Quality Account 2015/16
This report can also be made available upon request in Braille, audio cassette, large
print or in other languages.
Chinese
此份單張備有中文譯本,請垂詢索取
Kurdish Sorani
‫رهبهتسهد شیدروک ینامز هب هیهوارکواڵب مهئ تێرناوتهد‬
‫یراکاواد رهسهل تێرکب‬
Lithuanian
Paprašius, šį lankstinuką galima gauti ir lietuvių kalba.
Polish
Niniejszy dokument może być na życzenie dostępny w języku polskim.
Portuguese
Este folheto também pode estar disponível, sob pedido, em português.
Russian
Эту брошюру можно также получить по желанию на Русском языке.
Welcome
Lincolnshire Community Health Services NHS Trust (LCHS) provides
community healthcare services for Lincolnshire, one of the largest
healthcare communities in the country.
The trust’s 2,322 staff care for hundreds of patients every day in our
community hospitals, health clinics, minor injuries units and walk in centre. If
you are housebound, nurses and therapists come to you at home or in your
place of care. Health visitors and school nurses support children, young
people and families; the trust provides primary care services out of hours;
teams of nurses, therapists and specialists care for those across the county
whether suffering from respiratory conditions, heart problems, diabetes,
cancer, or wounds such as leg ulcers.
Teams support rehabilitation following stroke or other illnesses and
accidents with physiotherapy, occupational therapy and speech and
language therapy; sexual health teams provide a confidential and nonjudgmental service to all who need it. All teams provide health promotion;
advice and signposting to help patients, families and carers improve their
health. At the end of life, the trust is there to support you and your family
with dignity at home if that is your preference.
Contents
Welcome
Contents .................................................................................................................. 4
Statement from the Chief Executive and the Board ................................................ 6
Part 1 - Quality Achievements in 2014/15
Clinical Effectiveness............................................................................................. 10
Patient facing time will be increased through increasing ‘Time 2 Care’…………..14
Patient Safety ........................................................................................................ 16
Reduce the harm from falls in Community Hospital…………………………………16
Reduce all medication errors in Community Hospitals…………...........................18
Reduction of Grade 2, 3 and 4 Pressure Ulcers……………………………………..20
Patient Experience ................................................................................... ………. 24
The Friends and Family Test (Net Promoter) ……………………………………….24
Safe staffing levels – Right people, right skills, right place, right time…………...25
Patient-Led Assessment of the Care Environment ............................................... 27
Health Care Associated Infection .......................................................................... 28
Statements relating to quality of NHS services provided ...................................... 30
Review of Services ................................................................................................ 30
Participation in Clinical Audit ................................................................................. 30
NICE Quality Standards ........................................................................................ 31
CQC Inspection ..................................................................................................... 31
Examples of Outstanding Practice ........................................................................ 34
First Health and Home Event open to the public ................................................... 36
Part 2 – Quality Improvement 2015/16
Our priorities for quality improvement in 2015/16 ................................................. 39
Priority 1 - Clinical Effectiveness ........................................................................... 39
1.1 Increase the uptake for clinical supervision across all LCHS services ........... 39
1.2 Patient facing time will be increased through increasing ‘Time 2 Care’ .......... 41
Priority 2 - Patient Safety ....................................................................................... 44
Quality Account
2.1 Deliver safe services ................................................................. ………………..44
2.2 Reduce medication errors resulting in harm in the
Community………………...46
2.3 Reduction of Grade 2, 3 and 4 Pressure Ulcers .............................................. 47
Priority 3 - Patient Experience ................................................................................ 51
3.1 Safe staffing levels – Right people, right skills, right place, right time ............. 51
4. Complaints and Compliments ............................................................................ 53
4.1 National Health Service Litigation Authority (NHSLA) ..................................... 54
4.2 False and Misleading Information .................................................................... 54
Part 3 - Other Information
Annex 1 .................................................................................................................. 56
Statement of Directors’ Responsibility in respect of the Quality Account .............. 56
Annex 2 .................................................................................................................. 58
Statement on Lincolnshire Community Health Services NHS Trust ... Trust’s Quality
Account for 2014/15 ............................................................................................... 58
Annex 3 - Feedback from lead commissioner ........................................................ 59
Annex 4 - Feedback from membership .................................................................. 60
Patient Advice and Liaison Service (PALS) ........................................................... 61
Membership ............................................................................................................ 62
5
www.lincolnshirecommunityhealthservices.nhs.uk
Statement from the Chief
Executive
and the Board
Welcome to the Quality Account for Lincolnshire Community Health
Services NHS Trust (LCHS), covering the period April 2014 – March
2015.
The Report provides an overview of the arrangements that we have in
place for monitoring and improving quality in the trust, our
achievements over this last year, and areas where we need to
improve upon and our plans for 2015–2016.
Maintaining and improving the quality of our services continues to be
a key strategic priority for LCHS; we monitor this through the three
domains of Patient Experience, Patient Safety and Clinical
Effectiveness.
We have identified that our main challenges over the coming years
are to:
•
enable staff to spend more time with Patients delivering care
•
prevent people from suffering harm with particular focus on
preventing avoidable harm
•
ensure we have the right number of staff with the right skills
and the right support to ensure we provide quality service
today, but also prepare for future need
•
improve our systems for gaining feedback on our services from
patients and staff and ensure we have mechanisms to
communicate those changes we have made as a result.
As part of this work we will, continue to incorporate the
recommendations from the Francis Report (2013) as well as learn
from more recent guidance contained within the Five Year Forward
View (2015) to ensure we remain at the forefront of modern, effective
community provision. We will seek to improve quality beyond the six
6
Quality Account
Cs (care, compassion, competence, communication, courage and
commitment), identified in the national Nursing Strategy to include all
our staff as well as continue to be able to provide assurance both to
our regulatory bodies (CQC) and all our stakeholders on the quality of
services provided, building on our present CQC rating of Good.
The quality account has been developed through a process of
listening to feedback and consultation with our patients, their carers,
our membership, key stakeholders and our staff and provides specific
information on how we will strengthen services during 2015/16 in
alignment with other LCHS key priorities.
Our Clinical Strategy
LCHS continues to have a clear focus on quality, and this is reflected
in our clinical strategy and associated key documents. But this is also
a live driver for service improvement at all levels, as we strive to
provide high quality services for patients in their own homes or place
of choice. This continues to be against a backdrop of tighter economic
constraints (both local and centrally led) and national changes to the
way the NHS is managed and commissioned. The trust embraces
these changes as we recognise we are pivotal to providing care closer
to home which is both safe, effective and is financially sustainable.
Our clinical strategy outlines the following key outcomes:•
person-centred, co-ordinated care
•
keeping people healthier and out of hospital
•
giving children the best start in life, with better integration of
services targeted at children and their parents
•
maximising independence and improving overall wellbeing for
frail elderly people
These outcomes are reinforcements of the LCHS mission statement to
provide high quality, lifelong personalised care within local
communities.
7
www.lincolnshirecommunityhealthservices.nhs.uk
We aim to work in partnership with patients locally, to ensure the
delivery of services is responsive to individual and community needs,
but also continues to remain viable within the changing healthcare
economy. LCHS has clear aspirations, by working as a lead integrator
of services locally in partnership with other health and social care
providers, to truly build services around the needs of our distinct and
diverse communities ensuring LCHS continues to be able to deliver
high quality cost effective services required within those communities.
The formation of distinct community and geographical groups, with
appropriate staff and skills aligned to provide for local need,
commenced in 2014/15, as the majority of our community services
begin to align into integrated community teams. This work will
continue and extend during 2015/16 as all services continue to work
together to address the needs of the local community.
To the best of the knowledge of the Chief Executive the information
reported in the Quality Account is accurate and a fair representation of
the quality of healthcare services provided by LCHS.
Andrew Morgan
Chief Executive
8
Quality Account
Part 1 - Quality Achievements in
2014/15
Priorities for quality improvement in 2014/15
Quality Account End of Year Summary
The priorities for 2014/15 were identified using a range of information
gathered through public listening events; feedback from patients
through the Friends and Family Test and from complaints; internally
through risks and serious incidents and externally from organisations
such as Healthwatch, CCGs and NHS Choices. Staff have been
engaged in the process through existing service groups, the Clinical
Senate and engagement roadshows. From an initial long list, our key
priorities were agreed by the Trust Board and formed our aspirations
and trajectories:1. Increase the uptake for clinical supervision across all LCHS
services
2. Patient facing time will be increased through increasing ‘Time
2 Care’
3. Reduce the harm from falls in community hospitals
4. Reduce medication errors resulting in harm
5. Reduction of Grade 2, 3 and 4 Pressure Ulcers
6. The Friends and Family Test (Net Promoter)
7. Safer Staffing
9
www.lincolnshirecommunityhealthservices.nhs.uk
Clinical Effectiveness
Deliver clinically effective services
Increase the uptake for clinical supervision across all LCHS
services
Why this is a priority
Clinical supervision is important as a framework for clinicians to
undertake supported individual or group reflection, peer review and
sharing of learning to develop individual clinical knowledge, skills and
expertise, or team performance.
Clinical supervision will underpin the commitment of the trust to
ensure that clinicians have the right skills to meet the needs of
patients and their families.
How we will measure this
LCHS reviewed the April 2014 baseline position for practitioners
working within each of their service groups. Improvement trajectories
were agreed with each professional group to ensure that there was a
significant increase in uptake of (recorded) supervision and improved
clinical effectiveness through evidenced sharing of learning. There will
be an expectation that all professional groups achieve a target of 80%
of staff accessing clinical supervision. Clinical supervision should take
place at least once every 3 months and may take the form of
individual or group supervision. The 80% target takes into account
sickness and staff turnover and is an effective measure of continuous
improvement in clinical effectiveness.
Monthly reporting mechanisms were put in place to monitor
performance with the expectation that all services reach 80% for the
two consecutive quarters at the end of 2014/15.
10
Quality Account
The rationale for the target was to ensure that all services across
LCHS develop a supportive model for staff to engage in clinical
supervision and achieve an appropriate baseline which provides
assurance that practitioners are reflective and continually developing
their skills in providing patient care.
Although the 2014/15 target was not achieved, initially gradual,
improvement month on month was achieved, except during the end of
Quarter 3 and during Quarter 4 when reporting fell below the trajectory
set. This may have been impacted both by training and system issues
affecting the registration of supervision initially in Quarter 1 and
increased winter pressures within the health and social care economy
affecting team time in Quarter 3 and Quarter 4. Steps have been
taken to ensure that staff record informal clinical supervision, for
example hand over discussions, case management discussions and
care/treatment plan reviews in addition to the formal events. In
addition 2014/15 data will have been compromised by the recording
system (supervision and appraisal system) being unavailable for over
one month during Quarter 4. Informally staff verbally report higher
compliance of informal supervision than recorded and focussed work
continues in this area. Assurance has been given from teams that the
level of supervision has been maintained through the year (regardless
of reporting rates).
The table below details the clinical supervision that has taken place to
date as reported from the supervision and appraisal system
Business Unit
Assignments
Clinical
Supervision
completed in last
3 months
1776
921
51.8%
Chief Executive
2
2
100%
Clinical Governance
& Risk/Operations
Family & Healthy
Lifestyle Services
Medical Director
36
35
97.2%
441
239
54.1%
9
9
100%
East
486
287
50.8%
11
www.lincolnshirecommunityhealthservices.nhs.uk
North West
355
177
49.8%
South
407
182
44.7%
Winter Pressures
29
20
69%
Clinical Supervision % Compliance
100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
% Compliant
Target
The above graph details the percentage improvement in clinical
supervision reported (does not necessarily reflect clinical supervision
undertaken). It is also worth noting that reporting was not introduced
until the 1st April 2014 and the time taken for reporting to become
established appears to be reflected along with the impact of winter
pressures in Q3 and Q4 which can be seen in the above chart.
Although the reporting system has been available for 12 months, the
above issues have impacted on the data available so we perhaps
have not yet seen a full 12 month effect.
During 2014/15 several actions have been undertaken to enhance
both the recording/reporting of clinical supervision as well as the
impact of increased support for staff and services, these include:•
refreshing policy – delivered and implemented a clinical
supervision tool kit.
•
development of an electronic method to capture data.
•
development of a user guide and advice sheet.
•
promotional and educational activities were run through
2014/15.
•
clear link to the appraisal process.
12
Quality Account
•
work started linking clinical supervision to revalidation
(nursing).
•
ways to evidence implementation of reflective practice as KSF
evidence.
Work has continued during 2014/15 to implement seven key
enablers which will impact on success during 2015/16. These
have included:•
•
•
•
•
changes to SystmOne templates.
implementation of rotas and visits (SI).
upgrade of IT hardware
increase in success of mobile technology (increased
reporting)
changes to how work is allocated by the contact centre
(hub and spoke model) with focused team time.
Patient facing time will be increased through
increasing ‘Time 2 Care’
Why this is a priority
Feedback from staff and patients during 2013/14 indicated that there
was a need to increase time to spend on direct patient contact
activities as part of the overall job role of our clinicians and support
staff. Travel, attendance at meetings, completing administrative work,
compiling reports, dealing with complaints and computer based
activities all reduce the amount of time that is spent providing direct
patient care or supporting patients and their carers by telephone.
How we will measure this
The organisation implemented a number of initiatives to increase the
amount of time our clinical and care staff have available to spend in
direct contact with patients providing assessment, care planning and
support.
13
www.lincolnshirecommunityhealthservices.nhs.uk
This was measured as an increase in the average amount of time
spent by clinicians on activities which include direct patient contact;
this will be measured as a percent of total time available at work. The
performance team were responsible for measuring and monitoring the
changes in patient facing time. Progress was reported to the Quality
and Risk Committee as part of the monthly Quality Account update.
Following a review of performance in 2013/14, the average clinical
contact time was 38%. We were aiming to increase patient facing time
during 2014/15 by 20% of last year’s percentage to give a total of 45%
Current patient facing time is: 31.08% - Target patient facing
time: 45% Hence for 2014/15 we remain behind trajectory.
Due to non-achievement in 2014/15 this continues to remain a high
priority for the organisation. Work has continued during 2014/15 to
implement several key enablers in relation to supporting a reduction in
record keeping time and the implementation of rotas and visits, both
with an expected outcome of increased mobile working. However the
positive impact of these enablers has been variable across the county.
Focus in 2015/16 will be to gain greater understanding of the reason
for variation, as well as find bespoke solutions to solve them. The
inclusion/exclusion criteria in relation to what is classed as patient
facing time needs to be refined to move away from the present system
definition of patient facing to a more clinically relevant criteria. Going
forward the indicator may change as more staffing groups adapt this
as an outcome measure. A more refined approach to data capture
could increase the % dramatically but more accurately reflect patient
focussed activity.
14
Quality Account
15
www.lincolnshirecommunityhealthservices.nhs.uk
Patient Safety
Deliver safe services
Reduce the harm from falls in community hospitals
Why this is a priority
A fall can change your life. If you’re elderly, it can lead to disability and
a loss of confidence and independence. Over recent years increasing
attention has been paid to patient falls both in terms of harm and the
number of falls.
In our community hospitals falls continued to be a cause for concern
during 2013/14, however we are acutely aware that improving patient
mobility and level of independence leads to a range of positive
outcomes for patients and their families. This can then help reduce the
extent to which people require acute hospital admission or services at
home.
How we will measure this
LCHS set a target and trajectory for each community hospital ward to
reduce falls resulting in harm and to reduce falls overall.
Falls are reported to the Quality and Risk Committee as part of the
monthly Quality Account update
Wards will collectively reduce all falls by 25% against 2013/14
baseline
The total falls for 2013/14 was 444
The collective target for 2014/15 is 333
April
34
May
30
June
22
July
26
Aug
31
Sept
32
Oct
25
Nov
32
Dec
34
Jan
54
Feb
22
March
30
*NB – Butterfly Hospice falls included from Oct 14
16
Total
372
Quality Account
In September 2014 the trust implemented a new strategy aimed at
identifying and addressing the causes of falls, overseen by an
experienced clinician. A multi- disciplinary approach to the delivery of
the LCHS Frailty strategy considered the physical, physiological,
psychological and environmental aspects and a new assessment and
care planning process adopted.
Lessons learned were captured, reported and shared in order to
support continued improvement and reduce the risk of patient harm,
and a Falls Root Cause Analysis tool was implemented in Quarter 4 to
enable avoidability status to be confirmed.
Wards will collectively reduce falls resulting in harm by 50%
against 2013/14 baseline.
The total falls with harm 2013/14 was 146
The collective target for 2014/15 is 73
Total falls with harm from 01.04.2014 to the end of reporting period
April
14
May
10
June
8
July
11
Aug
10
Sept
13
Oct
9
Nov
12
Dec
8
Jan
27
Feb
7
Falls with harm by ward from 01.04.2014 to end the of reporting period
*NB – Butterfly Hospice falls included from Oct 14
The target seeks to ensure the greatest impact on improving patient
safety through systematic implementation of the falls strategy and
reducing variation in outcomes across the community hospital wards.
17
March
11
Total
140
www.lincolnshirecommunityhealthservices.nhs.uk
Greater numbers of frail and elderly people are being treated and are
accessing rehabilitation pathways in the community hospitals. The
proposed reduction was set in the acknowledged context of the
increasing numbers of frail and elderly patients being cared for in the
community. However with hindsight the complexity of our patients, the
frequency of patients who have already achieved their maximum
rehabilitation potential and the increasing number of patients also
suffering with dementia was underestimated.
During 2014/15 services were not successful in achieving the set
reduction targets and although the organisation saw that the number
of falls resulting harm was less than the prior year, patients
unfortunately continue to fall. A large amount of activity has been
undertaken in 2014/15 including appointment of a Falls Lead
(September 2014). It became clear following initial scoping work,
seeing falls in isolation was not going to achieve the best outcome, as
trying to address falls as a separate issue of the wider frailty agenda
would have limited impact.
Reduce medication errors resulting in harm
Why this is a priority
Medication errors are broadly errors in prescribing, dispensing or
administration of a drug. They are the single most preventable cause
of patient harm (National Patient Safety) LCHS decided to set
ourselves the goal of reducing the level of harm even further. In
addition, each community hospital agreed a stretch target for
improvement and implemented staff training and audits to improve
patient safety related to medicines management. This will build on the
improvements made in 2013/14.
How we will measure this
This was be measured by the development of a safety thermometer
for medication errors based on incident reporting and root cause
analysis in our community hospital wards.
18
Quality Account
We will reduce all medication errors by 20%
The total number of medication errors for 2013/14 was 252
The target for 2014/15 is 201
Total medication errors to end of reporting period
April
17
May
13
June
31
July
27
Aug
16
Sept
28
Hospital specific medication errors are shown below
Ward
Manby
Carlton
Gloucester
Scarborough
Welland
Scotter
Butterfly
Total
April
1
2
1
1
4
2
11
May
2
0
0
0
5
2
9
June
6
2
1
1
2
7
19
July
0
2
3
2
3
5
15
Aug
1
0
1
0
2
0
4
Oct
33
Nov
17
Sept
2
4
0
3
7
5
21
Dec
22
Oct
1
1
0
0
11
5
18
Nov
0
0
0
0
7
2
0
9
Jan
18
Dec
1
0
1
2
2
5
0
11
Feb
19
Jan
0
2
1
0
4
3
1
11
March
24
Feb
3
2
0
0
1
2
1
9
Total
265
March
5
2
2
1
1
2
0
13
We will reduce medication errors resulting in harm by 25%
The total number of medication errors resulting in harm for 2013/14
was 7
The target for 2014/15 was 5 and was achieved.
April
0
Total medication errors with harm to end of reporting quarter
May
0
19
June
0
July
0
Aug
0
Sept
0
Oct
1
Nov
0
Dec
1
Jan
0
Feb
1
March
1
Total
4
Total
32
17
10
10
49
40
2
150
www.lincolnshirecommunityhealthservices.nhs.uk
Although the trust did not achieve all of the medication error targets
set, the number adrift is a relatively small number of errors in
proportion to activity. During 2014/15 increased effort has gone into
ensuring the appropriate prescribing, dispensing and administration of
medicines. This includes:•
clear process for reporting errors
•
increasing pharmacy input on all hospital sites providing
additional scrutiny (may have strengthened and increased
reporting rates).
•
enhancement of the medication element of mandatory training
•
utilising datix system to capture data (presently does rely on
manual cleansing- system due for upgrade during 2015).
20
Quality Account
Reduction of Grade 2, 3 and 4 Pressure Ulcers
Why this is a priority
Most pressure ulcers, or bed sores, are a complication of illness
however with appropriate care these can be avoided. Our ambition to
prevent all avoidable harm continues to remain a priority to all health
and social care organisations and LCHS is no exception. This will be
measured by incident reports and investigation into the causes of
pressure ulcers.
How we will measure this
A multi-disciplinary approach to improved patient mobility was taken
and collaborative work with other providers developed shared
pathways for patients to promote continuity of care and risk
management. This was overseen in Quarter 3 and Quarter 4 by a
dedicated clinician within the organisation. Incident reporting and
investigations of pressure ulcers continue to identify risk factors and
gaps in practice.
Reduce avoidable Grade 4 pressure damage by 50%
Grade 4 pressure damage is severe and may be life threatening.
Currently the trust reports one or two incidents of avoidable Grade 4
harm each month. There are many factors which contribute to this, but
earlier intervention for patients will reduce levels.
The total avoidable grade 4 pressure damage reported in 2013/14
was 17
The avoidable target for 2014/15 is 8
April
4
3
21
May
3
2
June
1
0
July
2
2
Aug
4
4
Sept
3
1
Oct
2
0
Nov
0
0
Dec
0
0
Jan
3
1
Feb
1
0
March
1
1
Total
24 reported
14 avoidable
www.lincolnshirecommunityhealthservices.nhs.uk
Reduce all avoidable Grade 3 pressure damage by 50%
Grade 3 pressure damage is severe and debilitating, often
experienced by patients at end of life. We aim to develop a specific
pathway for patients at risk of Grade 3 harm and provide focus on
delivery with the ambition to halve this damage.
The total avoidable grade 3 pressure damage reported in 2013/14
was 174
The avoidable target for 2014/15 is 87
April
49
23
May
50
23
June
37
14
July
43
22
Aug
29
15
Sept
38
19
Oct
40
28
Nov
31
20
Dec
36
25
Jan
46
33
Feb
38
24
Total
482 reported
281 avoidable
March
45
33
Reduce all avoidable Grade 2 pressure damage by 80%
Grade 2 pressure damage may be an early indicator of deteriorating
mobility and health and can be prevented through earlier identification
of risk factors in elderly or less mobile patients. Often associated with
reduced mobility following illness, hospital admission, stroke or need
for the use of appliances such as wheelchairs or catheters, our
pathway will be enhanced to ensure earlier referral from primary care,
on hospital discharge for assessment, case management and
intentional rounding. The target is significant, but necessary in
preventing higher grade damage and working towards the aspiration
of zero harm from pressure damage for our patients.
The total grade 2 pressure damage reported in 2013/14 was 722, of
which 274 were deemed to be avoidable.
The avoidable target for 2014/15 is 55
April
49
14
May
52
10
June
57
11
July
75
19
Aug
64
7
Sept
66
17
Oct
57
11
Nov
68
14
Dec
69
9
Jan
73
15
Feb
39
7
March
71
6
Total
740 reported
140 avoidable
22
Quality Account
During 2014/15 LCHS saw a reduction in avoidable grade 4 and 2
pressure ulcers from 2013/14 but failed to achieve reduction in
avoidable grade 3 or any of the set trajectories outlined in last year’s
Quality Account. The trust is reporting comparatively high numbers of
pressure ulcers and dependant on criteria used is considered a local
outlier. Additional work was undertaken during 2014/15 to support
progress clinically ie pathway updates, enhanced training and the
establishment of the internal review panel. This activity and the
adoption of the 5 day Root Cause Analysis turnaround timeline, now
embedded should all support improvement.
Although work continues to reduce pressure damage, during 2014/15
LCHS provided care to increasing numbers of very frail, elderly
patients, often in the end stages of life. Historically these patients
would have remained in hospital longer, sought long term placement
in facilities outside LCHS care or not chosen to spend the last days of
their life at home. Increased elderly patients and patients managing
acute and chronic conditions would have received services outside
the community in the past. The care shift is appropriate but does have
implications for the complexity and scale of risk factors now seen in
patients on community caseloads.
There is a robust external review being undertaken in April/May 2015
and the organisations and local action plans will be reviewed following
this work. Reducing pressure ulcer damage remains a key priority in
the Quality Account.
23
www.lincolnshirecommunityhealthservices.nhs.uk
Patient Experience
Listen to our service users, value their views and
improve patient and carer experience
The Friends and Family Test (Net Promoter)
Why this is a priority
The Friends and Family Test (FFT) is our main mechanism for gaining
feedback on patient and carer experience of services currently in use
in the NHS. The ability to gain user feedback and then act on it to
improve services is a dynamic and rewarding process for teams and
the organisation as a whole. Use of the Friends and Family Test
across NHS and non NHS health providers allows for a common
understanding of what good experience of services feels like and
provides data for benchmarking.
The FFT identifies variation within an organisation, which is often
more evident than variation between organisations and provides a
24
Quality Account
mechanism for identifying trends, changes in service performance and
acts as an early warning indicator of emerging quality issues.
How we will measure this
The trust will continue to use the FFT in community hospitals, and
during 2014/15 the roll out of the Friends and Family Test continued
across all community services during Quarter 2/3. Real time patient
feedback was captured, analysed and acted on through a range of
methods and publication of ratings, findings and responses. The trust
employed the services of “iwantgreatcare” to collect and report back
on patient feedback. This was reported monthly through the Quality
and Risk Committee and feedback to all patients through a ‘you saidwe did’ approach.
There is a national target within hospitals to achieve a monthly sample
of 15% of service users and 75% positive score using FFT.
LCHS will seek to exceed this target achieving a monthly sample of
20% of service users and 80% positive score.
Apr-
May-
Jun-
Jul-
Aug-
Sep-
Oct-
Nov-
Dec-
Jan-
Feb-
Mar-
14
14
14
14
14
14
14
14
14
15
15
15
258
274
267
279
254
243
252
212
233
253
231
252
Score
71
78
75
73
100
138
80
69
79
89
64
85
28%
28%
28%
26%
39%
57%
32%
33%
34%
35%
28%
34%
Sample
size
No
patients
discharged
The monthly sample target of 20% was exceeded in each month. The
score of 80 was not achieved in all months. The scores from
September fell below the target of 80 in 6 months as a result of a
higher number of passive responses (neither likely or unlikely) which
adversely impacted the score. During this period no patients recorded
extremely unlikely as a response and only 5 patients recorded a
response as unlikely which equated to 0.83% of the total responses
received.
25
www.lincolnshirecommunityhealthservices.nhs.uk
Safe Staffing levels – Right people, right skills, right place,
right time
Why this is a priority
There is a national drive to ensure that lessons have been learned
following examples of care in recent times which have been identified
as unacceptable either through the Francis Inquiry or Keogh reviews.
The publication, ‘How to ensure the right people, with the right skills,
are in the right place at the right time’, sets out the national
expectations for Trust Boards and commissioners in ensuring that
there is an appropriate nursing and care workforce in place to meet
the increasing health needs of local populations. LCHS aimed to be
an early implementer of safe staffing levels for community hospitals
(and community nursing teams late in 2014/15).
How we will measure this
We developed a baseline for safe staffing across a range of our
services. Compliance with safe staffing levels will be monitored with
reporting mechanisms established to identify exceptions and
escalation of issues for resolution.
Community Hospitals – safe staffing levels have been assessed
using the Royal College of Nursing guidance for the care of elderly
patients. Although this guidance is only a baseline and interpretation
of data produced should not be seen in isolation.
Wards will have fluctuating staffing levels month in month. Ward staff
utilise the baseline data to flex staffing levels in relation to patient
numbers and dependency, as well as staff availability. Additional
actions including having a clear escalation process during times of
increased risk, cancelling training and closing beds in the short term
have also been utilised to maintain safe levels for existing patients
and staff.
26
Quality Account
The Trust Board receives a report on achievement of baseline hospital
safe staffing levels on a monthly basis, to include recognition of where
services are below safe levels, and are informed what action was
taken. The principle of safe staffing levels is to ensure the
organisation maintains the safety of patients and staff.
Nationally this is the first year that trusts are reporting on staffing
levels. LCHS is using this opportunity to ensure our internal work
informs our workforce planning and staffing plans. Separate safe
staffing reports are presented monthly to the Quality and Risk
Committee.
Safe staffing is not an easy indicator to measure as there are many
factors which can impact on the safety of staffing numbers. During
2014/15 in the absence of a national tool, the organisation developed
its own tool to set a baseline safer for community staffing and this will
provide figures on which to focus during 2015/16.
Patient - Led Assessment of the Care Environment
Patient-Led Assessment of the Care Environment known as PLACE
applies to all hospitals delivering NHS-funded care, including day
treatment centers and hospices. PLACE is an annual assessment
which covers the Community Hospitals run by LCHS. PLACE
considers a range of standards within the patient environment
including privacy and dignity, well-being, food, cleanliness and general
maintenance. This process provides valuable information regarding
the standards of environment being maintained and areas required for
improvement.
A key feature of PLACE is the essential role of patients and/or their
representatives who make up at least half of the team during
assessments. These individuals are trained in the role of PLACE
Assessor but are required to act on behalf of the patient and their
requirements at all times.
27
www.lincolnshirecommunityhealthservices.nhs.uk
After the assessments have been completed the results are published
following analysis by the HSCIC (Health and Social Care Information
Centre). An action plan to identify and address improvements is
produced for each of the sites assessed and this plan is monitored by
the Trusts Infection Control Committee.
The PLACE assessment programme for 2014/15 confirmed that
improvements over the last year were made and the resulting scores
were improved.
PLACE assessment outcomes by hospital
Cleanliness
Food,
Hydration &
Meal Service
Privacy,
Dignity &
Wellbeing
Condition
Appearance &
Maintenance
National Average
97.25%
88.79%
87.73%
91.97%
John Coupland Hospital
96.67%
96.15%
82.48%
93.52%
Johnson Hospital
97.64%
90.52%
89.52%
97.10%
Skegness Hospital
88.72%
87.70%
74.72%
80.75%
Louth Hospital
90.53%
92.95%
75.20%
78.27%
*LCHS Organisational Score
93.39%
91.83%
80.48%
87.41%
We are working with our stakeholders to ensure improvements are
achieved in year against the four areas being assessed.
28
Quality Account
Health Care Associated Infection
LCHS ensures that the risk of avoidable spread of infections is
minimised.
We support excellence and ensure that our staff have appropriate
knowledge and skills in infection prevention through the implementation
of policies, guidelines and mandatory training.
We have a robust programme of audit that permits appraisal of clinical
and non –clinical aspects of infection prevention.
We monitor the environmental cleanliness across our healthcare
premises in line with the NHS Cleaning Manual standards and report
the audit results to the Board monthly.
We undertake surveillance for alert organisms and have implemented
a dedicated surveillance system (Plumtree DartICS) that permits near
real time reporting. We additionally screen all patient admissions for
MRSA. Patients identified as MRSA positive receive MRSA
suppression therapy in line with a dedicated care pathway.
Performance in relation to MRSA screening is for the 2013/14 reporting period
2010/11
2011/12
2012/13
2013/14
2014/15
Number of admissions
4838
3715
3504
3285
2581
Number of screens completed
4877
3691
3571
3252
2538
80
59
80
63
30
Number of MRSA positive screens
29
www.lincolnshirecommunityhealthservices.nhs.uk
Statements relating to quality of NHS
services provided
Review of Services
“During 2013/14 Lincolnshire Community Health Services provided
and/or subcontracted 58 relevant health services.
Lincolnshire Community Health Services has reviewed all the data
available to them on the quality of care in 20 of these relevant health
services.
The income generated by the relevant health services reviewed in
2013/14 represents 30% per cent of the total income generated from
the provision of relevant health services by Lincolnshire Community
Health Services for 2013/14.”
Participation in Clinical Audit
A range of clinical audits were completed during 2014/15,
amongst which were:
•
record keeping audit – outcomes fed back to Heads of Clinical
Services at QSG, recommendations collated into action plan.
•
controlled drugs audits now passed by all community hospitals
– update being provided to Audit Committee.
•
patient satisfaction surveys across all areas – results being
provided to Quality & Risk Committee through monthly Patient
and Public Involvement report.
•
NICE baseline audits are completed as required throughout
the year and transferred to the clinical audit programme as
appropriate.
30
Quality Account
In terms of patient safety:
•
audit of safety around balconies on wards reviewed
•
weekly safety audits continue across all community hospital
wards and are demonstrating improved safety outcomes.
•
a comprehensive suite of infection prevention and control audits
were completed
NICE Quality Standards
NICE quality standards measure NHS Trusts delivery of high-quality,
cost-effective patient care. LCHS is committed to achieving these
standards across the organisation’s services.
CQC Inspection
The Care Quality Commission (CQC) is the independent regulator of
Health and Social care in England. For Lincolnshire Community
Health Services (LCHS) this means they monitor, inspect and regulate
services to make sure we meet fundamental standards of quality and
safety. As our regulatory body the CQC set out what Outstanding, and
Good care looks like as well as helping organisations to identify areas
of poor care which require improvement. They work closely with other
regulatory and professional bodies and provide direct access to public
feedback. LCHS CQC activity over the last 12 months has included
two formal inspections in addition to monthly assurances on general
compliance. Individual issues are raised to the local CQC inspectors
as required following local incidents
31
www.lincolnshirecommunityhealthservices.nhs.uk
Formal Inspections
OOH
LCHS was subject to a planned inspection of the OOH service on the
5th, 6th and 7th June 2014. The organisation received informal
feedback from the lead inspector immediately following the visit.
As a direct result of the feedback given, an action plan was
implemented immediately. This action plan has been monitored
through the Urgent Care Clinical Governance Group on a monthly
basis. The action plan was due to be completed by 31st March 2015,
(8 actions). 7 actions were signed off in full by 1 April 2015, and one
partially signed off with full sign off 30th April 2015.
In November 2014 a countywide lead for the OOHs service was
appointed for a 12 month period. In February 2015 an Interim Head of
Urgent Care was appointed who has the responsibility for driving the
agenda and implementing lessons learnt. The action plan will
continue to be implemented as part of service redesign and
improvement in 2015.
Trust Wide
In September 2014 LCHS services were evaluated by the CQC
through a ‘planned’ Chief Inspector of Hospitals (CIH) inspection,
which lasted for a total of 4 days. In addition regular contact with our
designated local Inspector has been maintained in order to provide a
level of assurance in respect of the concerns raised.
During the formal inspection five specific areas: end of life, family and
healthy lifestyles (F&HL), community services, community Hospitals
and urgent care were inspected across the 5 domains of well led,
safe, effective, responsive and caring.
Ahead of the receipt of the formal reports from the CQC the
organisation developed an interim action plan based on the informal
32
Quality Account
feedback received to ensure actions were implemented immediately.
LCHS received an overall rating of ‘Good’ with a total of 12 areas
‘Required to Improve’ and a further 25 that ‘Should be Improved’.
Following the Clinical Summit in December 2014, the CQC accepted
the formal LCHS Action Plan detailing that all 37 actions would be
completed by the end of March 2015. Thirty-three actions were signed
off in full to plan; four issues have been signed of partially and have
shown slippage on planned deadlines. Three are due to wider issue in
relation to workforce and transformation and are being mainstreamed
as part of the planned implementation of integrated community teams.
One action included sourcing additional external support and scrutiny
from the Trust Development Authority (pressure ulcer damage
prevention) and this was unable to be sourced until April 2015.
Ongoing compliance
All areas self-assess monthly (utilising performance plus) on
adherence to the CQC essential standards, including the uploading of
evidence to support compliance. Lines of reporting at service level via
the sub board committees, to board are also reported monthly with
any concerns escalated both internally and externally to our local
inspectors.
Since 1 April 2015 we have been required to post our CQC status in
our service areas. Within LCHS all services are registered with no
conditions and following the CIH inspection the organisation was rated
Good overall.
33
www.lincolnshirecommunityhealthservices.nhs.uk
Examples of Outstanding Practice
Key Achievements
•
Shortlisted for Value and Improvement in Acute Service
Redesign for the HSJ Value in Healthcare Awards
Healthcare organisations in Lincolnshire were shortlisted in the
Value and Improvement in Acute Service Redesign category at
the 2014 Health Service Journal (HSJ) Value in Healthcare
Awards, held on 23 September at the Grosvenor House Hotel,
London.
Health and social care providers from across the county
designed a new way of working to support health care
professionals in the community to care for patients in their own
home or closer to home to keep people out of hospital.
As a result, an innovative and transformational whole system
approach has been developed using funding to invest in out-ofhospital services and ambulatory care. This has radically
transformed patient experience and instigated a system-wide
change in attitude and behaviour in patient management.
•
Family Nurse Partnership (FNP) Launched in Lincolnshire.
The FNP is available to pregnant women in Boston, Skegness
and coastal areas of Lincolnshire who are aged under 20.
FNP is a free and voluntary programme which sees a specially
trained, experienced nurse making home visits from the early
stages of pregnancy until the child reaches two years old.
•
LCHS gained eight new Queen’s Nurses throughout
2014/15 – bringing LCHS’s total number to 15
•
LCHS gained three Fellows of Health Visiting Institute in
2014/15
•
Heart Failure Service shortlisted for Managing Long Term
Conditions and Cardiac Care categories of Patient Safety
and Care Awards
Lincolnshire’s Heart Failure Service received national
recognition for the support it gives to patients in the
34
Quality Account
community. The service was a finalist in two different
categories of the Patient Safety and Care Awards, which were
held in London.
The Heart Failure Service supports patients when they
experience unstable symptoms and plays a vital role in helping
to prevent conditions from escalating and requiring hospital
admission. In Lincolnshire, seven heart failure complex case
managers sit within community teams to help coordinate care,
both long and short term.
•
Opening of the Butterfly Hospice Inpatient Unit
In August, the first patients were welcomed to the Butterfly
Hospice in Boston, the result of an innovative partnership
between LCHS and the Butterfly Hospice Trust. The six-bed
inpatient unit provides palliative, end of life and respite care in
an informal environment for adults with life-limiting illness.
•
LCHS shortlisted for Continence Promotion and Care
category of the Nursing Times Awards
An innovative project to improve continence care in
Lincolnshire has been shortlisted for a national healthcare
award.
The project was among the finalists in the Continence
Promotion and Care category of the Nursing Times Awards.
The work sees NHS community teams and care home staff
supported to gain additional specialist knowledge and
encourages earlier assessment and referrals for patients
requiring continence care.
As a result, patient assessment waiting times have been
reduced by half, services are more efficient and regular patient
reviews give them greater dignity and comfort.
•
Phoenix awarded ‘Team of the Year’
The specialist team behind a service which supports hospital
patients to give up smoking scooped a national award.
The Phoenix NHS Stop Smoking Service was named as The
Advisor magazine's Team of the Year for its work in Boston
35
www.lincolnshirecommunityhealthservices.nhs.uk
Pilgrim and Lincoln County hospitals with the Stop Before Your
Op initiative.
Patients who stop smoking prior to surgery are more likely to
have a shorter stay in hospital, are likely to require less
anaesthesia and reduce the risk of developing post-surgery
complications, such as a stroke or heart attack. This service is
especially helpful to cardiac patients to prevent them from
relapsing to smoking again once they are discharged home.
First Health at Home event open to the public
Dedication, commitment and service above and beyond the call of
duty was honoured at Lincolnshire Community Health Services NHS
Trust's annual public meeting/celebrating success event.
The awards formed part of a special Health at Home event on where
the public were invited to find out more about LCHS and the services
it provides.
The occasion was also an opportunity for the trust to show its thanks
and appreciation to teams and individuals who were nominated for
awards by their colleagues across nine categories. An overall winner
was also selected by LCHS Chief Executive Andrew Morgan.
Paralympic skier Jade Etherington opened the event and joined trust
Chairman Dr Don White to present the awards. Councillor Christine
Talbot, Chairman of the Health Scrutiny Committee for Lincolnshire,
also presented awards to the finalists in the Outstanding Volunteer of
the Year category.
Visitors could also see a showcase of LCHS services from across
Lincolnshire and Peterborough and the afternoon concluded with the
trust's annual public meeting.
36
Quality Account
Celebrating Success winners:
Outstanding Patient Involvement Award - Victoria Wilson (Outpatients
Department, Skegness Hospital)
Outstanding Innovation Award - Mandy Street, Julie Cantwell, Joanne
Dalton, Kelly Waldie (breastfeeding website team, countywide)
Celebrating Equality and Diversity Award - Andrew Bohlman (Clinical
Systems Trainer, countywide)
Time 2 Care Award - Valerie Ronis (Clinical Education, countywide)
Behind the Scenes Award - Carolyn Barlow and Vicky Mitchell (Bridge
House, Sleaford)
Outstanding Leadership Award - Kim Barr (Matron, Johnson
Community Hospital, Spalding)
Outstanding Team of the Year - Children's Speech and Language
Therapy Assistants, countywide)
Outstanding Volunteer of the Year Award - Joint winners - Betty
Archer and Alyce Taylor (County Hospital, Louth) and Barbara Finch
(Skegness Hospital)
Chairman's Award - 'Unsung Hero' - Karen Lawrie (Children's Speech
and Language Therapy, South Lincolnshire)
Chief Executive's Award - Valerie Ronis (Clinical Education,
countywide)
37
www.lincolnshirecommunityhealthservices.nhs.uk
Part 2 – Our Priorities for Quality
Improvement in 2015/16
The priorities for 2015/16 have been identified using a range of
information gathered over the last 12 months through public listening
events; feedback from patients through the Friends and Family Test
and from complaints; internally through risks and serious incidents
and externally from organisations such as Healthwatch, CCGs and
NHS Choices. Staff have been fully engaged in the process through
team meetings, and staff roadshows. From an initial long list, our key
priorities were to be refined and agreed by the Trust Board and
stakeholders and partners to form our aspirations and trajectories:1. Increase the uptake for clinical supervision across all LCHS
services
2. Patient facing time will be increased through increasing ‘Time
to Care’
3. Increase the number of frail patient’s receiving a holistic
assessment and individual plan of care identified to enhance
outcomes (90% of potential patient group)
4. Reduce medication errors resulting in harm in the community
5. Reduction of Grade 2, 3 and 4 Pressure Ulcers
6. Safe staffing levels – Right people, right skills, right place, right
time
38
Quality Account
Priority 1 - Clinical Effectiveness
Deliver clinically effective services
1.1 Increase the uptake for clinical supervision across all
LCHS services
Why this is a priority
Clinical supervision remains important as a framework for clinicians to
undertake supported individual or group reflection, peer review and
sharing of learning to develop individual clinical knowledge, skills and
expertise, or team performance.
Clinical supervision will underpin the commitment of the trust to
ensure that clinicians have the right skills to meet the needs of
patients and their families, and are supported in this activity.
Lessons learnt during 2014/15 as well as findings recommend from
internal audit in relation to data quality, validation and reporting will
support improved outcomes for both patients and staff during 2015/16
particularly the positive impact on quality services and the increase in
reflective practice and learning.
How we will measure this
LCHS will review the current position for practitioners working within
each of these services. Improvement trajectories will be agreed with
each professional group to ensure that there is a significant increase
in uptake of reported supervision (reflective of supervision
undertaken) and improved clinical effectiveness through evidenced
sharing of learning. There will be an expectation that all professional
groups achieve a target of 80% of staff accessing clinical supervision.
Clinical supervision should take place at least once every 3 months
and may take the form of individual or group supervision. The 80%
target takes into account sickness and staff turnover and is an
effective measure of continuous improvement in clinical effectiveness.
39
www.lincolnshirecommunityhealthservices.nhs.uk
Monthly reporting mechanisms will be put in place to monitor
performance with the expectation that overall clinical supervision rates
are more than 80% in three quarters of the year.
The rationale for the target is to ensure that all services across LCHS
develop a supportive model for staff to engage in clinical supervision
and achieve an appropriate baseline which provides assurance that
practitioners are reflective and continually developing their skills in
providing patient care.
Board Sponsor: Sue Cousland, Chief Nurse/Director of Operations
Implementation/Programme Lead: Kim Todd, Practitioner
Performance Manager
40
Quality Account
1.2 Patient facing time will be increased through increasing
‘Time to Care’
Why this is a priority
Feedback from staff and the organisation as a whole during 2013/14
indicated that there is a need to increase time spent on direct patient
contact activities as part of the overall job role of our clinicians and
support staff. Travel, attendance at meetings, completing
administrative work, compiling reports, dealing with complaints and
computer based activities all reduce the amount of time that is spent
providing direct patient care or supporting patients and their carers by
telephone. During 2014/15 dedicated work was undertaken to outline
solutions to increase the patient facing time available to all clinical
staff, and some improvements were seen, however further increases
need to occur to achieve set trajectories, so this target will remain in
2015/16.
How we will measure this
The organisation will implement a further number of initiatives to
increase the amount of time our clinical and care staff have available
to spend in direct contact with patients providing assessment, care
planning and support.
This will be measured as an increase in the average amount of time
spent by clinicians in activities which include direct patient contact;
this will be measured as a percent of total time available at work.
Following a review of performance in 2014/15, the average clinical
contact time for our community teams each month ranged from 3035%. We are aiming to increase patient facing time during 2015/16 to
ensure front line community staff spend at least 50% of available time
directly supporting patients via a phased trajectory.
41
www.lincolnshirecommunityhealthservices.nhs.uk
Trajectory for patient facing time is below. Current community patient
facing time is: 35% - Target patient facing time: 50%.
Apr-15
May-15
Jun-15
Jul-15
Aug-15
Sep-15
Oct-15
Nov-15
Dec-15
Jan-16
Feb-16
Mar-16
Trajectory Target
32%
50%
33%
50%
33%
50%
35%
50%
37%
50%
39%
50%
41%
50%
43%
50%
45%
50%
47%
50%
49%
50%
50%
50%
The rationale for the target stems from the development of the
community response specification, rationalisation of SystmOne
templates and our ability to report on clinical and non-clinical activities
which contribute to the delivery of services for patients. We are now
able to measure in components of time captured through clinical
record keeping and the planned implementation of e-rostering. All
42
Quality Account
have a potential high impact on patient outcomes and allow our staff
to focus directly on patient supporting activity.
Lessons learnt over 2014/15 identify clinically led change supported
by large scale enablers has had the largest impact on facilitating
changes in how our staff are working. Large scale transformation
continues to deliver the additional time for patient contact and the
target represents the ambition and commitment of the organisation to
reduce travel time and support the workforce with mobile technology
solutions.
Board Sponsor: Sue Cousland, Chief Nurse/Director of Operations
Implementation/Programme Lead: Sarah Mc Kown Interim Deputy
Chief Nurse
43
www.lincolnshirecommunityhealthservices.nhs.uk
Priority 2- Patient Safety
Deliver safe services
2.1 Increase the number of frail patient’s receiving a holistic
assessment and individual plan of care identified to
enhance outcomes (90% of potential patient group)
Why this is a priority
Lincolnshire is a large rural county with an aging population, growing
at a rapid rate. The population faces several challenges to access as
well as an escalating need of both health and social care resources.
Challenges include impacts on family support available due to families
spreading outside Lincolnshire, as well as poor infrastructures making
travel difficult. In addition, some of our population live in areas of high
economic deprivation, which potentially may also impact on lifestyles.
Within the county the incidence of coronary heart disease, stroke,
chronic obstructive pulmonary disease, diabetes, cancer and
dementia is higher than the national average. Changes in patients’
health needs: Long term health conditions, rather than illnesses
susceptible to a one-off cure, now consume 70% of the health service
budget.
The frailty agenda within Lincolnshire is a high priority and services
must take additional steps now to promote patients to support the
management of their long term conditions, including appropriate nonhospital plans for deterioration as well as an increase the promotion of
self-care and telemedicine. The psychological and emotional effects of
frailty on both the patient and their family is huge, Proactive support
and prevention following a robust clinical assessment to determine
individual patients ongoing care, as well as being key in coordinating
the support offered from a range of health and social care providers
including third sector support is vital.
44
Quality Account
How we will measure this
Good quality, robust assessment on first contact, sets the standard for
individualised care, but often due to quality or clarity of referral this
cannot always be undertaken in a timely manner or key factors
relating to the patient are unknown to the person accepting the
referral.
The formation of multidisciplinary neighbourhood teams and clear role
definition for LCHS case management will enhance this function and
enable a full holistic assessment of physical and psychological health
and wellbeing as well as enabling case managers to identify all factors
that may affect health and well-being in the future so a proactive
approach can be taken.
In addition case managers via the neighbourhood team approach will
have improved access to a community wide team multidisciplinary
team to allow packages of care to be tailored to the full range of
individual needs which will improve outcomes.
This will be measured by an increase in the number of frail patients
identified, receiving an holistic assessment with an individualised plan
of care identified to enhance outcomes (90% of patients receive a
holistic assessment by Quarter 4 – phased trajectory).
The rationale for the target clearly addresses the current needs of
patients but also starts to proactively manage the increase incidence
of frail older people that will be seen by all services in the coming
years. Work undertaken during 2015/16 will ensure all future
developments are based on a quality baseline
Board Sponsor: Sue Cousland, Chief Nurse/Director of Operations
Implementation/Programme Lead: Kim Barr Frailty Matron
45
www.lincolnshirecommunityhealthservices.nhs.uk
2.2 Reduce medication error in the
community
Why this is a priority
Medication errors are broadly errors in prescribing, dispensing or
administration of a drug. They are the single most preventable cause
of patient harm (National Patient Safety Agency 2004). The level of
harm from medication errors in LCHS is very low; however we have
decided to set ourselves the goal of reducing errors even further and
extending good practice adopted within our community hospitals wider
into the community setting.
LCHS has relatively high levels of reporting with low levels of harm
(which demonstrates a positive reporting culture), however review of
the medication errors reported in 2014/15 has identified that 46% of
incidents were due to omissions. Each community team will therefore
agree a minimum stretch target for improvement and implement staff
training and audits to reduce omissions and improve patient safety
related to medicines management. This will build on the improvements
made in 2014/15 in our community hospitals.
How we will measure this
This will be measured as a rate of omissions per 1000 contacts. The
2014/15 rate was 0.17 omissions per 1000 contacts and the target is
to achieve an annual rate of below 0.1, which would reflect a 40%
reduction.
Board Sponsor: Dr P Mitchell, Medical Director
Implementation/Programme Lead: Petra Clarke, Medicines
Management Lead
46
Quality Account
2.3 Reduction of Grade 2, 3 and 4 Pressure Ulcers
Why this is a priority
Most pressure ulcers, or bed sores, are a complication of illness
however with appropriate care these can be avoided. During 2014/15
we have maintained a consistent level of performance on 2013/14
data, although we did not achieved our ambition to prevent all
avoidable harm and this continues to remain a priority. This will be
measured by incident reports and investigation into the causes of
pressure ulcers.
How we will measure this
A review of practice and patient outcomes for 2015/16 has identified
areas for improved practice which are being shared across the trust. A
multi-disciplinary approach to improved patient mobility will be taken
and collaborative work with other providers will develop shared
pathways for patients to promote continuity of care and risk
management. Incident reporting and investigations of pressure ulcers
will continue to identify risk factors, additionally gaps in practice and
trajectories for quality improvement will be set to achieve improvement
in key areas of harm for patients in order to support continued
improvement following outcomes during 2014/15.
In 2015/16 we will continue with work plans to date, but also give
special focus on enhanced usage of non-concordance guidance.
During 2014/15 non-concordance guidance was shared with
community teams, however it can be a challenge to clearly define true
informed choice and non-concordance, as opposed to insufficient
information shared with patients about pressure damage and their
consequences. Lack of patient/relative understanding with care
identified, fluctuating patient capacity and robust end of life
assessment, all require constant assessment and reassessment
although LCHS staff will continue to focus within the community on:-
47
www.lincolnshirecommunityhealthservices.nhs.uk
Pressure ulcers for the community is avoidable and attributable
grade 2,3,4 in existing patients per 1000 contacts. Reduction by
40 % on 2014/15 performance.
The annual pressure ulcer rate per 1000 contacts in 2014/15 was
1.08. The target is to reduce to a rate of 0.65 by the end of 2015/16.
1.2
1
0.8
0.6
0.4
0.2
0
Pressure ulcers for hospitals is avoidable and attributable grade
2,3,4 in existing patients per 1000 occupied bed days. Reduction
by 40 % on 2014/15 performance
The annual pressure ulcer rate per 1000 occupied bed days in
2014/15 was 1.2. The target is to reduce to a rate of 0.7 by the end of
2015/16.
48
Quality Account
1.4
1.2
1
0.8
0.6
0.4
0.2
0
For the purpose of the target a definition of avoidable/attributable will
be clarified and be population based. This shall reflect the increase in
numbers of frail, elderly, end of life patients, which all community
trusts are now caring for within the community and targets can then
better reflect demand.
Grade 4 pressure damage is severe and may be life threatening,
currently the Trust reports one or two incidents of avoidable/
attributable Grade 4 harm each month. There are many factors which
contribute to this, but earlier intervention for patients will reduce levels.
Grade 3 pressure damage is severe and debilitating, often
experienced by patients at end of life. We aim to develop a specific
pathway for patients at risk of Grade 3 harm and provide focus on
delivery with the ambition to halve this damage.
Grade 2 pressure damage may be an early indicator of deteriorating
mobility and health and can be prevented through earlier identification
of risk factors in elderly or less mobile patients. Often associated with
reduced mobility following illness, hospital admission, stroke or the
need to use appliances such as wheelchairs or catheters, our pathway
will be enhanced to ensure earlier referral from primary care, on
hospital discharge for assessment, case management and intentional
rounding. The target is significant, but necessary in preventing higher
grade damage and working towards the aspiration of zero avoidable
harm from pressure damage for our patients.
49
www.lincolnshirecommunityhealthservices.nhs.uk
In all instances of non-concordance cited as reason for damage,
robustness of patient assessment will be audited as part of the root
cause analysis process.
The triangulation of local team quality data, staffing levels and levels
of support, preceptorship and supervision will be explored alongside
pressure ulcer prevalence. However differences in population and
differentials such as nursing home numbers may have an impact. The
targets for 2015/16 are apportioned and each team will need bespoke
action plans to address local issues/local targets.
Board Sponsor: Sue Cousland, Chief Nurse/Director of Operations
Implementation/Programme Lead: Lisa Green Deputy Chief Nurse
50
Quality Account
Priority 3 - Patient Experience
3.1 Safe staffing levels – Right people, right skills, right
place, right time
Why this is a priority
There is a national drive to ensure that lessons have been learned
following examples of care in recent times which have been identified
as unacceptable either through the Francis Inquiry or Keogh reviews.
The publication, ‘How to ensure the right people, with the right skills,
are in the right place at the right time’, sets out the national
expectations for Trust Boards and commissioners in ensuring that
there is an appropriate nursing and care workforce in place to meet
the increasing health needs of local populations. LCHS was an early
implementer of safe staffing levels for community hospitals and
community nursing teams.
How we will measure this
During 2014/15 we have developed a baseline for safe staffing across
a range of our services. Compliance with safe staffing levels during
2015/16 will be monitored with reporting mechanisms established to
identify exceptions and escalation of issues for resolution.
Community Hospitals – safe staffing levels have been assessed using
the Royal College of Nursing guidance for the care of elderly patients.
This was presented to the Trust Board and further investment was
made to two of the six wards within the organisation in 2014/15.
Further work continues to ensure the skill mix continues to represent
the needs of the patients and will take into account not just nursing
and care staff but therapy support.
Community nursing teams – in the absence of a recognised national
assessment tool, during 2014/15 senior clinicians within the
organisation have devised their own tool for assessing safe staffing
levels in the community. This work has been refreshed following
51
www.lincolnshirecommunityhealthservices.nhs.uk
guidance in relation to neighbourhood team development and
baseline safer staffing for community nursing provision is now
identified and underpinned by a comprehensive workforce plan, which
will be implemented in 2015/16. Further work will utilise best practice
recommendations to align both therapy support and specialist nursing
provision to the identified 12 neighbourhood team structures.
Health visiting teams – the ‘Health Visiting call to action’ in 2012
defined the numbers of health visitors each community provider
should employ, however it did not offer guidance on how they should
be deployed. In the absence of a deployment tool the service
developed their own mapping tool. The tool is based around the
healthy child programme criteria for delivery and levels of dependency
of children and young people rather than pure numbers. This was
utilised to set the baseline for each team and the mapping tool will be
rerun every three months to ensure resources available matched local
need.
How this will be measured
The Trust Board will receive a report on achievement of actual against
baseline safer staffing levels (utilising national tools, or in the absence
of a national tool locally agreed criteria). Inpatient areas will report
monthly from Quarter 1, Community nursing and health visiting from
Quarter 3. Reports will include recognition of where services are
below safe levels and what action was taken. The principle of safe
staffing levels is to ensure the organisation maintains the safety of
patients and staff, however it will be reported alongside contextual
indicators such as skill mix, patient acuity, bed occupancy rates and
quality outcomes to ensure the level of real risk is understood.
LCHS is also using this data to ensure our internal work informs our
workforce planning and staffing plans for the next 3-5 years.
Board Sponsor: Sue Cousland, Chief Nurse/Director of Operations
Implementation/Programme Lead: Sarah Mckown, Interim Deputy
Chief Nurse
52
Quality Account
4) Complaints and Compliments
LCHS responds to all complaints received from patients or carers and
ensures that lessons are learnt from these to ensure that good quality
services are delivered to the population of Lincolnshire.
During 2014/15 LCHS received 123 complaints, of the complaints
received during this time period five have been reviewed by the
Ombudsman. One has been returned from the Ombudsman which
was upheld with recommendations. Feedback is awaited to advise if
further action will need to be taken on the other cases. LCHS
ensures that all complaints are acknowledged within the set national
standard of 3 working days. When acknowledgment of the complaint
is made a timeframe for the response is agreed with the complainant.
This is usually agreed as 35 working days. If however the complaint is
complex, an extension on the timeframe can be negotiated with the
complainant.
Some issues/concerns come through PALS or the Complaints
Team and can be resolved without you having to make a formal
complaint. A concern is usually where someone does not want to
make a formal complaint but wanted to bring something to our
attention. A concern is usually resolved within 1 day by a
telephone call or letter of apology from the BU following speaking to
the staff involved.
A complaint is where there is a formal investigation and letter of
response from the Chief Executive following our complaints
procedure.
53
www.lincolnshirecommunityhealthservices.nhs.uk
During the reporting period 2014/15 complaints decreased by a
total of 74 on the number received in the reporting period
2013/14. There were 170 concerns in 2014/15 compared with
158 concerns in 2013/14.
For the reporting period 2014/15, 242 contacts were made to
Patient Advice and Liaison Service (PALS) for LCHS with a
number of concerns being addressed by services directly; this
is a decrease of 138 from the previous year. (The figure 325
reported last year was for the period 1/4/13-14/2/14 not the
whole financial year) LCHS continues to take a proactive
approach to address issues through PALS by ensuring that
action is taken to resolve the issue at local level to ensure that
the contact is satisfied with the outcome and reduce the
likelihood of a formal complaint being made.
Trust wide learning from all complaints is monitored by the
Quality and Risk Committee. Compliments are received directly
by LCHS services from patients and carers. These compliments
are recorded by the services and influence the monitoring of
service quality.
4.1 National Health Service Litigation Authority (NHSLA)
The trust continues to be a member of the NHS Litigation Authority
(NHSLA) risk pooling schemes for clinical negligence and third party
liability.
The
NHSLA
have
now
ceased
the
discounts
and
assessments for Trusts against the Risk Management Standards, with
a greater focus being placed on an outcome based approach to
reducing
claims
through
the
NHSLA
Safety
and
Learning
Service. The Trust monitors its claim profile through the Audit
Committee and the trusts other formal sub-committees, with lessons
being identified and shared throughout the trust.
54
Quality Account
4.2 False or Misleading Information
The Care Act 2014 has put in place a new criminal offence to publish,
or otherwise make available, certain types of information that is either
false or misleading. The offence came into force on 1st April 2015,
under Section 92 of the Care Act and specifies that an offence has
been committed if the trust supplies, publishes or otherwise makes
available information of a specified description, that is required under
enactment or other legal obligation, and is false or misleading in a
material respect.
Lincolnshire Community Health Services NHS Trust is committed to
taking all reasonable measures to ensure that all information provided
by, or on behalf of the trust is both accurate and factual. The trust has
a number of measures in place to check the consistency and accuracy
of data being published and ensures that staff are fully aware of their
responsibilities under the Act.
4.3 Duty of Candour
The Duty of Candour requirement came into force during 2014. It
places a legal duty on NHS organisations to inform and apologise to
patients if there have been mistakes in their care that have led to
moderate of severe harm.
In simple terms, candour means the quality of being open and honest.
Patients should be well informed about all elements of their care and
treatment and all caring staff have a responsibility to be open and
honest to those in their care
In summary to meet the requirements of this regulation the Trust
continues to:
•
•
•
55
Recognise the event involving the patient as an incident
Establish that it has caused harm
Act in an open and transparent way with the ‘relevant person’.
www.lincolnshirecommunityhealthservices.nhs.uk
•
•
•
•
•
•
Tell the ‘relevant person’ as soon as reasonably practicable
after becoming aware that a notifiable safety incident has
occurred and provide support to them.
Provide and account of the incident
Advise the ‘relevant person’ what future enquiries the Trust
believes are appropriate
Offer an apology
Follow this up by giving the same information in writing, and
providing an update on enquiries.
Keep a written record of all communication with the ‘relevant
person’.
Part 3 - Other Information
Annex 1
56
Quality Account
Statement of Directors’ Responsibility in respect
of the Quality Account
The directors are required under the Health Act 2009 to prepare a
Quality Account for each financial year. The Department of Health has
issued guidance on the form and content of annual Quality Accounts
(which incorporates the legal requirements in the Health Act 2009 and
the National Health Service (Quality Accounts) Regulations 2012 (as
amended by the National Health Service (Quality Accounts)
Amendment Regulations 2011 and the National Health Service
(Quality Accounts) Amendment Regulations 2012).
In preparing the Quality Account, directors are required to take
steps to satisfy themselves that:
•
The Quality Account presents a balanced picture of the Trust’s
performance over the period covered;
•
The performance information reported in the Quality Account is
reliable and accurate;
•
There are proper internal controls over the collection and reporting
of the measures of performance included in the Quality Account,
and these controls are subject to review to confirm that they are
working effectively in practice; The data underpinning the
measures of performance reported in the Quality Account is
robust and reliable, conforms to specified data quality standards
and prescribed definitions, and is subject to appropriate scrutiny
and review; and
•
The Quality Account has been prepared in accordance with
Department of Health Guidance.The directors confirm to the
best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Account. By order
of the Board
NB: sign and date in any colour ink except black
57
www.lincolnshirecommunityhealthservices.nhs.uk
Chief Executive
Date
Annex 2
Statement on Lincolnshire Community
Health Services NHS Trust
Trust’s Quality Account for 2014/15
58
Quality Account
HEALTH SCRUTINY
COMMITTEE
FOR LINCOLNSHIRE
HEALTHWATCH
LINCOLNSHIRE
Statement on Lincolnshire Community Health
Services NHS Trust
Trust’s Quality Account for 2014/15
This statement has been prepared jointly by the Health Scrutiny
Committee for Lincolnshire and Healthwatch Lincolnshire.
Review of Priorities for 2014-15
We note that the Trust has not met all its priority targets for
2014-15, and accept the explanation that in some instances the
targets were too ambitious, and in future consideration will be
given to setting targets that are both challenging and achievable.
However, we accept that improvements have been made in a
number of areas, for example, there has been an increase in the
amount of 'patient-facing' time and a small reduction in the
number of medication errors resulting in harm to the patient.
There is detailed information on the targets for the Reduction of
Pressure Ulcers. This shows some improvement, for example a
reduction in the number of grade four pressure ulcers, but an
increase in the number of grade three ulcers. We are pleased to
see this priority carried forward into 2015-16.
Examples of Outstanding Practice
We commend the Trust on the successes and achievements
highlighted in the Examples of Outstanding Practice section of
the report.
Priorities for 2015-16
59
www.lincolnshirecommunityhealthservices.nhs.uk
We support the Trust's selection of priorities for 2015-16 and
note how these priorities have been developed, building on
activities in the last year. We add the following comments on
each priority:
•
•
•
•
•
•
Increasing Clinical Supervision – We note this priority has
been carried forward and we look forward to
improvements being achieved.
Increasing "Patient Facing" Time – We note the Trust will
be putting more effort into this priority in the coming year,
by undertaking several initiatives.
Increasing Holistic Assessments of Frail Patients and
Individual Care Plans – We strongly support the Trust's
emphasis on this activity.
Reducing Medication Errors – We look forward to further
reductions in the coming year.
Reducing Grade 2, 3 and 4 Pressure Ulcers – The levels
of pressure ulcers are a particular concern for us and we
strongly urge the Trust to put every effort into reducing
pressure ulcers in the coming year.
Safer Staffing Levels – The importance of ensuring the
correct number of staff on duty cannot be underestimated
and we look forward to the Trust seeking an increase in
the levels of staffing to meet the national standards.
We look forward to the Trust reporting on progress during the
course of the year on these priorities.
Patient-Led Assessment of the Care Environment
We are pleased to see the inclusion of detailed information on
Patient-Led Assessment of the Care Environment (PLACE) and
recognise that in some instances the figures for the Trust's
hospitals are well below the national average. We look forward
to the Trust making improvements in these areas.
Engaging the Public
We are pleased that the Trust has explained how it has engaged
the public over the last twelve months in various ways to
develop the priorities for the coming year.
In terms of
accessibility by members of the public, we are also pleased that
the Quality Account presents information on targets in both
60
Quality Account
actual numbers and percentages. This provides a degree of
clarity to the lay–reader, which is to be commended.
Engagement with the Health Scrutiny Committee and
Healthwatch Lincolnshire
The Health Scrutiny Committee has engaged with the Trust at
its meetings in the last year, by presenting information on the
Trust-wide inspection of the Care Quality Commission, which
was followed by a subsequent consideration of the Health
Visiting and School Nursing Services, about which the
Committee had some concerns. These services are valued by
the Committee.
Healthwatch Lincolnshire has maintained useful contacts with
the Trust throughout 2014-15, and is planning Enter and View
visits to the Out of Hours Services provided by LCHS during the
coming year.
Care Quality Commission Rating
We commend the Trust on its good rating from the Care Quality
Commission, and look forward to the Trust maintaining high
standards for future services.
Lincolnshire Health and Care
The Lincolnshire Health and Care programme is going to
change the approach to many services in Lincolnshire and a key
element in the year to come for the Trust is maintaining high
quality care for its patients, while planning for and implementing
changes in services.
Conclusion
We are grateful for the opportunity to make a statement on the
Trust's draft Quality Account.
Both the Health Scrutiny
Committee for Lincolnshire and Healthwatch Lincolnshire will be
seeking more engagement with the Trust during the coming year
on the progress with its priorities.
Annex 3
Feedback from Lead Commissioner
61
www.lincolnshirecommunityhealthservices.nhs.uk
Lincolnshire Community Health Services (LCHS)
The commissioning of high quality, safe patient services is the first
priority of the Lincolnshire East Clinical Commissioning Group
(LECCG) and welcomes the opportunity to review and add comment
on the LCHS quality account.
The report identifies areas of priority during 14/15 identifying the
requirements, aspiration and the outcomes. It is clear from the review
of performance in relation to the quality priorities identified by the
organisation last year that there is still work for LCHS to do to ensure
that the services deliver these priorities, and where the organisation
has not achieved this in 14/15, how this will be more effective in
15/16.
The key aim of the Commissioning for Quality and Innovation (CQUIN)
framework for 2014/15 is to support improvements in the quality of
services and the creation of new, improved patterns of care. LCHS
achieved a worthy 75.88% of its targets.
The quality schedule achievement during 14/15 was comparable with
previous years. As the commissioner of this service a greater level of
compliance during the 2015/16 contract year would be seen as a
worthwhile aspiration.
During 2014/15 the management and staff of LCHS were subjected to
winter pressures that tested every part of the organisation. The Out of
Hours (OOH’s) service saw a large increase in activity over the festive
period. The outstanding work carried out during those months is
noteworthy. However LCHS has been subjected to challenges in
relation to staffing levels and recruitment over the past year. The
commissioner notes the additional impact on service provision the
staffing challenges have and would like to see further development
work undertaken to address these particular challenges.
Lincolnshire East CCG has been working in partnership with LCHS to
support continuous improvement in patient care through a sustained
focus on the delivery of harm free care. The Trust has undertaken
significant work in 2014/15 to eliminate avoidable pressure ulcers at
category 2, 3 and 4. This work has seen a reduction in grade 2 and 4
pressure ulcers, which is welcome, however further work is required to
ensure a continuous sustained reduction in the occurrences of grade
3 Pu’s.
62
Quality Account
The commissioner notes that the Trust and OOH’s service received
CQC inspections. As a result, action plans were implemented based
on the informal feedback. Actions are under way and most are
expected to be completed by quarter 4 (Jan – Mar 2015).
Lincolnshire East CCG confirms that to the best of our knowledge the
accuracy of the information presented within the LCHS quality account
is a true reflection of the quality delivered by Lincolnshire Community
Health Services.
This quality account gives a valuable insight of outstanding work
identified within the report. The organisation and its staff should be
proud of their achievements.
The Lincolnshire Clinical Commissioning Groups look forward to
continuing to work with the Trust to provide an enhanced and
extended range of services for our patients.
Tracy Pilcher
Chief Nurse
NHS East Lincolnshire CCG
63
www.lincolnshirecommunityhealthservices.nhs.uk
Annex 4
Feedback from Membership
The quality account was shared with a random selection of our
membership, the responses received were varied and as such did
not identify any specific areas of concern. We were able to make
minor changes in response to the comments.
64
Quality Account
Patient Advice and Liaison Service (PALS)
PALS is a confidential service that helps patients, their families and
carers to find answers to questions or concerns regarding the care
or treatment received from NHS Trusts in Lincolnshire.
As a patient, relative or carer you may sometimes need to turn to
someone for on-the-spot help, advice and support. This is what the
Patient Advice and Liaison Service does on a daily basis. We
provide confidential advice and support, helping you to sort out any
concerns you may have about the care provided by the NHS and
guiding you through the different services available.
PALS can:
•
give you information about local health services
•
listen to any problems you may have in relation to your health
care or the health care of a loved one or friend
•
help you ask questions about your health care
•
tell you about help and support groups for you or your carer
Tel: 0845 602 4384
Calls via Typetalk/Text Relay are welcome
Email: info@lincspals.nhs.uk
Write to us at:
Lincolnshire PALS
Bridge House
Unit 16, The Point
Lions Way
Sleaford
Lincolnshire
NG34 8GG
A member of the team will be available Monday to Friday,
9am - 5pm (Except Bank Holidays). This service is
confidential.
65
www.lincolnshirecommunityhealthservices.nhs.uk
Membership
For further details of how you can get involved with Lincolnshire
Community Health Services NHS Trust and to find out how you can become
a member follow the link below:
http://www.lincolnshirecommunityhealthservices.nhs.uk/Public/cont
ent/ Lincolnshire-community-health-service-trust-membership
66
Quality Account
Trust Headquarters
Lincolnshire Community Health Services NHS Trust
Bridge House
Unit 16, The Point
Lions Way
Sleaford
Lincolnshire
NG34 8GG
67