the year influenced by the
increase in the use of femoral lines was reversed by the use of a chlorhexidine
impregnated sponge dressing for these vulnerable sites.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
During the year the threshold for achieving compliance for antimicrobial prescribing
standards was raised from 80% to 90% and by the year-end this standard had been
met for three consecutive months.
100
80
83
83
83
81
2004
2005
2006
2007
87
86
87
2008
2009
2010
86
86
87
National Inpatient Survey
In your opinion, how clean
was the hospital room or
ward that you were in?
60
40
20
0
2011
2012
2013
3.19 HEAT and PEAT inspections
The Trust maintained it’s overall scoring in the 2013 / 14 assessment process
(Appendix ??)
The annual PEAT (Patient Environment Action Team) inspections and Regular
HEAT (Hospital Environment Action Team) inspections are carried out throughout the
year in which teams consisting of representatives from Estates Department, Infection
Prevention and Control and Nursing & Midwifery provide reports to departmental
managers to enable action plans to be drawn up and implemented.
These are monitored through the Trust Hygiene Committee who also monitor
progress against the Hygiene code standards. The Hard work of the Housekeeping
team ensures the Trust maintains its high standards of cleanliness and any issues
highlighted through complaints are acted upon immediately and addressed through
action plans
As of April 2013 The PEAT process has been replaced with PLACE (Patient-led
assessments of the clinical environment), following a call from the Prime Minister in
January 2012 for assessments to be patient led. In general the assessments remain
the same, environment, food and privacy and dignity, with the main changes being
that the assessment process is led by 2 patients who and must constitute 50% of any
assessment team (patients, relatives, visitors, advocates, Healthwatch, FT members,
FT Shadow governors and voluntary sector representatives).
Through internal advertising the Trust received an extremely positive response from
interested individuals, with a large number now having completed their initial training
and currently involved with assessments.
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QUALITY ACCOUNT 2013-14
3.20 Patient Safety
3.20.1 Never Events
This year the Trust has reported 2 never events
This year the Trust had to report 2 Never Events. Both incidents involved swabs
being retained following a surgical procedure within the two theatre suites. The
incidents highlighted the need for the Trust to review the systems and processes in
the theatre suites. The Trust took the opportunity to relaunch the World Health
Organisation surgical checklist within the theatre suites and reviewed all
interventional procedures across the Trust to ensure that safe systems and
processes were in place. There is on going audit within the Clinical Business Units of
the changes implemented.
3.20.2 Safety Thermometer/Harm Free Care
The NHS Safety Thermometer has been developed for the NHS by the NHS as a point of
care survey instrument.
The NHS Safety Thermometer allows teams to measure harm and the proportion of
patients that are ‘harm free’ during their working day, for example at shift handover or
during ward rounds. The NHS Safety Thermometer provides a ‘temperature check’ on
harm and can be used alongside other measures of harm to measure local and system
progress. Harms that are measured are Falls, Pressure ulcers; Catheter related urinary
tract Infections and VTE.
The results include both inpatient and community services as outlined within the CQUIN
guidance.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Methodology for collection of this data has been based upon a team collecting inpatient
data and community services collecting district nurse caseload for one allocated day
which is agreed through the programme nationally.
Data has been collected on the day as outlined as preferable in guidance from the NHS
Information Centre.
October shows the 1st month where the Trust has dipped below the 95% measurement.
This was attributable to reporting of a harm relating to pressure acquisition. This has
been subject to a full root cause analysis as are all Trust acquired pressure ulcers.
The trust continues to consistently report low levels of harm and is now one of the
positive outliers when compared with other trusts.
Whilst this is very positive and provides assurance, it cannot lead to complacency.
The trust will continue to strive for further improvement and to further reduce the
chances of harm that a patient may experience whilst in the trust.
The Transparency in Care Project supports the work undertaken through the Harm
Free Care Programme. This provides rich data through the Route Cause Analysis
process. Information is also collected that provides snap shot insights into the
patients and staff experience at the time of the harm. Staffing levels are also
reviewed and this provides a detailed review of the environment when the harm
occurred. This process is in its infancy but it is hoped that it will provide further
insight to enable lessons to be learnt and harms to be avoided.
3.20.3 Venous Thrombo-Embolism (VTE) Risk Assessment.
Prescribed information: Southport and Ormskirk Hospital NHS Trust considers
that this data is as described for the following reasons : The Trust carries out
local audits to check validity of this data.
% of Patients Risk
Assessed for VTE
Q1
Southport &
Ormskirk NHS Trust
England
Highest Trust
Lowest Trust
95.53%
95.45%
100%
78.78%
2013/14
Q2
Q3
96.65%
95.74%
100%
81.7%
96%
95.8%
100%
77%
Q4
Data Not
published
yet
Q1
2012/13
Q2
Q3
92.2% 94.3% 93.6%
93.4% 93.8% 94.1%
100.0% 100.0% 100.0%
80.8% 80.9% 84.6%
Information Centre data
Southport and Ormskirk Hospital NHS Trust is pleased with the increase noted in
2013 / 2014 and has taken the following actions to improve this percentage and
thus the quality of its services:
107
Q4
93.4%
94.4%
100.0%
87.9%
QUALITY ACCOUNT 2013-14
•
•
•
•
Annual training for medical
Regular feedback from audit to relevant staff on how to improve their
performance
Monthly monitoring of data collection
Annual audit completed by junior medical staff
3.20.4 Safety Talkabouts
Improving patient safety ultimately requires a collaboration between staff at all levels.
Many changes are well within the scope of a committed team of staff, but where they
are not, the role of the Organisation’s leaders in empowering and supporting them is
crucial. Both Executive and Non-Executive teams enjoy the opportunity to regularly
talk in an open and honest way with frontline staff about safety issues, to find out first
hand about the processes and the systems and ultimately what worries them, in an
endeavour to make working easier and the delivery of care safer. As part of the
National Patient Safety First Campaign, the Trust is committed to undertaking one
Talkabout each month and since the inaugural Talkabout in September 2009, to date
the Executive Team have completed 49 visits and have visited a total of 79 areas,
with some visits comprising of multiple services.
Following the formation of the Integrated Care Organisation in April 2011, the
Executive Team embraced the opportunity to visits community sited services,
previously under the management of local PCTs, as well as continue their visits to
acute services. The programme for 2013 included scheduled visits to 4 community
sites and 18 acute areas across both the Southport and the Ormskirk sites. The
introduction of visits to community premises continues to be well received by both the
Executive teams and the staff based at those sites.
Whilst the Department of Quality and Integrated Governance facilitates and
undertakes the Patient Safety Talkabouts, along with volunteers from the Executive
and Non Executive Team, the responsibility to ensure appropriate actions are
undertaken or recommend an alternative course of action remains within the
Governance team for the respective areas. To provide assurance to the Trust Board,
action plans are monitored on a quarterly basis through the Operational Quality
Committee and are RAG rated and reassessed on a regular basis to show progress
against each action. It is recommended that action plans form part of the regular
agendas at Divisional / Business Unit meetings to ensure all levels of staff are fully
aware of issues raised and progress towards a solution being found. As a result of a
significant number of issues being raised in respect of the working environment, in
order to expedite necessary actions, a senior member of the facilities Team has now
joined the Talkabout Team and this has been well received by all involved.
Where actions require extensive funding or are extremely difficult to achieve, if
considered to be an areas of risk, it is recommended that these issues be added to
the relevant risk register and followed / escalated through that route
Through completion of the Talkabouts, the Trust Executive and Non Executive
Directors have:
• Demonstrated top level commitment to patient safety
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
• Established lines of communication about patient safety among employees,
Executives and managers
• Taken opportunities to learn about patient safety
• Identified opportunities for improving patient safety
• Encouraged reporting of issues, errors and near misses
• Promoted a culture for change pertaining to patient safety
• Established local solutions to minimise risk
As part of a requirement for the Quality Governance Assurance Framework (QGAF)
a database is maintained to monitor the ongoing work around the Talkabout visits.
The database enables a variety of reports which can be created upon request.
The database records the following information:
• All visits that have taken place to any one particular area
• The date of the visit
• Proposed future visit dates
• Names and designation of those present at the visit
• If the visit has been cancelled, the reasons supporting the cancellation.
• Direct links to both completed and outstanding action plans and progress
against them.
• Links to supporting Business Unit meeting minutes
• Facility for staff present on the visit is to identify the level of priority for revisit
i.e. high, medium, low priority. Although subjective to the views of those staff
attending the visit, this will assist in agreeing the recommended time between
future visits as it recognised that some areas identify more patient safety
issues than others
• Comparisons between visits to a single area to identify trends and ongoing
areas of concern and those areas of concern that have been positively
managed and reduced.
Safety Talkabouts – Examples of Changes in Practice
Area
Corporate
Maternity
Outpatient
Problem / Issue raised
This issue was raised within the Neonatal Unit but has
been addressed corporately.
Action taken
Exit survey
questionnaires have
been amended to add
The Team were advised of the possibility of staff
question “Would you be
members who have since retired returning as volunteers. willing to return to the
These volunteers could assist with some general and
Trust as a volunteer?”
housekeeping tasks.
There was a lack of suitable working surface at the
Review of work station in
Antenatal Clinic to
midwife work station in the Antenatal Clinic. This has
previously been highlighted as part of a Health & Safety provide staff with a more
audit and during investigation of a manual handling
suitable and safer
incident. It was understood that a survey has previously
working environment
been carried out by the Facilities department with costs
which also included an
for a suitable work surface provided to the CBU but no
alternative storage area
action had been taken at time of visit.
for clinic notes required
for all clinics was
Due to the clutter of notes and other paperwork, there
undertaken
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QUALITY ACCOUNT 2013-14
was a risk of misfiling / loss of results etc and risk of a
further manual handling incident
Community Referrals into the District Nursing Team were
unmanageable and often inappropriate
Community Staff were concerned that they were provided with a
limited amount of information following the referral of
patient’s from hospital for follow up community care
Community The Centre is located in an area where the only parking
available is outside of the clinic and was to incur a
charge from 1st April 2013. The new restrictions would
have prevented users returning within a period of 4
hours and all users would have to pay to park.
For District Nursing Staff based at the Centre there was
no alternative parking facility and staff had no option
other than to drive to work and to return to the Centre
throughout the day for a variety of reasons.
Approximately 33 District Nursing staff (and other staff)
were affected
Acute
From a patient perspective, the facilities at the Centre
were in the process of being upgraded with a view to
offering additional capacity and improved patient access
to a number of treatment room services. It was
considered that the imposition of car parking charges for
patients may deter patients from attending the Centre for
treatments opting instead to attend an alternate
treatment room with a free car park resulting in inequity
of health care provision for patients unable to access
health care elsewhere and result in increased demand at
those Health Centres with free car parking.
The Discharge Lounge area was extremely limited in
size and only able to accommodate a relatively small
number of patients able to sit on chairs provided or who
were in wheelchairs. The room was unable to
accommodate patients in beds and taking into
consideration the demographics of the local catchment
area, a large number of patients using the Lounge are
elderly, frail and unsafe / unable to sit in a chair,
therefore are bed bound. A large number of these
110
There was a review of
leaflet ‘do’s and don’ts’ to
identify the types of
referrals that should be
made and processes for
making referrals to the
District Nursing Service
Production of a checklist
containing a minimum
dataset of information
required for discharging
patients from hospital
into the community was
undertaken
Following a number of
discussions between
facilities managers and
Local Authority, car
parking charges were
temporarily removed for
staff working and
patients attending this
Centre
A full refurbishment of
the Discharge Lounge
has been completed and
the area now has facility
to accommodate beds
and
chairs
with
appropriate access to full
toilet facilities.
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Acute
Acute
patients were awaiting discharge and reliant upon
patient transport; therefore had to remain in the acute
ward area until transport arrives. The area also had
limited toilet facilities that could not accommodate a
wheelchair.
Due to its location, the area was also used as an
admission / waiting area for Programmed Investigation
Unit (PIU) which caused overcrowding at particular
times of day / week
There was insufficient shelving for linen required on a
daily basis which was causing storage problems in line
with infection control guidance
Ordering of supplies, which is carried out by Supplies
Personnel was not always taking into account existing
stock levels when ordering ‘top ups’. This was causing
inappropriate levels of stock and lack of storage facility
Acute
The rehabilitation ward was experiencing lengthy delay
in completion of maintenance jobs requiring repair.
Where this involved patient equipment, this was
highlighted as something that had potential to cause
hazards for patients who are vulnerable and delay
rehabilitation progress
Acute
There was a faulty printer being used on the Unit for
printing clinical reports whilst awaiting a replacement.
Staff were unable to print reports or on occasions,
incomplete reports are being printed. The new printer
had been on order for two weeks. This was a potential
patient safety risk if incomplete reports were being filed
into patient records
3.20.5
The area is no longer
used as a waiting area
for PIU patients, they are
accommodated
elsewhere
Additional
shelving
added to linen cupboards
on the ward
Following discussion with
Charge Nurse and
Procurement Manager, a
new process for ordering
of supplies was
introduced on the Ward
Meeting held with Senior
Sister
and
Facilities
Manager. System now in
place when jobs are
logged, the nurse placing
the job will document
whether it is urgent/ nonurgent. They will also
document if it is in
relation to patient safety
or if it is affecting patient
rehabilitation
potential
and
jobs
will
be
prioritised as appropriate
Following the visit and
discussion with the IT
team, there was an
Immediate replacement
of the printer
Lips System Level Aim
In 2010/11 three senior members of the Trust attended a weeks training in
Birmingham entitled “Leadership in Patient Safety” (LIPs) and were required to
implement a system level aim in their Trust on a topic of their choice, to improve the
safety of patients. This resulted in the Trust aiming to reduce the number of cardiac
arrests by 10% year-on-year by implementing a number of changes.
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QUALITY ACCOUNT 2013-14
•
•
•
•
Improvement in the Early recognition of the deteriorating patient.
Improved documentation of DNAR (Do not attempt to resuscitate)
Improved identification of those patients in the last few days of life.
Monthly monitoring of Cardiac Arrests on Quality dashboard
As reported in last years Quality Account the Trust achieved a massive reduction in
cardiac arrests of 55% over 4 years. Despite this we still aimed to achieve a further
reduction of 10% this year but did not manage it. Trustwide data was analysed and
this was discussed with a team of senior medical staff and nursing staff and it was
noted that at some stage with all improvements we reach a maintenance level. As
can be seen throughout this document we have continued to improve with the
recognition and care of the deteriorating patient and end of life is now well
recognised. Therefore a paper was put to Quality Safety to propose the maintenance
of this target and was duly accepted. However all the work will continue to maintain
the highest possible standards.
140
Cardiac Arrests
133
120
100
99
87
80
71
60
40
20
0
10/11
3.20.6
11/12
12/13
13/14
Recognition of Deteriorating Patient
The Trust continues to monitor clinical staff compliance to the policies for recognition
and treatment of deteriorating patients. The monthly audits carried out in each area
of the Trust by the Critical Care Outreach Team as see below show that Early
Warning Score compliance has been maintained well above 97%. The Fluid Balance
Monitoring trend needs to stabilise and maintain with us achieving a high in July 2013
with 96% and low in November 2013 with 84.2% compliance.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.20.7
Early Warning Scores (EWS) Audits
Early Warning Scores Performance 12/13 - 13/14
Target 12/13
Target 13/14
12/13
13/14
102%
97%
92%
87%
Apr-13
3.20.8
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Jan-14
Feb-14 Mar-14
Fluid Balance (FB) Monitoring Audit
Fluid Balance Performance 12/13 - 13/14
Target 12/13
12/13
Target 13/14
13/14
100%
95%
90%
85%
80%
75%
70%
Apr-13 May-13 Jun-13
Jul-13
Aug-13 Sep-13
Oct-13 Nov-13 Dec-13
3.20.9 Reported Patient Safety Incidents
Prescribed information: Southport and Ormskirk Hospital NHS Trust considers
that this data is as described for the following reasons : Trust staff now enter
data directly onto a web based system which all staff in the Trust have access to.
This data is automatically uploaded onto the NRLS.(National Reporting and
Learning System) from this database Local audits take place.
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QUALITY ACCOUNT 2013-14
Organisational incident data, October 2012 – September 2013
Oct 12 - Mar 13
Degree of harm
Severe
Death
Number of
incidents
occurring
Southport &
Ormskirk NHS Trust
England *
Highest Trust *
Lowest Trust *
Rate per 100
admissions
1,828
132,052 N/A
631
5272
6
1.68
16.73
Number
1
607
11
50
%
0.054855
0.459667
1.743265
0.948407
Number
7
221
19
7
%
0.383982
0.167358
3.011094
0.132777
Mar 13 - Sep 13
Degree of harm
Severe
Death
Number of
incidents
occurring
Southport &
Ormskirk NHS Trust
England *
Highest Trust *
Lowest Trust *
Rate per 100
admissions
1,916
133,207 N/A
1539
4888
6.32
3.54
14.49
Number
1
631
8
21
%
0.052192
0.473699
0.519818
0.429624
Number
12
262
2
1
%
0.626305
0.196686
0.129955
0.020458
Information Centre data
* Medium Acute Trusts Only
National average is not obtainable from the information centre
The national data has been obtained from the National Reporting and Learning
System (NRLS) as detailed above.
There has been a rise in the number of deaths recorded onto the system, while the
number has increased there is an issue about the Trust being responsible for the
death and the coding of the incidents. This is being reviewed following the
implementation of the new DATIX system.
All death are reviewed by a within a new mortality process and any unexpected
deaths are being reviewed during this process. This will enable accurate reporting
onto the system.
The Trust had previously made the decision to report Cardiac arrests on the risk
management system which increased the numbers being reported. The reason for
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
reporting was to ensure they were reviewed to establish if there was an issue with
the care and treatment given. However as there is no uniformity regarding this it
appear that doing so have impacted upon our reporting of incidents with a degree of
harm reported as deaths.
For the above reason the Trust intends to work with the NRLS to establish clear
definitions around which deaths are NRLS reportable.
The Information Centre only holds data up to September 2013, therefore the table
below represents local data.
13/14
Degree of harm
Severe
Number of
patient safety
incidents
Rate per
100
admissions
Number
%
Death
Number
%
Southport & Ormskirk
NHS Trust
England *
N/A
N/A
N/A
N/A
N/A
N/A
Highest Trust *
N/A
N/A
N/A
N/A
N/A
N/A
Lowest Trust *
N/A
N/A
N/A
N/A
N/A
N/A
3315 N/A
5 0.15%
13 0.39%
Southport and Ormskirk Hospital NHS Trust has taken the following actions to
improve this rate, and so the quality of its services, by :
•
•
•
•
Revision of the mortality audit process as described earlier
Implementation of web based incident reporting system allowing more timely
investigation of incidents by Risk Management Department with appropriate
actions.
Strengthened Serious Untoward Incident Investigation process and monitoring
of action plans for completion.
Implementation of webb based complaints, concerns and claims to allow
better triangulation of data.
The Trust would like to make the following comment:
“Due to the judgmental nature of this indicator it is difficult to be certain that all
incidents are identified and reported and that all incidents are classified consistently
within the organisation and nationally. One individuals view of what constitutes
severe harm can differ from another’s substantially. As a Trust we work very hard to
ensure all our staff are aware of and comply with internal policies on incident
reporting and standardisation in clinical judgements.”
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QUALITY ACCOUNT 2013-14
3.20.10
Patient Falls
This year the Trusts falls in the acute area has increased slightly from 602 last year
to 647.
Patient Falls
1400
1200
1000
800
600
400
200
0
08/09
09/10
10/11
11/12
12/13
13/14
• The Trust Falls Committee has been re-established as two separate groups.
One for acute and one for community. This will enable each group to focus
on issues within each area.
• The Trust is participating in the ‘Transparency’ Project in conjunction with NHS
England North. As part of this, the Root Cause Analysis process for falls has
been re-evaluated to enable more precise information to be collated.
• The Route Cause Analysis programme has been re-evaluated and weekly
meetings have been established to review any falls within the Trust
3.20.11
Hospital-Acquired Pressure Sores
All pressure ulcers are reported via the DATIX risk management system and are
defined as non hospital or non community acquired and hospital or community
acquired.
Pressure ulcers of grades three and above are classed as serious untoward incidents
and are reportable via STEIS. (This is a serious untoward incident which is reportable
to the commissioners and triggers an investigation). They are also considered to be a
safeguarding issue and are reported through to social services for investigation.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Pressure Ulcers
90
81
80
70
60
58
50
41
40
38
31
30
20
10
0
9/10
10/11
11/12
12/13
13/14
In 2013 / 2014 there has been a reduction in the number of pressure ulcers reported.
All hospital acquired pressure ulcers of grade 2 or above are subject to root cause
analysis review. The reviews are led by the Deputy Director of Nursing and the Lead
Tissue Viability Nurse.
The reviews result in action plans and close monitoring to ensure that lessons are
learnt and practice changed. There has been a significant reduction year on year in
the number of hospital acquired pressure ulcers as can be seen in the yearly Quality
Account. In 2012-2013 the Trust did not manage to achieve its target of 25%
reduction in 2012-2013 but did achieved a further 7% reduction making a total
reduction of 53% over the last 2 years.
Wards that are experiencing higher than usual pressure ulcer development are
intensively supported by the Tissue Viability Team and the deputy Director of Nursing
to ensure all staff are competent in ulcer prevention. This has proved to be very
successful with a number of wards reversing poor results.
The Trust has had no grade 4 pressure ulcers and the split of grade 2 and 3 can be
seen in the following graph:
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QUALITY ACCOUNT 2013-14
Community
As part of the Transparency in Care Project, this process has now been formally
extended to include community acquired pressure ulcers. This is proving to be a
more challenging process as it is difficult to define a ‘community acquired’ ulcer. The
District Nursing team may only see the patient for a very brief period. If a pressure
ulcer develops in such a patient we are currently considering this to be community
acquired
It is hoped that as the Transparency project develops, a clearer definition will be
developed and utilised across the whole health community.
Open and Honest Care (Transparency)
Since October 2013 the trust has provided reports that are submitted to NHS
England and also published on our intranet page.
The purpose of this project is to inform the general public via the Hospital website of
the care we give to our patients, to be open, honest and transparent.
The data that is published is collected from a variety of sources including:
• the national safety thermometer
• the friends and family test
• Amount of “harms “our patients incur each month. The harms collected are
pressure ulcers and falls.
The chart below details our prevalence since our first October submission.
A Patient Experience Story and an Improvement Initiative are also published in the
report. The Experience Story can be negative or positive and should reflect the data
published.
To date, improvement stories have included the opening of the FESS unit, the
opening of the prayer room at Southport and the recruitment of the Portuguese
nurses to our trust
The patient experience stories have been captured from patients by both face to face
conversations and letters.
Although this project currently focuses on the acute hospital, the community
submissions will be launched in March 2014 and the next wave includes Maternity,
followed by Paediatrics, Mental Health and Learning Disabilities.
It is expected that this work will expand further over the next twelve months and
demonstrate the care and commitment across the organisation.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.21 QUALITY and RISK STANDARDS
3.21.1
Clinical Negligence Scheme for Trusts (CNST)
In September 2012 Southport and Ormskirk Maternity services were assessed
against CNST level 2 standards and are proud to announce full achievement.
3.21.2
National Health Service Litigation Authority (NHSLA)
The Trust made a decision to apply for level 1 assessment to ensure that will the
formation of an ICO the policies in place were fit for purpose. The Trust subsequently
undertook level 1 assessment for NHSLA in 2013 and is proud to announce 100%
achievement.
For both Clinical Negligence Standards for Trusts and NHSLA, the Trust is awaiting
the national outcome of the NHSLA reorganisation to decide on the way forward.
3.21.3
Quality and Risk Profile (QRP)
The Care Quality Commission (CQC) produced a Quality and Risk profile for each
Trust up until the end of July 2013. There was a period of time after this where a
replacement was being compiled that Trusts did not receive a report and the CQC
have recently started to produce a shorter more interpretable document, titled the
“Intelligent Monitoring Report”. The Trust is now looking at how the data contained
in this document can be presented to Trust Board and other relevant committees on
a regular basis. This new report will be covered in more depth in next years Quality
Account.
The CQC, Quality and Risk profile when produced was monitored on a dashboard
and reviewed monthly at the Operational Quality Committee. Any problem areas
were investigated and actions implemented as required. It was also included in the
performance data presented to Trust Board on a monthly basis. The CQC 16
Essential Standards of Quality of Safety consist of:
Outcome 1 Respecting and involving people who use services
Outcome 2 Consent to care and treatment
Outcome 4 Care and welfare of people who use services
Outcome 5 Meeting nutritional needs
Outcome 6 Cooperating with other providers
Outcome 7 Safeguarding people who use services from abuse
Outcome 8 Cleanliness and infection control
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QUALITY ACCOUNT 2013-14
Outcome 9 Management of medicines
Outcome 10 Safety and suitability of premises
Outcome 11 Safety, availability and suitability of equipment
Outcome 12 Requirements relating to workers
Outcome 13 Staffing
Outcome 14 Supporting staff
Outcome 16 Assessing and monitoring the quality of service provision
Outcome 17 Complaints
Outcome 21 Records
The QRP which was published by the CQC allowed the risk estimates to be viewed
over a period of time. These risk estimates are based on a large amount of
information which the CQC obtained about the trust, covering all aspects of the 16
Essential Standards. Below can be seen the Trust performance against the 16
Essential Standards of Quality and Safety up to August 2013. The table below
shows those periods within the 12 months covered by this Quality Account where a
QRP was published.
KEY
Low
Green
High
Green
Low
Neutral/
Yellow
High
neutral/
Yellow
Low
Amber
High
Amber
Low Red
High Red
Reducing risk of non-compliance -- Increasing risk of non-compliance
Outcome
1
2
4
5
6
7
8
9
10
11
12
13
14
16
17
21
May 13
LY
LY
LY
LY
LY
LY
HG
LA
LG
LG
HG
HY
LY
LY
LY
LG
Jun 13
LY
LY
LY
LY
LY
LY
HG
LA
LG
LY
LY
HY
LY
LY
LY
LG
July 13
LY
LY
LY
LY
LY
LY
HG
LA
LG
LY
LY
HY
LY
LY
LY
LG
Period
3.22 Safeguarding adults
Safeguarding adults remains high on the agenda for Southport and Ormskirk
Hospitals NHS Trust. It is therefore paramount that all policies and procedures are
robust and processes for
Referral and case management are scrutinised to ensure they are fit for purpose.
Structural Changes to Safeguarding Adults
Since the introduction of the Health and Social Care Act in 2012, there have been
changes to the structure of safeguarding across the health and social care economy.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Local Authorities continue to be the lead statutory organisations for safeguarding but
they have new resources and levers now including the recently created local Health
and Well Being Boards. These are led by Public Health and sit within the local
authority.
The HWBB ensures that local health needs are continually assessed. The HWBB
then agree and set Joint Health and Well Being Strategies for r each local authority
area.
The Safeguarding Adults Executive Boards are now on a statutory footing and
membership includes the CCGs and the commissioning board.
The Executive
Board now has an independent chair that can set strategic direction for safeguarding
within the local community.
Whilst this does not have an impact in terms of day to day safeguarding delivery, it
does bring adults closer to statutory law with clearer responsibilities and legal
obligations.
3.22.1. Safeguarding Adult Referrals
DATE
OCTOBER
OCTOBER
NOVEMBER
NOVEMBER
DECEMBER
DECEMBER
YEAR
2012
2013
2012
2013
2012
2013
REFERRALS
7
24
17
18
13
10
Abuse Type
Types Of Abuse
Community aquired pressure
ulcers
financial Abuse
Medication errors
Neglect
Physical
Phycological
Sexual
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QUALITY ACCOUNT 2013-14
Training
Training is delivered across the organisation by the Adults at Risk Team during the
following sessions:
• Staff Induction
• Mandatory training
• IPL training for students/ therapists
• Specialist Domestic Abuse training for Midwifes (This will be expanded to all
staff across the organisation is 2014)
• E Reader
• Mental Capacity Act and Deprivation of Liberty Safeguards
• Domestic Abuse read and sign document is available
Reporting Requirements
The CQC are informed of all safeguarding referrals with police or social services
involvement on a monthly basis.
Collaboration
The team work closely with both local authorities and share information as
necessary. The trust is represented at both MARAC meetings.
3.22.2
Safeguarding children
Safeguarding children remains a high priority within the Trust. The Safeguarding
Assurance Groups have become established to ensure the quality of the
safeguarding service and assurance to the board. There is an established
safeguarding team which provides expertise and guidance, training and implements
policies and guidelines based on national guidance.
The Safeguarding and Child Protection Policy has been updated in line with updated
practice and guidance. In line with the quality contract a supervision strategy has
been developed and supervision sessions have been commenced for paediatric and
maternity staff, ad hoc supervision and advice are available at all times to all staff
within the trust. All children subject to a child protection plan are flagged on both
PAS and symphony systems to ensure information is shared with the child’s social
worker. There is a system in place to identify case conferences in which the trust is
required to input and staff attends or send a written report as appropriate. A
representative from the trust attends all MARAC meetings in order to share
information and implement any actions required from the trust. Work with the
electronic records system implementation has taken place to ensure safeguarding
information is appropriately inputted into the records. Safer Recruitment processes
are identified and adhered to. CRB /DBS (Disclosure& Barring Service) Checks are
requested and records maintained for relevant employees in line with protection of
Freedom Act 2012
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.22.3 Dementia
The Prime Minister issued a dementia challenge in March 2012 that aimed to
improve the care for people with dementia.
It is hoped that the programme of work will push further and faster to deliver major
improvements in dementia care and research by 2015, building on the existing
National Dementia Strategy.
This work has been an important part of the Care as Care Should Be programme for
2013 and there has been a significant amount of improvement across the
organisation. However, one area that continues to be a challenge is the completion
of the CQUIN requirements
CQUIN 2013 – 14
The requirements and results for CQUIN to date are stated below:
3.1
Dementia CQUIN Question 1
Dementia CQUIN Question 2
Dementia CQUIN Question 3
3.2 Named lead clinician for
dementia and appropriate
training for staff
3.3 Supporting Carers of People
with Dementia
Oct
Nov
Dec
15.2%
7.8%
3.8%
42.9%
n/a
40%
50%
Quarterly reports month by
month (requirement is 90%)
100%
85.7%
Dr McDonald
Training figures being collected.
Questionnaire
produced
Provider must confirm named
lead clinician and the planned
training programme (to be
determined locally) for
dementia for the coming year.
Provider must demonstrate that
they have undertaken a monthly
audit of carers of people with
dementia to test whether they
feel supported and reported the
results to the Board. Provider
and commissioner should work
together to agree the content of
the audit.
As a result of this areas have been targeted for further support to share successes of
other areas that manage to collect the information.
The results will be shared with the Senior Nursing staff at SNAP and completion will
become a mandatory professional standard for the future.
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QUALITY ACCOUNT 2013-14
Nursing Care
The Trust ‘Adults at Risk’ healing hands identifier is widely used in all areas
throughout the trust including the community. The district nurse teams are
highlighting patient’s case notes with the logo to sensitively identify those patients
with additional needs to all team members.
PRIDE
In October the first meeting of the Trust dementia champions was held and there was
good attendance from both acute and community staff. These champions have been
supporting both patients and staff within their ward and department area. It is hoped
that they can utilised as a conduit for information to all staff. They also identify areas
that require further training or support and share best practice across the Trust.
Caring for the Carers
The trust has recently introduced ‘Carers Packs’ across all inpatient areas. These
packs contain vital information for carers who are looking after both newly diagnosed
and long term patients with dementia and reduced cognitive function. The pack aims
to signpost the carer to services inside and outside of the organisation that offer
support and information about the many forms dementia can take. It also provides
information about local support groups and services that may make life easier for
those who are looking after someone with this disabilitating illness.
The packs have been in place for a number of months. An audit of their use across
the Trust will be implemented and reported on in the next CACSB report. Following
this, a carer survey will be carried out to determine if the packs contain the right
information.
Training and Awareness Raising
Equipping the staff with the skills and information to enable them to care for patients
with dementia is essential for high quality care.
The training is delivered in various formats. The programme has been developed in
conjunction with the Therapies team and is available face to face for all staff across
the trust.
•
•
Via the 1 hour mandatory training and induction talk on ‘Adults at Risk’ and
safeguarding.
A Three hour dementia workshop available for all trust staff via the training
prospectus
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
•
•
Bespoke training for departments, i.e. ODGH domestics
1 hour training for all volunteers who work for the trust and the Royal
Voluntary service
A Healing Environment
Providing an environment that enhances healing is important for all patients but has a
significant effect on patients with dementia. This can prove challenging when
providing acute services.
Patients with dementia can become more confused when out of their usual
environment. The trust purchased dementia friendly day, night and flip type clocks
for all inpatient areas including the bays and side rooms to assist with orientation.
There are also memory boxes available for patients to utilise with relatives or
volunteers. These can encourage the patients with dementia to talk about their past.
The Frail Elderly Short Stay Unit
Ward 9b in Southport has become the FESS unit, Frail Elderly Short Stay which
specialises in care for those patients who are suffering from:
•
•
•
•
Delirium (acute confusion)
Dementia
Patients susceptible to falls and have reduced mobility.
People not coping in the community due to the break down of social
care
• Patients with infection, dehydration or low blood sugar
The unit has a specialised team of therapists, social workers and discharge coordinators all working alongside the nursing staff and medical team to ensure
patients receive the care they need to quickly return back to the community.
Partnership working
The Trust maintains a successful relationship with all our community partners.
The Trust presented at the November 2013 Alzheimer’s Society Patient and Carers
Forum.
This provided an excellent opportunity to tell patients and their carers about the
support we offer at the hospital and to introduce them to the patients’ passports and
associated documentation.
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QUALITY ACCOUNT 2013-14
3.22.4 Trust Volunteers
Background
The Trust has been recruiting volunteers for the ward areas for over twelve months to
assist patients at meal times. Simultaneously, the RVS (formerly the WRVS) have
also recruited for volunteers in the Trust to assist confused patients, many with
dementia.
RVS
The RVS programme has been slow to develop but has gathered momentum
recently.
Currently, the RVS have thirteen volunteers in placement on the ward areas across
all areas of the organisation.
This group of Volunteers work with patients on an individual basis. They specifically
aim to support confused patients and have been trained in dementia care by the
RVS. They spend time with the patients, read to them, sing to them and discuss past
memories (reminiscence therapy). Their training is provided by both the RVS and
the Trust.
They do not provide direct care to the patients and do not assist with nutritional
needs.
SNAPSHOT REVIEW
During the time period 30.9.13 – 30.10.13 the RVS volunteers supported a total of
forty three patients over approximately sixty seven hours. They were involved in
many interactions including:
• Reading to the patients
• Talking and general conversation, including discussions about friends and
family
• Playing Games
• Encouragement to eat and drink
• Singing
• Anecdotal feedback and comments about this group has included:
‘’it’s so nice to be able to have a chat’
‘Lady was confused when I arrived, but after chatting and encouragement to draw
pictures and write letters, she really settled’
‘The patient loved going through the memory cards’
‘She was quite agitated but we spent the time singing and this calmed her down’
The plan is for the RVS volunteers to be available for all confused patients who
would benefit from their support. To assist with this a register is kept by the Bed
Managers. This is used to allocate the volunteer to the right ward. Recruitment is
on-going and recruitment events have been held across a number of education
facilities such as Edge Hill University and KGV College.
Dining Companions
The recruitment of Dining Companions has been very successful with a total of 21
volunteers on the wards. Currently, the support is focused on H ward, 7A and 14A.
The next ward will be 9B, the Frail Elderly Short Stay Unit. Each dining companion
will be based on the ward regularly to ensure they become part of the ward team.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
All of the Trust volunteers are taught how to assist the patients to eat and drink by
the Trust Dieticians. They only provide this for the patients that are able to manage
swallowing and have not got an underlying condition that may affect this such as a
stroke.
Trust staff have also volunteered as Dining Companions and are giving up their own
lunch times to assist with feeding on the wards.
The volunteers who have been in post the longest are now looking to move into
substantive posts or go into further education. This is unfortunate for the
organisation but demonstrates the value of the volunteer placement with the
organisation. Exit interviews are conducted with all of those that leave to ensure that
they have benefitted from their time here and to determine if we could improve the
experience in anyway.
Spiritual Volunteers
The Trust has started recruiting Spiritual Volunteers. This group of Volunteers will
work closely with the Hospital Chaplain and deliver pastoral care across the
organisation. This may include sitting and chatting to patients or praying with them.
There has been interest from a wide variety of people including past Chaplains.
.
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Appendix 1
GLOSSARY
A&E
ACP
Accident and Emergency Department
Advanced Care Planning
ACS
ACS
Acute Coronary Syndrome
Appropriate Care Score - All measures passed for an individual
ASU
AQ
patient
Acute Stroke Unit
CABAG
CBU
Advancing Quality
Coronary Artery Bypass Graft
CCU
C.diff
CMACH
CMACE
CNST
COW
CPAP
CQC
CQS / CPS
Clinical Business Unit
Coronary Care Unit
Clostridium difficile
Confidential Enquiry into Child Health
Centre for Maternal and Child Enquiries
Clinical negligence Scheme for Trusts
Consultant of the Week
Constant Positive Airways Pressure
Care Quality Commission
Composite quality Score - Aggregated delivery of several clinical
processes
Commissioning for Quality and Innovation
Data for Head and Neck Oncology
Director of Nursing
Deputy Director of Nursing
Director of Infection Prevention and Control
Do Not Attempt to Resuscitate
Delivering Same Sex Accommodation
Emergency Admissions Unit
European Computer Driving License
End of Life
Electronic Palliative Co-ordination System
Gold Standard Framework Acute Hospitals
Genito Urinary Medicine
Hospital Acquired Pressure Sores
Health Care Acquired Infections
Health Care Commission
Hygiene Environment Action Team
CQUIN
DAHNO
DON
DDON
DIPC
DNAR
DSSA
EAU
ECDL
EoL
EPaCCS
GSFAH
GUM
HAPS
HCAI
HCC
HEAT
128
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
HES
HII
Hospital Episode Statistics
High Impact Interventions
HONS
HRG
Heads of Nursing
Healthcare Related Groups
HSMR
HQIP
Hospital Standardised Mortality Ratio
Healthcare Quality Improvement Partnership
IBD
ICT
Irritable Bowel Disease
Integrated Care Teams
ITQ
IV
Information Technology Qualification
Intravenous
LAA
LCP
Local Area Agreements
Liverpool Care Pathway (adapted in this Trust as the VIGIL)
LD
LINks
Learning Difficulties
Local Involvement Networks
LIPS
MDT
Leadership in Patient Safety
Multi Disciplinary Team
MINAP
MRSA
Myocardial Infarction National Audit Project
Methicillin Resistant StaphlococcusAureus
MSA
NCEPOD
Mixed Sex Accommodation
National Confidential Enquiry into Patient Outcome and Death
NCISH
NHSLA
National Confidential Enquiry into Suicide and Homicide
National Health Service Litigation Authority
NICE
NICOR
National Institute of Clinical Excellence
National Institute for Clinical Outcome Research
National Institute for Health Research
National Neonatal Audit Programme
Northgate Information Solutions is the company which manages
the Proms data on behalf of the Department of Health
Obstructive Sleep Apnoea
Overview and Scrutiny Committee
Personal Development Review
Patient Environment Action Team
Patient Lead Assessments of the Care Environment
American Advancing Quality lead company
Preferred Place of Care
Patient Reported Outcome Measures
Red, Amber, Green
Risk Adjusted Mortality
NIHR
NNAP
NORTHGATE
OSA
OSC
PDR
PEAT
PLACE
PREMIER
PPC
PROMS
RAG
RAM
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QUALITY ACCOUNT 2013-14
RCOG
RCPH
REoLT
SHMI
SINAP
SIRRS
SNAP
S4BH
StEIS
SUI
SUS
TARN
UTI
VAP
VTE
WRVS
Royal College of Obstetricians and Gynaecologists
Royal College of Paediatric and Child Health
Rapid End of Life Transfer
Standardised Hospital Mortality Indicator
Stroke Improvement National Audit Programme
Serious Illness Recognition and Response Committee
Senior Nurse Advancing practice group
Standards for Better Health
Strategic Executive Information System
Serious Untoward Incident
Secondary Users Services
Trauma Audit and Research Network
Urinary Tract Infection
Ventilator Acquired Pneumonia
Venous Thrombo-Embolism
Women’s Royal Voluntary Service
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Appendix 2
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QUALITY ACCOUNT 2013-14
Appendix 3
Maintaining Mandatory Professional Standards
1.
Patient observations. We will adhere to the relevant policies regarding
written recording of patient observations. In particular the recording of early
warning scores and fluid balance where appropriate.
2.
Estimated date of discharge. We will give all patients an estimated
date of discharge.
3.
Cannula care. We will fully comply with the policy for siting and caring for
an intravenous cannula.
4. Antibimicrobial stop dates. We will provide stop dates for all
antimicrobials with guidance from the consultant microbiologist.
5. Patient records. We will record and store all patient documentation in
accordance with the Quality Strategy.
6.
Dress and uniform. We will dress appropriately at all times, ensuring
uniforms are fully compliant with the uniform policy and Quality Strategy.
7.
Patient nutrition. We will ensure patients always receive the appropriate
nutrition and are able to call for help easily if needed.
8. Patient discharge. We will make sure discharge checklists are
completed fully and discharge policies are followed.
9.
Punctuality. We will be punctual both when starting shifts and returning
from breaks.
10. Appraisal and training. We will keep up-to-date with our mandatory
training and ensure our yearly appraisals are undertaken.
11. Hand hygiene. We will be bare below the elbows on wards and will follow
the hand hygiene policy strictly.
12. Checklist compliance. We will follow and complete checklists where
they exist as an aid to policy compliance.
September 2012
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Appendix 4
The National Clinical Audits that Southport and Ormskirk Hospital NHS Trust participated in during April 2013 – March 2014 are
as follows:
Eligible – 31
Participated – 31
No
.
1.
National Clinical Audits
Eligible
Participated
Submitted
Required
Percentage
Changes in Practice
Case Mix Programme (CMP)ICNARC
Yes
Yes
512
512
100%
Report will be available
in Nov 2014
2.
Medical and surgical clinical
outcome review programme:
National confidential enquiry
into patient outcome and
death
National Audit of Seizures in
Hospitals (NASH)
Yes
Yes
Answered
separately
below
Yes
Yes
28
30
93%
National emergency
laparotomy audit (NELA)
Yes
Yes
Ongoing does
not finish until
2014-15
Patient leaflet has been
improved for epilepsy
patients to ensure it
includes a section on
driving dangers
Not complete until June
2014
490
109%
Ongoing data
collection
3.
4.
5.
National Joint Registry
(NJR)
Yes
Yes
12 at present
535
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QUALITY ACCOUNT 2013-14
No
.
6.
National Clinical Audits
Eligible
Participated
Submitted
Severe trauma (Trauma
Audit & Research Network,
TARN)
Yes
Yes
Full figures not
available until
June 2014 –
data entry
deadline
Required
Percentage
Changes in Practice
Approx 83%
116 at present –
Trauma call activations
have increased.
Trauma care in the
Trust has advanced a
lot since 2012-13 and
our data accreditation is
1 of the best in the
region
No reports received to
date
116 at present
7.
National Comparative Audit
of Blood Transfusion
programme:
Yes
Yes
Split into 3
audits
•
Anti D
38
•
Patient consent
to transfusion
24
•
Red Cell Use
All applicable
patients
100%
46
8.
Bowel cancer (NBOCAP)
Yes
Yes
160
n/a
9.
Head and neck oncology
(DAHNO)
Yes
Yes
15-20
n/a
10.
Lung cancer (NLCA)
Yes
Yes
140
n/a
11.
Oesophago-gastric cancer
(NAOGC)
Yes
Yes
70
n/a
134
Figures still being
inputted for year end –
final figures available
in June
Aintree Hospital
completed this for us as
we are a satellite centre
Deadline is not until
October 2014
Deadline is not until
October 2014
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
No
.
12.
National Clinical Audits
Eligible
Participated
Submitted
Required
Percentage
Changes in Practice
Acute coronary syndrome or
Acute myocardial infarction
(MINAP)
Cardiac Rhythm
Management (CRM)
Congenital heart disease
(Paediatric cardiac surgery)
(CHD)
Coronary angioplasty
National Adult Cardiac
Surgery Audit
National Cardiac Arrest
Audit (NCAA)
Yes
Yes
211
All eligible
patients
100%
As at 28/03/14
Yes
Yes
83
All 2222 calls
100%
18.
National Heart Failure Audit
Yes
Yes
254
All cases
100%
Performing well and 1
of the top hospitals in
the region for all but 1
area.
No report received –
due August 2014
19.
20.
National Vascular Registry*
Diabetes (Adult) ND(A),
includes National Diabetes
Inpatient Audit (NADIA)*
No
Yes
Yes
National
Diabetes IP
audit -36
All eligible
patients
90%
All eligible
patients
100%
13.
14.
15.
16.
17.
No
No
No
No
National
Diabetes Audit
- 1415
21.
Diabetes (Paediatric) (NPDA)
Yes
Yes
117
135
Interim report still
being circulated around
the Trust – Inpatient
Diabetic Specialist
Nurse now in place and
work being done on
improving Diabetic
Foot care throughout
the Trust
Report not yet received
for National Diabetes
Audit
Report due for release
September 2014
QUALITY ACCOUNT 2013-14
No
.
22.
National Clinical Audits
Eligible
Participated
Submitted
Required
Percentage
Changes in Practice
Inflammatory bowel disease
(IBD)*
Yes
Yes
3
50
6%
23.
National Chronic
Obstructive Pulmonary
Disease (COPD) Audit
Programme*
24.
Renal replacement therapy
(Renal Registry)
Rheumatoid and early
inflammatory arthritis*
Yes but
completi
on not
due until
2014-15
No
Completed
organisational element
but could not do
clinical due to long
term sickness of IBD
specialist nurse and the
resulting pressures on
the rest of the IBD
team including the
consultants
Not due for submission
until May 2014
25.
26.
Falls and Fragility Fractures
Audit Programme (FFFAP)
No
details as
yet on
when
this is
starting.
Yes
Yes
n/a
311 for NHFD
(#NOF )
136
All cases
100%
Full audit begins after
May 2014
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
No
.
27.
National Clinical Audits
Eligible
Participated
Submitted
Required
Percentage
Changes in Practice
Sentinel Stroke National
Audit Programme (SSNAP)*
Yes
Yes
359 as at
02/04/14 – Full
figures not
available until
all patients have
been locked on
the system
All cases
Not complete
Ongoing changes made
to and discussions had
about Stroke Care at
monthly stroke strategy
group where these
results are discussed. 2
audits on the 2014-15
audit plan that focus on
deficiencies in care
found from submitting
to this audit database.
28.
Elective surgery (National
PROMs Programme)
Epilepsy 12 audit (Childhood
Epilepsy)
Maternal, Newborn and
Infant Clinical Outcome
Review Programme
(MBRRACE-UK)
Neonatal intensive and
special care (NNAP)
Paediatric intensive care
(PICANet)
BTS Emergency Use of
Oxygen
Yes
Yes
892
All cases
100%
Yes
Yes
18
18
100%
Yes
Yes
13
13
100%
Yes
Yes
361
361
100%
Yes
Yes
10
All eligible
wards
100%
CEM Moderate or Severe
Asthma in Children
Yes
Yes
50
50
100%
29.
30.
31.
32.
33.
34.
No report received
No
137
Report sent to
Respiratory Team
meeting for discussion
and for action plan to
be compiled
No report received
QUALITY ACCOUNT 2013-14
No
.
35.
National Clinical Audits
Eligible
Participated
Submitted
Required
Percentage
Changes in Practice
BTS Paediatric Asthma
Audit
Yes
Yes
16
16
100%
36.
37.
CEM Paracetamol Overdose
CEM Severe Sepsis & Septic
Shock
CEM Consultant Sign-off
Audit
National Care of the Dying
Yes
Yes
Yes
Yes
50
50
50
50
100%
100%
Report currently being
circulated for action
plan development
No report received
No report received
Yes
Yes
40
40
100%
No report received
Yes
Yes
50
50
100%
No report received
38.
39.
138
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Appendix 5
The National Confidential Enquiries that Southport and Ormskirk Hospital NHS Trust participated in during April 2013 – March
2014 are as follows:
Organisational Questionnaires 2013 – 2014
NCEPOD Project
NCEPOD - Tracheostomy Study
NCEPOD - Lower Limb Amputation
NCEPOD - Alcohol Related Liver Disease
NCEPOD – Subarachnoid Haemorrhage
Date National Report Received
Awaiting
Awaiting
June 2013
November 2013
(NCEPOD – national confidential enquiry into perioperative deaths)
Clinical Data Collection Questionnaires 2013 - 2014
Confidential Enquiry Data Collection
NCEPOD – Gastrointestinal Haemorrhage
NCEPOD – Tracheostomy Care
NCEPOD – Lower Limb Amputation
NCEPOD – Alcohol Related Liver Disease
Eligible
Yes
Yes
Yes
Yes
Participated
Yes
Yes
Yes
Yes
139
Submitted
Ongoing
6
4
3
Percentage
100%
100%
100%
QUALITY ACCOUNT 2013-14
Appendix 6
Local Clinical Audits undertaken by Southport and Ormskirk NHS Hospital Trust.
Local Clinical Audit Projects Undertaken during April 2013 – March 2014:
Audit Unique Identifier
13-001
Audit Title
Audit of Transfer Policy (Hand over of care)
13-005
Continuous Mortality Audit using Global Trigger
Tool
Audit of staff attitude on wards and use of red
bags for soiled clothes
Audit of nursing documentation – pain care
plans / pain scores on observation chart / bed
rail care plans
Critical Incident audit when incident relating to
specimen pots not containing specimens are
received.
13-008
Audit of Nutrition Policy
13-009
Audit of Anti-natal ward rounds
Patients with SCI in Manchester postcode area
and their experiences of care received
Audit of Chemotherapy Outpatient Waiting
Times
13-002
13-003
13-004
13-010
13-011
140
Changes in Practice
Re-audit was undertaken which highlighted the new transfer forms had not
been printed so wards will still using the old forms. Supplies were notified
and the new forms were ordered. Plan to re-audit in 2014 when new forms
are in use.
During the end of 2013 the mortality process was reviewed. All inpatient
deaths are now reviewed at a meeting held 3 times a week to identify
lessons to be learned and possible avoidable deaths. Quarterly reports are
produced from the audit and presented to the Trust Core Quality Group.
Medical Director has re-issued advice to doctors around professional
conduct
Member of the clinical audit team now attends the nursing documentation
group to feed in results of documentation clinical audit projects.
Audit indicated new process has been implemented successful to ensure
samples are not lost.
Re-audit has been undertaken and work is currently underway to ensure
all wards have access to weighing scales.
Improvement noted from initial audit project and on most days a ward
round was occurring twice.
No actions required
No actions required as a result of this service evaluation.
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Audit Unique Identifier
Audit Title
13-012
Random audits of case notes to ensure that the
swab counts are being performed and being
counter signed.
13-015
Re-audit of adherence to the clinical audit policy
13-016
CG29 Pressure ulcer management
13-018
13-019
Live notes audit of NHSLA
Audit of all trauma team activations, time to CT,
consultant attendance and use of tranexamic
acid in trauma
13-022
Audit of Discharge Procedures
13-024
Smoking status
13-035
CG103 Delirium
13-040
CG84 Diarrhoea and vomiting in children
CG102 Bacterial meningitis and meningococcal
septicaemia
13-043
141
Changes in Practice
Shift leaders to periodically check all perineal documentation prior to
transferring from the Delivery Suite to the Postnatal Ward / home. There
is a proforma already in place to support this practice. Individual feedback
to staff not complying with standards. Cascade results of audit to trainers
of Perineal Repair workshops to ensure dissemination of results and
ensure considered as part of training updates. Dissemination of
information on standards on Delivery Suite and signing of ‘HOT SPOT
FILE’
New system has been introduced to sign off audit project plans with the
audit lead and research and development manager.
Project indicated excellent use of the skin bundle for pressure ulcer care.
Plan to reaudit in 2014.
An ongoing audit of notes was undertaken measuring against NHSLA
standards. The results of the project were feedback to the Trust Standards
Steering Group as evidence of policy implementation.
As a result of this audit there will be more trauma team activations and an
extra audit will be undertaken next year to show patients that should have
triggered a trauma call that didn't and looking at the reasons why
A lot of audit activity has centred around discharge planning in 2013/2014
with the introduction of the discharge group. The head of audit and
effectiveness attends the group and identifies any necessary projects to
improve the discharge planning process. This project is ongoing and has
been carried over to 2014/2015 for further audit.
Project undertaken as part of the quality contract. The nursing
documentation is currently being modified with prominence at the top of
the documentation to encourage staff to complete smoking status for all
patients.
Further audit required to look at clinical assessment of delirium and why
particular tools used – carry out in May 2014.
Parents/Guardians/Carers should be offered written information i.e. leaflet.
Guideline (NICE / local) and reaudit
Local guideline in line with NICE guideline. Audiology Follow up-Check list
at discharge. Improve Documentation in clinical notes
QUALITY ACCOUNT 2013-14
Audit Unique Identifier
Audit Title
Random audits of case notes to ensure that
speculum and internal examinations are
documented within the patient’s case notes.
Changes in Practice
}All healthcare professionals are reminded of the need to offer and
document: procedure explained and verbal/written consent obtained - For
doctors- that chaperone offered and if declined, documented, if acceptedname and position held of chaperone documented in record - that findings
noted on examination are documented in the applicable areas - that
findings of examination is explained to patient and documented.
13-046
Audit of community patient identification
checklist. (Venepuncture)
13-048
Novasure endometrial ablation
13-049
MVA for miscarriages and TOPS's
13-050
13-056
Bladder care following childbirth
Use of Oxytocin
13-058
13-059
13-061
13-085
Induction of Labour
Severely ill pregnant women
Vaginal birth after Caesarean section
Monthly review of risk (bells and bars) identified
by Dr Fosters.
Audit of patients readmitted within 28 days of
discharge
Audit of under 19's unplanned hospital
admissions for asthma, diabetes, epilepsy
13-087
Consent Audit
13-091
Audit of Dermatology minor surgery pathway
13-094
Audit of Massive Haemorrhage Protocol
Two audit tools were being used. A single template now in place and
accessible via the Intranet
Document agreed 100% offered follow ups following procedure. Analysis
of information around previous c-sections. Dedicated sections for
discussion of potential complications to increase patient satisfaction,
Due to financial constraints, it is not possible to provide a separate waiting
area for these patients.
Leave catheter in for 12 hours - new guidance in place for this. Clear plan
for action required in difficulty voiding 6 hours post delivery and escalation
of treatment - again new guidance in place. Increasing awareness of risk
of voiding difficulties developing
Refresher training for medical staff on Delivery Suite
Compliant with exception of maternal request IOL and this has been
corrected by introduction of a Bishops Score label
Refresher training around C Section instrumental delivery
Compliant with CNST Standards
Ongoing project investigating the risks identified by Dr Foster, will continue
in 2013 / 2014
Ongoing project investigating the risks identified by Dr Foster, will continue
in 2013 / 2014
No actions required as audit demonstrated good practice and people
under 19 are not being admitted to hospital unnecessarily.
Completed and action plan to be monitored 6 monthly - re-audit due in 6
months as part of action plan
Audit found good compliance in the completion of the pre-operative
pathway.
Reasons identified in cases where protocol not followed and acted upon.
Results of audit presented at appropriate forums. Concerns around data
capture. Working on developing more robust monitoring systems
13-045
13-081
13-084
142
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Audit Unique Identifier
13-095
Audit Title
13-099
13-100
Re-audit of Bedside Audit transfusion
Care as care should be audit (part of Quality
dashboard)
Colorectal cancer
13-103
13-109
13-111
13-112
E-Discharge audit
Admission to neonatal unit
Examination of the Newborn
Support for parents
13-113
CT pulmonary nodules
Compliance with Guidelines for use of MRI in
Shoulder and knee joints
Audit of #NOF nailing
Re-audit of peri-operative recovery following
general surgery
Dural Tap Management in Obstetric
Anaesthesia
Patient identification/wristband audit
13-120
13-121
13-124
13-125
13-134
13-135
Changes in Practice
Incident forms completed for each non-compliance from audit and
forwarded to ward managers as per Trust policy.
Ongoing - reported at SNAP
Locums to be alerted to target for serosal involvement.
Project undertaken as part of quality contract and indicated e-discharged
are being completed, but there is still an improvement needed in
completion of some of the sections of the e-discharge.
No changes as over 75% compliant against CNSTstandards
Ongoing training
Ongoing training
To add a proforma in the casenote recording date of original scan (when
nodule detected) and dates of anticipated follow up so this is clearly
documented from the outset and the information is then readily available
for completion of CT requests
MRI request form to be changed to improve recording of reasons for
request
No changes to practice required
Re-audit to show improvement in pain scores
13-139
Head Injury Management in the ED
12 Month Follow Up after discharge from
cardiac rehab programme Audit - Post phase 3
Re-audit of the initial management of suspected
bacterial meningitis
13-156
FNA Breast re-audit
13-157
US axilla re-audit
Dislocation rate following THR compared with
National figures
13-138
13-160
143
No changes to practice required
Plan to re-audit in 2014 to ensure new policy has been implemented.
Improved documentation of verbal CT scan reports. Standardised
observations for head injuries in department Re-audit in 2014-15
Completed - Excellent compliance shown.
Consultant Microbiologists always reinforcing need for prompt
investigations
Re-audit demonstrated that good practice being maintained. No changes
necessary
1.To ensure all preop diagnosed patients with breast cancer have US
axilla. 2. To ensure any recommendations in alternative imaging are
followed up preoperatively
No changes to practice required
QUALITY ACCOUNT 2013-14
Audit Unique Identifier
13-167
13-169
13-170
Audit Title
13-196
Obstetric Anaesthesia Annual Audit
Re-audit of CVP lines under ultrasound
Cuff pressures in LMAs and ETs
Cleaning of bed space against Trust policy
(Mattress Audit)
Outcome of Carpal Tunnel
Reconciliation of Medicines against trust policy
re-audit
Re-audit of smoking cessation (staff
questionnaire)
13-203
Urinary catheter practice Quality Contract
Indicator PS03
13-204
Non-Medical Prescribing
13-213
In-patient satisfaction Survey
13-215
Changes to discharge prescriptions
13-216
13-223
13-224
Risk Register Quality Impact Assessments Audit
Non Surgical Management of BCC's
Isotretinoin inc recurrent courses
13-225
Ward Referrals including Payment
13-228
Aliteretinoin Audit
Re-audit of adequacy of drip and cannula
fixation
13-172
13-178
13-181
13-231
Changes in Practice
Planning for electronic data acquisition to enable more efficicient &
accurate auditing
No action required
No action required
Project indicated good compliance and will be reaudited in 2014.
No changes to practice required
Briefing e-mail circulated to all Pharmacists and technicians involved in
Meds Reconciliation to remind that all details need to be completed
Patient self-referral to smoking cessation service now possible through
hospedia
All patients with indwelling catheter to have a care plan describing the
catheter care to be provided. To include reason for insertion, review dates
for re-insertion, catheter site care, catheter drainage system, fluid intake
advice, action to take if catheter blocks and service contact details (last
point also to be included in patient notes). Re-audit has already taken
place and shown a marked increase in compliance in all these areas
None needed, as this second audit cycle demonstrated a huge
improvement in compliance against identified standards.
Process discharge prescriptions in advance of estimated day of discharge.
Each stage of discharge process to be entered on the tracker separately
rather than altogether following final check
Develop a list of common acute medications which should be double
checked when completing discharge prescription by doctors.
Currently updating the process for recording risk registers so plan to
reaudit in 2014 / 2015
Better documentation introduced by the network
Data input completed M/E March - report not available yet
Introduction of a new proforma to help triage referrals to see patients more
appropriately
Look at introducing a proforma to improve documentation at all stages of
treatment. All women of child-bearing potential need to be entered into the
PPP prior to treatment. Aim to achieve100%. Continue DLQI and PGA
severity scoring prior to and at 12 and 24 weeks of treatment. Aim to
achieve 100%
no changes required
144
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Audit Unique Identifier
13-234
13-235
13-237
Audit Title
Diabetes Insulin Pump audit
Audit of mental health screening during
pregnancy
NCE Asthma Deaths
13-238
Missed lung Cancers on Chest radiographs
13-245
13-248
13-250
13-251
Changes in Practice
No report received
Testis cancers 2008-12- comparison of original
report with MDT review
Patient satisfaction survey for OOH phlebotomy
pilot
Patient satisfaction/experience
13-254
Efficiency of Quality of Life Feeding Summary
Documentation of the conversation about dying
and the prescribing of anticipatory EOL prn
drugs for symptom control.
13-255
Spiritual/Religious Care Needs Assessment
13-259
Antibiotics for surgical prophylaxis in urology
Use of gonad protection in radiology of the
pelvis (re-audit)
Clinical Risk Assessment (Antenatal)
Clinical Risk Assessment (Labour)
Postnatal care
Effectiveness of service involving chronic care
team
13-260
13-263
13-265
13-267
13-273
13-274
13-275
Self-administration of Medicines
District Nursing care for those who may be in
the last year of life
145
Standardised clinic assessment form has been developed.
No deaths found in 2013-14
All definite lung cancers and lesions suspicious of cancer should be coded
L5 on the report.
Reminder to all pathologists that all central review reports should be
appended in full to original report on laboratory information system; Underreporting of vascular invasion brought to the attention of the relevant
pathologist to allow improvement in practice and to allow reflection at next
appraisal.
Project illustrated the need for out of hour’s service provision. Discussions
with funding CCG currently underway.
Questionnaire amended
Produce standardised Swallow Guideline sheet for each QOL feeding
patient to prompt staff to consider GSF referral
No changes in practice as such. Recommended actions around monitoring
of documentation and education and use of appropriate phraseology
At least one representative from each relevant ward/area to attend
"Opening the spiritual gate" programme
(i) Dipstick testing will not be carried out for CSU (ii) Dipstick positive MSU
to be sent for culture (iii) pre-op gentamicin dosing to be based on trust
guidelines (iv) antibiotic choice to be guided by sensitivities if cultures are
positive
Radiation Supervisors to take on board. Suggested monthly re-audit to
improve compliance
Compliant with CNST Standards
Compliant with CNST Standards
Compliant with CNST Standards
Chronic Care Coordinators now using iPM to log contact with patients.
Display patient information framework on all patient bedside lockers and
educate patients.
System in place so that D/N teams informed when patient GSF registered
by GP; GSF register held by each D/N team.
QUALITY ACCOUNT 2013-14
Audit Unique Identifier
13-276
13-277
13-278
13-279
Audit Title
Changes in Practice
All actions completed• Ward staff are to be made aware of the existence of
the Action Card
• Departments need to ensure their staff know if it is to be used for another
purpose in a major incident and following info given to ward staff
• Managers need to advise staff of the location of the Action Card
No change in practice. Reinforce message re importance of documenting
contact information
MIP Action Card Audit
Emergency contact & NOK recording Specialist Palliative Care Services
Speech and Language Therapy Input with
Adults with Learning Difficulties
13-280
Pain Service Audit
Monitoring of specialist palliative care patients
attending hospital
13-281
Achieving preferred place of care
13-283
Discharge Planning
13-285
13-287
13-288
13-293
Biomechanical Assessment
Safe entry in laparoscopic surgery
An audit of ovarian cancer diagnoses
Glaucoma medications (baseline audit)
Effectiveness of use of botulinium toxin for
strabismus ocular motility
Audit of NBM
Audit on the correct labelling of specimens in
theatres according to the WHO checklist and
the specimen policy
Audit on the correct use of the WHO checklist
(within the peri-operative checklist) in theatres
at S & O Trust
Audit on consultant ward round documentation
13-295
13-299
13-304
13-305
13-306
146
Business case currently being produced.
No changes necessary as audit demonstrated that the pain service is
benefitting its patients.
Flow chart created and agreed and in use November 2013; SPCS are
informed of all pts known to the team who are admitted or attend hospital
Includes Review failed rapid EOL transfers through mortality audit;
implementation of D/N GSF and discussion of wishes and preferences
from the beginning; use of community DNACPR forms as appropriate
Admin support in place to assist with data entry/retrieval; discharge
planning database in use; ongoing work to standardise "whiteboards" to
record EDD
Supply temporary insole on first visit even if patient is to receive bespoke
orthotic (unless footwear is unsuitable); advice sheet provided on first visit
Flow chart created and agreed and in use November 2013
No actions required
No changes required
Introduce documentation in the notes of induction of BT procedure. If no
post BT orthoptist visit justify reason.
On-going work towards the introduction of a trust guideline on nil by mouth
Ongoing work being done throughout the Trust on this - New checklist is
now in place in theatres and a monthly audit takes place that is regularly
monitored by the quality committee
Ongoing work being done throughout the Trust on this - New checklist is
now in place in theatres and a monthly audit takes place that is regularly
monitored by the quality committee
No actions required
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Audit Unique Identifier
13-313
Audit Title
Changes in Practice
Review the way in which patients are booked into ARC especially those
with already existent Clinic appt. status. Limit the number of “advance
booking into next available ARC” slots. Restrict the number of revisits to
ARC- create ARC follow up slots in consultant clinics to accommodate
revisits. Once a month or so perhaps have an entire clinic of revisits
together with an ARC. Need to leave more slots for actual emergency
bookings, within 48-72 hours of the clinic—block at least 3 slots for
booking for that day. Double clinics before /after a Bank holiday weekend.
Referrals into Emergency eye clinic
Follow up for repeat newborn bloodspots with implementation of
competency workbook
13-315
Newborn Bloodspots repeats
13-317
RCR early breast cancer radiotherapy audit
13-318
16-18 year old referrals to Liaison
13-319
13-323
13-327
13-328
13-330
13-331
13-333
Audit of Southport A&E referrals. Completion of
liaison into staff referrals of audit behaviour and
impact on children
Safeguarding info is filed in the relevant section
of records to include not for disclosure
documentation ref Sties 2012/00685
Audit of Stillbirths
Coding in foot & ankle procedures
Use of Vigil Care Plan Leaflets
Audit of Alcohol brief interventions
An investigation into the role of occupational
therapists in emergency departments
Number of clips used has changed from 4/5 to 10 as a result of the
recommendations from the audit.
Results of the audit to be shared with managers at SDGH A&E in order for
staff to be reminded of responsibilities for referring 16-18yr olds to Paed
Liaison. Audit to be shared at Safeguarding Steering Group. Discussions
with managers re possibility of carrying out regular quality assurance
regarding referrals
To liaise and meet with new link nurses for safeguarding at Southport
A&E, and discuss ways of increasing staff knowledge of the importance of
providing detailed information. Results also to be shared with managers of
A&E in order for them to support staff with this. Copy of referral to be faxed
to Paediatric Liaison with each liaison referral. Liaise with link nurses for
safeguarding in A&E to discuss ways of ensuring that staff are aware of
when a situation requires a paediatric liaison referral.
Advise electronic management staff of where information is to be filed
Every stillbirth now undergoes a full root cause analysis review.
Re-audit to show improvement in accuracy in coding
Leaflets are present on patients' lockers for relatives to read.
Re-audit undertaken in Jan 2014 illustrated improvement of the use of the
audit-c in A&E
Project undertaken as part of further study and requires no actions.
147
QUALITY ACCOUNT 2013-14
Audit Unique Identifier
13-336
Audit Title
Delayed Admissions to Critical Care - Themed
Audit
Audit of cardiac arrests to assess recognition &
monitoring/treatment prior to arrest
13-339
Audit of resuscitation trolley and de-fibrillator
checking
13-340
13-341
Relative Satisfaction Survey for CCU
15 steps challenge
13-343
13-351
13-352
Holistic Needs Assessment
Analgesia of shoulder surgery with nerve
stimulator or ultrasound
Reconciliation of anticipatory prescribing goal
(4.1) on Vigil care plan with inpatient drug sheet
Outcomes of Powerwand Pilot
Review the use of testing dipsticks within the
ward areas to ensure they are used for the
purpose they are provided
Use of Ambulatory care on the medical wards
13-353
Use of Ambulatory care on the SSU
13-354
13-355
13-356
Review of Cancer MDT meetings
MRSA admission screen compliance
Initial audit of nursing 3 year Visual Screening
13-357
Audit of IV Paracetamol
Audit of Incontinence Products - Care Plans and
Reasons
Impact of chronic pain conditions/poorly
controlled pain on hospital admissions and bed
days
13-335
13-345
13-349
13-350
13-359
13-361
148
Changes in Practice
now a themed omissions of care audit and combines data from 13-336
cardiac arrest audit
now a themed omissions of care audit and combines data from 13-335
delayed admissions to CCU
Policy changed and daily checking of the ward trolley is now required there is 100% compliance in all put 2 areas and Carol White is going to
focus on improving this over the course of the year
Poster to be created to show the results on the ward in the hope it will
encourage more relatives to take part
Ensure patients alerted if visits running late or have to be cancelled
Project has been re-audited in February 2014 which indicated an
improvement in practice. This will be audited again in 2014 / 2015 to
ensure change has been maintained.
None at present as whole service needs to be included in re-audit
In the new Vigil Care Plan, requirement for ticking that individual drugs
have been prescribed will be removed
No actions required
Audit indicated all nursing staff were testing blood and urine appropriately.
Re-audit required May 14
Hospital wide snapshot audit to be undertaken on Ambulatory Care
Pathways
Changes made include ensuring mobile phones are not answered during
the meetings and research projects available are discussed at the
meetings.
Develop dedicated daily screening checklist for emergency admissions
Improvement notes
Update to IV paracetamol monograph to include dosage adjustment
guidelines
Project has been presented at SNAP to ensure continence care plans are
completed.
Develop audited direct referral care pathway from AED to Community Pain
Clinic service.
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Audit Unique Identifier
13-364
Audit Title
Paediatric orthopaedics service referral
evaluation
13-365
Audit of Anaesthetics and Cardioversion
13-366
13-367
Re-audit of adherence to NICE Policy
The Neurogenic Bowel Dysfunction Score Audit
13-369
13-374
13-375
13-377
Audit of Troponin T pathway
Brief audit of platelet use in the NW Regional
Transfusion Committee region
CT Colon Service review
A & E Mortalities
13-378
An audit of compliance with policy for out of
hours emergency surgery
13-384
13-385
Audit of Incontinence referrals to the Community
VTE prophylaxis being appropriately prescribed
13-386
Audit of women less than 25 yrs referred to
Colposcopy
13-388
13-389
13-390
Audit of Medical Records Work Instructions
CT Urograms (carried over from 2012)
Audit of diabetes inpatient care plans
13-391
Audit of staff access to out of hours medicines
list
13-393
13-395
Changes in Practice
Patient Experience Survey - Intermediate Care
Assessment of teaching in Obs and Gynae for
4th yr students at ODGH
149
No actions required
Audit completed and staff reminded to record conversations with patients
in relation to possible dental damage on anaesthetic form.
Indicated policy is being followed. NICE process has been changed to
increase compliance with the introduction of staff dedicated to NICE who
will meet with lead clinician to complete the gap analysis.
Plan to re-audit in 2014 / 2015
Audit indicated good compliance with 60 minute target for producing Trop
T results. Plan to re-audit using a bigger sample.
No changes made to practice. Results of audit showed appropriate use of
platelets
Issue addendum on reports for referring clinicians to action
Actions will link with Trust mortality process
Policy will be changed. Allow NCEPOD 1 cases between 12 midnight and
8 am and any case that the consultant surgeon and anaesthetist deem
necessary.
Continence referral form now added to stroke care plan 164. Continence
referral form altered for ease of use and now uploaded onto the internet.
More leaflets available on ward for patients explaining the continence
referral system. Community continence team now directly e-mail ward
managers if have to reject referral. Re-audit required 2014
Compliance with quality contract
Implementation of new database will ensure that all records include
colposcopic opinion. Already in place in Ormskirk – currently awaiting IT to
update system in Southport clinic
Audit indicated staff were aware of how to access medical records
instructions and when updates are produced.
USS to be first line investigation of choice
Improvement demonstrated and no further actions required.
Project completed indicating staff are aware of where the out of hours
medicines list is stored on the intranet and also how to access the room
storing the drugs. All wards are accessing the out of hours drug store.
Use of an Intermediate Care leaflet, with contact numbers and relevant
information
Redesign the student timetable .
QUALITY ACCOUNT 2013-14
Audit Unique Identifier
13-401
13-404
Audit Title
Re-audit post anaesthesia care after emergency
surgery at night
13-412
13-414
Audit of Blue MDT Sheets
HDU Care - Compliance with Hospital
Guidelines
Non cytological referral to Colposcopy clinic
13-415
Audit into the prescription of thromboprophylaxis
in postnatal women
13-434
13-419
13-421
13-422
Prescribing of controlled drugs on discharge
Audit of Pharmaceutical Contributions
13-423
Audit of wheelchair services for EOL patients
Audit of completion of preoperative assessment
tests prior to planned elective surgery
13-425
13-428
13-430
13-431
13-440
setting up database for annual audit review, producing new guidelines
Nursing documentation is currently being updated to include MDT sheet
and encourage use when planning discharge.
No actions required. The new electronic system will address any issues
The recommendation is to continue with current practice
Remind staff of the need to increase the dosage of LMWH according to
RCOG guidelines
Re-education of EPAU staff about the importance of proper definitions,
using a poster to highlight definitions. Provide EPAU with copies of
proforma. Reaudit in one year
Pregnancy of unknown location
Community Palliative Care Nurse specialist
(CPCNS) involvement with Nursing
homes/Palliative care link nurses
Re-audit of % of patients starting oral
anticoagulation treatment referral to
anticoagulation service with incomplete
information
13-418
Changes in Practice
Formal documentation of teaching sessions; 6 weekly meetings
established between PCNS and their named link nurses/nursing homes
Audit of Intentional Rounding
Cardiac Rehab Questionnaire
Audit of blood glucose requests carried out.
Compliance with BCSH guidelines on the use of
biophosphates therapy in treatment and
prevention of myeloma
150
Considering bringing forward Anticoagulation training session for new
junior doctors from November
Encourage discharges to be clinically checked on wards rather than in the
dispensary. Where discharges are written electronically, encourage
pharmacists to print off the electronic TTO and ask doctors to write total
quantities in words and figures on the printed TTO, then sign it.
No changes in practice
Change documentation to allow more precise identification of reasons
when standards appear not to have been met
No changes to practice required
Further development of intentional round for 2014 with the introduction of
senior nurse rounding.
Poster to be designed to go up in Salus Centre with the audit results
No actions required as audit indicates good practice.
Report received and being discussed at Aprils Haematology Team
meeting - Dr Khine will send me the minutes and actions once discussed
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Audit Unique Identifier
13-446
Audit Title
Physiotherapy utilisation post enhanced
recovery arthroplasty (accelerated rehab in
TKR)
Audit of Trauma notes documentation
Five-Year Retrospective Review of Group A
Streptococcal Bacteraemias in Patients
Admitted to Southport and Ormskirk NHS Trust
13-442
Coding Audit
13-444
13-445
151
Changes in Practice
No action required
Re-audit in May 14 to show improvement in documentation
Laboratory to ensure Group A Streptococcal isolates from Blood Cultures
are sent off as advised in local SOP and national guidance to inform
organism surveillance .
Dermatology OP assessment form has been redesigned so that the
appropriate coding information is easier to see
QUALITY ACCOUNT 2013-14
Appendix 7
Specialties involved in the Clinical Research Studies at Southport and Ormskirk Hospital NHS Trust
A&E
Obstetrics
Maxillofacial
Occupational therapy
Paediatrics
Rheumatology
Physiotherapy
Orthopaedics
Neonatal
Spinal Injuries
ICU
Infection control
Gynaecology
Ophthalmology
Nursing
General surgery
Diabetes - Paediatrics
Microbiology
Pain Management
Vascular
Diabetes - adult
Cellular Pathology
Ageing
Dermatology
Stroke
Haematology
Sexual Health Services
Epilepsy
Gastroenterology
Education
Clinical psychology
Oncology
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Appendix 8
Type
Journal
Publication
Title
Successful implementation of a paediatric community home
nursing service as a model of service delivery in acute
paediatric care.
A programme of “compassionate conversations” to help staff
cope.
Review of insulin treatment in stress related hyperglycaemia
in children without pre-existing diabetes
Author’s
Ng SM, Mariguddi S,
Coward S, Middleton H
Journal
British Journal of Nursing
2014: 23 (4):
Garner S.
BMJ 2014; 348
Ng SM, Balmuri S.
ActaPaediatrica 2013
Journal
Publication
. Recurrent primary paediatric herpetic whitlow of the big toe.
BMJ Case Reports 2013
Journal
Publication
Institution of multiple daily insulin regimen compared with
twice daily pre-mixed insulin regimen for children with Type 1
Diabetes Mellitus.
The Use of Iodine as First Line Therapy in Graves' Disease
Complicated with Neutropenia at First Presentation in a
Paediatric Patient.
Growth and metabolic control in children and adolescents
with type 1 diabetes mellitus associated with other
autoimmune diseases.
Children with Type 1 Diabetes mellitus developing
concurrent autoimmune disease are not at risk of worsening
metabolic control or growth impairment.
Intensive insulin pump therapy improves glycaemic control
and emotional well-being in children with Type 1 diabetes
mellitus in whom multiple daily insulin regimen had
previously been used to maximal effect.
Murphy A, Martin P,
Jukka C, Menon A, Ng
SM
Murphy C and Ng SM.
Journal
Publication
Journal
Publication
Journal
Publication
Journal
Publication
Journal
Publication
Journal
Publication
153
Gangadharan A,
Hanumanthaiah H, Ng
SM.
Soni A, Shaw EJ,
Natarajan A, Ng SM.
American Journal of
Clinical Medicine
Research2013 1 (1).
British Journal of
Medicine and Medical
Research, 3(2):
Endocrine
Abstracts 2013; 33
Soni A , Shaw EJ,
Natarajan A, Ng SM.
Paediatric Diabetes 2013,
Suppl 18 Vol 14
Ng SM, Wong J.
Paediatric Diabetes 2013,
Suppl 18 Vol 14 P234
QUALITY ACCOUNT 2013-14
International
conference
presentations
Successful implementation of a paediatric community home
nursing service as a model of service delivery in acute
paediatric care
Ng SM, Mariguddi S,
Coward S, Middleton H
International
conference
presentations
Intensive insulin pump therapy improves glycaemic control
and emotional well-being in children with Type 1 diabetes
mellitus in whom multiple daily insulin regimen had
previously been used to maximal effect.
Ng SM, Wong J.
International
conference
presentations
Diabetes nurse specialists with smaller case loads are
associated with better clinical outcomes, reduce hospital
admissions and reduce length of stay.
Ng SM, Finnigan L,
Connellan L.
International
conference
presentations
Children with Type 1 Diabetes mellitus developing
concurrent autoimmune disease are not at risk of worsening
metabolic control or growth impairment.
Soni A, Shaw EJ,
Natarajan A, Ng SM.
International
conference
presentations
Review of insulin treatment in stress related hyperglycaemia
in children without pre-existing diabetes.
Ng SM, Balmuri S.
National
conference
Use of Electronic Diabetes Information Management System
and routine uploading of Glucometers and Pumps in Acute
Ng SM, Finnigan L,
Connellan L.
154
The 19th annual
International Forum on
Quality and Safety in
Healthcare.
Paris, April 2014
Annual
International
Society for Paediatric and
Adolescent
Diabetes
meeting,
Gothenburg,
Sweden,
16th-18th
October, 2013.
Annual
International
Society for Paediatric and
Adolescent
Diabetes
meeting,
Gothenburg,
Sweden,
16th-18th
October, 2013.
Annual
International
Society for Paediatric and
Adolescent
Diabetes
meeting,
Gothenburg,
Sweden,
16th-18th
October, 2013.
Annual
International
Society for Paediatric and
Adolescent
Diabetes
meeting,
Gothenburg,
Sweden,
16th-18th
October, 2013.
Child Health Annual
Conference 2014 April
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
presentations
Paediatric Care
National
conference
presentations
Successful implementation of a paediatric community home
nursing service as a model of service delivery in acute
paediatric carewill
Ng SM, Mariguddi S,
Coward S, Middleton H
National
conference
presentations
Growth and metabolic control in children and adolescents
with type 1 diabetes mellitus associated with other
autoimmune diseases
Soni A, Shaw EJ,
Natarajan A, Ng SM.
155
and published in the
Archives of Disease in
Childhood Journal 2014
Suppl.
Royal College of
Paediatrics and Child
Health Annual
Conference 2014 April
and published in the
Archives of Disease in
Childhood Journal 2014
Suppl.
British
Society
for
Paediatric Endocrinology
and Diabetes, Brighton,
UK, 13rd-15th November
2013.
QUALITY ACCOUNT 2013-14
Appendix 9
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
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QUALITY ACCOUNT 2013-14
PART 4
ANNEX
STATEMENTS OF ASSURANCE
The Draft Quality Account was circulated for comments to both CCGs, both
Healthwatches and to the Overview and Scrutiny Committee. On the following pages
are the responses received.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
4.1 Sefton Healthwatch
HealthwatchSefton
Sefton CVS
3rd Floor, Suite 3B
North Wing, Burlington House,
Crosby Road North, Waterloo
L22 0LG
Tel:(0151) 920 0726 ext 240
info@healthwatchsefton.co.uk
www.healthwatchsefton.co.uk
Southport and Ormskirk Hospital NHS Trust 2013 - 2014 – Quality Account
Commentary.
The report layout is well structured and provides many indicators which will be
useful for reviews we may wish to undertake. Section 2.3, Quality Strategy Work
Plan 2013-13 only shows a tick by each indicator and where not met a comment
stating "close target". It would have been helpful for figures to have also been
included.
Many complaints received relate to high costs associated with car park charges. Is
the Trust going to consider bringing the cost down to a more reasonable level? The
cost has increased by nearly 200% in a few short years. We are informed that local
groups across Sefton who have a focus on disability/access find charging Blue Badge
holders for parking unacceptable.
Given that targets relating to Gynaecological and Obstetrics are always
significantly red within the dashboards, it will be interesting to see if
improvements are made with the work of the midwife led case team. This is
something we will monitor.
The report makes reference to significant input from LINks which were abolished,
31st March and should not be referenced. Healthwatch Sefton has had involvement
in the Operational Quality Committee, but as this has been disbanded, we are
concerned as to how we to observe and contribute in the future, having no seat on
the newly formed Quality and Safety Committee? We have been invited to have a
seat on the Patient Experience Group during this period but due to us setting up
our own governance structures have only recently been able to take up this
request. There is no mention within the Quality Strategy work plan for the coming
year to triangulate information from internal data, ‘Friends and Family’ data and
independent experiences shared by Healthwatch which we feel is a missed
opportunity. There is no reference to the ‘Patient and Public Involvement Steering
group’ (PPISG) whose work was brought to an end during this period.
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QUALITY ACCOUNT 2013-14
The Trust is routinely in breach of mixed-sex accommodation, mainly on Intensive
Care Unit and High Dependency Unit. We note that patients and family have been
surveyed and do not find this objectionable. We would be interested to find out
how the Trust interprets the Department of Health information in reporting
breaches.
We remain concerned with staffing levels and are aware of the moderate concern
that the Care Quality Commission had following its inspection during this period.
We would like to know how this issue is being addressed.
We are also concerned about Infection Control in particular cases of clostridium
difficile which are beyond target, with hand hygiene targets not always being met.
We however congratulate the Trust on no cases of MRSA during this period.
We were pleased on the initiatives put in place in relation to patient falls, for
example ‘Falls link nurses’ and the introduction of the frail elderly unit but would
like to know more information about the recording of falls, particularly falls with
serious harm.
We look forward to working with the Trust over the coming 12 months in our role as
critical friend. Is there a commitment to produce a public-facing summary of the
account?
4.2 Lancashire Healthwatch
No feedback has been received from Lancashire Healthwatch.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
4.3 Sefton Overview and Scrutiny Committee
Children’s Services
On the 12th May 2014, Angela Kelly, Deputy Director of Nursing accompanied by
Mandy Power, Assistant Director of Integrated Governance and Damian Reid,
Deputy Chief Executive and Finance Director attended the Overview and Scrutiny
Committee for Children’s Services to present on the Trust’s draft Quality Account for
2013 / 2014.
The committee had previously been supplied with a full version of the Trust’s draft
Quality Account. The Overview and Scrutiny Committee (Children’s Services) made
no specific comments about the Trust’s Draft Quality Account.
RESOLVED
(1) The report be noted
(2) The draft Quality Account and the presentation be noted
Health and Social Care
On the 12th May 2014, Angela Kelly, Deputy Director of Nursing accompanied by
Mandy Power, Assistant Director of Integrated Governance and Damian Reid,
Deputy Chief Executive and Finance Director attended the Overview and Scrutiny
Committee for Health and Social Care to present on the Trust’s draft Quality Account
for 2013 / 2014.
The Committee had previously been supplied with the full version of the Trust’s draft
Quality Account.
With regard to Sexual Health Services, the Chair enquired whether the terms of this
service had now been agreed and the Trust representatives indicated that they would
confirm. She also referred to the recommendations concerning patients to staff ratios
and was advised that the Trust would be introducing this next year. The Chair also
referred to the use of technology by Liverpool Community Health NHS Trust.
In response to a question by a Member of the Committee regarding the recruitment
of staff, the representatives advised that cadets came to work within the health
service and that they were supported whilst they were undertaking their university
training.
RESOLVED
(1) The presentation and the draft Quality Account for 2013/14 from the Southport
and Ormskirk Hospital NHS Trust be received;
(2) The Southport and Ormskirk Hospital NHS Trust be requested to confirm whether
the terms of the service for the Sexual Health Service have now been agreed.
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QUALITY ACCOUNT 2013-14
4.4 South Sefton CCG and Southport & Formby CCG
Southport & Formby CCG, as co-ordinating commissioner, is pleased to provide a
statement for inclusion in this Quality Account. Southport & Ormskirk Hospital NHS
Trust has taken steps to corroborate the accuracy of data provided within this Quality
Account and consider it contains accurate information in relation to the services
provided. Information contained accords with data received throughout 2013 -2014,
and which is considered within monthly Clinical Quality and Performance Meetings.
Southport & Formby CCG actively collaborates with Merseyside and West
Lancashire CCG colleagues to commission services for their local population; ensure
that the providers meet the required quality standards and supports the priorities
selected by the Trust last year. The work the Trust has undertaken, described within
this Quality Account has helped to improve patient safety and the quality of patient
experience and endorses the Trust’s commitment to provide safe, clean and friendly
care.
Of particular note is the achievement of the continued successes in reducing the
numbers of grade 2 and 3 pressure ulcers across the Trust, and the Trust has had no
grade 4 pressure Ulcers. Additionally the trust has had zero cases of MRSA in
2013/14.
Although the target for Clostridium difficile cases was not achieved in 2013/14, the
Commissioners noted the Trust’s comprehensive 26-point action plan which was fully
supported and endorsed by all stakeholders, and it is envisaged that this action plan
will support the reduction in Health Care Acquired Infections (HCAIs) which is set out
in their quality strategy work plan of 2014/15.
We are pleased to note that the Trust has further developed the Care Closer to
Home model and are beginning to see the benefits of this exciting new model of care
both in reducing and shortening hospital admission and increasing support in the
community. We look forward to further developing this model in 2014/15 and hope to
see more evidential assurance of its success
The NHS is striving to ensure that the patient experience of care is central to good
quality of care and is used to ensure that the care delivered is right for patients. We
believe the approach taken by Southport & Ormskirk reflects this and that the Quality
Account accurately describes the journey the Trust has been on. The CCGs continue
to be supportive of the process that Southport & Ormskirk has undertaken to
proactively seek feedback from patients and carers and demonstrated how this has
impacted upon changes in service delivery. Southport & Formby CCG is pleased to
note the engagement with stakeholders that led up to the publication of this Quality
Account and commend the Trust for taking its responsibilities for engagement
seriously.
It is felt the priorities for improvement identified for the coming year are both
challenging and reflective of the current issues across the health economy. We
therefore commend the Trust in taking account of new opportunities to further
improve the delivery of safe, clean and friendly care.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
4.5 CHANGES MADE TO THE QUALITY ACCOUNT AFTER 30TH APRIL 2014
-Governors were changed to Shadow Governors (Page 81)
-Removed sentence about stakeholder events as part of Foundation Trust
Application (Page 7)
-Added - Shadow Governors play a key role in engaging with members of the public,
patients and partnership organisations. During 2013/14 we held a number of
membership engagement events including Patient Experience – Car Parking
Forums, Health & Well Being Fair which included advice on self care and information
regarding services available to patients and the public from across the Trust,
Community Services and the Voluntary Sector. We also recruited over 30 members
of the public/patients/carers to join the Trust PLACE teams. (Page 7)
-Added feedback from Healthwatch Sefton, Sefton Overview and Scrutiny Committee
and South Sefton CCG and Southport & Formby CCG
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QUALITY ACCOUNT 2013-14
4.6 Independent Auditors Limited Assurance Report to the Directors of
Southport and Ormskirk Hospitals NHS Trust on the Annual Quality Account
164
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
165
QUALITY ACCOUNT 2013-14
166
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
167