The Chelmsford
Quality Account
for 2013-14
Contents
Welcome to Aspen Healthcare
3
National Awards During 2013 -14
5
Statement on Quality from the Chief Executive Aspen Healthcare
6
Introduction to The Chelmsford Hospital
Vital Stats
8
Statement on Quality
Accountability Statement
9
Quality Priorities for 2014 -15
Patient Safety
Clinical Effectiveness
Patient Experience
10
tatements of Assurance S
Review of NHS Services Provided 2013 -14
Participation in Clinical Audit
National Confidential Enquiry
National Clinical Audits
Local Audits
Participation in Research
Goals Agreed with Commissioners
Statements from the Care Quality Commission
Statements on Data Quality
Quality Indicators
12
Review of Quality Performance for 2013 -14
Patient Safety
Clinical Effectiveness
Patient Experience
17
Welcome to Aspen Healthcare
Aspen Healthcare Hospitals and Clinics locations:
The Chelmsford is part of the Aspen Healthcare Group.
Aspen Healthcare Ltd was established in 1998 and is a UK-based private healthcare
provider with extensive knowledge of the healthcare market. The company’s core
business is the management and operation of private hospitals and other medical
facilities, such as day surgery clinics, many of which are in joint partnership
with our Consultants.
Aspen Healthcare is the proud operator
of four acute hospitals, a cancer centre, and
three day-surgery hospitals in the UK.
Aspen Healthcare’s current facilities are:
•Cancer Centre London
Wimbledon, SW London
•The Chelmsford
Chelmsford, Essex
•The Claremont Hospital, Sheffield
•The Edinburgh Clinic, Edinburgh
•Highgate Private Hospital
Highgate, N London
•Holly House Hospital
Buckhurst Hill, NE London/Essex
•Midland Eye, Solihull
•Parkside Hospital
Wimbledon, SW London
Aspen Healthcare’s facilities cover a wide
range of specialties and treatments providing
consulting, diagnostic and surgical services,
as well as state of the art oncological
services. Within these eight facilities,
comprising over 250 beds and 17 theatres,
in 2013 alone Aspen has delivered care to:
• Almost 36,000 patients who were
admitted into our facilities
• More than 26,000 patients who required
day case surgery
• More than 10,000 patients who required
inpatient care
• More than 215,000 patients who attended
for outpatient care.
Aspen is now one of the main providers
of independent hospital services in the UK,
and through a variety of contracts provided
over 11,000 NHS in-patient/day case
episodes of care and 44,000 outpatient
consultations last year. We work very closely
with other healthcare providers in each
locality including GPs, Clinical Commissioning
Groups and NHS Acute Trusts to deliver
the highest standard of services to all our
patients.
Cancer Centre London
The Chelmsford
Claremont Hospital
The Edinburgh Clinic
Highgate Private Hospital
Holly House Hospital
Midland Eye
Parkside Hospital
It is our aim to serve the local community and
excel in the provision of quality acute private
healthcare serves in the UK. We are pleased
to report that in 2013 four out of five of our
patients in our hospitals that provide inpatient
services rated the overall quality of their care
as “excellent,” with 98% “extremely likely”
or “likely” to recommend the Aspen hospital
visited.
Across Aspen we strive to go ‘beyond
compliance’ in meeting required national
standards and excel in all that we endeavour
to do. Although every year we are happy
to look back and reflect on what we have
achieved, more importantly we look forward
and set our quality goals even higher to
constantly improve upon how we deliver
our care and services.
We have delivered this care always with
Aspen Healthcare’s mission statement
underpinning the delivery of all of our
care and services.
MidlandEye
Specialists in complete eye care
Our aim is to provide first-class independent healthcare for the local
community in a safe, comfortable and welcoming environment; one in
which we would be happy to treat our own families.
3
4
National Awards During 2013-14
During 2013 Aspen Healthcare was pleased to receive
national recognition for their innovative and quality focussed
care and services.
2013 Laing & Buisson Independent Healthcare Awards
Category Winners
Category Finalists
ealthcare Outcomes – “demonstrating
H
evidence of genuine improvements in
outcomes through the provision of high
quality coordinated programmes of patient
care, education, research and advocacy”:
Nursing Practice – “recognising outstanding
nursing practice and its effect on patient
experience”:
• Holly House Hospital for the
development of their stress management
programme, “The Calm Choice”,
improving outcomes for patients
suffering neck and shoulder pains,
jaw pain, and low back pain.
Medical Practice – “recognising outstanding
examples of medical practice which has
positively impacted on patient treatment
and care”:
• The Cancer Centre, London for the
development of a new rehabilitation
pathway for neuro-oncology patients
which reflects a holistic and
multi-disciplinary approach to support
patients during their radiotherapy
treatment for brain tumours.
• The Claremont Hospital for the
development of innovative out-reach
pre-admission assessment clinics.
Experienced Sisters and Charge Nurses
from the Claremont pre-admission
assessment team take their service
to a local hospital to carry out
pre-admission assessment checks
and discuss co-morbidities saving
patients travelling long distances on
repeated occasions in preparation for
their forthcoming hospital admission.
Management Excellence – “recognising
a manager or executive and their high
expertise in their field in making the most
effective contribution towards the success
of a team, unit, or company in the last
12 months”:
• The Group Clinical Director for the
development of a bespoke model
which rigorously aligns all elements
of governance and clearly demonstrates
Aspen’s commitment to excellence
and quality.
Statement on Quality from the
Chief Executive Aspen Healthcare
We are pleased to provide this Quality
Account for The Chelmsford. This is our
annual report to the public and other
stakeholders about the quality of services
we have provided over the last year and
also, importantly, to look forward and set
out our plan of quality improvements for
the following year.
Aspen Healthcare is committed to
excelling in the provision of the highest
quality healthcare services and in working
in partnership with the NHS to ensure
that the services delivered result in safe,
effective and personalised care for all
patients. This is evidenced by our high
quality performance over the past year
and by ensuring that we continuously
make improvements to the services we
provide to our patients. The new quality
framework we introduced last year,
centred on nine drivers of quality and
safety, is now well embedded across our
business and helps us ensure that quality
is incorporated into every one of our
hospitals/clinics and that safety, quality
and excellence remains the focus of all
we do whilst delivering the highest
standards of patient care.
This Quality Account presents our
achievements in terms of clinical
excellence, effectiveness, safety and
patient experience and demonstrates that
our managers, clinicians and staff at The
Chelmsford are all committed to providing
continuous, evidence based, quality care
to those people we treat. It provides a
balanced view of what we are good at
and where additional improvements
can be made.
The experience that patients have
in all our hospital/clinics is of the
utmost importance to Aspen and
we are committed to establishing an
organisational culture that puts the patient
at the centre of everything we do. We aim
to keep developing our initiatives around
quality and safety to ensure we are able to
bring further benefits to our patients and
the care they receive.
The majority of information provided in
this report is for all the patients we have
cared for in 2013/14 – NHS and private.
Pride of Britain Awards 2013
Lifetime Achievement Award - “recognising
an individual whose achievements have
been far-reaching, possibly on a national
or international level”:
Two doctors at the Cancer Centre, London,
Professor Trevor Powles and Professor Ray
5
Powles received this highly prestigious award
for their work in cancer and research. Their
work has saved thousands of lives in Britain
and around the world.
Des Shiels
Chief Executive, Aspen Healthcare
6
Introduction to The Chelmsford’s
Quality Account for 2013-14
Located in Chelmsford, Essex, The Chelmsford
day surgery hospital is a private diagnostic
and ambulatory surgery centre established
in February 2006.
The facility comprises a theatre suite,
out-patient clinics with specialist consultants
supported by onsite physiotherapy and gym,
MRI, Ultrasound, X-ray and surgical facilities.
We ensure the one-to-one care patients receive
is the best in the vicinity.
During 2013 -14, 11,057 patients attended
for outpatient care and 1,134 day case
surgery.
Vital Stats
7
General Consulting rooms
5
Free Parking
Specialist ophthalmology
consulting room
OPD treatment room
2
Accept all major insurers
1
Diagnostics suite comprising:
Theatre
1
Theatre procedure room
1
GA recovery -first stage
1
Diagnostics x ray
Diagnostics MRI 1.5 T
Diagnostics ultrasound
Procedure Admission and
Discharge lounge
1
Choose and Book
1
1
1
8
Statement on Quality
Quality Priorities For 2014-15
We are proud to present our first Quality Account. Our commitment to quality is
evidenced by our high quality performance and aspiration to continually improve the
outcomes and experience for our patients.
National Quality Account guidelines require us to identify at least three priorities
for improvement. We have a number of quality and safety initiatives planned for the
forthcoming year and the following information focuses on the key priorities that
have been determined by our senior management team. These have been informed
by feedback from both our patient and staff, audit results, national guidance and
recommendations from the various hospital/clinic teams across Aspen Healthcare.
We have aimed to provide an objective
indication on what has been achieved over
the last year and to identify where we want
to make improvements during 2014 -15.
The delivery of a high quality service has
always been at the heart of our organisation
and we want everyone to have complete
confidence that The Chelmsford will provide
the best care for all patients. Our aim as an
organisation is to provide safe, effective and
personalised care to every patient, every day.
As part of Aspen Healthcare there is a wellestablished Integrated Governance structure,
ensuring all the necessary controls are in
place to confirm clinical excellence and that
The Chelmsford is properly managed
and directed at all times.
We have a comprehensive audit programme
in place that demonstrates all our clinical
professionals deliver high quality, good
clinical outcomes, which meet or exceed the
ever increasing expectations of our patients.
Through the dedication of all of our team,
we continuously have very high levels of
patient satisfaction and extremely low rates
of dissatisfaction.
The Chelmsford continues to have no
hospital acquired infection and zero tolerance
to MRSA, MSSA or C. difficile infections.
Accountability Statement
Directors of organisations providing hospital
services have an obligation under the 2009
Health Act, National Health Service (Quality
Accounts) Regulations 2010 and the
National Health Service (Quality Accounts
Amendment Regulation 2011) to prepare a
Quality Account for each financial year.
This report has been prepared based on
guidance issued by the Department of
Health setting out these legal requirements.
To the best of my knowledge, as requested
by the regulations governing the publication
of this document, the information in this
report is accurate.
Dated: 02/05/2014
Rachel Bradbury
Director of Clinics, Aspen Healthcare
9
This report has been reviewed and
approved by:
Our quality priorities will be reviewed at our
Quality Governance Committee which meets
quarterly to monitor, manage and improve
the processes designed to ensure safe and
effective service delivery. Regular reporting
on these priorities will also be provided to
the Group Quality Governance Committee,
to Aspen’s Executive Team and Board of
Directors, and also the commissioners of
NHS services.
The Chelmsford is committed to delivering
services that are safe, of a high quality, and
clinically effective and we constantly strive to
improve our clinical safety and standards. The
priorities we have identified will, we believe,
• Patient Safety
This is about improving and increasing the
safety of our care and services provided
• Clinical Effectiveness
This is about improving the outcome of
any assessment, treatment and care our
patients receive to optimise patients health
and well-being
• Patient Experience
This is about aspiring to ensure we exceed
the expectations of all our patients.
The key quality priorities identified for 2014 -15 are as follows:
Dr Carol McCartney (Medical Advisory
Committee Chairperson, The Chelmsford)
Patient Safety
Des Shiels (CEO, Aspen Healthcare)
ocus on further embedding a positive
F
Patient Safety Culture
A positive safety culture underpins the
improvement of patient safety. How our
staff perceive the importance of safety and
have confidence in our safety systems and
processes is vital to this. We will build upon
last year’s assessment of our safety culture
and work with our staff to actively promote
a positive safety culture and undertake a
further more detailed survey in autumn
2014 to assess our progress.
Judi Ingram (Clinical Director, Aspen
Healthcare)
drive the three domains of quality - patient
safety, clinical effectiveness and patient
experience:
Patient Safety Leadership Training
To support our staff in consistently providing
high quality and safe care to our patients we
will further develop their understanding in
how this is integral to their everyday roles
and start to roll out bespoke Patient Safety
Leadership Training. Having staff that are
empowered to lead on patent safety will
make a tangible difference to improving
patient safety at the frontline of care delivery.
Review of Nurse Staffing Levels
Having the right number of staff, with
the right skills, in the right place, will help
ensure that appropriate numbers of skilled
nursing staff are available to care for our
patients safely. We will implement tools that
will help us to objectively assess this and
determine how many nursing staff and with
what skill mix is required. This will include
consideration of the typical dependency of
our patients and the amount of time each
individual requires.
10
Clinical Effectiveness
Patient Experience
Infection Prevention and Control
‘Deep Dives’
A clean and safe environment of care matters
to our patients. A comprehensive ‘deep dive’
assessment of our Infection Prevention and
Control (IPC) practices will be led by Aspen
Healthcare’s Consultant Nurse for IPC and
the Group Health and Safety Manager. The
aim of these visits is to complement our
existing audits that are in place and provide
an objective assessment of the clinical
practices of our staff and ensure compliance
with the Health and Social Care Act Infection
Prevention and Control Code of Practice.
‘Hello my name is and I am…’
Providing compassionate care and building
therapeutic relationships often needs to
simply start with the right introduction. Every
member of staff who approaches any patient
for the first time will introduce themselves
and say ‘Hello. My name is ‘x’ and I am one
of the nurses/care assistants/managers
who will be looking after you today. How
are you feeling?’
Care Plans Documentation
High standards of patient documentation
supports communication and decision
making about our patient’s care and is
vital to ensure the continuity, safety, and
effectiveness of patient care. A review will be
undertaken of the quantity, quality and style
of patient care plan documentation and any
revisions required will be made to ensure
improvements in the quality of our
clinical records.
Pre-operative Assessment
Our pre-assessment team helps to ensure
that our patients are fit and prepared
for surgery and, where appropriate, are
assessed in advance of their admission to
reduce the chance of their operation being
cancelled for safety or clinical reasons.
In 2014 -15 work will be undertaken to
review our assessment and documentation
processes and develop a revised care
pathway that meets best practice and
further supports the provision of effective
patient care.
Review of Patient Information
Our patients need to be properly informed
so that they can share in decisions about
their care and treatment. We will undertake
a review of the information we provide to
our patients and ensure that this is accurate,
impartial, evidence based and well written.
This will help to ensure our patents have
accurate expectations of any procedure, have
an improved understanding of the diagnosis
and their treatment options, and support
improved after-care compliance helping to
improve patient satisfaction.
Staff Satisfaction
Our levels of staff satisfaction are very
important to us as satisfied, well trained and
competent staff will help to ensure patient
safety and a good experience of care. A staff
satisfaction survey is currently undertaken
every two years and is bench marked against
the other Aspen UK hospitals and clinics. We
believe that ‘satisfied staff means satisfied
patients’ and we will hold regular staff forums
to address areas for improvements identified
in the last survey
While targeting the above areas, we will also continue to:
• Strive to further improve upon all our quality and safety measures
• Continue with our programme of development relating to other quality initiatives
• Continue to develop our workforce to ensure they have the skills to deliver high quality care
in the most appropriate and effective way
• Meet the Quality Schedule of our NHS Contracts where in place
Statements of Assurance
Relating to the quality of NHS services provided
This section of the Quality Account provides the mandatory information for inclusion
in a Quality Account, as determined by Department of Health regulations, and reviews
our performance over the last year ( April 2013 to March 2014).
Review of NHS Services Provided 2013 -14
During April 2013 to March 2014, The Chelmsford provided spot NHS contract services only
in collaboration with our local NHS Trust. This included services for MRI, oral maxilla-facial and
ocular plastics. Patient satisfaction and feedback has therefore been incorporated with the
private services.
The income generated by the NHS services reviewed in 2013 -14 represents 100% per
cent of the total income generated from the provision of NHS services by The Chelmsford for
the year ending 31 March 2014.
“The nursing staff were
amazing very supportive &
friendly. The theatre team was
fab especially Linda thank
you. Nurse Suzanne was very
helpful, friendly ”
11
12
Local Audits
During 2013, Aspen Healthcare
implemented an annual clinical audit
programme which identified the topics and
frequency of audit assessment.
Participation in Research
Six clinical topics were periodically audited
by The Chelmsford during 2013 -14,
as shown below (for outcomes see
page 19):
Consent
There were no NHS patients recruited during the reporting period for this Quality Account
to participate in research approved by a research ethics committee.
Goals Agreed with Commissioners
Records compliance
Controlled Drugs
Surgical Safety (WHO) Checklist
Pre-operative VTE risk assessment
The Chelmsford income in 2013-2014 was not conditional on achieving quality improvement
and innovation goals through the Commissioning for Quality and Innovation (CQUIN) payment
framework because no Choose and Book contracts to provide any NHS service were in place
for this period .
Infection, Prevention and Control (IPC)
Statements from the Care Quality Commission
The reports of the local clinical audits were reviewed and The Chelmsford intends to take
the following actions to improve the quality of healthcare provided
•Continue to periodically audit the same topics during 2014 -15 with a view to identifying
specific areas for improvement, thereby working towards 100% compliance;
•To introduce wall mounted soap dispensers and detergent wipes to assist with hand
hygiene and cleaning
•To review competencies and increase skills within the Outpatient team to enable more
procedures to be carried out within the outpatient treatment room to enhance the patients
experience for minor procedures
•To review patient pathways documentation to ensure compliance with standards and audit
•Increase the clinical emergency scenario training to ensure staff are able to maintain their
skills in emergency situations.
All standards were met when the service was inspected
The Chelmsford is required to register with the
Care Quality Commission (CQC) and is able to
provide the following regulated activities:
1. Treatment of disease, disorder or injury
2. Diagnostic and screening procedures
3. Surgical procedures.
special reviews or investigations by the CQC
during the period covering this report.
The Chelmsford received an unannounced
inspection on 4th March 2014 and of the
seven essential standards reviewed, all were
assessed as fully compliant.
The CQC has not taken any enforcement
action against The Chelmsford during
2013 -14 and has not participated in any
“Always a smile to greet, the
staff make you feel calm, and
my consultant explains the
procedure as he is doing it.
Overall an excellent experience
from people who care.
Well done”
13
14
Statements on Data Quality
Quality Indicators
The Chelmsford recognises that good quality information underpins the effective
delivery of patient care and is essential if improvements in quality of care and value
for money are to be made. We ensure that our Information Governance policies
guide and inform our standards of record keeping, supporting the delivery of care
and treatment and that accuracy, completeness and validity of those records are
monitored on an on-going basis to continually improve data quality.
The Department of Health has identified a core set of quality indicators for inclusion
within the Quality Account.
The Chelmsford will be taking the following
actions to further improve data quality:
• The Chelmsford will implement Aspen’s
patient administration system (APAS),
which will provide an improved reporting
system;
• All staff will continue to receive annual
training relating to data quality and
information governance;
• The Chelmsford will work closely with
the local Clinical Commissioning Groups
(CCGs) to ensure accurate data sharing.
Secondary Uses System (SUS)
The Chelmsford did not submit any returns
to the Secondary Uses System (SUS) for
2013/2014 for inclusion in the Hospital
Episode Statistics as we have not been part
of the national Choose and Book system.
To enable The Chelmsford to submit to SUS
in the future we have introduced the Aspen
APAS IT system over the last 3 months.
This will allow connectivity to SUS and we
will now be able to run regular reports to
ascertain and check that the data submitted
is that of the required standard.
Clinical Coding Error Rate
The Chelmsford was not subject to the
Payment by Results clinical coding audit
during 2013 -14 by the Audit Commission.
Information Governance
The Information Governance Toolkit is a
performance assessment tool, produced
by the Department of Health, and is a set
of standards that organisations providing
NHS care must complete and submit
annually by 31 March each year. The toolkit
enables organisations to measure their
compliance with a range of information
handling requirements, thus ensuring that
confidentiality and security of personal
information is managed safely and effectively.
Aspen Healthcare’s Information Governance
Assessment overall score for 2013 -14 was
67% and graded green, and we achieved
level 2 in all categories meeting national
requirements.
The Chelmsford considers that the data is as described in this section as it is collated
on a continuous basis and does not rely on retrospective analysis.
When anomalies arise, each one is reviewed with a view to learning why an event or incident
occurred so that steps can be taken to reduce the risk of it happening again.
As The Chelmsford provides outpatient and day surgery services, not all indicator measures
are applicable; however those that are relevant are highlighted in the table below:
Indicator
Source
2012 2013
2013 2014
Patient satisfaction
survey
n/a
99%
The Chelmsford will continue
to monitor patient experience
through telephone follow-up
surveys and introduce a new
outpatient survey in 2014.
Percentage of The
Chelmsford Staff who
would recommend their
service to Family and
Friends
Staff Survey
n/a
100%
The Chelmsford will continue
to monitor staff experience
through staff surveys and
informal feedback.
Percentage of Patients
who would recommend
the Chelmsford to
Family and Friends
Patient satisfaction
Survey
n/a
100%
Continue to monitor
regularly. To maintain 100%
compliance
Number of clostridium
difficile infections
reported
From Public
Health England
returns
0
0
The Chelmsford will continue
to monitor infection status
of all patients; ensuring staff
receive ongoing training
in infection prevention
and control and adhere to
policies and procedures
Number of patient
safety Incidents which
resulted in severe harm
or death
Local Incident
Reporting
0
0
The Chelmsford will continue
with monitoring safety
processes and encourage
reporting
Responsiveness to
the personal needs of
patients
100% of The Chelmsford Staff would
recommend their services to Family and
Friends
15
Actions to improve quality
100% of patients would recommend The
Chelmsford to Family and Friends
16
Review of Quality Performance
for 2013-14 (previous year)
This section reviews our progress with Aspen Healthcare’s key quality priorities
as identified in last year’s Quality Account (2013 -14).
Patient Safety
Safety Culture Assessment
Each hospital and clinic will undertake a safety
culture assessment, develop an improvement
plan as appropriate, and monitor change
over time.
Progress:
•I feel safe in my workplace and I understand
my health and safety responsibilities.
NHS National Safety Thermometer
A safety culture was undertaken in Autumn
2013. The overall response rate across
Aspen Healthcare was 75%, with The
Chelmsford staff rating patient safety as
excellent, very good, or good at 100%. Work
to continue to promote a positive safety
culture will continue into 2014 -15.
A Safety Thermometer survey (improvement
tool for measuring, monitoring and analysing
patient harms and ‘harm free’ care over a
period of time) will be completed on a monthly
basis for all relevant patients and submitted
centrally to the Health and Social Care
Information Centre.
Within the results of the staff survey for
The Chelmsford (TC) there was over
90% agreement regarding the following
statements:
Progress:
•If you had a concern that could harm
staff or patients or were concerned about
negligence or wrong doing by staff or
consultants at TC would you feel able
to report your concerns?
•My supervisor/manager seriously considers
staff suggestions for improving patient
safety
•Staff are able to freely speak up if they
see something that may negatively affect
patient care
•The Chelmsford management treat staff
fairly, cares about employees and acts upon
suggestions where appropriate
•The actions of TC management show that
patient safety is a top priority
•Customer/patient care is the top priority
for my department and facility
•There is good team work and people
work together
17
•Overall, I believe that TC provides excellent
service to its patients.
All Aspen hospitals now complete and
submit information to the NHS National
Safety Thermometer, which identifies the
number of pressure ulcers, patient falls,
urinary tract infections in patients with a
catheter, and new venous thromboembolism
(pulmonary embolism or deep venous
thrombosis). These four harms are monitored
by the Department of Health’s Safe Care
programme because they are common,
and because there is a consensus that they
are largely preventable through appropriate
patient care. The measurement of these
harms at the frontline of care delivery aims
to focus attention on patient safety. During
2013 -14, all our hospitals achieved an
overall score of 99-100% relating to
these indicators.
Infection Prevention and Control
Infection prevention and control (IPC) continues
to be an on-going high priority for The
Chelmsford. During 2013 -14, considerable
Infection
MRSA positive blood culture
MSSA positive blood culture
E. Coli positive blood culture
C. Difficile infection
Endophthalmitis
work has continued in terms of staff education
and IPC audits, resulting in no infection rates,
as indicated in the table below:
2012-13
0
0
0
0
0
2013 -14
0
0
0
0
0
No healthcare associated infections reported for the last
2 years.
Although most of the indicators apply to
acute inpatient services, The Chelmsford risk
assesses all patients over 65 years of age
who may be at risk of having a fall. During
2013 -14, The Chelmsford assessed 100%
of all patients who were within this category.
18
Clinical Effectiveness
Integrated Governance Audit
Programme
•Patient care records/documentation
standards
We will implement a new annual audit
programme, focusing on key areas where
we wish to assure ourselves that we are
maintaining, and excelling, the required
standards.
•Controlled Drugs management
Progress:
•Surgical Safety Checklist Completion
•Diagnostics – Standards for Reporting
MRI Scans
•Pathology
This audit programme was fully implemented
across Aspen Healthcare in 2013 -14. These
helped us identify areas for improvement and
actions were taken in each hospital and clinic
to address these.
•Physiotherapy Record Keeping
The main audits in the programme included:
The results can be seen in the table below:
Whilst not all of the above audit topics are
applicable to The Chelmsford, the relevant
ones were undertaken at least two or three
times during the year.
•Patient falls
•Venus thromboembolism (risk assessment
and prophylaxis)
•Patient Consent
Indicator
Average score of % compliance
2013 -14
Patient falls
100%
Venous thromboembolism (VTE)
96%
Patient consent
90%
Record Keeping
90%
Controlled drugs
94%
We will implement an accreditation
programme to our operating theatre
environments across the Aspen Group aiming
to excel in perioperative practice.
Surgical Site Safety Checklist
100%
Progress:
Several actions have been taken to improve compliance with record keeping and consent,
including the review of time entry and the updating of staff signatory sheets, ensuring
patient receives copy of consent. All the audit results have provided areas to focus on
for improvement and the last audit result for VTE achieved 100% compliance.
Theatre Accreditation Programme
This programme commenced in 2013 -14
and has focussed on the accreditation /
credentialing of our theatres across Aspen
Healthcare. Assessments against recognised
national standards for perioperative practice
pertaining to patient safety and outcomes
have been made and this work will continue
into 2014 -15. We have pledged to
benchmark all the 17 theatres within the
Aspen Group against these standards and
ensure 100% compliance by the end of
2014. The outcomes of the programme
to date is that our staff are really engaged
in the accreditation process, have developed
solutions to further improve their practices
and patient safety, have pride in achieving
external validation, and that the profile of
the perioperative environment has been
significantly raised.
“I have always been impressed with the attitude of the clinic
staff. Julie is a super, professional, kindly physio and I would not
hesitate to recommend her to others. She is always positive and
gives you hope and confidence.”
19
20
Patient Experience
World Host® Customer Care Training
Inpatient Survey
Complaints
We will implement an innovative and new
customer care training programme, for clinical
and non-clinical staff, across all our facilities in
2013/14. We aim to become an accredited
World Host® recognised business and
showcase our outstanding customer service
with the focus being on teamwork
and communication.
All our hospitals will refine the inpatient survey
tool to obtain improved information on the
views and perceptions of our patients on the
care they have received and to inform the
continued development and improvement of
our services.
Whilst The Chelmsford strives to provide
consistently excellent care and services,
there are occasions when service users
have reason to complain. Every complaint
is considered a valuable source of feedback
Progress:
Indicator
Progress:
The World Host® Customer Care Training
programme has commenced at all Aspen
Healthcare facilities. Five of our eight
facilities have now achieved World Host®
accreditation status demonstrating our
commitment to providing excellence in
patient experience.
As at 31 March 2014, all members of
the team (100%) at The Chelmsford have
received World Host® training and the facility
achieved World Host accreditation in
January 2014.
The inpatient survey tool was revised last
year to improve the information we received
from our patients on their experience whilst
at an Aspen hospital. Four out of five of our
patients in our hospitals rated their overall
quality of their care as excellent. We were
one of the first independent hospital groups
to implement the national Friends and Family
Test on how likely a patient is to recommend
our hospitals to friends and family if they
needed similar care or treatment. 98%
responded that they were extremely likely
or likely to recommend the Aspen hospital
they visited.
and information on how our services can be
improved. All complaints are investigated
and any opportunity for learning or service
improvement acted upon.
2012-13
2013 -14
Number of complaints
(Written and verbal)
6
8
% per patient contacts
0.06%
0.07%
Progress:
Changes have been made throughout the year in response to issues raised by complainants
and these include:
• Designated clinical practitioners have been assigned to specific specialist clinics to improve
the patient pathway
• Rigorous monitoring of theatre and clinic schedules and patient pathways
• Robust patient satisfaction feedback audits and process review as applicable.
Although The Chelmsford does not provide
an inpatient service, feedback is obtained
by our own patient satisfaction feedback
form. This method is much appreciated by
the patients and during the reporting period
99% stated that they found the quality of
care to be excellent, very good or good.
A new outpatient survey will be introduced
in 2014 to further enhance the feedback we
receive on our patients experience at
The Chelmsford.
“Was very apprehensive at having the MRI scan as I am very
claustrophobic, but staff were amazing reassuring me through
the whole procedure. Couldn’t have proceeded without Marissa
holding my hand throughout the whole procedure-excellent.”
21
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Thank you for taking the time
to read our Quality Account.
Your comments are always welcome and we would
be pleased to hear from you if you have any questions
or wish to provide feedback.
Please contact us via our website:
www.thechelmsford.co.uk
www.aspen-healthcare.co.uk
Or call us on:
01245 253760 The Chelmsford
020 7977 6080 Head Office, Aspen Healthcare
Write to us at:
The Chelmsford
Fenton House
85 -89 New London Rd
Chelmsford
Essex CM2 0PP
Aspen Healthcare Limited
Centurion House (3rd Floor)
37 Jewry Street
London EC3N 2ER