previously nhs north east essex pct provider services (neeps) quality account 2010 - 2011 · 2011....

Anglian Community Enterprise(Community Interest Company)previously NHS North East Essex PCT Provider Services (NEEPS)

Quality Account 2010 - 2011

From 1st January 2011 North East Essex Provider Services (NEEPS) became Anglian Community Enterprise (ACE) Community Interest Company hereafter referred to as ACE. This change occurred as a result of the requirement for North East Essex PCT to divest itself of its Provider arm. ACE is a provider of NHS community services and also provides Learning Disabilities Therapy and some Specialist Nursing. At present our services are mainly provided to the population of North East Essex, with some Learning Disability services provided across North Essex. In the same way as a private company, ACE is controlled by the appointed Board Members and its shareholders. However, in addition, the Directors and Shareholders are responsible for ensuring that the company is run in such a way that it will continue to satisfy the Community Interest Test. The Management team runs the organisation on a day-to-day basis, and the board ensures that through systems of oversight, constructive challenge and stewardship that management delivers on its strategy and complies with proper standards of conduct Contact details for ACE: Anglian Community Enterprise (ACE) Community Interest Company Kennedy House Kennedy Way Clacton on Sea Essex CO15 4AB Tel: 01255 206060

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Contents

Part 1 Statement from Anglian Community Enterprise

Managing Director

Statement from Anglian Community Enterprise Chairman

Review of Services

Part 2 Priorities for Quality Improvement 2011-12

National Mandatory Audits

Participation in Clinical Audit Participation in Clinical Research Goals Agreed with Commissioners Care Quality Commission Data Quality

Part 3

Feedback on the 2009/10 Quality Account

Priorities for Quality Improvement for 2010-11

How we performed?

Patient Safety – Priority 1 Patient Safety – Priority 2

Clinical Effectiveness – Priority 3 Clinical Effectiveness – Priority 4 Patient Experience – Priority 5 Patient Experience – Priority 6 Capturing Quality – Priority 7

Review of Quality Performance

Annual Patient Experience Survey Compliments and Complaints Clinical Audits Hand Hygiene and Essential Steps Incidents

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Recognising and Rewarding Quality Stakeholder Engagement Supporting Statements

NHS NEE Commissioning PCT Essex & Southend Local Involvement Network Essex Health Overview & Scrutiny Committee

Appendices Appendix 1. Participation in Local Clinical Audit Appendix 2. Essential Standards Monitoring Appendix 3. Action Plan for CQC Report Appendix 4. Strategic Objectives 2010-15 Appendix 5. MUST Assessment Tool Appendix 6. EQ5D Health Questionnaire Appendix 7. Monitoring Clinical Outcomes Glossary of Terms Acknowledgements Notes

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Part 1

Statement from Anglian Community Enterprise (ACE) Community Interest Company Managing Director.

I am pleased to present Anglian Community Enterprise’s (ACE) Quality Account for the period 2010-11 which gives us the opportunity to look back and reflect on the quality of our services during 2010-11 and to set out our priorities for quality improvements for 2011-12. First and foremost this Quality Account is written and provided to the population we serve and has been influenced by the outcomes of our 2010-11 Annual Patient Experience Survey, discussions with staff, and a review of the many indicators of quality we measure as a matter of routine. We have continued to build on communication and engagement with Health Overview and Scrutiny Committee and Local Involvement Network colleagues so that we can better understand the communities we serve and to form lasting partnerships to improve patient and carer experience. During 2010-11, we have been through transition from North East Essex Provider Services to the launch of Anglian Community Enterprise on 1 January 2011. During this transition period we have continued to focus on Transforming Community Services in partnership with staff to design improved ways of working and service delivery that will enable us to have a greater impact on the health and wellbeing of the patients and local communities. As a Social Enterprise we have greater freedom to innovate, identify efficiencies and improve productivity. Members of staff are shareholders in the organisation and have an increased community focus. These key areas are supported by our vision:

To be the leader in the communities that we serve, providing

innovation, quality, and value for money as we deliver community healthcare services that are accessible to all.

I write on behalf of ACE’s Senior Executive Team to pledge our continued commitment to strive for high quality, safe and effective care and to confirm that the content of this report is an accurate account.

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Lynne Woodcock Managing Director Anglian Community Enterprise (Community Interest Company) previously North East Essex Provider Services (NEEPS) May 2011

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Statement from Anglian Community Enterprise (ACE) Community Interest Company Chairman.

Our 2010/11 Quality Account reflects the results and ambitions of our past year’s achievement as reflected by both our stakeholders and internal measurements. We continue to consult and engage with staff, patients and community groups to ensure we strive for our right first time and continuous improvement ethos which remains at the heart of our responsibility to deliver a quality service. The board continues to take every opportunity to engage via staff and patient forums as well as safety and quality walkabouts to meet with front line clinicians and users of our services to augment and improve upon our patient experience. The past year has seen the conclusion of our journey towards separation from the Primary Healthcare Trust as a standalone Social Enterprise. Our new found status as Anglian Community Enterprise CIC and the opportunities presented by the freedoms to expand our influence and service to commissioners are reflected in our approach and transformational plans for the coming year.

Quality continues to be our benchmark for success within our overall responsibilities. The past achievements of the organisation combined with

the opportunity to transform community services provide confidence that our enterprise is well able to deliver its vision for the future.

Richard Kearton, Chairman Anglian Community Enterprise (CIC) May 2011

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Review of Services

During 2010/11 ACE (previously NEEPS) provided 50 + 5 Learning Disability NHS services. ACE (previously NEEPS) has reviewed all the data available to them on the quality of care in all of these NHS services. In addition to reports on quality received, the Executive and Non-Executive Team are committed to ensuring the delivery of high quality and safe care. We have participated in patient safety walkabouts in accordance with National Patient Safety Agency guidance and have taken other opportunities to meet with front line clinicians and users of our services. The income generated by the NHS services reviewed in 2010/11 represents 95% of the total income generated from the provision of NHS services by ACE/NEEPS for 2010/11.

Part 2

Priorities for Quality Improvement 2011-12 During 2011-12 ACE has identified the following priorities for quality improvement. The ACE Clinical Audit Programme will link to the Quality Account priorities (Clinical Effectiveness, Patient Experience and Patient Safety Darzi 2008 & 2009) and to the ACE Strategic Objectives (Appendix 4) to ensure full monitoring and management of these key areas. They have been determined in a number of ways: as the top 3 reported patient safety incident types; through the annual patient survey and other local indicators and through national imperatives. The sub priorities e.g. 'How to raise a concern’ are also related to issues identified within Department of Health guidance and requirements. Each of the 3 domains of safety will have a minimum of 3 priorities; where appropriate we will carry out at least one audit against each of these 3 priorities. ACE will also continue to advise and promote that all services aspire to undertake at an audit of their choice on an annual basis.

Progress on these priorities will be reported in a number of ways utilising the ACE website, through publishing reports, both internally to staff and the ACE board; externally to our patients and other stakeholders and to the commissioners of our services.

1. Patient Safety Priority 1 - Slips, trips and falls Audit 1 – Falls Audit (Ward based)

Audit 2 – NICE Audit Assessment and Prevention of Falls in Older people

(CG21)

Priority 2 - Pressure ulcers Audit 3 – NICE Pressure Ulcer Management and Prevention (CG29)

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Priority 3 – Patient Information and Governance Audit 4 – Record Keeping

Audit 5 - Administration of Insulin (NEE13)

Audit 6 – Medicines Policy (NEE23)

In addition during 2011/12 ACE will also be implementing the DATIX software for Patient Safety system. This will allow us to disseminate communications form the Department of Health’s Central Alerting system (CAS), the Medicines and Healthcare Products Regulatory Agency (MHRA) and the National Patient Safety Agency (NPSA). It will allow us to broadcast information about medical devices and other healthcare safety issues, automatically recording responses and formulating action plans. We shall also be auditing 2 Patient Safety Alerts in 2011/12. These have yet to be decided.

2. Patient Experience Priority 4 - How to raise a concern The Annual Patient Survey acts as a useful audit tool to measure the effectiveness of our complaints handling service and identify if we need to do more to assist patients, families and the public to raise concerns they may have about the services we deliver. This years survey has identified that more emphasis may be required to ensure our patients, families and the public are aware of where and who they should approach to discuss their concerns with. Data is collected throughout the year and this is used to identify trends. Quarterly reports are produced and action plans are put in place and monitored to address those key trends. Outcomes from the action plans are shared across the organisation with the aim of ‘learning from patient experience’. Assistance to members of the public is offered by: ACE literature (posters and leaflets) is available within all ACE service areas

and highlights how to raise a concern. Spring 2011 – We have added additional resources to the existing Complaints

team to receive and act on comments and concerns received from patients, carers and their families.

We will be raising awareness of the outcome of the survey with front line staff and provide additional training and education to encourage them to handle concerns locally wherever possible.

Priority 5 - Cleanliness Audit 7– Hand Hygiene Audits for Community Hospitals (monthly)

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Audit 8 – Essential Steps – Preventing the Spread of infection (monthly all areas except Community Hospitals)

Audit 9 - Environmental Infection Control Audit (yearly for all service areas)

Priority 6 – Improving Communications Audit 10 – Annual Patient Experience Survey

Audit 11 - Patient Opportunistic Surveys

Audit 12 - LD Annual Survey

3. Clinical Effectiveness

Priority 7 – Discharge from Hospital

Audit 13 – Policy Audit – Audit of Discharge Policy (Community Hospitals) NE266

Priority 8 – Improving Participation in Clinical Audit It is acknowledged that it is not only important to improve participation, but also to ensure that any recommendations made following an audit are carried out and follow-up audits can demonstrate how effective the changes were. This would then complete the audit cycle. ACE will aspire to complete 100% of audits, where appropriate, within 3 months of the stated end date. It will have sub-objectives.

Audit 14 – Audit of the Clinical Audit Policy (see below)

Once a clinical audit is complete and the action plan is implemented the lead of the clinical audit project completes an outcomes form (appendix 7). This enables the team to report how the audit report/results are disseminated to patients, staff and others. The Clinical Audit Strategy is currently under review and will evolve into a new Clinical Audit Policy. The policy will provide further clarity around feedback to patients/public.

Priority 9 – Patient Reported Outcome Measures (PROMS) Audit 15 – PROMS pilot to include Continence, Prolotherapy & Podiatry

Audit 16 - End of life audits – Palliative Care Quality Toolkit

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National Mandatory Audits These are ‘must do’ audits mandatory to each organisation. HQIP to confirm audit programme for 2011/12 although it is likely to include:

National Diabetes Audit

National Audit of Falls and Bone Health Participation in clinical audit 2010-11 During April 2010 to March 2011, 4 national clinical audits covered NHS services that Anglian Community Enterprise provides. There were no applicable national confidential enquiries. During that period Anglian Community Enterprise participated in 100% of national clinical audits and they are as follows:

National Audit of Continence Care National Audit of Falls & Bone Health National Diabetes Audit (NDA) Diabetes E Questionnaire

The national clinical audits and national confidential enquiries that ACE participated in, and for which data collection was completed during 2010-2011, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

Title of National Clinical Audit No of cases required for audit

No of cases submitted for audit

Reasons for non submission of cases

National Audit of Continence Care- Royal College of Physicians (RCP).

Patients with urinary incontinence- 50 Patients with bowel incontinence- 50

100% (50) 0% (0)

Not submitted as the organisation did not have patients which fulfil the sample requirements, RCP notified.

National Audit of Falls and Bone Health (RCP)

The report of 1 national clinical audit was reviewed by the provider in 2010-2011 and Anglian Community Enterprise (ACE) intends to take the following actions to improve the quality of healthcare provided:

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National Audit of Continence Care- Royal College of Physicians (RCP). Recommendations Actions Men with bladder (and/or bowel) incontinence should have a Digital Rectal Examination (DRE) (with their consent) as a basic part of assessment. Healthcare professionals should ensure that they are competent to perform Digital Rectal Examination. Those responsible for services should ensure that there are practitioners who are appropriately skilled to perform the examination and that training is provided to all non-specialist clinicians engaged in assessment of patients with urinary (and faecal incontinence.)

Discussions with team. Plan to offer Digital Rectal Examination (DRE) as part of assessment for men over 50 years old. Release of half day per week Whole Time Equivalent band 6 Digital Rectal Examination trained and experienced staff to provide this and also offer flow test at home when thought appropriate.

Use of scoring for functional ability/ cognitive ability

Discussions with team as to usefulness of scores and which system would be appropriate

Use National Occupational standards to guide training and competency for continenence team members

Discussions with team and look at training and competency documents to see how standards can be incorporated

User Group to advise, comment etc on service

Discussions with users, staff. Possibly arrange meeting for stakeholders

The reports of 66 local clinical audits were reviewed in 2010-2011 and ACE intends to take a number of actions to improve the quality of healthcare provided. These are detailed at Appendix 1. Participation in clinical research Whilst ACE does not have dedicated research resources it is supportive of clinical research and will participate and assist with any proposals as far as possible. Goals agreed with commissioners A proportion of North East Essex Provider Services income in 20010/11 was conditional on achieving quality improvement and innovation goals agreed between North East Essex Provider Services (ACE) and NHS North East Essex Commissioners through the Commissioning for Quality and Innovation (CQUIN) payment framework. Greater detail on the CQUIN’s can be found online on the following link: http://www.institute.nhs.uk/images/documents/wcc/PCT%20portal/CQUIN%20schemes/North%20East%20Essex%20Provider%20Services%20Scheme.doc

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http://www.institute.nhs.uk/images/documents/wcc/PCT%20portal/CQUIN%20schemes/North%20East%20Essex%20Provider%20Services%20Scheme.doc

http://www.institute.nhs.uk/images/documents/wcc/PCT%20portal/CQUIN%20schemes/North%20East%20Essex%20Provider%20Services%20Scheme.doc

Further details of the agreed goals for 2010/11 and for the following 12 month period are available on request from: Tanya Matilainen, Director of Governance Anglian Community Enterprise (Community Interest Company) Kennedy House Kennedy Way Clacton on Sea CO15 4AB Care Quality Commission (CQC) ACE is required to register with the Care Quality Commission (CQC) and its current registration status is full registration without conditions. Last year upon registration - because of information gathered via the Quality Risk Profile - NEEPS had conditions imposed against its registration. Action plans were drawn up to show full monitoring of these conditions and ACE has made progress by 31st March 2011 in taking such action. Details on this progress can be found in the action plan at appendix 3. ACE has not participated in any special reviews or investigations by the CQC during the reporting period. The Quality Risk Profile (QRP) is an essential tool that the Care Quality Commission (CQC) compile on an annual basis for gathering together key information about healthcare providers to support how they monitor our compliance with the Essential Standards of Quality and Safety. The QRP enables CQC compliance inspectors to assess where risks lie and could prompt front line regulatory activity, such as further enquiries. QRPs are also an important tool to support continuous monitoring of compliance, by ensuring that everyone is working from the same information, and to improve how care is provided and commissioned. Our QRP should be used to support how we quality internally, by identifying areas of lower than average performance and taking action to address them where necessary. The QRP combines both quantitative (numerical) and qualitative (textual) information. Most quantitative data comes from existing nationally-held data sets from:- • The Information Centre for Health & Social Care. • The Department of Health. • Medical royal colleges. • Other organisations with an interest in healthcare. • National assessments carried out by CQC (e.g. patient surveys, reviews and studies). Qualitative information can come from a variety of sources including:- • Engagement activities by local CQC staff with providers and stakeholders. • Information from providers. • Information from people who use the services. • Our inspection reports, for example, findings from monitoring compliance with regulation on cleanliness and infection control. The QRP is produced using information from people who use services. Sources include:- • Information from user representative bodies such as. Local Involvement Networks (LINks)

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• Information from statutory bodies, such as foundation trust boards of governors and overview and scrutiny committees. • Information from people’s feedback on NHS Choices and Patient Opinion. • Findings from the national NHS patient survey programme, for example, inpatient survey, outpatient survey. QRPs focus on the 16 essential standards that most closely relate to quality and safety being Respecting and involving people who use the services; Consent to care and treatment; Care and welfare of people who services; Meeting nutritional needs; Co-operating with other service providers; Safeguarding people who use the services from abuse; Cleanliness and infection control; Management of medicines; Safety and suitability of premises; Safety, availability and suitability of equipment; Requirements relating to workers; Staffing; Supporting workers; Assessing and monitoring the quality of service provision; Complaints; Records. It should be noted that the information contained within the QRP is for guidance for organisations only as the data may relate to their pre-merger organisations. Plus there may be more than one instance of the same measure (item), as it was measured in all predecessor organisations. Within North East Essex Provider Services our QRP is mainly 'similar to expected' - 66%. 23% falls within the 'better than expected' margin and 11% falls within the 'worse than expected' margin. Action plans have been developed against all items within the QRP that were recorded as being 'worse than expected' and these will be monitored at our IGC.

QRP Score % Numbers Much better than expected 13.83% 39 Positive comment 1.06% 3 Tending towards better than expected 9.22% 26 Similar to expected 65.60% 185 No information 0.35% 1 Tending towards worse than expected 4.61% 13 Much worse than expected 3.55% 10 Negative comment 1.77% 5 Grand Total 100% 282

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NEEPS Quality Risk Profile - Scoring by Percentage (against a total of 282 items of information)

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Data Quality The Integrated Governance (IG) Toolkit is an online system which allows NHS organisations and partners to assess themselves against Department of Health Information Governance policies and standards. It also allows members of the public to view participating organisations' IG Toolkit assessments. It is a requirement of Clinical Information Assurance that procedures are in place to ensure the accuracy of service user information on all systems and/or records that support the provision of care. Given that ACE (CIC) is a new organisation we have received special dispensation from Connecting for Health as it has been recognised that we would not have been in a realistic position to meet all level two requirements of the toolkit in such a short space of time. ACE is therefore now expected to attain this level by July 2011 and is working to this deadline. Many of the changes in version 8 of the toolkit have meant a number of Trusts have failed this year’s submission primarily because they have been unable to provide the evidence to support compliance; this has also been an issue for ACE (CIC). ACE will be taking the following actions to improve data quality. Error reports are to be produced and made available to Heads of Service and Assistant Directors to review. Training is linked in with the reporting to ensure where errors are identified training is given accordingly. ACE holds a Data Quality Policy which is available to all staff on the intranet. Currently the IG department are working with Heads of Service and the Essex Shared Service Agency to review the informatics requirements to ensure that quality at all levels is addressed. Monitoring of compliance of the use of the NHS Number as the prime default patient identifier is carried out in the annual Record Keeping Audit. This is a requirement of the Patient Identification Policy (NEE83)

Results (based on requirements version 8 )

Overall Results 50% (RED)

Initiative Results (based on requirements version 7 )

Clinical Information Assurance 55% (RED)

Confidentiality and Data Protection Assurance

50% (RED)

Corporate Information Assurance Not Categorised for 2011/12

Information Governance Management

60% (RED)

Information Security Assurance 46% (RED)

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Overall ACE’s Information Governance Assurance Report score for 2010/11 was 50% and was graded Red with the caveats previously mentioned. ACE (previously NEEPS) did not submit records during 2010/11 to the Secondary Uses Service for the inclusion in the Hospital Episode Statistics which are included in the latest published data.

ACE (previously NEEPS) were not subject to the Payments by Results clinical coding audit during 2010/11 by the Audit Commission.

Part 3

Feedback on the 2009/10 Quality Account

The following comments were provided by the Health Overview and Scrutiny Committee with a view to improving future quality accounts. Their original comment is made in black with the action ACE has taken/will take in blue. General comments

• An introduction and explanation of the services NEEPS provide is needed Brief detail of services provided contained within introduction and expanded within the glossary of terms

• Clinical terms should also be included in the Glossary

This year we have included an enlarged glossary of terms.

• The Quality Account should provide contact details on the front page We have included this for 2010/11

• Quality Account overall is long and complex – It could be written in a more

accessible way also a summary with appendices might be considered in order to improve the usefulness of the report for the public in future This year we have attempted to write the account in a more-simplified, easier-to-read way, with limited use of jargon which we hope will improve its readability and usefulness. The Glossary of Terms has also been expanded.

Specific comments, questions and/or suggestions for improvement Part 1: Priorities for Quality Improvement 2010-11 Priority 1

• Information on the target, how the trust will measure, monitor and report on progress needs to be made clearer and accessible to the community Environmental audits are carried out annually by the Infection Prevention and Control Team, this requires the area manager to complete an action plan to address any issues that are identified in terms of cleaning; in addition our cleaning contractors carry out weekly audits. Each of the clinical areas has cleaning schedules in line with The National Standards of cleanliness for the NHS.This is reported to the ACE Infection Prevention and Control Committee.

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With regard to Methicillin Resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile (C Diff) our ceiling for 2009/10 is: • MRSA bacteraemia (bloodstream infection) 4 for the North East Essex community, this target is not broken down specifically for North East Essex Provider Services • The ceiling for Clostridium Difficile is 55 for the North East Essex community, a ceiling has not been set specifically for our 2 Community Hospitals How will we measure and monitor? The data for MRSA bacteraemia and Clostridium Difficile is updated daily for the whole of the North East Essex. The Anglian Community Enterprise Infection Prevention & Control Team monitor the daily microbiology list. How will we report on progress? Monthly reports are provided to the service managers and to our Governance and Risk Committee. In addition, we will report on a monthly basis to our commissioners and also at the quarterly Infection Control Committee.

• Need to be defined MRSA and C-Difficile, health economy, acute and non-

acute settings Definitions for each can be found within the Glossary of Terms

Priority 2

• A sample care plan to ensure in-patients from being malnourished could be appended for the public to see. A MUST assessment sheet is included at Appendix 4.

Priority 3

• A sample questionnaire could be appended to the Quality Account. The EQ5d Questionnaire is included at Appendix 5

• Clinical terms not defined enough

An updated and enlarged glossary of terms has been included this year to include commonly used clinical terms

• How often progress will be reported to the Integrated Governance

Committee? The Integrated Governance Committee has now been reconstituted into the Governance and Risk Committee and meets bi-monthly with progress being reported at each meeting

• What representation is there within the Integrated Governance Committee in

terms of race, disability, age, sex, faith etc? Whilst ACE is an Equal Opportunities employer representation at each meeting is focussed towards individuals undertaking specific professional roles irrespective of race, disability, age, sex, faith etc. However should there be the need to discuss elements likely to need particular expertise or input on any of the above than this will be taken into account when looking for an appropriate member of staff.

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Priority 4

• The term ‘Dementia Diversion tool’ needs to be defined The Tiptree Box is a toolkit originally designed for staff in acute hospital wards, which was felt to be of use for patients residing on community hospital wards. It has been developed to provide distraction therapy for patients with dementia. It is named after the ward in Colchester Hospital University Foundation Trust (CHUFT) where it was conceived.

• How will ‘incidents relating to patients with dementia etc’ will be monitored?

An indicator has been established on DATIX to enable us to capture which patient incidents relate to those who are suffering from ‘cognitive impairment (CI)’. The first full quarter data will not be available until the end of May 2011 This will be used to highlight the trends showing the relationship between those patients who have CI and those who do not in terms of %. This historic information will be report on a quarterly basis to Ward Sisters.

• A sample survey to capture the views of patients, carers and visitors would

have been useful. These are the 5 core questions that are used across all service areas for all service users for the opportunistic surveys - these questions have been agreed with our commissioners:-

• How satisfied are you with the service you have received? • What do you think of the information given to you? • How satisfied are you with the attitude of our staff? • Were you given enough privacy when discussing your condition or

treatment? • Were you involved in decisions about your treatment and care?

• How often will progress be reported to the Integrated Governance

Committee? Bi-monthly reports to the Governance and Risk Committee

Priority 5

• More information needed on how the Trust will capture patient experience and monitor complaints and specific plans to increase user satisfaction Patient experience survey results will be co-ordinated into statistical data arising from complaints, concerns, compliments and feedback from other sources. Action plans are put in place and monitored for all complaints and most concerns. We have 18 months of data showing work undertaken to improve service delivery on the wards and elsewhere in the organisation. This coming year, we will focus on ‘auditing’ that the measures have resulted in actual improvements. This work will be tied in with the other monitoring we currently undertake in reviewing action plans in respect of Rapid Response(RR) /Alerts, incidents/claims and Serious Incidents (SI’s).

Priority 6

• What is the objective of the carers’ assessment? The objective of the carers’ assessments is to raise awareness of the financial and practical support and advice that is can be made available to (in this case) adult carers.

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`The CQUIN relating to carers has been very successful – with over 600 (out of 10000 letters sent for period up to 1 Dec 10) carers (not previously known) being identified and offered carer assessments by Essex County Council. A further 5000 letters have been sent since 1/12/10.

Priority 7 • Needs an indication of timescales and examples of measurable indicators

During 2010 the organisation developed a Quality Dashboard that displays quality performance indicators. This dashboard is reported at Board level and will evolve further during 2011 to fully capture all areas of the quality spectrum within ACE.

Priorities for Quality Improvements 2010/11 How we performed?

The following section details progress made on the 7 priorities identified in 2009/10. Future monitoring and assurance will be maintained through a range of tools such as clinical audits either national or local; reports to standing committees or groups or as part of the general admission/treatment process. In some cases they have been identified as continuing priorities for 2011/12.

Patient Safety

We will ensure that when patients need our services they receive the safest possible care

Priority 1 Standards of Cleanliness Environmental audits were carried out annually by the infection prevention and control team, this required the area manager to complete an action plan to address any issue that were identified in terms of cleaning; in addition our cleaning contractors carried out weekly audits. Each of the clinical areas had cleaning schedules in line with The National Standards of cleanliness for the NHS. This was reported to our infection prevention and control committee.

With regard to Methicillin Resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile (C Diff) our ceiling for 2009/10 was:

• MRSA bacteraemia (bloodstream infection) 4 for the North East Essex community, this target was not broken down specifically for North East Essex Provider Services

• The ceiling for Clostridium Difficile was 55 for the North East Essex

community, a ceiling was not set specifically for our 2 community hospitals

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How will we measure and monitor? The data for MRSA bacteraemia and Clostridium Difficile is updated daily for the whole of the North East Essex. ACE Infection Prevention & Control team monitor the daily microbiology list. How will we report on progress? Monthly reports are provided to the service managers and to our Integrated Governance Committee. In addition, we will report on a monthly basis to our commissioners and also at the quarterly infection control committee. Priority 2 Assessing the risk of malnutrition in the community hospital setting Outcomes

• Clacton and Harwich Community Hospitals uphold the NICE Clinical Guideline 32 ‘Nutrition support in adults’.

• Nutritional screening using Malnutrition Universal Screening Tool (‘MUST’) is

undertaken on patient’s admission to a community hospital ward, at regular intervals during their stay and on discharge

• Nutrition support is considered in patients who are malnourished or at risk of

malnutrition. Nutritional care plans have been developed and are used.

• The community hospital wards currently have access to registered dietician who is skilled and trained in nutritional requirements and different methods of nutrition support

• Patients who require nutritional support are monitored

• All healthcare professionals who are directly involved in patient care receive

education and training on the importance of providing adequate nutrition.

• MUST scores and action taken is recorded on a spread sheet by ward clerks.

How we will measure and monitor? • By continuing to record that MUST is carried out on patient’s admission and

discharge and appropriate action is taken. How we will report on progress? Assessing the risk of malnutrition in the community hospital setting was identified as a CQUIN for NEEPS for 2010/11 and we have been monitoring our progress on a monthly basis as follows:-

• ALL admissions to our community hospitals must have a MUST (malnutrition universal screening tool) assessment

• ALL patients with a MUST score equal to 1 must be monitored and all patients with a MUST score over 1 must have a nutritional plan

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• ALL patients discharged from our community hospitals must have a MUST assessment

We achieved compliance with these measures for 2010/11 as demonstrated below:-

We also used this information to monitor any change of MUST score during the patient's stay in their community hospital so that we could demonstrate scores that had remained stable and scores that had improved:-

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As the year progressed we saw a gradual increase in MUST score improvements compared to MUST scores declining. Finally, we ensured that when patients were discharged they were either informed about nutrition if their MUST score was still 1 or above or they were referred to a dietician if their MUST score was 3 or above:-

For 2011/12 this monitoring will continue but it will become a standard KPI as opposed to a CQUIN.

Clinical Effectiveness

We will ensure that the care and treatment that we give is based on evidence in order to provide the most effective care possible.

Priority 3 Patient Reported Outcome Measures (PROMs)

PROMs are measures of a patient’s health status or health-related quality of life. They are typically short, self-completed patient questionnaires which measure the patients’ health status or health related quality of life at a single point in time. This is measured at the beginning of their episode of care and at an agreed time following their end of care. PROMs remains important to ACE in ensuring that we measure quality as assessed by patients themselves, allowing us to measure effectiveness of care from the patient’s perspective.

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Throughout 2011/12 we will continue to introduce PROMs across our services in order to ensure that patients views of how they feel about the effectiveness of treatment are gathered along side what the clinician measures. Our aim is to align PROMs with patient experience questionnaires gaining a greater consolidated view of the patient’s perspective which will enable us to respond more effectively. How we will measure and monitor PROMs will be measured using agreed service specific patient questionnaires as part of a pilot programme. These results will be accessible to clinicians on a daily basis and will provide ACE with valuable information on the efficacy of treatment. Once combined with the patient experience questionnaires PROMs will be measured and monitored more routinely across service areas. How we will report on progress PROMs information is reported bi-monthly to the Clinical Effectiveness Group at an operational level and the Governance and Risk Committee for assurance against the project delivery. In addition, a quarterly report to the commissioners will be produced as part of our contract monitoring arrangements.

Outcomes A PROMs Pilot was undertaken at Clacton and Harwich Community Hospitals in May 2010. A report was completed in August 2010 and the following outcomes were achieved:

• 85% of patients felt an improvement in their health status following their episode of care within the Community Hospitals.

• The EQ5d (sample at appendix 5) was a suitable questionnaire to be used in the Community Hospital setting.

• A greater understanding was required by staff of the processes involved in obtaining the PROMs data. This outcome would be on hold until the PROMs Project across other service areas had been completed.

An overall positive outcome was achieved by the pilot but a clear benchmark of best practice will be established for follow up PROMs to support more effective measurement of these outcomes. The PROMs Project due to be underway in December 2010 has been delayed due to unforeseen IT constraints. These have been addressed and the project will commence in March 2011. The outcomes from the project will be reported in July 2011. The PROMs Pilot will be conducted over a 3 month timeframe using agreed service specific questionnaires; these will be monitored by an IT model which will support analysis of the results. These results will be accessible to clinicians on a daily basis and will provide ACE with a patient mandate for the development of services. NICE Quality Standards NICE Quality Standards are independent standards that clarify what high quality care looks like in relation to the 3 dimensions of quality:

24

• Clinical Effectiveness • Patient Safety • Patient experience ACE will use the NICE Quality Standards to support benchmarking of current performance against evidence based measures of best practice and to identify priorities for improvement. How we will measure and monitor ACE undertake baseline reviews of all published NICE Quality Standards, assessing the results and establishing action plans where appropriate. ACE will work with partners and providers to ensure best practice and continuity of service provision in line with care pathways. As further NICE Quality Standards are developed and published ACE will agree on how the quality measures outlined within the standards will be used as potential quality indicators for measuring quality in line with the NHS Outcomes Framework 2011/12.

How we will report on progress NICE guidance and NICE Quality Standards are reported bi-monthly to the Clinical Effectiveness Group at an operational level and the Governance and Risk Committee for assurance on compliance and any exceptions or areas to consider for improvement. In addition a quarterly report to the commissioners is produced as part of our contract monitoring arrangements.

Priority 4 Improved care for people with confusion and dementia Progress during 2010/11 Bespoke training was commissioned and delivered by Essex University in collaboration with NEEPT (Previously MHPT). This was made available to all ACE staff and received good attendance from across community hospital and community services. Plans are now in development to repeat training or cascade and to provide further bespoke 'situational' training i.e. specific for service needs. The community ward sisters are developing a project to review the methodology for dependency scoring for patients with confusion and dementia which includes the development of an integrated care pathway, risk assessments and procedures for effective and safe in patient management. How we will measure and monitor

Uptake of training - register of attendance more detailed incident reporting regarding the identification of patients with

dementia and confusion experiencing incidents and complaints - use 2011 as baseline for improvement thereafter

Implementation of ICP and procedural documents Reviewed and updated discharge processes for patients with dementia and

confusion

25

How we will report on progress

Monthly update on progress will be provided via the community hospitals QIPP meetings.

Patient Experience We aim to ensure everyone who needs our care and their relatives

and carers consistently have the best possible experience.

Priority 5 Improved Communications During 2010/11 we successfully set up an 'Information and Involvement' working group to help us demonstrate compliance with the Care Quality Commission, who are one of our main regulatory bodies. This group meets bi-monthly and is accountable to our Governance and Risk Committee. The aim of this group is to ensure that we respect and involve people who use our services and make sure that the information that is available to them will enable them to make informed choices about their care, treatment and support. This group also aims to ensure that people who use our services - or those acting on their behalf - are sufficiently involved in making decisions about their care, treatment and support. This group also has representatives from our local LINKs attending. We also have a 'Suitability of Staffing' working group that meets on a bi-monthly basis that is also accountable to our Governance and Risk Committee. The aim of this group is to ensure that staff have the right skills, qualifications, experience and knowledge to enable them to support all service users. How we will measure and monitor By feedback from LINKs representatives and through the introduction of hand-held survey devices which allow for real-time reporting across a wide selection of services. This will allow for a prompt response to the issues/observations/comments which the public are identifying. How we will report on progress Reports on progress and status for both of these groups are part of our standard Governance and Risk Committee agenda and will continue to be so for 2011/12.

Priority 6 Supporting carers and improving carer experience

Since April 2010, all patients have been asked if they have any caring responsibilities or if they have someone caring for them on an informal basis. We have adapted our methods of engaging with potential carers. Using both face to face and postal methods to identify and offer support to those caring for others. A leaflet, produced in partnership with Essex County Council detailing the support available for carers is available to all patients.

26

Excellent progress has been made. To date, more than 10% of all the patients we have contacted have identified themselves as 'informal' carers. Essex County Council have advised us that; as a result of the activity we have undertaken, they have been contacted by over 600 carers who had not been identified as carers previously. There is further potential to identify more carers over time. It is estimated that, up to 10% of the population are providing informal care - in North East Essex, this figure could be as high as 35,000. We are continuing to work with our partners in support of Carers. NHS North East Essex has recently established a Joint Carers Task Team. The aim of the team is to identify and resolve whole economy issues concerning carers and to improve communication between organisations.

How we will measure and monitor ACE is a partner in this initiative and the measurement and monitoring is the responsibility of Essex County Council. How we will report on progress As ACE is a partner in this initiative it has still to be decided as to how progress will be reported. Priority 7 Capturing Quality During 2010/11 we devised a quality dashboard that has a suite of quality indicators from Infection Control, Patient Experience, Patient Harm and Safeguarding that is reported to our Board (copy attached). During 2011/12 this information will be enhanced further to incorporate trends and action plans. Review of Quality Performance Anglian Community Enterprise (CIC) is a community health service provider and currently delivers services across 3 ‘divisions’ or departments:

1. Community Services i.e. District Nurses, Intermediate Care Teams, Community Matrons, Community Rehabilitation and other health care professionals working out in the community in patients homes or within clinics.

2. Childrens and Health & Wellbeing Services i.e. Health Visitors, School

Nurses, Health Trainers and Health Promotion Services i.e. smoking cessation and breast feeding.

3. Specialist Services i.e. Specialist clinical teams such as respiratory, diabetes

and heart failure services, dental services, retinal screening, 2 General Practices and 2 community hospitals.

During 2010/11 we will be developing and implementing an enhanced set of core quality indicators that are applicable to all service areas together with service specific indicators for future quality monitoring.

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Annual Patient Experience Survey On an annual basis ACE runs a paper-based annual survey which targets 5% of the population across all our service lines. This survey has 30 questions structured around specific themes which are - the environment; the staff; communication and information; and overall. Service users are given several months to respond to this question enabling them to give a considered response to how well we are doing. This annual survey is complemented throughout the year by discharge surveys and opportunistic surveys which are carried out across various service lines as appropriate. These surveys differ in their nature as they are 'short and snappy' and are designed to capture more of an 'on the spot' reaction of our service users. During 2010 the organisation undertook a project that targeted 35 service lines with paper-based opportunistic surveys. These surveys consisted of 5 core questions (as above) plus some additional service-specific questions where relevant and did not total more than 10 questions in total for any one service line. By carrying out this project we were able to drill down into areas of potential concern within specific services. For the main annual survey the results highlighted a very positive response in relation to the care and/or treatment received; encouraging comments were also documented by many patients. An overall satisfaction score of 90% was achieved, while 81% of patients described the quality of care received as being either excellent or very good. Patients using the Community Matrons’ Service were surveyed separately. The overall satisfaction score of 80% was achieved. Additionally 78% of patients described the quality of care received as being excellent, very good or good Compliments and Complaints We value the feedback we receive about the services we provide. All complaints and concerns raised are investigated fully. Action plans are formulated to ensure that the risks of such events happening in the future are minimised and patient care is improved. All action plans are monitored by Managers until they are completed. Complaints are reported to and action plans are reviewed by the Governance and Risk Committee and Patient Safety Working Group.

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Compliments In the period 1 April 2010 to 31 March 2011, there have been a total of 430 compliments received by the organisation. A breakdown by directorate within ACE is detailed below as well as some examples of the type of compliments staff receive.

Compliments by Directorate

185

43

202

Adult Community andSpecialist ServicesChildren's Health andImprovement ServicesCommunity Hospitals

An example of compliments received by each Directorate: “To all staff in Kate Grant Ward. Thank you for getting my husband home to me.”

Community Hospitals and Specialist Services “Thank you so much for all your care, kindness and gentleness. I could not have

been looked after better. You gave me back my confidence, I seem to have lost.” Adult Community Services

“I am writing this letter to express my gratitude for your breastfeeding service

and to one of your staff members. Her help and advice was second to none. She gave me some hints and tips (and) made herself readily available either by phone or text so if I needed her, she could offer advice. I was so much more comfortable with the whole process (and) definitely gave my daughter the best start in life! Thank you very much for this service” Children’s and Health Improvement Services

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Complaints In the period 1 April 2010 to 31 March 2011, there have been a total of 150 complaints and concerns received by the organisation. Of that number there were 94 actual complaints received.

Outcome of Complaints Closed

Complaints by Directorate and Outcome following Investigation of Complaint

Complaint Withdrawn

*Not Applicable

Complaint Not Upheld

Complaint Partially Upheld

Complaint Upheld Total

Adult Community Services 0 8 6 3 8 25

Children's and Health Improvement Services

0 2 2 2 4 10

Community Hospitals and Specialist Services

2 8 6 11 18 45

Totals: 2 18 14 16 30 80

* Not applicable: Refers to MD letters for information only and are responded to in writing by the Patient Experience Team in line with Policy. The following table represents the number of complaints that have been closed during the period 1 April 2010 to 31 March 2011.

Outcome of Complaints following Investigation

218

1416

30

Complaint Withdrawn

Not Applicable

Complaint Not Upheld

Complaint PartiallyUpheldComplaint Upheld

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The main aspects of complaints relate to the following subject types:

Breakdown of Complaints by Main Subject Type Communications (All) 59Failure to Access/Treat/Care Appropriately 41Hygiene/Cleaning/Infection Control 1Premises and Access to 7Prescribing 3Privacy/Dignity/Respect 5

We are very keen to ensure that we can identify and act on trends in respect of complaints received. All complaints are held on our DATIX reporting system and each aspect of the complaint is recorded individually and collectively. The system provides us with the ability to easily identify where trends are appearing and allows us the opportunity to act on these; by identifying key areas of concern and working with teams to improve service delivery. We have processes in place to ensure that action plans are developed and monitored on a regular basis and the steps we have taken to improve services. Clinical Audits A detailed breakdown of the clinical audits carried out during 2010/11 is located at appendix 1. Hand Hygiene & Essential Steps We measure compliance with Hand Hygiene in order to ensure staffs are following best practice in terms of preventing the spread of infection and that they are following Trust and National guidelines. Essential Steps to Safe Clean Care is a Department of Health Initiative which is designed to assure organisations and the public that staff are following best practice in relation to specific procedures i.e. urinary catheter care. There is a compliance and reporting framework in place to ensure that where compliance is less than 100% actions are taken by the service to ensure immediate feedback is provided to the person being observed. If necessary a change in actions or practice is implemented. A feedback form is completed detailing actions /recommendations and sent to the head of service. This informs subsequent onward reporting to the infection prevention and control groups and committee. With regard to MRSA and C-Difficile our ceiling for 20010/11 is:

• MRSA bacteraemia x 4 for all non-acute settings, this is a target for the whole health economy and is not broken down specifically for North East Essex Provider Services

• The ceiling for C Difficile for non acute services across the local health

economy is 55. A ceiling set specifically for our 2 community hospitals is 6.

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How we will measure and monitor The data for MRSA bacteraemia and C Difficile is updated daily for the whole of the North East Essex health economy. The NEEPS Infection Prevention & Control team monitor the ‘alert organisms’ list which is provided daily by microbiology. How we will report on progress Monthly reports are provided to the service managers and to our Integrated Governance Committee. Progress during 2010/11 Methicillin-resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile (Cdiff) figures continue to remain low and remain below trajectory. There has been 1 case of Cdiff and 1 MRSA bacteraemia for the year 2010/11 to date in the community hospitals. Incidents Risk Management is an essential feature of a modern, health and social care organisation. Although a risk free environment is generally considered impossible, much can be done to minimise risk by having all embracing adequate policies and procedures in place. The ultimate objective of Anglian Community Enterprise (CIC) is to protect the public, patients, staff and the organisations’ assets and reputation. Our primary concern is therefore, the provision of safer, risk controlled environments together with working policies and practices which address identified risks. To achieve this principle objective we have adopted a pro-active approach with its Risk Management programme addressing all clinical, non-clinical, organisational, financial and strategic and information governance risks. The main categories of incidents reported are:

Key categories of Reported Incidents

1528

365

270

0

50

100

150

200

250

300

350

400

Information Security &Confidentiality

Medication Slip, Trips & Falls Tissue Viability

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These 4 key categories of incidents make up almost 80% of all incidents reported in the period 1 April 2010 -31 March 2011. The largest numbers of reported incidents come from the in-patient and specialist services areas:

Incidents by Directorate

Community Services 306

Children, Health & Well-being 54

Specialist Services 488

Learning Disabilities 13

Community Services Children, Health & Well-being Specialist Services Learning Disabilities

It is essential that risk awareness and control becomes part of all employees’ everyday working life and those incidents, accidents, near misses and hazards are reported using Anglian Community Enterprise's newly acquired DATIXWeb Incident Reporting system.

Community Services Incidents

1 1 3 5 3 1 1 5 1 3 1 1 212

1 2 4 1 2 1 110

243

10

50

100

150

200

250

300

Burn

s/Sc

alds

Com

mun

icat

ions

Dia

gnos

is/T

reat

men

t

Dis

char

ge &

Tra

nsfe

r

Equ

ipm

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Gen

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Equi

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t - M

edic

al

Exam

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of p

atie

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ill H

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Hea

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Inap

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avio

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Info

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& C

onfid

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IT &

Clin

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Sys

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s

Man

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andl

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Med

icat

ion

Oth

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Pat

ient

Acc

iden

t (N

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lip, T

rips

& F

alls

)

Pro

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Ref

erra

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Saf

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rdin

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Self

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Sha

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and

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Slip

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Tiss

ue V

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33

There has been an increase in the reporting of tissue viability incidents due to the new processes implemented following NICE guidance (CG29). NICE guidance states that all pressure ulcers graded 2 and above should be reported as a local clinical incident.

* There was a sharp rise in the numbers of Serious Incidents being declared in Q4 (Jan-Mar 2011). This was due to a national requirement applicable from January 1st for all NHS healthcare providers to declare grade 3 and 4 pressure ulcers as serious incidents. During this period, all pressure ulcers were being declared by ACE regardless of whether or not the patient was receiving care from our nursing teams at the time the ulcer was identified.

Specialist Services Incidents 1 April 2010 – 31 March 2011

4 4 2 1 2 6 1 4 1 217

1 3 3 3 9 1 2 5 113

1 1 12 1 2 2 3 1

349

227

20

50

100

150

200

250

300

350

400

Abs

cond

ing

Adm

inis

tratio

n Er

ror

Appo

intm

ent I

ssue

s

Bloo

d &

Blo

od P

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cts

Burn

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Com

mun

icat

ions

Con

tact

with

Obj

ect

Con

tract

Issu

es

Del

ay

Dia

gnos

is/T

reat

men

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Dis

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Env

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Gen

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& C

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Man

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Med

icat

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Non

Inci

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Oth

er

Pat

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Acc

iden

t (N

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lip, T

rips

& F

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)

Pro

perty

Los

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Patie

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& 99

9 Am

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Ref

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Saf

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Sec

urity

Slip

, Trip

s &

Falls

Sta

ffing

Tiss

ue V

iabi

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Vio

lenc

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ress

ion

Children’s Health & Wellbeing Services Incidents

1 April 2010 – 31 March 2011

7

13

2

1

2 2

1

9

3 3

2

6

2

1

0

2

4

6

8

10

12

14

Adm

inis

tratio

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ror

Com

mun

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Dia

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men

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Equ

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Med

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ill H

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&C

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Pat

ient

Acc

iden

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otS

lip, T

rips

& Fa

lls)

Safe

guar

ding

Issu

es

Slip

, Trip

s &

Falls

Viol

ence

and

Agr

essi

on

34

Learning Disabilities Incidents 1 April 2010 – 31 March 2011

1 1 1 1

4 4

1

0

1

1

2

2

3

3

4

4

5

Bul

lyin

g an

dH

arra

ssm

ent

Equ

ipm

ent -

Med

ical

ill H

ealth

Man

ual H

andl

ing

Pat

ient

Acc

iden

t (N

otS

lip, T

rips

& F

alls

)

Slip

, Trip

s &

Falls

Vio

lenc

e an

dA

gres

sion

Serious incidents

Serious Incidents by Type*

Information Governance 4

Medication Errors 2SOVA 1

Unexpected Death 1

Pressure Ulcers 34

Pressure Ulcers Information Governance Medication Errors SOVA Unexpected Death A Serious Incident (SI) requiring investigation is defined as an incident that:

• occurred in relation to NHS funded services and care • resulted in unexpected or avoidable death • resulted in serious harm • threatens an organisations' ability to continue to deliver healthcare services • resulted in allegations of abuse

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With the new direction of the organisation it is essential that effective risk management is at the heart of the business, and that work begins in earnest to learn lessons from incidents. A positive indicator that lessons are being learned and the organisation supports a reporting culture would be to see a further increase in the amount of incidents reported, but a decrease in the severity of these incidents. The complexity and breadth of risk management inevitably means some lessons still need to be learned from incidents. Recognising and Rewarding Quality ACE recognises its staff as our greatest asset. We will recognise and reward staff in terms of their commitment to innovation and striving to continually improve the services we provide. We are holding our annual ‘Sharing Best Practice’ event on September 7th 2011 which helps us to reward innovation and disseminate learning across the organisation. In the future we will hold more of these events in order to stimulate innovative ideas and quality improvements. *See note on page 33 regarding the reporting of pressure ulcers

Stakeholder Engagement Staff and stakeholder involvement in the governance of ACE is an important aspect for both the organisation and to remain as a Community Interest Company (CIC).

Engagement and involvement of stakeholders is a key principle in the development of ACE and the work that we have done with members of community during the right to request process to become a social enterprise will be used as a firm foundation for their continued involvement in the future. To achieve ACE’s Social Mission we will utilise surpluses from our operations to prioritise and invest in local projects and initiatives that improve health and well-being. We are delivering training in clinical audit and best practice on a bi-monthly basis to all ACE clinical staff. ACE will continue to develop a meaningful partnership arrangement between Essex Health Overview and Scrutiny Committee (HOSC) and the Essex & Southend Local Involvement Network (LINk) so that they are fully informed about what we do and what we are continually striving to achieve. Both organisations were represented at our annual ‘Sharing Best Practice’ event in May 2010, which helped us to celebrate some of the high quality care delivered during 2009 and to help form our quality priorities for 20010/11. This year the HOSC and LINk were both happy with our progress and had no concerns which they wished to raise with us. LINk are in the process of transforming their role into a new body, ‘Healthwatch’. We will of course be building on our good relationship with LINk as and when it transfers its role to Healthwatch. ACE will be holding another Sharing Best Practice event on 7th September 2011.

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Supporting Statements: NHS NEE PCT Commissioners NHS North East Essex (Primary Care Trust - PCT) welcomes this Quality Account as a commitment to an open and honest dialogue with the public regarding the quality of care in Anglian Community Enterprise CIC (ACE). Assurance from the PCT is required to ensure that the information in this Quality Account is accurate, fairly interpreted, and representative of the range of services delivered. Though the PCT are commenting on a draft version of this Quality Account, it is pleased to be able to assure the accuracy of the content in general. The PCT is however unable to assure all data reported, as some was yet to be reported and therefore missing from the draft sent for assurance. A number of areas that could not be fully assured are detailed below. The information presented in this Quality Account gives an overall picture of the quality of the services provided, and represents most of the required elements. The information is presented in a range of appropriate formats, and highlights positive achievements and improvements. ACE have responded to the comments from stakeholders relating to last year’s Quality Account and clearly recognises areas for improvement from 2010-11 performance. The PCT would like to confirm these, and to add further areas to be considered for 2011-12. The PCT wishes to comment on significant achievement in 2010-11 in contributing to an excellent local result in reducing the incidence of healthcare associated infections, with NHS North East Essex achieving the lowest rate in the East of England in C-Difficile infections. Similarly, ACE have demonstrated good working across the local health economy in their liaison with other health providers to enhance outcomes of the Safety Express and High Impact Actions for Nursing initiatives, and in hosting events to share good practice. The PCT commends ACE’s commitment to improving clinical effectiveness through participation in local and national clinical audits. The Quality Account demonstrates how the outcomes of local audit activities are translated into quality improvement actions. The data from national audits in which ACE have participated is not fully reported. The PCT would like to see ACE clinicians also taking part in research. There are some areas of data recording and reporting which the PCT would like to see improved. There is a discrepancy in the numbers of pressure ulcers, for which ACE are reporting a higher number than the PCT have on record. There is no data reported on NHS Number compliance or General Medical Practice Code validity. The PCT can confirm that this data is available and demonstrates good performance. There is no information relating to clinical coding accuracy, and how ACE are addressing any required improvements in this area, which the PCT would like ACE to consider as a priority, in addition to confirming how information is used for improvement. The PCT considers the quality indicators chosen as priorities for 2011-12 to be suitable and relevant to the services provided. The indicators have been agreed in consultation with stakeholders and the PCT and cover all domains of quality, linking coherently to the organisation’s strategic objectives. The PCT looks forward to working with ACE to support the achievement of these objectives.

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In summary, this Quality Account has given a positive overview of the quality of services in ACE, and identified some areas for improvement, reflected in the priorities chosen for 2011-12. The PCT encourages and will support ACE to continue to implement the multiple and wide-ranging efforts and initiatives to improve the quality of its services.

Sarah-Jane Relf Director of Quality and Governance NHS North East Essex May 2011 Essex & Southend Local Involvement Network The current contract for Essex and Southend LINk is finishing on 31st March 2011. The organisation is in transition between E & S LINk and Healthwatch. I can confirm that at this stage we have no comments at this time regarding the quality account process. Sharon Cohen Project Coordinator (North East Locality) Essex & Southend LINk Room 431 4th Floor Queensway House Essex Street Southend on Sea Essex SS1 2NY Web: www.essexandsouthendlink.org.uk

Essex Health Overview & Scrutiny Committee The HOSC works on the basis that if it has any issues/concerns, etc it will raise these with the health body direct and at the time. As a result it will only comment on the Accounts if there have been any concerns during the year. During 2010/11 there have been no concerns with Anglian Community Enterprise, therefore the HOSC has no comments to make. Submitted on behalf of Essex Health Overview & Scrutiny Committee Graham Redgwell Policy, Community Planning and Regeneration Essex County Council

http://www.essexandsouthendlink.org.uk/

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APPENDICES Appendix 1 Clinical Audit Participation in local clinical audits During 2010-2011, 4 national clinical audit and 66 local audits were undertaken which covered the NHS services which ACE provides. During that period ACE participated in 100% of national clinical audits which it was eligible to participate in. These are detailed in part 2. There were no national confidential enquiries applicable to ACE. The national clinical audits that ACE participated in, and for which data collection was completed during 2010-2011, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Title of National Clinical Audit

No of cases required for audit

No of cases submitted for audit

Reasons for non submission of cases

National Audit of Continence Care- Royal College of Physicians (RCP).

Patients with urinary incontinence- 50 Patients with bowel incontinence- 50

100% (50) 0% (0)

Not submitted as the organisation did not have patients which fulfil the sample requirements, RCP notified.

The report of 1 national clinical audit was reviewed by the provider in 2010-2011 and ACE intends to take the following actions to improve the quality of healthcare provided. National Audit of Continence Care- Royal College of Physicians (RCP). Recommendations Actions Men with bladder (and/or bowel) incontinence should have a Digital Rectal Examination (DRE) (with their consent) as a basic part of assessment. Healthcare professionals should ensure that they are competent to perform Digital Rectal Examination.

Discussions with team. Plan to offer Digital Rectal Examination DRE as part of assessment for men over 50 years old. Release of half day per week Whole Time Equivalent band 6

39

Those responsible for services should ensure that there are practitioners who are appropriately skilled to perform the examination and that training is provided to all non-specialist clinicians engaged in assessment of patients with urinary (and faecal incontinence.)

Digital Rectal Examination trained and experienced staff to provide this and also offer flow test at home when thought appropriate.

Cure rather than containment should be the principle aim of treatment. Healthcare professionals should fully discuss treatment options with patients. Local audit cycles should be used to push up standards and adherence to national guidance.

Plan to release a staff member half day per week, whole time equivalent band 6 continence specialist nurse to oversee review of continence assessments for elderly residential home clients and some housebound clients who have been provided with containment products but may be cognitively able and willing to consider pelvic floor exercises, bladder training and possibly medication such as tolterodine, solifenacin etc

Use of scoring for functional ability/ cognitive ability

Discussions with team as to usefulness of scores and which system would be appropriate

Use National Occupational standards to guide training and competency for continenence team members

Discussions with team and look at training and competency documents to see how standards can be incorporated

User Group to advise, comment etc on service

Discussions with users, staff. Possibly arrange meeting for stakeholders

The reports of 66 local clinical audits were reviewed by the provider in 2010-2011 and ACE intends to take the following actions to improve the quality of healthcare provided NICE Pressure Ulcer Audit Recommendations Actions To agree how to measure monthly patient activity for Pressure ulcers To agree when a referral needs to be made to the Tissue Viability Team. To agree when regular assessments and photographs and tracings need to be undertaken

Discuss with operational leads how this could be measured. An activity return could be completed monthly. Set clear criteria for referrals. Set clear criteria for regular assessments, photographs and tracings for community nursing and the community hospitals.

To view documentation and consider European Pressure Ulcer Advisory Panel and clinical incident reporting as additions and streamline the assessment paperwork

Revise documentation.

Look at training requirements.

Ensure all staff are appropriately trained – look at training undertaken within teams.

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To agree repositioning regimes

Set clear criteria for repositioning regimes.

To agree when a referral needs to be made to the Tissue Viability Team

Set clear criteria for referrals.

To agree when regular assessments and photographs and tracings need to be undertaken

Set clear criteria for regular assessments, photographs and tracings for community nursing and the community hospitals.

To agree when it is appropriate to order pressure relieving equipment

Set clear criteria for appropriate ordering of pressure relieving equipment.

To consider whether the Health care Quality Team need to support the completion of the Record Keeping Audit

Discuss at the Clinical Effectiveness Group and Governance and Risk Committee for agreement.

To agree whether the National Institute for Health and Clinical Excellence (NICE) Pressure Ulcer Audit becomes the annual audit for the Tissue Viability Team.

Look at the paperwork and findings and revise where appropriate. More questions may need to be added. Partnership working may need to be considered.

Annual Record Keeping Audit – DOMSEM Recommendations Actions Repeat the audit in one year

Update data collection form, in line with any changes to the Policy. Clinical Audit Specialist to send relevant data collection forms to Service Lead, ready for data collection to be undertaken by service areas within the agreed timeframe. Data analysis & collation of final report to be carried out by the Clinical Audit Specialist.

Ensure that the patient’s next of kin is recorded for all patients where appropriate Ensure that all entries are timed

Discussion with Dr Marfleet and instructions from the System One team of where to store the data on Systmone when next of kin is necessary. Systemone now times all entries

Ensure that the patient’s gender is clearly recorded

Systemone now has a record of all genders from main spine

Ensure that ethnicity is recorded where applicable

Ethnicity is now being recorded on Systemone

Document clearly all known allergies or if there are no known allergies

Allergies are already discussed with patient and recorded when applicable. We will now make a note on Systemone when there are no known allergies

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Annual Record Keeping Audit – Physiotherapy Clacton Recommendations Actions Repeat the audit in one year


All staff to be made aware by e-mail and staff meeting on the need to improve note keeping. Especially to ensure all entries are timed, have the NHS no on all pages. Allergies should be documented clearly. Each Physiotherapist must make sure they print name alongside signature. Medication provides a general background to the patient’s health and so drugs are included when taken however physiotherapists are not trained in specific doses so this information does not affect treatment. Patients who are being treated away from the hospital should have next of kin if known in their notes. It is not necessary for those being treated in out patients as system one information is readily accessed Random checks will be made by senior staff throughout the year to check a high standard is maintained.

Annual Record Keeping Audit - Physiotherapy Harwich Recommendations Actions Repeat the audit in one year

Update data collection form, in line with any changes to the Policy. Clinical Audit Specialist to send relevant data collection forms to Service Lead, ready for data collection to be undertaken

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by service areas within the agreed timeframe. Data analysis & collation of final report to be carried out by the Clinical Audit Specialist.

Staff have been informed by e-mail and will be given feedback at the next staff meeting to ensure that notes include the following: All pages are correctly numbered, timed and contain the N.H.S number. Student notes are counter signed. Medication doses are included (if known) - documentation of specific dosages are outside our scope of practise

If appropriate next of kin to be taken off system one (this applies to those being seen at home). For those patients seen at hospital NOK can be easily accessed if required.

Random checks to occur during the year to check compliance.

Annual Record Keeping Audit – Podiatry Services Recommendations Actions Repeat the audit in one year


Record all known allergies Quick launch button added to podiatry template to assist staff in recording allergies. This information can be shared with other units. Staff to record all known allergies

Clearly identified patient care planning

All staff to ensure that all new patients have a clear care plan

Avoid use of jargon

Ensure all staff have attended record keeping training

Document all relevant medication, doses and frequency

Encourage all staff to complete this within Systmone

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Annual Record Keeping Audit – Podiatric Surgery Recommendations Actions Repeat the audit in one year


Clearly document that the patient has either consented or de-consented to their information being shared with other non-NHS organisations

This requires an alteration to the Systmone template. Will need to discuss with Lynda Simpson.


Administrative task. Questionnaire collected at assessment contains patient information on ethnicity.

Ensure that all pages contain the patients NHS number Ensure that all entries are timed When the records contain any alterations or additions, make sure that these have been dated, timed and signed in such a way that the original entry can still be read clearly

This data is already collected as a Systmone entry?

Annual Record Keeping Audit – Occupational Therapy Clacton Recommendations Actions Repeat the audit in one year


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Staff to be made aware by e-mail and at the next staff meeting in September, that Occupational Therapy notes should include: correct gender, medication and changes to medication, allergy status if known, and to ensure that student notes are countersigned.

Random checks will be carried out by senior staff to monitor notes during the coming year.

Annual Record Keeping Audit – Speech & Language Therapy – Gainsborough Wing Colchester Hospital University Foundation Trust Recommendations Actions Repeat the audit in one year


Ensure that a next of kin is recorded for all patients where appropriate

Liaise with System One team to determine how this can be put into patient template

Ensure that a complete register of signatures to be placed in the front of every set of records

Dept to have an updated set of signatures that are kept in dept, not always relevant for paper lite records.

Annual Record Keeping Audit- Tier 2 aims Recommendations Actions Repeat the audit in one year


Improve outcome Moving all records to Systmone

Annual Record Keeping Audit- Child Health Recommendations Actions Repeat the audit in one year

Update data collection form, in line with any changes to the Policy.

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Clinical Audit Specialist to send relevant data collection forms to Service Lead, ready for data collection to be undertaken by service areas within the agreed timeframe. Data analysis & collation of final report to be carried out by the Clinical Audit Specialist.

Share findings of audit with Child Health admin staff and advise Head of Children’s community Services to do the same re School Nurse input. Ensure all mandatory fields are completed in the records e.g. NHS numbers, date and times etc.

Share with relevant staff at staff meeting and 1 to 1 supervision sessions.

Clearly document if there are or have been child protection concerns about a child in order that these concerns are able to be identified immediately Clearly document that the patient (or parent of) has either consented or de-consented to their information being shared with other non-NHS organisations

Ensure all staff are aware of the appropriate documentation to use to record child protection concerns. Consent stamp to be ordered for use in the notes as a reminder to ensure consent or de consent to information sharing has been recorded.

Annual Record Keeping Audit- Paediatric Speech and Language Recommendations Actions Repeat the audit in one year


Staff Awareness of areas for improvement targeted

Presentation of report recommendations at Speech and Language Therapy team meeting. Copy of report and recommendations and target list for team audit to team leaders

Documentation amended to enable compliance with standards

Common Assessment Framework triangle form to be devised for use.

Maintain improvements over the year Standing item on team agendas Quarterly review of progress through team leader meetings Gain clarifications from record keeping working group with a view to re-audit

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Annual Record Keeping Audit- Paediatric Speech and Language (Learning Disabilities) Recommendations Actions Repeat the audit in one year


Staff Awareness of areas for improvement targeted

Presentation of report recommendations at Speech and Language T team meeting Copy of report and recommendations and target list for team audit to team leaders

Documentation amended to enable compliance with standards

Common Assessment Framework triangle form to be devised for use.

Maintain improvements over the year Standing item on team agendas Quarterly review of progress through team leader meetings Gain clarifications from record keeping working group with a view to re-audit

Annual Record Keeping Audit - Paediatric Rehabilitation Recommendations Actions Repeat the audit in one year


Repeat smaller audit within service 6 months by December 2010 to ensure action points are improving

Use existing data forms with agreement from the Audit team for internal collation by Head of Specialist & AHP services.

Improve staff awareness of results of survey to target areas for action. .by adding complying with record keeping policy as an objective for each staff member in their yearly Personal Development Plan and by presenting this years report results at staff meeting.

By adding complying with record keeping policy as an objective for each staff member in their yearly Personal Development Plan and by presenting this years report results at staff meeting. Standing item on staff meeting agenda

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Clearly document that parent or patient has consented or de consented to information being shared with other non NHS organisations.

New consent stamps ordered for paper record files and stamp will be used to mark the front history sheet of record to reduce the risk of clinician not asking for consent/de consent. Clinicians to use consent option on systmone.

Annual Record Keeping Audit- Specialist Health Visitor Recommendations Actions Repeat the audit in one year


To ensure each child’s record has their G.P practice recorded on front sheet

This information should be recorded and checked as correct at each review appointment

To ensure each child’s Date of birth/age is documented at every contact

Most assessment contacts will be made during a short time span so child would be the same age. To ensure age recorded at each review

Where applicable ensure parent/carer has consented to referral to other organisation

To ensure parent/carers sign the 332 referral forms to education

Ensure every page contains the child’s full name and NHS number

Initially to complete with all new referrals and then as children return for reviews to gradually update the records

To ensure that every entry has been documented with clinicians job title

This is important if the record doesn’t specify whose record it is

To document the place of contact All contacts are in Children’s Development Centre other than for 2 clinicians

Annual Record Keeping Audit- Children’s Service for Central and North Colchester Recommendations Actions Repeat the audit in one year

Update data collection form, in line with any changes to the Policy. Clinical Audit Specialist to send relevant data collection forms to Service Lead, ready for data collection to be undertaken

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by service areas within the agreed timeframe. Data analysis & collation of final report to be carried out by the Clinical Audit Specialist.

Ensure all entries are timed To be highlighted to practitioners discussing the importance and legal implications. Refer to policy

The child’s age Date of Birth is documented when applicable for every entry.

To be highlighted to practitioners and the reasoning behind this action. Refer to policy.

Ensure that letters of correspondence, reports and others such as documents placed in chronological order and treasury tagged.

To be highlighted to practitioners discussing the importance and legal implications. Refer to policy

Annual Record Keeping Audit- Children’s Service for South, East and West Colchester Recommendations Actions Repeat the audit in one year


Ensure that the record reflects the use of the Assessment framework Triangle, inc observations an attachment patterns

To redistribute the Assessment triangle as A5 laminated copy. To be highlighted to the practitioners discuss the importance and legal and safe guarding implications. Refer to policy

Annual Record Keeping Audit- Children’s Service North Tendring Recommendations Actions Repeat the audit in one year

Update data collection form, in line with any changes to the Policy. Clinical Audit Specialist to send relevant data collection forms to Service Lead, ready for data collection to be undertaken by service areas within the agreed timeframe.

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Data analysis & collation of final report to be carried out by the Clinical Audit Specialist.

When applicable document the child’s school / nursery

To be discussed with practitioners: To be acknowledged that the majority of clients seen by Health Visitors would not be of an age to attend school or nursery. In future this section of the audit to be completed as N/A to prevent the presentation of non completion.

Ensure that ethnicity is recorded Highlighted to practitioners: Acknowledgement shown that the ethnicity was not recorded on the written record until 2008: Refer to policy.

To include a full sized centile chart if applicable.

To remind practitioners that this is applicable for children who are being monitored for growth or a Child Protection Plan.

Clearly document that the patient has consented or de consented to their information being shared with other non NHS organisations.

This is recorded on Systmone

Annual Record Keeping Audit- Children’s Service South Tendring Recommendations Actions Repeat the audit in one year


Ensure that ethnicity is recorded Highlighted to practitioners: Acknowledgement shown that the ethnicity was not recorded on the written record until 2008: Refer to policy.

The child’s age Date of Birth is documented when applicable for every entry.

To be highlighted to practitioners and the reasoning behind this action. Refer to policy.

Date time and sign all alterations ensuring original remains clear to read.

To be highlighted to practitioners discussing the importance and legal implications. Refer to policy.

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Annual Record Keeping Audit- District Nursing, Tendring Recommendations Actions Repeat the audit in one year



Current paperwork reviewed new notes implemented to allow ethnicity to be documented. Inform all staff of record keeping audit and outcomes for all recommendation for whole of report. Record keeping is on the agenda for all community service meetings.

Ensure that all pages contain the patients name in full and NHS number

Current paperwork reviewed new notes implemented to allow patients name in full and NHS number

Ensure that all entries are made in black ink

Informed staff of their reasonability to ensure that all entries are made in black ink.

Ensure that all entries are timed

Current paperwork reviewed new notes implemented to allow recording of timed entries

Ensure that all entries listed in chronological order

Current paperwork reviewed new notes implemented to allow recording of all entries listed in a chronological timed order

Ensure that all entries are free of jargon

Current paperwork reviewed new notes implemented to ensure entries are free of jargon.

Ensure that letters of correspondence, reports and other such documents placed in chronological order and treasury tagged (e.g. held securely within the file)

Current paperwork reviewed new notes implemented with dividers to ensure all documents/correspondence are placed in chronological order. Folders are provided to ensure notes are held securely.

Document clearly that diagnostic and/or screening tests have been requested and when applicable that the results been received and explained to the patient and acted on appropriately

Current paperwork reviewed new notes implemented to ensures diagnostic screening and tests can be documented, to enable explanation to the patient where appropriately.

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Documentation of all relevant medication, doses and frequency Documentation and clear identication of all known allergies or if there are no known allergies

Current paperwork reviewed new notes implemented with dividers to ensure all relevant medication is documented and known allergies highlighted.

On the first occasion that a health professional makes an entry that they print his/her name designation alongside his/her signature

Current paperwork reviewed new notes implemented to ensure professionals identify names, designation and signature. Informed staff of their reasonability

Clearly document any unexpected outcomes, complications of treatment or remedial actions and the discussion of these with the patient and/or his/her family

Current paperwork reviewed new notes implemented to ensures any agreed treatment, complication or remedial action are documented. Informed staff of their responability .

Annual Record Keeping Audit- District Nursing, Colchester Recommendations Actions Repeat the audit in one year


Ensure that all pages contain the patients NHS number

Record keeping is on the agenda for all community service meetings. Current paperwork reviewed new notes implemented to allow patients name in full and NHS number

On the first occasion that a healthcare professional makes an entry that they print his/her name and designation alongside his/her signature

Current paperwork reviewed new notes implemented to ensure professionals identify names, designation and signature. Informed staff of their responsibility.

Ensure that all entries made by unqualified personnel e.g. students have been countersigned by a qualified member of the team

Current paperwork reviewed new notes implemented to allow countersigning by qualified staff.

Ensure that a complete register of signatures to be placed in the front of every set of records

A complete set of signature lists are held at office base. Current paperwork reviewed, new notes implemented with interdisciplinary log enabling all discipline to document involvement.

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Clearly document if a patient has refused treatment

Current paperwork reviewed, new notes implemented to show clear documentation of a refusal of treatment by a patient.

Annual Record Keeping Audit- Community Matrons, Tendring Recommendations Actions Repeat the audit in one year




Where appropriate, document clearly the care that is planned for the patient. Ensure that all entries are timed

Current paperwork reviewed new notes implemented with dividers for clear documentation. Ongoing plan of care to be included in care plan and documented. Current paperwork reviewed new notes implemented to allow recording of timed entries


Current paperwork reviewed new notes implemented to allow patients name in full and NHS number

Annual Record Keeping Audit- Community Matrons, Colchester Recommendations Actions Repeat the audit in one year


Ensure that all entries are timed Record keeping is on the agenda for all community service meetings.

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Current paperwork reviewed new notes implemented to allow recording of timed entries Recording all information on Systmone


Current paperwork reviewed new notes implemented with dividers to ensure all relevant medication is documented and known allergies highlighted. Informed staff of their responsibility



Annual Record Keeping Audit- Falls Service Recommendations Actions Repeat the audit in one year


The following areas have been identified as benefiting from some improvement – Ensure that all pages contain the patients name in full and NHS number

Action still waiting for clarification on the issue above since the assessment form is a single document with all demographic details on the front page. There is conflicting information with some advising us that if it’s a single document with several pages patients name is only required on the front page

Annual Record Keeping Audit- Intermediate Care Services Recommendations Actions Repeat the audit in one year


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All Pages contain the patients NHS Number

Current paperwork reviewed and altered to allow NHS Number to be recorded

Record GP and Ethnicity

Current paperwork reviewed and altered to allow recording of Ethnicity and GP

Ensure that all entries are legible On the first occasion that a healthcare professional makes an entry that they print his/her name and designation alongside his/her signature Ensure that all entries made by unqualified personnel e.g. students have been countersigned by a qualified member of the team

Record Keeping and Documentation to be added to rolling programme of education within Intermediate Care to be reinforced at monthly staff meetings and handovers

Ensure that a complete register of signatures to be in place in the front of every set of notes.

A complete set of signatures are kept in the office. All staff who visit each client is logged and timed on Systmone in the patient journal

Where appropriate document clearly the arrangements for continuing care

On going plan of care to be included in care plan. Discharge plan and where clients are referred onto to be included in notes and recorded in Patient journal in Systemone.

Annual Record Keeping Audit- Kate Grant Ward, Clacton Hospital Recommendations Actions Repeat the audit in one year


Gender to be recorded on admission Staff to ensure that gender is documented as part of admission process

All entries to be timed in main record, on Morse Falls Risk assessment & Bedrails Decision Aid

Staff to ensure this is completed as part of admission process and when updated

Entries are made in black ink

Staff to ensure all members of the team including bank staff use black ink

Healthcare professional prints name, designation alongside signature

Staff to ensure that printed name, designation and signature is documented

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Annual Record Keeping Audit- St Osyth Priory Ward, Clacton Hospital Recommendations Actions Repeat the audit in one year


Feed back to all staff Staff to be made aware that they are only to use black ink also to be fed back to NHS Professional. Staff to be reminded to record gender and ethnicity, time all entries especially on risk assessments and bed rails assessments. Staff must remember to put patients name on each page. On the admission page of booklet 1 the admitting Registered Nurse must print and sign their name. All must scores must be completed. Patients with a high risk for falls must have an Integrated Care Pathway. In the Multi Disciplinary Team log staff must remember to document medication changes.

Re Audit in 3 months To be completed by ward managers All staff as appropriate to attend/be booked for the clinical record keeping up dates.

2 hour update must be completed every 3 years. Training records keep on the ward, and the extranet

Annual Record Keeping Audit- Durban Ward, Clacton Recommendations Actions Repeat the audit in one year


Feed back to ward staff Staff made aware that all patients’ records need to contain their NHS number. All staff must not use highlighter pens on legal documents.

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All contact referrals must be signed by the patient to show consent of sharing of information. The first entry in booklet 1 by the admitting Registered Nurse must be printed and signed, ensure that Integrated Care Pathway is used for all patients that are of a high risk of falls.

Annual Record Keeping Audit- Jubilee Ward, Clacton Hospital Recommendations Actions Repeat the audit in one year


Ensure patients gender is recorded Print first 3 pages of Patient Administration System which include all patient details clearly written and place in nursing notes.

Ensure all entries are timed

This has now been discussed with all trained nurses who have also had access to audit report to see what needs action. Reminder to be added to unit meetings to reinforce compliance

First entry in patient notes to have signature and printed details of staff member

To be discussed with staff during week of 27th September 2010

Annual Record Keeping Audit- Minor Injuries Unit, Clacton Hospital Recommendations Actions Repeat the audit in one year


Ensure that ethnicity is recorded for all patients where appropriate

Reiterate to reception staff the need for 100% compliance Introduce use of booking in form which records this information

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Ensure that a next of kin is recorded for all patients where appropriate

Reiterate to reception staff the need for Next of Kin recording Encourage Nursing staff to complete ‘accompanied by’ section of template Introduction of Minor Injuries Unit module in Systmone will make this mandatory field

Document clearly that consent (verbal or written) for significant/invasive procedures or treatment e.g. catheterisation, diagnostic tests has been discussed with the patient

Remind clinical staff of need to document consent Introduce box in template to reflect this when Minor Injuries Unit module in place

Annual Record Keeping Audit- Trinity Ward, Clacton Hospital Recommendations Actions Repeat the audit in one year


Ensure that all entries are timed Inform all staff at Ward meeting Review at weekly record validation Inform staff who are not meeting target

Ensure that all entries are legible

Inform all staff at Ward meeting Review at weekly record validation Inform staff who are not meeting target

Document that the results of any diagnostic and/or screening results have been explained to the patient and acted upon appropriately

Inform all staff at Ward meeting Inform staff who are not meeting target

Ensure that all details on the Care Pathway 11 and integrated care pathway for falls are documented appropriately

Inform all staff at Ward meeting Review at weekly record validation Inform staff who are not meeting target

Annual Record Keeping Audit- Dietetics Recommendations Actions Repeat the audit in one year


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Page contains NHS no This should no longer be an issue. The service has moved over to Systmone where the NHS number will always be recorded

All entries are timed This should no longer be an issue where the time is recorded at each contact.

Register of signatures We have a register of signatures in the office which is updated on a yearly basis. Many of the notes are kept on computer now so a signature is not necessary. The register will continue to be kept anyway. Where signature where not found on the paper records these was actually print off of the computer records when it could be verified whose notes they were.

Annual Record Keeping Audit- Occupational Therapy, Learning Disabilities Recommendations Actions Repeat the audit in one year


Ensure that all entries made by unqualified personnel e.g. students have been countersigned by a qualified member of the team.

We have electronic notes on systm1. Apparently no other services in ACE do this on systmone

Ensure that a complete register of Signatures to be placed in the front of every set of records.

Again, we are keeping electronic notes so no longer relevant.


To create a form to be completed with the client/carer during the first visit.

Annual Record Keeping Audit- Physiotherapy Learning Disabilities Recommendations Actions Repeat the audit in one year

Update data collection form, in line with any changes to the Policy.

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Clinical Audit Specialist to send relevant data collection forms to Service Lead, ready for data collection to be undertaken by service areas within the agreed timeframe. Data analysis & collation of final report to be carried out by the Clinical Audit Specialist.




Document clearly any reason for the discontinuation of medication - not sure we would know this or it is relevant for Physiotherapy.

Change from EPEX information system to System1 – Sept 2010 :- Meet with staff 2 weekly to ensure that the above information can be inputted for patients. To monitor reports produced by the Systmone team to ensure required data is collected

Annual Record Keeping Audit- Speech and Language Therapy, Learning Disabilities Recommendations Actions Repeat the audit in one year


Ensure ethnicity is recorded for all patients registered for Speech and Language Therapy input on Systmone

All clinicians to check records for their caseloads on epex and transfer eligibility information to Systmone registration Ethnicity information to be recorded at Speech and Language Therapy Triage appointments Consider adding ethnicity to the referral form for Learning Disabilities Allied Health Professionals.

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Non-qualified staff and Speech and Language Therapy student records to be countersigned by a qualified Speech and Language Therapy

All patients seen by unqualified staff or students to have an allocated responsible clinician Discuss with systmone team how students can access patient records for recording purposes. Agree with team wording for patient records that will make clear who is the supervising clinician. Where records are printed supervising clinician to sign all entries by unqualified staff. This to be requested by unqualified staff member when appropriate or at supervision.

Ensure that records do not contain subjective statements

Ensure that member of staff completing audit fully understands what a ‘subjective statement’ means. Agree amongst team how to word reported events or patient behaviour in an objective manner.

Annual Record Keeping Audit- Safeguarding Colchester Recommendations Actions Repeat the audit in one year


Cascade the results of audit out to all of the teams.

Head of Safeguarding will put together a short brief offering the highlights of the results report. Safeguarding Lead to share with Children’s Health & Well-Being Division.; most likely at a regular Heads of team meeting. Heads of service to then start the cascade of audit outcomes/recommendations to their team leaders/coordinators at their regular team meetings. Team leaders/service leads/managers to present at local team meetings

Consider introducing quarterly peer review into the audit cycle.

Discuss further with Heads of Service

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Refresher training for staff Will need further discussion as to the best way to proceed with this. Has resource implications and may impact on business continuity. Discussions to include Systmone trainers.Further consideration to be given to the audit of individual practitioner’s record keeping. Consider using Systmone reporting alongside peer review.

Annual Record Keeping Audit- Safeguarding Tendring Recommendations Actions Repeat the audit in one year


Cascade the results of audit out to all of the teams.

Head of Safeguarding will put together a short brief offering the highlights of the results report. Safeguarding Lead to share with Children’s Health & Well-Being Division.; most likely at a regular Heads of team meeting. Heads of service to then start the cascade of audit outcomes/recommendations to their team leaders/coordinators at their regular team meetings. Team leaders/service leads/managers to present at local team meetings

Consider introducing quarterly peer review into the audit cycle.

Discuss further with Heads of Service

Refresher training for staff Will need further discussion as to the best way to proceed with this. Has resource implications and may impact on business continuity. Discussions to include Systmone trainers.Further consideration to be given to the audit of individual practitioner’s record keeping. Consider using Systmone reporting alongside peer review.

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Annual Record Keeping Audit - Cardiac Services Recommendations Actions Repeat the audit in one year


Share audit results with team Review audit results at next team meeting and engage staff with this process, reminding them of there professional obligations to record keeping. Remind staff of the Nursing and Midwifery Council Guidance for record keeping. Provide copies of this if needed

Review paper records

Team to review paper work & make amendments to paper record with reference to recommendations from audit to ensure all data is captured.

Offer staff clinical record keeping study day

Managers to nominate staff or staff to nominate themselves. Send Training, Education and Development forms to training dept

Annual Record Keeping Audit – Continence and Urology Services Recommendations Actions Repeat the audit in one year


On the first occasion that a healthcare professional makes an entry that they print his/her name and designation alongside his/her signature

Agree staff all to write name and designation at first entry.

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Agree exactly what we will write – Health Care Assistant, Associate Practitioner, Clinical Nurse Specialist or in full? Or Nurse or Registered Nurse Agreed at team meeting ‘Nurse’ is only designation needed. Discuss need for this.

Ensure that if a patient has refused treatment that this is clearly documented

Agree on documentation – exactly what to put. Agreed this happened rarely and that the event noted was really a choice rather than a refusal to have treatment

Annual Record Keeping Audit - Respiratory Services Recommendations Actions Repeat the audit in one year


Ensure that the patient’s gender is clearly recorded

Action 1: all to record on current paperwork (front cover) Action 2: to amend the front sheet to include "GENDER"


Action 3: Kay/Janet/Yvonne: please amend the front sheet to include "Consent to Sharing Information"


Action 4: all to record where known on the front cover Action 5: Kay/Janet/Yvonne: please amend the front sheet to include "KNOWN ALLERGIES"


Action 11: All comply

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Annual Record Keeping Audit – Dental Services Recommendations Actions Repeat the audit in one year


Inform Team Report disseminated and discussed at Team meeting

Paperless records

All staff to comply and have resources to support this

Do not include Dental Services in NHS Number count

Inform Audit Team

Annual Record Keeping Audit – Diabetes Services Recommendations Actions Repeat the audit in one year


Ensure that the patient’s next of kin is recorded for all patients where appropriate

Discuss with team members and document where appropriate

Ensure that all entries made by unqualified personnel e.g. students have been countersigned by a qualified member of the team

Student nurses are not to document within our notes as they will not be reviewing patients on their own.


To ensure staff are aware of the Allergy key within system one and input data id appropriate.

If any diagnostic and/or screening tests have been requested to ensure they are documented within the healthcare record and results are recorded

To document blood test request made

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Annual Record Keeping Audit - DRSS Recommendations Actions Repeat the audit in one year


Ensure that the patient’s next of kin is recorded for all patients where appropriate

There isn’t a facility to record this on the current software however, an updated version is being installed late Sept 2010 where this will be investigated

Ensure that all entries are free from jargon and subjective statements

All information is recorded onto a clinical database where only Optoms can record data. This will be highlighted to them


Medication is documented and necessary however, does and frequency is not required


An information leaflet is given to every patient to consent to treatment and information sharing

Annual Record Keeping Audit – Epping Close GP Practice Services Recommendations Actions Repeat the audit in one year


Discussed at staff meeting Training carried out as required Entries timed; Following changes cannot be made; 1).All records electronic so no signatures

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2). Records always show GP by name and role but not possible to show role of other staff on consultation header. All shown on User Manager. 3). Reference to entries ‘on official documentation’ N/A computerised

Countersignature of entries by students

Computerised. Induction to include instruction by training clinicians – trainee should state name of clinician with whom discussed entry

Documentation of consent /non consent to sharing information with non-NHS organisations

Read coding where available

Annual Record Keeping Audit – Frinton road Medical Practice Services Recommendations Actions Repeat the audit in one year


Next of Kin Details To incorporate Next of Kin Details on the New Patient Questionnaire, and other questionnaires given out by the practice, so that details can be added to the patient record.

Lack of capacity, due to Mental Capacity Act 2005

Make all clinical team aware of the need to record why consent was not agreed, due to lack of capacity, under the Mental Capacity Act 2005, including the basis upon which treatment decisions were made.

Annual Record Keeping Audit – Tissue Viability Services Recommendations Actions Repeat the audit in one year


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Nurses to be aware to document all relevant medication, doses and frequency

Clearly document that the patient has either consented or de-consented to their information being shared with other non NHS organisations

Nurses to clearly document that the patient has either consented or de-consented to their information being shared with other non NHS organisations

Service Users Feedback on Child Health (Childrens Health and Wellbeing Services) Recommendations Actions No Recommendations identified. to be implemented at this time

No actions identified

Service Users Feedback on Immunisation Sessions (Childrens Health and Wellbeing Services) Recommendations Actions No Recommendations identified. to be implemented at this time

No actions identified

Productive ward Audits for St Osyth Priory Ward Recommendations Actions Patient Status at a Glance The “white board” Handover sheet Re-audit handover sheet

Updated every day as changes occur Updated every night, more frequently if required None at present

Patient Observations Staff to ensure that all areas of chart are completed.

Well Organised Ward None Required Knowing How We Are Doing None Required Ward Rounds Consultants will undertake ward round on designated day. Ward round will not interfere with patient meals

Consultants will ensure ward is aware if day needs to change. Consultants made aware that they cannot undertake round during patient meal times

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Productive ward Audits for Durban Ward Recommendations Actions Patient Status at a Glance The “white board” Handover sheet Re-audit handover sheet

Updated every day as changes occur Updated every night, more frequently if required None at present

Patient Observations Staff to ensure that all areas of chart are completed.

Well Organised Ward None Required Knowing How We Are Doing None Required Ward Rounds Consultants will undertake ward round on designated day. Ward round will not interfere with patient meals

Consultants will ensure ward is aware if day needs to change. Consultants made aware that they cannot undertake round during patient meal times

Blood transfusion Audit Recommendations Actions Planned meeting with Doctors within the first working week at Clacton Hospital

Lead Nurse for Blood transfusions to be advised by Dr Rasool / Dr Chan Personal Assistant when New doctors are due to start and book a 1 hour discussion slot

Clear accurate records to be held by ACE of all staff who have attended blood transfusion updates and are competent in caring for patients receiving a transfusion.

Clinical Training and development will update the register held every time a member of staff attends an update or renews competency.

All bleep holders must be up to date with transfusion training and have a valid competency.

Clinical Matron and line managers MUST ensure that if a member of staff is requested to hold the bleep they meet the transfusion requirements. Staff who are not up to date must state this if asked to carry the hospital bleep

Transfusions to only take place when ward doctors are on duty.

Transfusions only to take place between 0800 and 2000hrs Monday to Friday.

To look at alternative ways of supporting staff to maintain competencies and up to date training

e-learning and regular classroom updates.

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Access Time for Rehabilitation referrals Medical Wards Clacton Re - Audit Appropriateness of referrals to OT and Physio from Care of the Elderly wards at Clacton Hospital Audit (combined ) Recommendations Actions Share the report

Circulate this audit report to Physiotherapy and Occupational Therapy inpatient teams and relevant professionals

Further discussion regarding arrangements, competencies and work allocation for cover of staff annual leave and ensuring this is incorporated into department planning and standards of care.

Discussion and arrangements to be discussed with rehabilitation Services manager in the first instance

Repeat the audit to ensure improvements and quality of service. If a significant difference continues, it may indicate that further investigation and changes might be needed.

Re audit using same methodology. Discuss with Clinical Services manager if systmone inputting needs adjustment to assist with identifying cause of delays. Verify with management if Occupational Therapist and physiotherapist should be covered in the same audit, or separate audits and if they wish to use the same standards.

Spinal Triage Outcomes (Community Services) Recommendations Actions To develop/include a checklist of required information to the MRI magnetic resonance imaging Request Form

Compilation of list

To develop/include a checklist of required information to the X-Ray (for spine) Request Form

Complete

Reject referrals that are not on a fully completed current spinal pathway referral form or documented on a full referral letter

Letter to all GPs

To develop series of workshops and/or paper based information for GP's giving top-tips on the spinal pathway and spinal problems.

Workshops need to be discussed with Practice Based Commissioning team. The top tips can be written separately

School Teachers Presenting with Voice Problems Recommendations Actions To endeavour to see if there is a viable business / health promotion opportunity to give voice care advice to schools

Audit results to be discussed at the Integrated Governance Committee to determine if suitable for development.

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Podiatry Service Re-Profiling, New Patient Audit (Community Services) Recommendations Actions Share audit results with the Podiatry team, ensure those not attending have access to results

Presentation of audit to Podiatry Staff – Admin and Clinical staff. Results included in minutes of meeting circulated to all staff members

Podiatry DNA (Did Not Attend) policy brought in line with Provider services Policy

Ensure all clinical and admin staff are aware of the Provider services DNA (Did Not Attend) policy and ensure all new patient letters reflect this policy.

Change in discharge system - Administration team (previously clinical staff) to undertake discharging of patients off system one and ending referral

Agreement of change of admin roles regarding discharging patients required from both clinical and admin staff. A system of communicating which people are for discharge needs to be implemented.

X-ray Request Audit (Community Services) Recommendations Actions Share results with podiatry team to identify how improvements can be made

Presentation of results at staff meeting, ensure those not attending meeting have access to the results.

Identify where information about x-ray requests should be placed within patient record

Discussion with staff at staff meeting and decide on location within patient record for information regarding rationale and follow-up of x-rays.

Encourage appropriate recording of thought process in patient record

Ensure staff are aware of what level of information is required in the patient record and that staff are up to date on their mandatory training on record keeping.

Assess whether recording of x-rays has improved

Submit an audit proposal Carry out re-audit

X-ray Request Re - Audit (Community Services) Recommendations Actions Share results with podiatry team, showing how our recording has improved over the past year

Presentation of results at staff meeting, ensure those not attending meeting have access to the results.

Encourage continued recording of thought process in patient record

Ensure staff are aware of what level of information is required in the patient record and that staff are up to date on their mandatory training on record keeping

71

In accordance with IRMER (requirements, assess whether Ionizing Radiation (Medical Exposure) Regulations) recording of x-rays continues to improve

Submit an audit proposal Carry out re-audit in a years

Review of use of Catheterisation Record Audit Recommendations Actions Nurses should always be aware of rationale for catheter – need to make sure they do or they find out

High Impact Actions catheter plan – active

Catheters need to be documented in nursing notes - encourage and monitor


Catheters need to be documented in medical notes - encourage and monitor


Should always be review of catheter or reason why not - monitor High Impact Actions catheter plan – active

Improved liaison between Colchester Hospital University Foundation Trust and Anglian Community Enterprise. Perhaps co-ordinate paperwork


Ensure enough supplies in patient home, but not excessive amounts of bags/valves/catheters etc


Bowel Care Audit Recommendations Actions Repeat the audit in one year

Continence Team to complete audit of Community Hospitals and Community patients within the agreed timeframe. Data analysis & collation of final report to be carried out by Nurse Specialist – Continence with guidance from Clinical Audit department

To update the questionnaire as appropriate.

Documentation from evidence based practice, national guidelines and good practice to be incorporated

All areas to be working to and implementing action plans based on individual results.

Action plans to be put in place for all service areas to improve on information gathered in the documentation.

All staff to attend Bowel Management training where appropriate (all staff should be able to evidence their competence and knowledge in this area)

Bowel Management course should be complete by all clinical staff. Details and relevant application forms can be found on the Training & Education intranet site.

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To update Bowel Management Policy

Review Bowel Management Policy against outcomes of Audit and National guidance taking into consideration any comments received.

Quality of Dental Radiographs Audit (Specialist Services) Recommendations Actions To check operator issues To rectify over exposure and under

exposure issues with the equipment To check display functions. To rectify over exposure and under

exposure issues with the equipment Prescribing Audit (Specialist Services) Recommendations Actions Improve patient safety by standardising drugs and regimens prescribed and share best practice. Outliers will be identified

This second audit had reduced the incidence of outliers.It was decided to continue the audit and revisit annually. Prescribing regimens had become more consistent. It was agreed that guidelines for this group would not be written as an independent document but clinicians should follow guidance in the British National Formularly.

Diabetes Inequalities Project (Specialist Services) Recommendations Actions The pilot is rolled out as a permanent project across the Anglian Community Enterpriseand becomes part of the service delivered by the specialist diabetes team.

The pilot is rolled out as a permanent project across the Anglian Community Enterprise and becomes part of the service delivered by the specialist diabetes team.

All patients should be referred by their GP practices according to need

All patients should be referred by their GP practices according to need

All patients identified as having an HbA1c (The most common test is the HbA1c test, which indicates your blood glucose levels for the previous two to three months.) more than9% or less than 6% including hard to reach are referred to the service

All patients identified as having an HbA1c (The most common test is the HbA1c test, which indicates your blood glucose levels for the previous two to three months.)more than 9% or less than 6% including hard to reach are referred to the service

PARR++ (Patients at Risk of Readmission) is used across North East Essex to identify patients who have high admissions and require support

PARR++(Patients at Risk of Readmission) is used across North East Essex to identify patients who have high admissions and require support

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To reduce sudden impact on service, the team to be allocated a group of practices to provide continuity of care.

Practices to be introduced onto the scheme in a stepped approach according to QoF (Quality Outcomes Framework) results and which practices show greater numbers of patients more than 9%.

Personalised Care Plan Audit Recommendations Actions Report all results to all team members within each speciality

Cascade at team meetings

Undertake Pilot of New PHP (Personalised Health Plan) documentation

In all areas pilot the new PHP (Personalised Health Plan) documentation

Reinforce to all team members Team Leaders to feedback full results to all team members

Activity on referrals for Dysphasia Audit Recommendations Actions Establish whether Royal College Speech and Language Therapy guidance re response times is appropriate to a Community Learning Disability service. Agree response times for Adult Services

Discuss with the Adult Acquired Speech and Language Therapy Team to develop a consistent approach across Adult services. Follow and contribute to the National debate and with Royal College Speech and Language Therapy as to National guidance Be informed by Service Specification currently being discussed with Learning Disability Commissioners

Develop system to record factors influencing clinical judgement as to urgency of referrals in order to maintain consistency & transparency

Identify & record the factors to be considered when making a decision regarding urgency Develop appropriate paperwork to be used in conjunction with the Case, caseload and workload indicators for Speech and Language Therapy Investigate whether it is advisable to save this onto the Community Information System

Establish guidelines and consistency within the Speech Language Therapy team as to what is meant by the first ‘contact’ and when does the clock start ticking

Follow National debate and get advice from National Dysphasia advisors. Discuss within Learning Disability team and establish consistent approach and recording.

Minimise delay in receipt of referrals by the Speech and Language Therapy team

Work with other Allied Health Professionals to establish the new system of referrals after April 2010 when other Learning Disabilities colleagues move to Hertfordshire Foundation Trust.

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Ensure that all referring agents are aware of the new procedures Establish a system of quickly alerting senior clinicians as to new Dysphasia referrals

Ensure succession planning within the team for Dysphasia qualification

Train another therapist to post graduate Intermediate level in Dysphasia

Aseptic Non Touch Technique - Principles of Best Practice for Clinical Procedures (Learning Disabilities- Allied Health Professionals) Recommendations Actions Report all results to all team members within each speciality

Cascade at team meetings

Undertake Pilot of New Personal Health Plan documentation

In all areas pilot the new Personalised Health Plan documentation

Reinforce to all team members Team Leaders to feedback full results to all team members

Essential Steps – Compliance of Clinical Interventions (monthly audit for all Community Hospitals) Recommendations Actions Measure compliance with effective hand hygiene

Further audit requirements as identified from Aseptic Non-Touch Technique audit undertaken July /August 10. To focus on: Community hospitals – observing a range of clinical skills (as opportunity allows) clinical and non clinical staff. Community – Health Care Assistant’s undertaking wound care. Community -Clinical skills other than wound care i.e. catheterisation / enteral feeds / venepuncture / central lines.

Development of Aseptic Non-Touch Technique policy /procedure

Further development of the policy to include Aseptic Non-Touch Technique pictorial guides

To ensure all associated policies are Aseptic Non-Touch Technique compliant e.g. catheterisation Intravenous therapy, central venous access device

All relevant policies to be updated with principles

Assurance staff take part /attend appropriate learning and practice activities to effectively maintain and develop competence and performance relating to Aseptic Non-Touch Technique

Bench mark practice - % of clinical staff attending existing clinical skills training past 3 years/and or attained competency against the number staff undertaking /expected to use this skill in their practice.

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Focus on 5 key areas – wound care TIME (Tissue management; Inflammation and infection control; Moisture balance; Epithelial) Leg ulcer), catheterisation (links to urinary catheter plan), Intravenous therapy / central lines, enteral feeds. Declaration of competency’ work in progress (Community nursing)

Delivery of Aseptic Non-Touch Technique principles to clinical staff ensuring staff have up to date knowledge and skills when undertaking clinical skills.

Raising awareness: Development of Aseptic Non-Touch Technique workshops. (Timetable of workshop delivery (hospital and community). Stands/display lunch periods Consider e-learning programme to support clinical skills training.

Develop Aseptic Non-Touch Technique Assessors

Identify Aseptic Non-Touch Technique assessors for hospital & community. Consider TV link practitioners Train the assessor programme in Aseptic Non-Touch Technique

Aseptic Non-Touch Technique Training & competency assessment available to all staff (includes Clinical staff new to the trust and newly qualified staff – preceptorship –links to above i.e. establishing the trust standard for clinical staff attending essential clinical skills training to be arranged.

Development of Aseptic Non-Touch Technique training session for clinical staff. Train the Aseptic Non-Touch Technique assessors Update preceptorship packs to ensure Aseptic Non-Touch Technique compliant.

All existing clinical skills training to incorporate Aseptic Non-Touch Technique principles

Incorporate Aseptic Non-Touch Technique into existing learning packages and clinical skills training Professional Practice Portfolios, catheterisation, Intravenous therapy, and venepuncture. Standard statement in introduction of learning packages and adjust competency accordingly.

Provision of wound care training and competency assessment for clinical staff. Aseptic Non-Touch Technique (compliant)

Develop general wound care training / learning package / Professional Practice Portfolios, /competency benchmark / for (Aseptic Non-Touch Technique compliant)? Incorporate into existing TIME (Tissue management; Inflammation and infection control; Moisture balance; Epithelial) Leg ulcer) training or workbook that includes general wound care including dressings.

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Medical Devices Audit Recommendations Actions Overdue bed maintenance Discuss with EBME (Electro-Biomedical

Engineering- hospital equipment technicians Manager the need to ensure beds are checked as per the agreed Service Level Agreement

Revise staff training records Update competency statements Remove old Continuous Passive Motion machine and arrange Disposal

Contact Porters

Add new armchair to asset register

Update the planet system

Arrange repair of urine analyser

To order spare parts

Area Month Preventing the

Spread of Infection

Enteral Feeding

Urinary Catheter Care

- Insertion

Urinary Catheter Care - Continuing

Care

Central Venous -

Ongoing Care

Peripheral Intravenous Cannula - Insertion

Peripheral Intravenous Cannula - Ongoing

Number of

Returns Teams Submitted

Number of

Teams

Community Hospitals April (25/25) 100.0% (20/20) 100.0% (7/7) 100.0% (20/20) 100.0% (5/5) 100.0% (13/14) 92.9% (19/19) 100.0% (28/28) 100.0% 5

May (24/25) 96.0% (15/15) 100.0% (13/13) 100.0% (20/20) 100.0% (5/5) 100.0% (15/15) 100.0% (20/23) 87.0% (28/28) 100.0% 5

June (25/25) 100.0% (7/7) 100.0% (9/9) 100.0% (20/20) 100.0% (5/5) 100.0% (16/17) 94.1% (16/16) 100.0% (28/28) 100.0% 5

July (25/25) 100.0% (15/15) 100.0% (6/6) 100.0% (20/20) 100.0% (5/5) 100.0% (14/15) 93.3% (16/16) 100.0% (28/28) 100.0% 5

August (25/25) 100.0% (6/6) 100.0% (7/7) 100.0% (20/20) 100.0% (5/5) 100.0% (8/8) 100.0% (13/13) 100.0% (28/28) 100.0% 5

September (25/25) 100.0% (4/4) 100.0% (7/7) 100.0% (20/20) 100.0% (5/5) 100.0% (12/13) 92.3% (18/18) 100.0% (28/28) 100.0% 5

October (25/25) 100.0% (6/6) 100.0% (8/8) 100.0% (20/20) 100.0% (5/5) 100.0% (14/14) 100.0% (16/16) 100.0% (28/28) 100.0% 5

November (22/22) 100.0% (5/5) 100.0% (11/11) 100.0% (16/16) 100.0% (5/5) 100.0% (15/15) 100.0% (16/16) 100.0% (28/28) 100.0% 5

December (25/25) 100.0% (5/5) 100.0% (14/14) 100.0% (20/20) 100.0% (5/5) 100.0% (17/17) 100.0% (21/21) 100.0% (28/28) 100.0% 5

January (25/25) 100.0% (2/2) 100.0% (10/10) 100.0% (20/20) 100.0% (5/5) 100.0% (10/10) 100.0% (13/13) 100.0% (28/28) 100.0% 5

Community Nursing

April (55/55) 100.0% (3/3) 100.0% (18/18) 100.0% (19/19) 100.0% (0/0) No Op (0/0) No Op (0/0) No Op (68/68) 100.0% 12

May (56/56) 100.0% (1/1) 100.0% (17/17) 100.0% (17/17) 100.0% (2/2) 100.0% (0/0) No Op (0/0) No Op (68/68) 100.0% 12

June (52/52) 100.0% (5/5) 100.0% (18/18) 100.0% (12/12) 100.0% (4/4) 100.0% (0/0) No Op (2/2) 100.0% (68/68) 100.0% 12

July (52/52) 100.0% (5/5) 100.0% (25/25) 100.0% (16/16) 100.0% (1/1) 100.0% (0/0) No Op (0/0) No Op (68/68) 100.0% 12

August (46/48) 95.8% (5/5) 100.0% (9/9) 100.0% (12/12) 100.0% (1/1) 100.0% (0/0) No Op (0/0) No Op (75/75) 100.0% 13

September (52/52) 100.0% (5/5) 100.0% (15/15) 100.0% (21/21) 100.0% (2/2) 100.0% (0/0) No Op (0/0) No Op (68/68) 100.0% 12

October (52/52) 100.0% (4/4) 100.0% (17/17) 100.0% (12/13) 92.3% (7/7) 100.0% (0/0) No Op (0/0) No Op (68/68) 100.0% 12

November (52/52) 100.0% (4/4) 100.0% (18/18) 100.0% (14/14) 100.0% (5/5) 100.0% (0/0) No Op (0/0) No Op (68/68) 100.0% 12

December (46/46) 100.0% (0/0) No Op (14/14) 100.0% (4/4) 100.0% (3/3) 100.0% (0/0) No Op (0/0) No Op (68/68) 100.0% 12

January (47/47) 100.0% (2/2) 100.0% (13/13) 100.0% (13/13) 100.0% (3/3) 100.0% (0/0) No Op (0/0) No Op (68/68) 100.0% 12

Appendix 2 Essential Standards Monitoring

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78


Spread of Infection

Enteral Feeding


- Insertion


Care

Central Venous -

Ongoing Care



Number of


Number of

Teams

Children's Services April (42/42) 100.0% (13/13) 100.0% 13

May (40/40) 100.0% (13/13) 100.0% 13

June (42/42) 100.0% (13/13) 100.0% 13

July (37/37) 100.0% (13/13) 100.0% 13

August (40/40) 100.0% (13/13) 100.0% 13

September (44/44) 100.0% (13/13) 100.0% 13

October (41/41) 100.0% (13/13) 100.0% 13

November (39/39) 100.0% (13/13) 100.0% 13

December (46/46) 100.0% (12/12) 100.0% 12

January (45/45) 100.0% (11/11) 100.0% 11

Learning Disabilities

April (6/6) 100.0% (2/6) 33.3% 6

May (20/20) 100.0% (6/6) 100.0% 6

June (20/20) 100.0% (6/6) 100.0% 6

July (16/16) 100.0% (6/6) 100.0% 6

August (16/16) 100.0% (6/6) 100.0% 6

September (17/17) 100.0% (6/6) 100.0% 6

October (15/15) 100.0% (6/6) 100.0% 6

November (15/15) 100.0% (6/6) 100.0% 6

December (16/16) 100.0% (6/6) 100.0% 6

January (20/20) 100.0% (6/6) 100.0% 6

79


Spread of Infection

Enteral Feeding


- Insertion


Care

Central Venous -

Ongoing Care



Number of


Number of

Teams

Children's AHP Services April (10/10) 100.0% (3/3) 100.0% 3

May (12/12) 100.0% (3/3) 100.0% 3

June (10/10) 100.0% (3/3) 100.0% 3

July (10/10) 100.0% (3/3) 100.0% 3

August (10/10) 100.0% (3/3) 100.0% 3

September (10/10) 100.0% (3/3) 100.0% 3

October (10/10) 100.0% (3/3) 100.0% 3

November (10/10) 100.0% (3/3) 100.0% 3

December (11/11) 100.0% (3/3) 100.0% 3

January (10/10) 100.0% (3/3) 100.0% 3

Specialist Services

April (19/19) 100.0% (6/6) 100.0% 6

May (19/19) 100.0% (6/6) 100.0% 6

June (21/21) 100.0% (6/6) 100.0% 6

July (19/19) 100.0% (6/6) 100.0% 6

August (21/21) 100.0% (6/6) 100.0% 6

September (22/22) 100.0% (6/6) 100.0% 6

October (22/22) 100.0% (6/6) 100.0% 6

November (22/22) 100.0% (6/6) 100.0% 6

December (25/25) 100.0% (6/6) 100.0% 6

January (25/25) 100.0% (6/6) 100.0% 6


Spread of Infection

Enteral Feeding


- Insertion


Care

Central Venous -

Ongoing Care



Number of


Number of

Teams

Rehabilitation (Adult)

April (14/15) 93.3% (3/3) 100.0% 3

May (14/15) 93.3% (3/3) 100.0% 3

June (15/15) 100.0% (3/3) 100.0% 3

July (11/15) 73.3% (3/3) 100.0% 3

August (15/15) 100.0% (3/3) 100.0% 3

September (15/15) 100.0% (3/3) 100.0% 3

October (15/15) 100.0% (3/3) 100.0% 3

November (15/15) 100.0% (3/3) 100.0% 3

December (15/15) 100.0% (3/3) 100.0% 3

January (15/15) 100.0% (3/3) 100.0% 3

Minor Injuries Unit Clacton

April (5/5) 100.0% (1/1) 100.0% 1

May (3/5) 60.0% (1/1) 100.0% 1

June (5/5) 100.0% (1/1) 100.0% 1

July (5/5) 100.0% (1/1) 100.0% 1

August (5/5) 100.0% (1/1) 100.0% 1

September (5/5) 100.0% (1/1) 100.0% 1

October (4/4) 100.0% (1/1) 100.0% 1

November (5/5) 100.0% (1/1) 100.0% 1

December (5/5) 100.0% (1/1) 100.0% 1

January (5/5) 100.0% (1/1) 100.0% 1

80


Spread of Infection

Enteral Feeding


- Insertion


Care

Central Venous -

Ongoing Care



Number of


Number of

Teams

PMS Practices April (8/8) 100.0% (2/2) 100.0% 2

May (6/6) 100.0% (2/2) 100.0% 2

June (6/6) 100.0% (2/2) 100.0% 2

July (6/6) 100.0% (2/2) 100.0% 2

August (6/6) 100.0% (2/2) 100.0% 2

September (10/10) 100.0% (2/2) 100.0% 2

October (8/8) 100.0% (2/2) 100.0% 2

November (8/8) 100.0% (2/2) 100.0% 2

December (6/6) 100.0% (2/2) 100.0% 2

January (6/6) 100.0% (2/2) 100.0% 2

Green Elms

April (0/0) No Op (1/1) 100.0% 1

May (0/0) No Op (1/1) 100.0% 1

June (0/0) No Op (1/1) 100.0% 1

July (0/0) No Op (1/1) 100.0% 1

August (0/0) No Op (1/1) 100.0% 1

September (0/0) No Op (1/1) 100.0% 1

October (0/0) No Op (1/1) 100.0% 1

November (0/0) No Op (1/1) 100.0% 1

December (2/3) 66.7% (1/1) 100.0% 1

January (5/5) 100.0% (1/1) 100.0% 1

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Spread of Infection

Enteral Feeding


- Insertion


Care

Central Venous -

Ongoing Care



Number of


Number of

Teams

OVERALL TOTAL April (184/185) 99.5% (23/23) 100.0% (25/25) 100.0% (39/39) 100.0% (5/5) 100.0% (13/14) 92.9% (19/19) 100.0% (127/131) 96.9% 52

May (194/198) 98.0% (16/16) 100.0% (30/30) 100.0% (37/37) 100.0% (7/7) 100.0% (15/15) 100.0% (20/23) 87.0% (131/131) 100.0% 52

June (196/196) 100.0% (12/12) 100.0% (27/27) 100.0% (32/32) 100.0% (9/9) 100.0% (16/17) 94.1% (18/18) 100.0% (131/131) 100.0% 52

July (181/185) 97.8% (20/20) 100.0% (31/31) 100.0% (36/36) 100.0% (6/6) 100.0% (14/15) 93.3% (16/16) 100.0% (131/131) 100.0% 52

August (184/186) 98.9% (11/11) 100.0% (16/16) 100.0% (32/32) 100.0% (6/6) 100.0% (8/8) 100.0% (13/13) 100.0% (138/138) 100.0% 53

September (200/200) 100.0% (9/9) 100.0% (22/22) 100.0% (41/41) 100.0% (7/7) 100.0% (12/13) 92.3% (18/18) 100.0% (131/131) 100.0% 52

October (192/192) 100.0% (10/10) 100.0% (25/25) 100.0% (32/33) 97.0% (12/12) 100.0% (14/14) 100.0% (16/16) 100.0% (131/131) 100.0% 52

November (188/188) 100.0% (9/9) 100.0% (29/29) 100.0% (30/30) 100.0% (10/10) 100.0% (15/15) 100.0% (16/16) 100.0% (131/131) 100.0% 52

December (197/198) 99.5% (5/5) 100.0% (28/28) 100.0% (24/24) 100.0% (8/8) 100.0% (17/17) 100.0% (21/21) 100.0% (130/130) 100.0% 51

January (203/203) 100.0% (4/4) 100.0% (23/23) 100.0% (33/33) 100.0% (8/8) 100.0% (10/10) 100.0% (13/13) 100.0% (129/129) 100.0% 50

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NOTES

Columns 1 - 7:

Figures in brackets e.g. (4/7) 57% There were 7 opportunities to undertake all the elements within the respective clinical intervention. Four were carried out correctly but during three of the opportunities there were some elements either missed or carried out incorrectly.

No Op:

This is recorded where the team have not had any patients with an invasive device.

Column 8: Number of returns teams submitted

This indicates how many teams within the particular service have sent in returns. The figures in the brackets i.e. (63 / 73) indicate that 73 returns were expected but only 63 were returned (NB Within some services there are teams that only undertake the essential steps relevant to their practice).

Column 9: Number of Teams

This represents the number of teams in the service.

IMPORTANT Precise detail of data indicating individual team’s performance in each essential step and the number of opportunities available is held electronically by the heads of

service and also sent to The Infection Prevention and Control team.

PLEASE NOTE In August 2010 the Community Nursing teams were restructured. Brightlingsea team became Brightlingsea & Gt Bentley, Mistley & Gt Bentley became Mistley & Harwich. Walton, Frinton & Harwich became Frinton & Walton. Data prior to August 2010 reflects the old teams, whereas data post August 2010 reflects the new teams.

Green = 100.0% Amber Btw 95.0% 99.9% Red < 95.0%

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Appendix 3 Action Plan for the CQC Improvement Report Reference Number FRR-9C20:5PW-1-3 CQC Review of Compliance Reference Number – 1-112824377

Update Date – 30th September 2010 Owner – Denise Hagel, Interim Director of Clinical Services

Regulation

Outcome

Actions to achieve compliance and

timescales

Lead

Progress

Status

12 8 Why CQC have

concerns The outcome for people that should be achieved

The staff survey results 2008/9 highlights that the perception of the availability of hand washing facilities was worse for this trust compared with other similar trusts.

The trust must demonstrate that activities within the trust staff survey action plan address these concerns and that the trust complies with the requirements of the Code of Practice for Health and Adult Social Care on the prevention and control of infections and related prevention and control of infections related guidance including provision of sufficient hand washing facilities.

During 2009/10 hand hygiene packs containing hand wash, soap and moisturising cream were issued to all peripatetic staff working in the community. These packs were purchased so that staff who could not be guaranteed hand washing facilities out ‘in the field’ i.e. in patients homes were enabled to follow high quality and safe practice.

Jane Bazzali Head of Infection Prevention and Control

Compliant Completed

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Packs are topped up by the individual teams as required. In all clinic bases and hospital wards hand hygiene facilities are available together with hand gel. Weekly audits are undertaken across all ward areas for correct hand hygiene procedures – compliance with hand hygiene best practice observations is consistently 100%. A further audit to assess hand washing facilities in non clinical bases is to be carried out in June 2010. In terms of Infection Prevention and Control training the 2009 staff survey indicates an increase of 12% from the 2008 survey in staff accessing this training within the last 12 months.

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In terms of staff access to hand hygiene materials; the 2009 staff survey indicates an increase of 6% from 2008 in ‘always being able to access facilities.’ The Hand Hygiene and Infection Prevention and Control Policies were highly praised by the NSHLA assessment which took place in March 2010 following which NEEPS obtained level 1 compliance of the NHSLA Risk Management Standards.

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Regulation

Outcome


timescales

Lead

Progress

Status

23 14 Why CQC have


In the staff survey results 2008/09 show that the trust was consistently in the worst 20% of issues relating to staffing such as staff appraisals, work-related stress, staff experiencing verbal or physical abuse, work related injury, harassment or support from immediate managers.

The trust must demonstrate that activities contained within the trust staff survey action plan address these concerns and that the trust ensures that staff are properly trained, supervised and appraised to provide high quality patient care to people who use services.

Following the publication of the 2008/09 staff survey a small staff working group lead by HR and the Joint Staff Council was established in order to take forward the developments in response to staff concerns. A new ‘Managing Stress’ Policy was implemented, together with ‘Dealing with Stress’ workshops designed to support staff and managers in identifying and dealing with stress. Each year we also hold a number of staff ‘Pamper Days’, these include head massages, manicures etc. in order to help reduce staff stress.

Carole Hughes Interim Director of Human Resources

The ‘Stress Management Policy’ has been implemented within NEEPS and has also been assessed – and passed - at NHSLA level 1. The ‘dealing with stress’ workshops have been rolled out and information about these can be found internally within our Training and Education Directory. NEEPS held its latest Health and Wellbeing day on Friday, 24th September. HR have also introduced a ‘Wellbeing at Work’ scheme, run in-house by Occupational Health, to help identify recurring staff issues - such as headaches – and offer advice and guidance.

All completed - compliant

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In addition, staff are encouraged to access NEEPS health trainers for advice and support for weight management, smoking cessation and health & well being strategies. The approach to appraisals has been simplified and a new process is being implemented. The completion of appraisals for all those with more than one year service will take place between May and July. Performance is to be fed back during Corporate Management Team monthly meetings.

The simplified appraisal approach has meant that the % of completed appraisals this year has increased significantly and now stands at 81% for all staff with more than on year service. Appraisal uptake and completion is now monitored at the monthly Corporate Management Team meetings.

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The 2009 staff survey shows a 10% increase in staff having had an appraisal in the past 12 months, with and increase of 4% of staff reporting they feel very satisfied with the level of support their manager gives. The level of physical abuse was high in earlier years due to the learning disabilities service which has now been transferred to another NHS provider as part of a tender process. The LD staff who remain continue to have PI training - the type and level of training is being reviewed during 2010. E-learning is being piloted and will develop during 2010.

No change from this progress report as staff surveys are annual. The Physical Intervention training for LD staff is mandatory on an annual basis for all relevant staff. Information about these courses, including the training grid which advises levels of training required, is available in our in-house training directory. Updates of mandatory training are monitored. E-learning has been implemented. The SHA has asked NEEPS as an exemplar to be represented on the SHA e-learning project group to offer guidance.

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The 2009 staff survey shows a 6% decrease in staff experience of violence from patients/service users in the past 12 months. The health and wellbeing agenda within NEEPS will continue to look at stress reduction and improving mental health well being.

No change from this progress report as staff surveys are annual. The introduction of the ‘Wellbeing at Work’ project, which commenced in August 2010 run by Occupational Health, will help support stress reduction and improving mental health wellbeing.

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Regulation

Outcome


timescales

Lead

Progress

Status

10 16 Why CQC have


The trust scored worse in the staff survey 2008/09 than similar providers for fairness and effectiveness of procedures for reporting errors, near misses or incidents.

The trust must demonstrate that activities contained within the trust staff survey action plan address these concerns and that the trust ensures that patients benefit from safe, quality care treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

NEEPS was granted the Right to request to become a social enterprise by the PCT Board in March 2010. As part of the transition work programme for NEEPS to become a social enterprise by Jan 2011, we are currently undertaking a full review of our Incident Reporting and Management Policy and Serious Untoward Incident Policy. The processes will be more transparent and easier to follow (by August 2010)

Elaiyne Jennings, Interim Head of Patient Experience and Risk Management

As part of the NEEPs transition to become a social enterprise in January 2011, NHS North East Essex has approved the move into shadow form from 1st October 2010. As part of the approval process a Due Diligence Review was undertaken by Price Waterhouse Cooper, the report rated the organisation as Green on arrangements for Clinical Governance and Risk Management. Work has been completed in respect of the review of the risk management strategy and policy and the Serious Incident handling Policy.

In progress - AMBER

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The Risk Management Strategy will also be reviewed in the next three months. NEEPS is currently in the process of purchasing its own Datix system in preparation for its separation from the commissioning PCT.

Both policies are due to be presented for approval at the IGC meeting on 4 October 2010 and will be effective during the ‘shadow’ phase. During the ‘shadow’ phase all risk management policies and processes will undergo a further review to ensure that they are fit for purpose and enable ownership at all levels of the organisation and this will include the Incident Reporting/ Management Policy. Completed. The purchase of a ‘stand alone’ DATIX system has been approved. The intention is to take this forward as part of the overall review of Policies and Processes within Risk Management and will be completed during the ‘Shadow phase’.

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Once this is achieved, there will be a further roll out of Datix web to enable more staff can access this easier and more user friendly reporting system. DATIX training will be part of the roll out programme (NEEPS stand alone Datix system to be in place by end of September 2010) NEEPS has a designated risk management team who will work to raise the profile of incident reporting within the organisation. They will also be a driving force for ensuring lessons are learned through trend analysis and dissemination of those findings (continuous).

Datix training will take place during ‘Shadow’ phase. Confirmed – in place.

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Appendix 4

Strategic Objectives

2010-2015

1. Survive and Thrive To manage the business to ensure continual and ongoing viability

2. With you, not to you To deliver safe, high quality care

3. Keep lean, keep keen To continually develop efficient services that meet customer needs

4. One enterprise, one purpose, one voice To develop a culture where we are one team with a common purpose

5. Make and measure social impact To make a social investment

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Appendix 5

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Appendix 5 (contd)

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Appendix 6

EQ5d Health Questionnaire By placing a tick in one box in each group below, please indicate which statements best describe your own health state today. Mobility I have no problems in walking about I have some problems in walking about I am confined to bed Self-Care I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself Usual Activities (e.g. work, study, housework, family or leisure activities) I have no problem with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities Pain/Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed © EuroQoL Group 1990

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To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today © EuroQoL Group 1990

9 0

8 0

7 0

6 0

5 0

4 0

3 0

2 0

1 0

100

Worst Imaginablehealth state

0

Best Imaginablehealth state

Your own health state

today

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Appendix 7

Monitoring Clinical Outcomes.

This form is to be used to notify the Quality Improvement Team of the outcomes of Clinical

Audits, which have taken place. These will be entered on the Trust’s Clinical Audit Database. The purpose of the database is to:

• Facilitate Clinicians to record their audit activity • Avoid duplication of Audit Projects within the organisation • Ensure service improvement is based upon the most recent government

guidelines. • Enable lessons learned from projects to sensitively inform other services

across the Trust. • Inform organisational reports and the Healthcare Commission.

Patient/client/service user and staff outcomes. Q1. Has the audit led to improvements for patients/clients/service users? Yes No Don’t know

Q2. Has the audit led to a re-audit? Yes No Don’t know

Q3. Has the re-audit confirmed measurable improvements in practice following the last audit? Yes No Don’t know

Q4. Please provide details of improvements to patients/clients/service users care as a result of this audit…

100

Q5. Please provide details of improvements to staff/organisation as a result of this audit…

Protocols or Guidelines: Q6. Have protocols or guidelines been written as a result of this audit? Yes No Don’t know

Q7. If YES, please provide brief details: Guideline name

Government document utilised to create the guideline

Created by

Brief details

Approval date

Review date

Dissemination of Audit Results Q8. Please provide details of which forum/people the results were presented to…

Q9. On what date/s did this dissemination/presentation take place

Q10. Have results been disseminated to patients? Yes No

Q10a. If yes, please give brief details of dissemination to patients (method and date, and say whether done or planned):

Q10b. If NO, are there any plans to disseminate results to patients? Q11a. Are you planning a re-audit? Yes No

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Q11b. Reason, if no re-audit planned:

Potential for future work: Q12a. Proposed re-audit date: / /

Q12b. Details of any potential future work:

Q13a. Research Patient Involvement Project Other

Q13b. Details of any lessons learned: (Things you would do differently next time / any important or significant difficulties encountered at any stage of project)

Learning about Clinical Audit. Q14a. What have you learned about the Clinical Audit Process from undertaking this audit.

Name of person completing summary form: Date: / / Signature:

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Glossary of terms Acute Care/Services Services provided usually in large general hospitals with immediate access to emergency care, theatres and intensive care facilities and specialist staff. Care Quality Commission (CQC) The Care Quality Commission (CQC) replaced the Healthcare Commission, Mental Health Act Commission and the Commission for Social Care Inspection in April 2009. The CQC is the independent regulator of health and social care in England. It regulates health and adult social care services, whether provided by the NHS, local authorities, private companies or voluntary organisations. Visit: www.cqc.org.uk Clostridium Difficile (Cdiff) Clostridium Difficile (or Cdiff) is a type of bacterium, or extremely small organism that can cause serious illness and that is very difficult to treat Children's Services Services provided for the Children and families of North East Essex including Health Visiting, School Nursing, Children's Health Clinics, children who are 'Looked After' and Safeguarding Children, Paediatric Rehabilitation and Paediatric Speech and Language Therapy. This service has been crucial within North East Essex for many generations, with some well known and well respected team members. Clinical audit Clinical audit measures the quality of care and services against agreed standards and suggests or makes improvements where necessary. Commissioners Commissioners are responsible for ensuring adequate services are available for their local population by assessing needs and purchasing services. Primary care trusts are the key organisations responsible for commissioning healthcare services for their area. They commission services (including acute care, primary care and mental healthcare) for the whole of their population, with a view to improving their population’s health. Commissioning for Quality and Innovation (CQUIN) High Quality Care for All included a commitment to make a proportion of providers’ income conditional on quality and innovation, through the Commissioning for Quality and Innovation (CQUIN) payment framework. Visit: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091443 Community Services This includes Community Nurses, Matrons, Hospital staff in both Harwich and Clacton and many other services such as Physiotherapy, Minor Injury Units, Intermediate Care, Occupational Therapy, Podiatry, Falls Prevention, Physio Direct and Adult Speech and Language Therapy.

http://www.dh.gov.uk/en/Publicationsandstatistics/

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CQUIN Commissioning for Quality and Innovation (CQUIN) is a nationally agreed framework schemes linked to additional payments for successful achievement of locally agreed quality improvement initiatives. Clinical Dashboard A ‘Clinical Dashboard ‘ is a toolset of visual display developed to provide clinicians’ with the relevant and timely information they need to inform daily decisions that improve quality of patient care. DATIX DATIX is a commercial incident reporting tool system Dementia Diversion Tool (also known as ‘Tiptree Box’) An evidence based method of engaging and stimulating people with dementia, often in the form of a ‘memory box’ full of recognisable memorabilia such as photographs which has been show to reduce wandering further confusion of the patient This box is also known as The Tiptree Box named after the hospital ward it was designed on at Colchester Hospital University Foundation Trust (CHUFT). Department of Health The Department of Health is a department of the UK government but with responsibility for government policy for England alone on health, social care and the NHS. Essential Standards of Quality and Safety These standards detail what essential standards of quality and safety that people who use health and adult social care services have a right to expect. Health Economy A discrete geographical area such as North East Essex for example, where a number of health and social care providers operate. The Healthcare Quality Improvement Partnership (HQIP) Promotes clinical audit and healthcare quality improvement. HQIP is currently contracted by the Department of Health to deliver a programme of activity to reinvigorate clinical audit. Health Overview and Scrutiny Committees Since January 2003, every local authority with responsibilities for social services (150 in all) have had the power to scrutinise local health services. Overview and scrutiny committees take on the role of scrutiny of the NHS – not just major changes but the ongoing operation and planning of services. They bring democratic accountability into healthcare decisions and make the NHS more publicly accountable and responsive to local communities. Health and Wellbeing Services A team that promotes a health and wellbeing philosophy across North East Essex delivering a range of services to the population within their own community locations.

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This team provides clients with a range of options to improve their health and will often be seen at many community locations, workplaces and public events such as the Clacton Air Show. Services provided include; Smoking Cessation, Sexual Health, Weight Management classes for both adults and children, Healthy Walks, NHS Health Checks, Health Trainers, Volunteer Health Champions, School Road shows and Cornerstone. Cornerstone is a multi-agency centre where you can drop in free of charge and get general health advice, sexual health advice and much more, including a FREE health check. Healthcare Quality Improvement Partnership, HQIP, promotes clinical audit and healthcare quality improvement. HQIP is currently contracted by the Department of Health to deliver a programme of activity to reinvigorate clinical audit. High Impact Changes for Nursing A national project lead by the Chief Nursing Officer of England to ensure that nurse are contributing to innovative and evidence based practice to delivering high quality care. High Quality Care for All High Quality Care for All, published in June 2008, was the final report of the NHS Next Stage Review, a year-long process led by Lord Darzi, a respected and renowned surgeon, and around 2000 frontline staff, which involved 60,000 NHS staff, patients, stakeholders and members of the public. Integrated Governance Committee (IGC) The IGC is a sub-committee of the Provider Services Committee (PSC) and has delegated authority on behalf of the PSC to monitor the quality and safety of our services and risk management processes across NEEPS. Learning Disability Services (LD) This is a specialist service which provides holistic, person centred assessment and care for a wide range of patients including those with profound and complex needs. The service also trains other professionals and staff, including doctors and nurses, in how to communicate with and manage patients who have learning disabilities. The aim is to support all our patients to have improved health and well-being living an ordinary life in the community. Highly trained staff work in multidisciplinary teams and have a capacity for cross-boundary and cross-discipline working which is unique to this service. Patients are cared for mainly by community teams across North Essex. It also provides an intensive inpatient assessment and treatment service in Colchester as well as a Community Outreach Team based in Braintree. All referrals must be made through one of the community teams, except for inpatient assessment and treatment

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Local Involvement Networks (LINks) Local Involvement Networks (LINks) are made up of individuals and community groups which work together to improve local services. Their job is to find out what the public like and dislike about local health and social care. They will then work with the people who plan and run these services to improve them. This may involve talking directly to healthcare professionals about a service that is not being offered or suggesting ways in which an existing service could be made better. LINks also have powers to help with the tasks and to make sure changes happen. Malnutrition Malnutrition is a nutrient deficiency state of protein, energy or micronutrients (vitamins and minerals). This causes measurable harm to body composition, function or clinical outcome. Malnutrition is both a cause and consequence of ill health. We tend to visualise malnutrition as solely affecting starving children in the developing world but it is common at home, particularly in elderly and hospitalised populations and massively increases a patient's vulnerability to disease. Methicillin-Resistant Staphyloccocus Aureus (MRSA) MRSA stands for methicillin-resistant Staphylococcus aureus, which is a type of Staphylococcus aureus that is resistant to the antibacterial activity of methicillin and other related antibiotics of the penicillin class.

The treatment of infections due to Staphylococcus aureus was revolutionised in the 1940s by the introduction of the antibiotic penicillin.

However,, most strains of Staphylococcus aureus are now resistant to penicillin. This is because Staphylococcus aureus can make a substance called ß-lactamase (pronounced beta-lactamase), that degrades penicillin, destroying its antibacterial activity.

MRSA infections are a particular problem in hospitals. As with ordinary strains of Staphylococcus aureus, some patients harbour MRSA on their skin or nose without harm (such patients are said to be 'colonised').

However, these patients may develop infections if the MRSA spread to other parts of the body (eg if MRSA spread from the colonised nose to a wound). When this happens the resulting infection is described as 'endogenous'.

National Patient Safety Agency The National Patient Safety Agency is an arm’s-length body of the Department of Health, responsible for promoting patient safety wherever the NHS provides care. Visit: www.npsa.nhs.uk NHS East of England NHS East of England is the strategic health authority for the east of England, covering Bedfordshire, Cambridgeshire, Essex, Hertfordshire, Norfolk and Suffolk. NHS East of England is the regional headquarters of the NHS, and provides strategic leadership for all NHS organisations across the six counties.

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NHS Next Stage Review A review led by Lord Darzi. This was primarily a locally led process, with clinical visions published by each region of the NHS in May 2008 and a national enabling report, High Quality Care for All, published in June 2008. Non Acute Services Services that are delivered often over longer periods of time usually within community settings i.e. District Nursing or primary care i.e. GP practices. Opportunistic Survey Surveys undertaken at random to take advantage of a given situation Primary Care trust A primary care trust is an NHS organisation responsible for improving the health of local people, developing services provided by local GPs and their teams (called primary care) and making sure that other appropriate health services are in place to meet local people’s needs. Providers Providers are the organisations that provide NHS services, for example NHS trusts and their private or voluntary sector equivalents. Provider Services Anglian Community Enterprise (ACE) provides services that are aimed at, improving health, promoting well being, preventing ill health, preventing admission to hospital and providing either long term care or rehabilitation. We aim to provide this as close to the home as is safe and practical. ACE services are provided to residents of North East Essex and others, often in close collaboration with other statutory and non-statutory agencies, and are and will remain, for the most part, free at the point of use. Registration From April 2009, every NHS trust that provides healthcare directly to patients must be registered with the Care Quality Commission (CQC). In 2009/10, the CQC is registering trusts on the basis of their performance in infection control. Research Clinical research and clinical trials are an everyday part of the NHS. The people who do research are mostly the same doctors and other health professionals who treat people. A clinical trial is a particular type of research that tests one treatment against another. It may involve either patients or people in good health, or both. Secondary Uses Service The Secondary Uses Service is designed to provide anonymous patient-based data for purposes other than direct clinical care such as healthcare planning, commissioning, public health, clinical audit and governance, benchmarking, performance improvement, medical research and national policy development. Visit: www.ic.nhs.uk/services/the-secondary-uses-service-sus/using-this-service/ data-quality-dashboards

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Serious Incidents A serious incident requiring investigation is defined as an incident that occurred in relation to NHS-funded services and care resulting in one of the following:

• Unexpected or avoidable death of one or more patients, staff, visitors or members of the public;

• Serious harm to one or more patients, staff, visitors or members of the

public or where the outcome requires life-saving intervention, major surgical/medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological harm (this includes incidents graded under the NPSA definition of severe harm);

• A scenario that prevents or threatens to prevent a provider organisation’s

ability to continue to deliver healthcare services, for example, actual or potential loss of personal/organisational information, damage to property, reputation or the environment, or IT failure;

• Allegations of abuse; • Adverse media coverage or public concern about the organisation or the

wider NHS; • One of a pre-determined list of ‘Never Events’: healthcare events which

should never happen for example, wrong site surgery Social Enterprise The government defines social enterprises as "businesses with primarily social objectives whose surpluses are principally reinvested for that purpose in the business or in the community, rather than being driven by the need to maximise profit for shareholders and owners." Specialist Services A service that provides care for Patients that have certain medical conditions. The areas of expertise include Cardiac Rehabilitation, Heart Failure, Cardiac Obstructive Pulmonary Disease (COPD), Diabetes including Digital Retinal Screening, Dental, Tissue Viability / Leg Ulcer and Continence and Urology. In addition, 3 GP practices, the 2 community hospitals and the 2 MIU are managed within Specialist Services. These teams have many years experience and provides their services across all of North East Essex. Transforming Community Services The Government is committed to helping the NHS work better by extending best practice on improving discharge from acute hospital and increasing access to care and treatment in the community.

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The Transforming Community Services (TCS) programme aimed to deliver this, through supporting the NHS to empower clinicians to deliver the best outcomes and results, and put patient's needs at the heart of community services. Quality Account A Quality Accounts is produced annually in order to demonstrate to purchasers of healthcare services and the general public their quality improvement agenda. Each Quality Account contains a section looking back at how the organization performed against its stated objectives for the previous year as well as publishing its quality intentions for the coming year. Each account has internal and external scrutiny. Acknowledgements I would like to thank all those staff, managers and directors who contributed to the production of this year’s Quality Account. David Baker Patient Safety Manager May 2011

NHS North East Essex

Kennedy House

Kennedy Way

Clacton-On-Sea

Essex CO12 4AB

T : 01255 206060

previously nhs north east essex pct provider services (neeps) quality account 2010 - 2011 · 2011....

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