Cataract Centre Ltd
Quality Accounts 2014 - 2015
SECTION 1: INTRODUCTION AND STATEMENT FROM
MANAGEMENT BOARD
WHAT IS A QUALITY ACCOUNT?
These are The Cataract Centre Ltd quality accounts to the public about the quality of
services we offer. The Health Act 2009 and corresponding regulations place a legal
obligation on providers of NHS healthcare services in England to publish these on an
annual basis.
Our quality accounts are reviewed by our commissioning Clinical Commissioning
Group and published electronically on NHS Choices website and a copy is also sent
to the Secretary of State.
PURPOSES OF THE QUALITY ACCOUNT:
One of the key aims of the account is to:
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Improve transparency and accountability to the public.
Engage key stakeholders both internal and external in quality improvement
Drive and enable providers to review services and identify where
improvement is needed.
Create and share quality improvement plans
Provide information on the quality of services to the public.
A requirement of the quality account is to include a statement from the management
board summarising the quality of NHS services provided, the organisation’s priorities
for quality for the forthcoming year, a series of statements from the board which are
set out in the regulations and a review of the quality of services provided during the
year.
In developing a quality account and setting priorities for the future there is an
expectation that we will engage with staff, external stakeholders, commissioners,
and patients including their carers and relatives.
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QUALITY STATEMENT FROM THE MANAGEMENT BOARD
The Cataract Centre Ltd is pleased to present its second set of quality accounts for
the year 2014-15. We are fully committed to fostering and continue to drive an
organisational culture that puts the patient first and foremost and at the heart of
everything we do.
The Cataract Centre was established by its founding surgeon in 1993 with the vision
to demonstrate the highest levels of patient safety, quality, excellence in clinical
outcomes and positive patient experience and satisfaction. This vision has formed
the heart and soul of the Cataract Centre and is reflected in the dedication and the
highest levels of quality shown by our team and reflected in the care received by our
patients.
The Cataract Centre was registered with CQC in March 2012 with no conditions, as
a provider who specialises in Ophthalmology services across the London Borough of
Enfield, with a view to expanding our services further across London. As Clinical
Director of The Cataract Centre, I am passionate about being committed to:
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Delivering consistently high quality patient care
Excellent patient outcomes with year on year improvement
Excellent medical and clinical leadership
Supporting all staff to ensure they are equipped to deliver continuously high
standards of service
Involving patients in decision making so they can influence the delivery of their
care.
Measuring and demonstrating the impact we make.
Driving best practice by keeping up to date with new clinical and technological
developments in the field of Ophthalmology.
2014-15 was another significant year for The Cataract Centre, as we have
progressed to expanding our range of services and clinics in the community and
surgical capacity with our partner Trust namely Royal Free Hospitals NHS
Foundation Trust. In 2014-15 we have seen over 9000 patients in community
outpatient clinics, and undertaken over 3000 surgical procedures which include:
Cataract surgery, glaucoma surgery, squint surgery, adnexal surgery, and YAG laser
procedures for glaucoma and post cataract opacification.
The year has seen us transform our booking processes, and we have become a
unified service with a single accountability and governance structure for patient
pathways. This begins from referral to community service, management of chronic
disease in the community to surgical intervention where required. In 2014-15 we
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have expanded our administrative structure from that implemented in 2013, as the
demand for services continues to increase.
As part of good governance we have documented clinical and quality policies that
are reviewed annually and we keep abreast of requirements from the CQC and other
national regulatory bodies. We ensure our services are delivered by the most
appropriate qualified clinicians and nurses with the relevant skills required.
An important part of this transformation is the establishment of quality meetings with
Enfield Clinical Commissioning Group, where quality performance, service delivery
and patient experience are all discussed and improvement plans assessed.
Discussions are also afoot with local patient participation groups.
The Cataract Centres internal transformation ran parallel to significant changes
within the local health economy and in line with ever increasing demand for the
service. We are immensely proud in the determination and manner in which our
staff have focused towards meeting the needs of the organisation in ever-changing
dynamic and pressured times, ensuring excellence in patient service.
We continually monitor changes and review our performance so we can drive
improvements for the benefit of all our patients.
The need to ensure clinical excellence is the role of all in the organisation and is not
based on the reliance of solely one or two people. At The Cataract Centre we
nurture an ethos of close team work and collaborative working and professionalism.
We believe in investing in our staff, our clinics and equipment to ensure safe and
consistent delivery of care at all times and to keep up with technological
enhancements in service delivery.
We encourage staff, partners and commissioners to view our quality accounts to get
an overview of what we do well and what we intend to improve in the coming 12
months.
Patient feedback is extremely important to us and we have continued to undertake
patient experience programmes in 2014-15 and have also incorporated the national
friends and family test questions into our programme.
The Cataract Centre is accustomed to the disciplines of regulatory compliance with
the CQC and contractual requirements as set by our commissioners, to regularly
report, where applicable: performance, complaints and serious incidents. The
organisation maintains a log of all complaints and incidents with actions being
undertaken to resolve issues or reduce risk.
To the best of our knowledge, the information contained within this quality account is
accurate and a fair representation of the quality of services delivered.
Dr Raymond Lobo, Clinical Director - The Cataract Centre Ltd
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THE CATARACT CENTRE LTD
The Cataract Centre Ltd is a private Ophthalmology services provider situated in
North London in the Borough of Enfield. The organisation offers services to NHS
patients and those who wish to fund their own treatments.
The Cataract Centre Ltd provides a full range of ophthalmic services, including:
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Community outpatient consultations and treatment
Diagnostics
Surgery
Long term conditions management
Follow-up care
During the period 2014-15 the service has seen over 9000 patients in the community
through its community ophthalmology service and has carried out surgical
procedures on over 3000 patients.
Currently 19 specialist ophthalmic consultants and specialist doctors work for the
service and are supported by 37 clinical staff, a skills mix of Nurses, most of whom
are ophthalmic specialty trained, Healthcare technicians, Orthoptists, Optometrists,
21 Administration staff and some dedicated facilities and housekeeping support.
The service has been commissioned by Enfield Clinical Commissioning Group to
provide community ophthalmology services and has a partnership agreement with
Barnet and Chase Farm Hospitals NHS Trust (BCFH) to undertake surgical
procedures where required and they have been chosen by patients as their preferred
choice of location.
The service has built excellent relationships with The Royal Free Hospitals NHS
Foundation Trust following its acquisition of our original partner Barnet and Chase
Farm Hospitals NHS Trust, commissioners and referring GP’s and clinical
commissioning leads over the last 20years.
Our service manager recruited in 2013 with a background in ophthalmology nursing
continued to provide and build vital relationships to the optometry community and
GP’s to ensure their needs and expectations are being managed through a clear and
effective referral process and streamlined pathways for subsequent patient choice
referrals.
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SECTION 2
PROGRESS AGAINST 2014-15 IMPROVEMENT PRIORITIES
Our improvement priorities have been decided upon by evaluating and acting upon
our governance processes and learning from our patients experience programme
and staff feedback. We have a clear commitment to our patients and we work in
partnership with the NHS both in terms of CCG, GP’s and Acute Hospital Trusts to
ensure our services are safe and of high quality in meeting local requirements. We
constantly strive to improve clinical safety and standards by a process of
governance, including audit and feedback from all stakeholders participating and
experiencing in our services.
PATIENT SAFETY
A. Never Events
These are serious and in most cases preventable patient safety incidents that should
never occur if adequate preventable measures have been put in place. There are 25
nationally recognised never events of which 4 are core to the service.
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Wrong site surgery –The service had no incidences of wrong site surgery on
2014-15. This is supported by the well embedded use of WHO surgical
checklist by our surgical teams and the continued vigilance of all medical and
nursing staff.
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Wrong Implant – “Wrong intraocular lens implant; learning from reported
patient safety incidents” (SP Kelly Feb 2011) showed that a large percentage
of incidents of wrong implantation of IOL were due to wrong IOL selection.
The Cataract Centre did not have any never events relating to this in 2014-15.
The service has a thorough pre-operative setup with robust lens check
protocol in place ensuring that all lenses are clearly available, identified and
prepared the day prior to surgery and labelled appropriately with pre-surgery
biometry information and patient details. Further to this lenses are double
checked prior to being used in the operating for each patient. For clarity there
are three separate checks in place before the lens is implanted in a patient’s
eye.
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Retained Foreign Object Post Operation - this rarely occurs due to the
nature of our surgery. However due vigilance is undertaken due to the tiny
microscopic sutures often used, most ophthalmic surgery is performed under
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a microscope which gives a good view of the operating field and thus prevents
any foreign bodies from inadvertently entering the eye. This is also mitigated
through the effective use the WHO Surgical Safety checklist process.
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Overdose of Midazolam during conscious sedation – minimal invasive
procedures require the need for sedation for some of the surgical care
delivered by The Cataract Centre, particularly for anxious and nervous
patients. No incident of this nature occurred in 2014-15, but the use will be
monitored and reported under policy guidelines.
B. WHO Checklist Compliance
The WHO Surgical Safety Checklist is an effective tool used to improve the safety of
surgical procedures by bringing together the entire surgical team, comprising
surgeons, anaesthetists, and nurses. They are brought together to perform a
number of key safety checks during vital phases of perioperative care, prior to the
induction of anaesthesia, prior to skin incision and before the surgical team exits the
operating theatre.
The Cataract Centre has implemented the World Health Organisation (WHO)
recommendation for safer cataract surgery checklist. The checklist is a tool used
throughout cataract surgery to improve the safety of surgery by driving good
communication and setting out safety checks throughout the perioperative process.
The service had achieved a 100% compliance rate for completion of the checklist in
2014-15.
C. Implementation and delivery of an Enhanced Community Patient
administration system
The Cataract Centre has successfully implemented a new patient administration
system in 2014-15 which has enhanced the way in which we monitor and deliver our
services to patients. It has improved visibility of patient waiting lists and has
streamlined administrative processes which also enhance the patient experience as
it has made the answering of patient queries easier and quicker. This has been
complemented by the increase of administrative staffing resource to further support
the delivery of the service. Further embedment and development work will continue
with the system to further enhance its capability in 2015-16.
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PATIENT EXPERIENCE
A. Overview
We have built on our patient experience programme from previous years and
expanded the scope of patient experience to cover the entire pathway from
outpatient phase to inpatient surgical phase and follow-up care. In addition to this
we have incorporated the national NHS friends and family test (FFT) questions into
our programme. Patient Experience feedback was one of the service CQUINs for
2014-15.
Overall, feedback was positive and results echoed the positive feedback and
compliments clinicians and administrative staff received in person from patients (at
the time of writing performance is based in Q1&2 2014-15). Results found that
patient perception of the service is good and confidence in the service has been
established and improved from 2013-14 with over 80% of community patients and
90% of surgical patients surveyed stating that they would use the service again and
rating the service as either ‘Excellent’ or ‘Good’. In addition to this over 70% of
community patients and 90% of surgical patients stated they would be ‘extremely
likely’ or ‘likely’ to recommend the service to their friends and family.
The Cataract Centre Ltd received four formal complaints in 2014-15, of which three
have been satisfactorily resolved with patients being satisfied with the outcome and
one currently in the resolution process. The complaints were associated with the
following:
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1 complaint regarding the delay in booking a specialised diagnostic test. The
delay was due to capacity constraints due to winter pressures and delays in
the process of securing prior approval from commissioners for the provision of
a specialised diagnostic test.
o We are currently reviewing the prior approval process to streamline it
and make the decision making process with commissioners quicker.
o We have also learnt and re-iterated to administrative staff the
importance of better communication with patients to keep them
informed of progress and next steps.
2 complaints regarding delays in booking follow-up appointments. These
were largely due to misunderstanding of when the patients should expect to
be contacted for the booking of their follow-up.
o We have advised clinical staff to ensure that they clearly inform
patients of a guide timeline for their follow-up and when they can
expect to be contacted by our booking team to arrange their follow-up
appointments.
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1 complaint regarding behaviour and professionalism of a member of staff.
This complaint is currently under review and in the resolution process with the
patient.
In light of the complaints received in 2014-15, communication is a key area of focus
in 2015-16 and further insight into communication will be placed when collating
feedback from patients as part of patient experience contact and surveys.
B. CQC Compliance
In 2014-15 we have developed and implemented a mock CQC inspection
programme within our services to encompass the entire patient pathway from the
community clinics to surgical services delivered at the Chase Farm Hospital site.
This allows pro-active assessment of compliance against CQC Essential Standards
of Quality and Safety and identifies key areas of focus where further action needs to
be taken to maintain or improve compliance and ultimately the service and
experience for our patients.
In 2014 The Cataract Centre Ltd had an unannounced inspection undertaken by the
CQC and was found to be compliant with all standards assessed. Subsequent mock
inspections undertaken by the service have shown continued compliance. This
provided patients with a level of assurance regarding the quality of care they could
expect to receive. Our mock CQC inspection programme is now a core component
of governance within our service.
Further to this we have undertaken a compliance assurance exercise to ensure all
our community partner practices where services are being delivered are compliant
with CQC standards and where improvement is required sufficient plans are in place
to deliver compliance and to mitigate against any impact to patients. Furthermore
this assurance process will be continual through service delivery to ensure all
satellite sites continue to be compliant and to ensure we deliver the best possible
care to patients in the most appropriate environments.
C. Increased Access to Community Services
In 2014-15 we have increased our clinical resource and the level of services we
offer. The community service now operates 7 days a week with additional clinics
being run both midweek and during weekends, across multiple sites in the Borough
of Enfield. This allows greater access to services both in terms of location and day
of week, especially out of hours. This was a positive change made in response to
patient feedback from 2013-14 patient experience programme. This has been well
received from patients and is reflected from both positive comments from patients
and by the positive uptake and utilisation of the extra clinics.
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CLINICAL EFFECTIVENESS
The Cataract Centre Ltd has Integrated Governance/Clinical Quality Review
meetings with CCG: contractual, clinical and quality leads on a quarterly basis
throughout the year to monitor quality and effectiveness of care.
All complaints, incidents, near misses, patient and staff feedback are reviewed to
determine any trends that may require further root cause analysis investigations, and
subsequent action plans for remedial action. Remedial action plans are presented to
the group where lessons learned and progress is shared and disseminated. We also
review and assess progress internally on a monthly basis.
In addition to this the service adheres to the governance and complaints
policies/processes for services delivered on behalf of Royal Free Hospitals NHS
Trust. The service now has Quarterly review meetings in place with the Trust to
review and discuss clinical and operational matters and to ensure the continued
delivery of service. We pro-actively share details of any incidents with the Trust and
promote collaborative action and learning. We have found that this helps to promote
our culture of being open and honest, patients safety incident reporting and aids in
disseminating lessons learnt and aligning best practice.
Cataract surgery outcomes audit – The Cataract Centre Ltd undertook an internal
audit of Cataract Surgery in Q1 to looking at activity undertaken in 2013-14. The
audit showed positive outcomes for patient and did not highlight any areas of
concern.
WHO surgical safety checklist audit – the service undertook and audit of 100
surgical patients in 2014-15 and found 100% compliance with the WHO surgical
checklist.
Documentation audit – the service undertook a review of documentation and
records management in 2014-15 and identified some areas for development.
Following the review and with the support of the Quality Lead from commissioners,
we have developed a new records management and storage policy which
encompasses guidelines for good record maintenance and the fundamentals of a
good medical record. This has now been disseminated across the service and is
being pro-actively embedded to ensure all admin and clinical staff are adhering to it.
The service views documentation maintenance as essential to delivery of service
and it is envisaged that by the adherence to this policy and by delivering an
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improved medical record it will improve both clinical practice of our clinicians but also
the patient experience.
The policy has also been reviewed and signed-off by commissioners prior to
implementation.
PRIORITIES FOR 2015-16
The Cataract Centre Ltd have selected priorities for 2015-16 in line with the three
Lord Darzi domains of quality and also in view of feedback from patients and internal
review of areas for development.
PATIENT SAFETY
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To reduce waiting times for patients from referral to 1st appointment in the
community to ensure they receive they receive the most appropriate care in a
timely manner as follows:
o Average Referral to 1st Community Outpatient appointment wait to be
less than 28 days. (Baseline - 2014/15 Average = 34 days)
o To support this 1st attempt to contact patient should be within 5 working
days of receipt of referral. (Baseline - 2014/15 Q4 Average = 8 days)
Reducing waiting times not only impacts on patient safety but also clinical
effectiveness. Research has found that increased waiting times have
correlated to increased risks for patients. Reducing waiting times supports
the reduction in risk and the progression of a patient’s illness and prevents
any clinical harm that could arise from untimely treatment. It also benefits
patient flow through the patient journey and supports patients getting the
appropriate care in an appropriate timeframe.
Furthermore, this can result in better outcomes for patients clinically with
reduced risk of complications as well as improving the patients’ experience
and overall wellbeing and quality of life.
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Evidence continuous learning and change in clinical practice arising from the
analysis of incidents, serious incidents and patient complaints.
Ensure all staff have received training in safeguarding and know how to
escalate any safeguarding concerns.
To ensure continued compliance against the WHO surgical checklist.
PATIENT EXPERIENCE
To implement learning and actions from our 2014-15 patient experience programme
feedback. Key actions include:
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To run a series of Patient & Carer Focus groups to identify areas for
improvement directly from both patients and their carers. This is to be done
for both community and for acute care/surgical patients following initial review
in the community.
To recruit additional female medical staff to work in the community.
To increase waiting room space for weekend clinics and Chase Farm Hospital
site.
Review surgery booking schedule to reduce patient and carer waits during
surgery days.
To improve FFT response rates and scores so that greater than 90% patients
state they would be ‘extremely likely’ or ‘likely’ to recommend the service to
their friends and family. (Baseline - 2014/15 Q1-2 = 74.3%)
Rollout of New Patient Experience Survey Tool – the service has recently
procured some patient experience software that allows surveys to be
undertaken on the day both in community clinics and surgical ward via tablet
and also patients will be able to complete the survey online. This is in
addition to our current patient experience programme where patients are
contacted via telephone for qualitative feedback. The software questions can
be tailored by the service and will be based on existing questions used plus
some additional new questions to be added following discussion and
agreement with commissioners. This will enhance the level of feedback we
get from patients and further allow us to make informed changes to improve
services for our patients.
CLINICAL EFFECTIVENESS
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Undertake a defined Clinical Audit for Cataract Surgery with Commissioners
for external review and report the outcomes and improvements to quality in an
Annual Report to the commissioner Clinical Quality Review Committee.
Ensure lead clinicians play an active role in clinical audit.
Increase diagnostic capability to improve the patient journey. –
Implementation of OCT scanning diagnostic service.
Ensure services are compliant with NICE guidelines.
Maintain compliance with CQC Essential Standards of Quality and Safety.
STAFF DEVELOPMENT
The Cataract Centre Ltd appreciates the importance of staff development and voice
in ensuring the continued delivery of a high quality service and care for our patients.
Staff are also instrumental in the service improvement process, thus it is essential
that we understand how our staff feel and any recommendations they may have. In
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view of this and following the changes in staffing structure in 2014-15, next year we
aim to undertake the following:
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Staff satisfaction survey.
Staff Development Day – with key sessions on team building, sharing best
practice, and ideas forum for staff to share ideas and agree goals for
quality/service improvement.
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STATEMENTS OF ASSURANCE
In line with NHS requirements, the following are a series of statements that all
providers must include in their quality account. In reflection of this The Cataract
Centre Ltd make the following statements of assurance:
REVIEW OF SERVICE
During 2014-15 The Cataract Centre provided Ophthalmology services to the NHS
through the agreed NHS Standard Acute Contract. It did not subcontract out any of
those services.
The Cataract Centre has reviewed all the data available to them on the quality of
care in all of these NHS services
The income generated by the NHS services reviewed in 2014-15 represents 100% of
the total income generated from the provision of NHS services by The Cataract
Centre Ltd for 2014-15.
PARTICIPATION IN CLINICAL AUDITS
During 2014/15 no national clinical audits or national confidential enquiry covered
NHS services that The Cataract Centre Ltd provides.
However, even though there were no national clinical audits directly relevant to the
service, The Cataract Centre Ltd plans to undertake a series of local audits in
2015/16 to identify areas and set actions for specific quality improvement.
PARTICIPATION IN CLINCIAL RESEARCH
The number of patients receiving NHS services provided by The Cataract Centre in
2014-15 that were recruited during that period to participate in research approved by
a research ethics committee was zero.
USE OF THE CQUIN PAYMENT FRAMEWORK
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The Cataract Centre LTD income in 2014-15 was conditional on achieving quality
improvement and innovation goals through the Commissioning for Quality and
Innovation payment framework. The Cataract Centre Ltd achieved CQUIN goals for
2014-15.
REGISTRATION WITH THE CARE QUALITY COMMISSION
The Cataract Centre Ltd is required to register with the Care Quality Commission
and is currently fully registered with no condition to provide the following services for
everyone:
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diagnostic and screening procedures
treatment of disease, disorder or injury,
surgical services
The Cataract Centre had an unannounced CQC inspection on 10th January 2014
and was found to be fully compliant against all inspected outcomes.
The Care Quality Commission has not taken enforcement action against The
Cataract Centre during 2014-15.
The Cataract Centre has not participated nor required to do so in any special reviews
or investigations by the CQC during the reporting period.
Dr Raymond Lobo is the registered manager for the provision of the above and also
the clinical director of the organisation.
DATA QUALITY
Statement on relevance of Data Quality and your actions to improve Data Quality
The Cataract Centre collates and tracks community patient data on a local system in
line with the data protection act and NHS information governance toolkit.
For all activity undertaken on behalf of The Royal Free Hospitals NHS Trust
(Formerly known as Barnet and Chase Farm Hospitals NHS Trust), our staff have
completed the Trust statutory and mandatory training to include information
governance. The service tracks and outcomes patient data using the Trust Cerner
PAS system, in line with the Trust information governance guidelines. All staff have
been suitably trained on all systems.
We will be taking the following actions to improve data quality:
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The Cataract Centre Ltd has implement and will continue to embed and develop the
enhanced patient administration database, which tracks patient referral status,
appointment history and outcomes.
PATIENT SAFETY INCIDENTS
The Cataract Centre has had no patient safety incidents in 2014-15. We
acknowledge this to our continued vigilance and continual focus on patient safety
underpinned by procedures relating to estate and equipment safety, effective patient
record keeping and information. .
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2014-15 – Overview of Performance against commissioned Quality KPIs
KPI No.
1
KPI
Patient’s waiting no longer than 4 weeks for an appointment
Threshold
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
<= 28 days
24
29
30
24
33
30
16
15
17
13
10
8
Comments
We have found this to cause some difficulty due to the elderly nature of the majority of
our patients, of which a large proportiong require a chaperone. As a result we see a
high level of reschedules and DNAs.
2
100% of patient’s who cannot be contacted with choice of
appointment automatically given an appointment within 5
working days of receipt of referral
Following commissioner 'Walk the Pathway' visit, and a discussion around this The CC
have shared letter templates for unable to contact and DNAs, which have been agreed
and are in use. This requests the patient to contact the service within a given timeframe,
otherwise they are discharged back to the care of their GP.
100%
We are also in the process of reviewing DNAs and how we can work with primary care
colleagues in reducing the occurance of this.
We aim to treat as many patients in the community as possible. Many patients elect to
continue further treatment or on-going management with other acute providers, for
which due to the right of patient choice we have limited control over.
3
90% of routine patients, referred via SCAS, assessed and
treated in the community service
90%
80.4%
78.5%
77.4%
77.3%
82.7%
76.8%
78.4%
81.1%
80.4%
82.3%
84.3%
79.1%
4
100% of routine referrals sent to the Enfield Referral Service
triaged within 3 working days
100%
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
5
100% of patients, where the community service is deemed to
be inappropriate for the patients needs, returned to the Enfield
Referral Service within 2 days of triage.
100%
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
6
Outcome of patient appointments (for 95% of patients)
communicated to the referring healthcare professional within 5
days
7
95% of provider performance reports produced to agreed
format within 10 working days following the end of each month
8
1st to Follow ratio capped to 1:1 ( Cumulative 2013/14)
9
Less than 10% of outpatients converting into a secondary care
referral
95%
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Action: There are a number of treatements currently undertaken in secondary care,
which we beleive can be undertaken in the community, with the added benefit of giving
commissioner substantial cost savings. These are currently being proposed to you and
are due for discussion.
This is largely the case. However as mentioned in previous correspndence we cannot
account for postal delays.
Action: We are currently scoping the possibility of emailing outcome letters to GP
practices, but this does have a number of logistical challenges and also would require
the buy in of GP practices. We will initially pilot this with a small cohort of practices
and assess the benefits. We will inform you of progress in due course.
We recognise and acknowledge the delays that the commisioners have experience in
receiving the activity report.
We have increased our adminitstrative resource and have made some investment into IT
reporting processes that will improve the turnaround of this. The addition of diagnosis
to the activity dataset is the key reason for delay. It is suggested that we review the
target in light of this.
<=1
0.85
0.75
0.71
0.68
0.69
0.65
0.64
0.64
0.67
0.68
0.69
0.71
< 10%
19.60%
21.50%
22.60%
22.70%
17.30%
23.20%
21.60%
18.90%
19.64%
17.66%
15.71%
20.90%
This is somewhat of a duplication of KPI.3, as those that are not seen and treated in the
community service are referred into secondary care.
Action : We propose to commissioners that we have one indicator.
10
11
12
13
90% of the patients rating the community service as good or
excellent.
90%
As per Q1&Q2 Patient Experience exercise : 79% rated the service as good
or excellent ( Excellent = 55%, Good = 24%)
93% rated Excellent to Satisfactory.
Q3 - Q4 patient experience exercise currently in progress
As our last CQC visit was almost a year ago, the service envisages a visit in the very
near future. In particular as it is now post merger with regards to our partner
organisation CFH, now Royal Free Hospitals NHS Foundation Trust. We will notify
commissioners of if and when the CQC undertake any review.
Provider to advise commsioners with details of any Care Quality
Commission (CQC) visit within 48 hours of notification.
Provider to send commsioners a copy of any Care Quality
Commission (CQC) inspection visit report within 48 hours of
publication.
Less than 5% of patients appointments cancelled by the
provider
(excludes patient cancellations and DNAs)
QUALITY ACCOUNT
We undertake patient experience survery as an on-going process throughout the year
but form them as part of bi-annual patient experience exercises, where we group finding
and develop action plans in responses to areas for development. We continue to make
service improvements to ultimately improve the quality of care we deliver and the
experience of our patients.
Reports are available via the CQC website. We will advise commissioners of when they
are published and provide copies and a link the electronic report accordingly.
It is extremely rare for the service to cancel appointments. We are aware that we have
not cancelled any appointments in the last two months. Going forward we will include
any cancelled appointments in our datasheet to allow for percentage calculations to be
shown.
5%
2013-14
STATEMENT FROM COMMISSIONERS - NHS Enfield Clinical Commissioning
Group
The Cataract Centre v3
NHS Enfield Clinical Commissioning Group (CCG) has reviewed the Quality Account for
2013/14 published by The Cataract Centre.
This statement has been reviewed by the chair of the CCG’s Quality and Safety Committee,
to whom its approval has been delegated by the committee, having in turn been delegated
the duty to review and endorse Quality Accounts by its Governing Body.
The Quality Account in general complies with governance as set out by both Monitor (for
NHS Foundation Trusts) and the Department of Health (to all other NHS trusts and
commissioned service providers).
Last year commissioners noted that not all priorities were focused on areas where deficient
performance required improvement. Nor was there specific alignment of priorities to the core
domains of quality; namely patient experience, patient safety and clinical effectiveness.
Commissioners are pleased to see that this feedback has been acknowledged this year,
which has contributed to the priorities demonstrating more in terms of outcomes and
meaning.
As regards the review of quality in 2014/15, commissioners acknowledge the positive benefit
to patient care from increased access to community services and our joint partnership
working in relation to records management and ongoing monitoring which is required to
ensure compliance.
Commissioners also note that the provider was compliant with standards required by the
Care Quality Commission having been subject to an unannounced inspection during the
year.
The CCG looks forward to continuing to work in partnership with the provider to monitor its
identified priorities and progress.
NHS Enfield Clinical Commissioning Group
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QUALITY ACCOUNT
17
2013-14
The Cataract Centre Ltd
134 Lots Road
Fulham
London
SW10 0RJ
Email: TheCataract.centre@nhs.net
Limited Company Registered in England & Wales Number: 03336479
CQC Registration Reference: 1-368009263
Director: Mr Richard Vaughan
CQC Registered Manager and Clinical Director: Dr Raymond Lobo
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QUALITY ACCOUNT
18
2013-14