NHS Bolton Provider Services Quality Account 2010/11

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1 NHS Bolton Provider Services Quality Account 2010/11 1

2 Contents Page Part 1: Chief Operating Officer Statement 3 Part 2: Priorities for Improvement 12 Statements of Assurance from the Board 13 Review of Services 14 Participation in Clinical Audits 15 Research 19 Goals agreed with Commissioners 20 CQC registration 23 Data Quality 23 Part 3: Review of Quality Performance Safety Effectiveness Experience 40 2

3 1. Statement from the Chief Operating Officer NHS Bolton Provider Services is the Provider Arm of the Primary Care Trust in Bolton. We deliver a wide range of services within Bolton and some beyond our geographical boundary. We have a long history and reputation for the emphasis we place on the quality of service we provide and we always appreciate feedback from our patients, their carers and external organisations who can help us improve the way we do things. The Triple Aim Our strategy is based on the NHS Bolton triple aim of achieving better health for the population of Bolton, by delivering best care and value for money in services. These services place the patient at the centre of everything we do. We empower our staff to deliver this and we value them and invest in their development. Well motivated and well developed staff offer the best standard of care. 3

4 As a provider of Community based services for people in Bolton, our high level objectives for 2010/11 reflected this strategy. Our approach to quality in this organisation is to treat it as a journey; each year we take steps toward the achievement of excellence. We are always stretching and challenging ourselves to go beyond our targets /8 had been a year of rapid growth in our services. 2008/9 was the year in which we consolidated our service portfolio. 2009/10 was our year to improve efficiency and safety in our services. In July 2011 we will join with the Royal Bolton Hospital NHS Foundation Trust to form a new integrated care organisation called the Bolton NHS Foundation Trust. Some of the things we currently do will be done differently in the future as we manage end to end pathways of care for the benefit of patients, but both organisations already share the same ethos of service improvement, innovation and effective use of the precious resources we have. So, has been a year of preparation for service transfer, transformation and integration with our local hospital service provider. We look forward to new opportunities to work together to deliver better care for our population The quality account is designed to demonstrate to you the progress we have made in improving the way we provide the care necessary to meet your needs. As our strategy puts you at the heart of what we do, we encourage you to feedback to us your experiences both good and not so good, so that we know how satisfied you are and can plan to improve the areas that need to perform better. The safety of our services is paramount and we strive to ensure good standards of infection prevention and control. We also have the dignity of our patients at the core of how we do things. In achieving this we often ask our staff: Would you be happy for a member of your family to be treated in the service in which you work? Many of our staff live, as well as work, in Bolton so they and their families are our patients and this motivates them to strive to deliver the best possible standard of care. All staff, both clinical and non clinical, contribute to this improvement agenda and are empowered to take action to achieve it. We work with our commissioners and our partners in care provision to ensure this is ingrained in our everyday business and at the beginning of the year we agreed with our commissioners some key objectives for us to focus on. 2010/11 has seen us perform well against the majority of our objectives; others have been challenging and we have not quite met the targets we set ourselves. However, we have in all cases been able to demonstrate improvements on previous years. Some of our objectives have been impacted by changes within the NHS and by 4

5 circumstances beyond our own control. This is the reality of life in a public service. However we will continue to strive for further improvement moving forward. I hope this report gives you a flavour of the achievements and challenges we have faced on this leg of our quality journey and confirm to you that the information contained in the report is an accurate reflection of our busy and successful year delivering health care to you. Our work continues. Wendy Pickard Chief Operating Officer NHS Bolton Provider Services 5

6 Our performance during 2010/11 against a set of indicators agreed with our commissioners is as follows; The report shows the March 2011 end of year position. Best Care Indicator Target Achievement Trend Commentary To increase the number of people who set a date to quit smoking. Last Year total was 4553 This year total is 4943 Achieved To Increase the number of people who remain smoke free 4 weeks after quitting. To offer eye screening to all patients in Bolton who have diabetes. To Increase the number of young people offered screening for Chlamydia to date Achieved.Data collection continues 17 th June 100% 86% Not met The service has had staffing difficulties during the year which have impacted on this target Not met Although this target was not met Bolton has one of the highest rates of screening in Greater Manchester and we increased our number of screens by 401 over the previous year total. to 6

7 Patient Centred Care Indicator Target Achievement Trend Commentary Number of N/A 1001 Good compliments received from patients in 2010/11 Number of N/A 165 Reduction of complaints 28% 9218) received from patients in from previous year 2010/11 Best Care : Safety Indicator Target Achievement Trend Commentary No avoidable Zero cases achieved cases Annual number of cases of MRSA bacteraemia occurring in bed-based services. Annual number of cases of clostridium difficile cases in bed-based services No avoidable cases Zero cases achieved 7

8 Best Care : Outpatient and clinic access Indicator Target Achievement Trend Commentary Reduce the Zero patients One patient Good number of patients who at year end are waiting longer than the national standard of 13 weeks. Reduce the number of patients who at year end have waited more than 6 weeks for an outpatient appointment. Zero patients 5 patients good Within tolerance The percentage of patients who have been treated within 18 weeks of referral in March The percentage of patients seen by the orthopaedic service in March 2011 offered a choice of secondary care provider within 6 weeks Genito-Urinary Medicine appointment offered within 90% 99% Target exceeded 100% 80% Target not met Bolton service 100%. 100% Target met Referral numbers to this service have exceeded the contracted number and this has resulted in service pressures. 8

9 48 hours in March Number of patients waiting longer than 6 weeks for Audiology diagnostics Ashton Leigh and Wigan service 100%. 100% Target met Zero patients 5 patients Target met Within accepted tolerance Best Care : Community Equipment Access Indicator Target Achievement Trend Commentary Community loan equipment provided within 7 days 100% 99.6% Target met Within tolerance Best Care : Urgent Care Access Indicator Target Achievement Trend Commentary Walk in Centre 100% Achieved patient seen within 4 hours!00% Percentage of 95% 95.2% Achieved urgent GP Out of Hours patients clinically assessed within 20 minutes Percentage of non urgent GP out of Hours patients 95% 94.8% Narrowly missed target. Benchmarks favourably with other providers. 9

10 clinically assessed within 60 mins of call being prioritised in March Average occupancy levels of nursing beds at Darley Court Average length of stay in Darley Court nursing beds Percentage bed occupancy rate in intermediate care facilities Average length of stay in intermediate care Number of new intermediate care at home packages provided Average length of stay on intermediate care at home package step up care. Average length of stay on intermediate care at home package step 85% 92.04% Target exceeded 42 days 27 days Target exceeded 85% 94.71% Target exceeded 42 days 33 days Target exceeded 25 per month 55 Target exceeded 42 days 16 days Target exceeded 42 days 22 days Target exceeded 10

11 down care. Percentage of medicines prescribed generically in intermediate care. 85% 89.29% Target exceeded Best Care : Hospital Avoidance and early discharge Indicator Target Achievement Trend Commentary Percentage of 14.41% hospital admissions avoided by admission to Bolton Community Unit in March Number of early 120 per month 191 Target exceeded. supported hospital discharges following a stroke in March Number of very high intensity users under the care of an active case manager in March good 11

12 Value for Money Indicator Target Achievement Trend Commentary Cumulative activity for the 789, ,822 Achieved Within accepted year against tolerance plan across all services. Rate of Less than 5% 4.48% Achieved missed patient appointments Financial performance at year end Balanced Position Balanced position Achieved Value and develop staff Indicator Target Achievement Trend Commentary Percentage of Staff sickness Below 5% 6.01% Action plans in place absence Staff turnover rate Below 10% 7.56% Achieved 2. Priorities for Improvement Our priorities for improvement in 2011/12 have been agreed in partnership with the RBH NHS FT as our Community Services will be integrating with those of the Acute Trust from 1 st July The following priorities were agreed: To work together to reduce hospital mortality-many community interventions and factors have a potential impact on hospital mortality 12

13 To continue our work to reduce the number of people who do not attend their outpatient appointments-whilst we achieved our target across all services there is variation between services, highlighting areas for further improvement To improve the timeliness and quality of clinical correspondence-we have a joint plan to introduce digital dictation in Consultant-led services To improve the coverage and quality of appraisals and mandatory training for our staff To improve patient safety through the Safety Express programme Statements of Assurance from the Board During 2010/11 NHS Bolton Provider Services provided and/or subcontracted the following NHS service lines: Active Case Management Adult Audiovestibular Service Adult Audiology Anticoagulation Asylum Seeker and Refugee Specialist Nursing Service Biomechanics Bolton Community Practice (GP Services Bolton Community Unit Bolton IV Therapy Team Breast Disease Tier 2 Children s Community Nursing Community Medicines Management Community Paediatrics Complex Falls Service Community Stroke Team Continence Service Dermatology Tier 2 Service Diabetes Specialist Service Diabetes Screening Dietetics-Adults & Children District Nursing Elderly Medicine Epilepsy Specialist Nursing Expert Patient Programme Falls & Community Therapy GP Out of Hours Service Health Visiting Immunisation Team Integrated Community Equipment Service Integrated Sexual Health & Family Planning Minor Surgery 13

14 Musculo-Skeletal Therapy New born Hearing Screening Oral Health Promotion Orthopaedic CATS Paediatric Audiology Paediatric Therapy Services Palliative & End of Life Nursing and Therapy Services Podiatry Psychological Therapies Religious Circumcision Retinal Screening Rheumatology School Nursing Smoking Cessation/Stop Smoking Service Special Care Dentistry Specialist Weight Management Team Specialist Nurses-Children & Young People Speech & Language Therapy-Adults and Children The Parallel Young Person s Health Service Walk- in Centre Wheelchair Service The following Services are delivered in partnership with Bolton Council: Darley Court Nursing Beds/Intermediate Care Intermediate Care Residential Integrated Community Equipment Service Learning Disabilities Services Review of Services NHS Bolton Provider Services has reviewed all the data available to them on the quality of care in all of our service lines, representing all of the income derived from our provision of services to the people of Bolton for the period Data reviewed included the following: Care Quality Commission compliance self-assessments Equality & Diversity self-assessment Toolkit submissions Routine performance reports Provider quality and CQUINS schedules NICE compliance returns Patient surveys (for all relevant services) Staff surveys 14

15 Clinical Audit NHS Bolton Provider delivers an annual programme of clinical audit activity across all Divisions in accordance with a broad set of priorities identified by the commissioner. A central register of clinical audit activity is maintained and all practitioners undertaking audit are asked to complete an initial audit registration form and to provide regular updates on progress to the central database. At the end of the audit the audit lead is required to send a summary report to the integrated governance administrator so that key findings and learning are captured. During 2010/11 a very small number of national clinical audits covered NHS services that NHS Bolton provides. Most of the national audits relate to the acute aspects of care rather than the community-provision of care for the condition concerned. During 2010/11 NHS Bolton participated in one national clinical audit of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that NHS Bolton Provider Services was eligible to participate in during 2010/11 are as listed: National Sentinel Stroke Audit National Audit of Psychological Therapies The national clinical audit that NHS Bolton Provider Services participated in during 2010/11 was the National Sentinel Stroke Audit. The reports of 68 local clinical audits were reviewed by the Provider in 2010/11 And the Provider intends to take the following actions to improve the quality of healthcare provided: One example of audit activity from each Division is given. Further details can be provided on request. 15

16 SERVICE AUDIT TITLE FINDINGS & RECOMMENDATIONS AUDIOVESTIBULAR MEDICINE PALLIATIVE CARE THERAPY TEAM Audit of Benign Paroxysmal Positional Vertigo (BPPV) in elderly patients referred to the Adult Audiovestibular Medicine clinics Lone Worker Procedure Audit. Aim was to establish whether the members of the PCTT were adhering to the procedure-7 criteria used: Completion of prehome visit risk assessment form Recording of all home visits in departmental diary Access to work mobile and personal attack alarm Access to contact details of other team members and Duty Director Awareness of procedure to follow if incident occurs on home visit 16 Of those with probable or definite BPPV (15 patients) 100% had particle repositioning therapy There was a range of 3 months to 20 years (median 2 years) from onset of symptoms to time first seen Falls (or the absence of) were documented in 80.5% of notes 56.1% of patients had a documented history of recent falls Drug history was documented in 70.7% of notes Co-morbidity is high Lying & standing blood pressure was recorded in 90.5% of notes Actions proposed: Improve documentation of falls and drug history Fine tune the Bolton falls pathway to include diagnosis and management of vestibular pathology Raise profile of service amongst referrers to reduce the time from onset of symptoms to time referred to clinic Audit Findings & Recommendations Compliance with all 7 aspects of procedure variable Procedure required review in line with new working arrangements such as use of IT, access to lone worker devices Ensure all members of team complete mandatory training Ensure procedure for Lone Home Visits is included on the departmental induction checklist

17 Department of Audiology School Screening Audit Aware of procedure to follow if risk identified Up to date with conflict resolution mandatory training School Hearing Screening Audit The aim of the audit was to identify children who have an acquired or progressive permanent sensori-neural hearing loss at the age of 5/6 (year 1) To identify any areas of improvement in the quality of the screening programme This is an ongoing yearly audit carried out nationally and locally. Results 6 children identified and referred to the Audiology Department with sensorineural hearing loss Audit highlighted the importance of the school screening system to pick up children even when they have passed the newborn hearing screening and the fundamental role of the school nurses Research activity NHS Bolton Provider encourages and supports many clinical staff both leading and participating in research studies. The following research studies involving the NHS Bolton Provider Services were approved by the PCT in 2010/11: Title/Subject of Study Use of assistant staff in the delivery of community nursing services in England DYSCERNE NorthWest: A web based diagnostic system for rare disorders the acceptibility and feasibility of using a webbased system to facilitate the diagnosis and management of children referred from DGHs with rare multiple anomaly syndromes? The effectiveness of mirror box therapy for improving arm motor skills in children with spastic hemiparetic cerebral palsy TArgeting Synovitis in Knee OA (TASK) What are the barriers and facilitators for parents accessing local psychology services, when experiencing low mood or anxiety after the birth of their child? Speech Perception Assessments with Deaf/Hearing Impaired clients: An investigation Sponsor University of York Central Manchester University Hospitals NHS Foundation Trust Manchester Metropolitan University Salford Royal Foundation NHS Trust Lancaster University University of Wales Institute, Cardiff 17

18 into their efficacy as a clinical tool. People with Long Term Conditions (CLAHRC) This study aims to explore the experience and self care support needs and practices of socially and health disadvantaged people living with kidney disease, diabetes and/ or heart disease and to assess lay peoples systems of support and access to resources which influence engagement with services, information and coping strategies. Accomplishing Serious Case Reviews in the NHS This study aims to explore the views of NHS Named and Designated Safeguarding Children Professionals in relation to the purpose and process of producing Serious Case Reviews. The role of basic emotions in binge eating behaviours within a treatment seeking obese population. Client and clinician attachment styles and psychological mindedness Education and Training for Health and Social Care Staff in End of Life Care in North West England: a Scoping, Gap Analysis and Solution Finding Study The principal objective of this project is to scope the extent and nature of education and training for health and social care staff in North West England in End of Life Care, comparing provision with benchmark guidelines (scoping exercise). Can the presence of Cortical Auditory Evoked Potentials in infants under 3 months(corrected age) with Auditory Neuropathy Spectrum Disorder predict speech listening ability at the age of 12 months? This information would allow the clinician working with infants with Auditory Neuropathy Spectrum Disorder to use Cortical Auditory Evoked Potentials immediately after diagnosis in order to get audiological information that is currently unavailable through other assessments Intervention for Parents with Young Asthmatic Children The research evaluates an evidence based parent education and Skills training programme for parents of asthmatic children. The intervention uses the established Triple P Positive Parenting Programme. University of Manchester University of Huddersfield. University of Lancaster University of Manchester UCLAN University of Manchester Central Manchester University Hospitals NHS Foundation Trust 18

19 The number of patients receiving NHS services provided or subcontracted by the Provider during 2010/11 that were recruited during that period to participate in research approved by a research ethics committee has not been ascertained to date due to the dispersed nature of these projects and the fact that in many cases the Provider is purely acting as a Patient Identification Centre. Goals agreed with Commissioners Quality Schedules and CQUINS A proportion of NHS Bolton Provider s income in 2010/11 was conditional on achieving quality improvement and innovation goals agreed between the Provider and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Additionally the Provider Arm has worked to delivering a range of additional national quality indicators. Successful outcomes have been achieved in the following areas Ensuring sufficient appointment slots are available to cover contracted activity levels in consultant led services Delivering a Single Sex Accommodation (DSSA) Plan Contributing to a reduction in teenage conception rates by increasing the acceptance of Long Acting Reversible Contraception by women aged 18 years and under Recording the height and weight of children in reception class to address childhood obesity - 97% achieved Less than 13% patients excluded from retinal screening programme achieving 3.91% No breaches of same sex accommodation requirements No inpatient suicides by use of non collapsible rails No wrong route administration of chemotherapy No misplaced naso gastric tubes No Intravenous administration of mis -selected concentrated potassium chloride Achievement of locally agreed quality standards have been demonstrated in the following areas No issues escalated by the clinical governance group 100% of patients on an end of life pathway having a care plan Only 3.9% of consultant led clinic appointments have been cancelled by the service There is further work needed to ensure 19

20 95% of patients on an end of life pathway dying in the preferred place of death In line with Commissioning for Quality and Innovation Scheme (CQUINS) payments have been received for work undertaken to establish baseline positions in the following areas which can then be improved in 2011/12 Timeliness of discharge letters from Bolton Community Unit, Darley Court, Winifred Kettle and Alderbank Intermediate Care Units Timeliness of reporting attendance at outpatient appointments Timeliness of receipt of audiology test results The quality of discharge letters Producing an action plan to improve the timeliness and quality of clinical correspondence Compliance with the collection of a community minimum data CQC NHS Bolton Provider Services is required to register with the Care Quality Commission and is currently registered with no conditions. The Regulated Activities for which NHS Bolton Provider Services is registered are listed in the following table,: REGULATED ACTIVITY Personal Care Accommodation for persons who require nursing or personal care Treatment of disease, disorder or injury Surgical procedures Diagnostic and screening procedures Transport services, triage and medical advice provided remotely Services in slimming clinics 20

21 Nursing Care Family planning The Care Quality Commission has not taken enforcement action against NHS Bolton Provider during 2010/11. NHS Bolton Provider Services is subject to periodic reviews by the Care Quality Commission and has had no site inspections to date. NHS Bolton has participated in one special reviews or investigation by the Care Quality Commission relating to Supporting Life After Stroke, details of which are provided below: CQC Supporting Life After Stroke This review looked at the care experienced by people who have had a stroke (or TIA-which is similar to a stroke but the symptoms disappear within 24 hours) and their carers. It started from the point people prepare to leave hospital to the longterm care and support that people may need to cope with stroke-related disabilities. The overall assessment for Bolton PCT was Fair performing, numerically scoring Bolton was placed 87 th out of 151 organisations. The report looked also at Adult Social Care, as well as links to other relevant services, such as local support groups and services to help people participate in community life. The results for the areas of most relevance to the PCT Provider are shown below: Quality Marker Relevant Services Score 0-5 (5 IS Best) Management of transfer home Community-based services Early supported discharge Meeting individuals needs Support for participation in community life (care plans with outcome-focussed goals) Community stroke rehab. services Specialist rehab. services Community stroke rehab. services PCT & Commissioner joint work on Equality Impact Assessment for implementation of National Stroke Strategy Community stroke rehab. services

22 End of Life Care Range of information provided Review and assessments after transfer home Outcomes at one year (HES 1 year mortality and HES I year emergency readmissions Community Nursing & Therapy Services Community stroke rehab. services Community stroke rehab. services Community stroke rehab services The Chief Operating Officer for Provider Services prepared a response to this report in partnership with RBH FT s Medical Director-this was presented to members of the Board of NHS Bolton in March The following were identified as areas for development Meeting individual needs and improving the range of information provided to patients on transfer home-to be provided in CD/DVD format, large print, Braille, audio and different languages. Improving outcomes at 1 year, reducing SMR and emergency re-admissions at 1 year TIA care and support Systems in place for review after transfer Increasing the percentage of people with a care plan in place Increasing the percentage of people given a Helpline number Working together and integrated reviews NHS Bolton Provider s Children s Community Nursing Team participated in the National Cancer Peer Review, completing a self-assessment on 31 st August Internal Validation was undertaken on 30 th September The Operational Policy was reviewed and stated to be very clear, especially with regard to the list of CNNs and their training status. The following comments were made in the Internal Validation report: This is a well-established team that has developed significant expertise over the years. There are a high number of specialist nurses. The service regularly receives 22

23 compliments from parents who have really appreciated the standard of care and flexible nature of the service. This is clearly a dedicated team who are passionate about providing a holistic service for children and their families. No immediate risks or serious concerns were identified. The only concern noted was that the training manual was in draft, awaiting finalisation from Manchester Children s Hospital. Data Quality NHS Bolton Provider Services is not required to submit data to the Secondary Uses service for inclusion in the Hospital Episode Statistics. Information Governance NHS Bolton s score for 2010/11 for Information Quality and Records Management, assessed using the Information Governance Toolkit,was an overall Satisfactory score. The assessment was undertaken for the organisation as a whole and therefore includes both Provider and Commissioner elements. NHS Bolton was not subject to the Payment by Results clinical coding audit during 2010/11 by the Audit Commission. 3. Review of Quality Performance 3.1 Safety Infection Control NHS Bolton s Infection Control Annual Report was presented to the Board of NHS Bolton in May Full details of the Provider s contribution to the achievement of the overall health economy MRSA and C.Difficile targets can be found in this report available on the PCT website The following extracts relate specifically to the Provider Services: Following on from the campaign and the introduction of ongoing hand hygiene audits in 2009/10, hand hygiene audits are now routinely undertaken in 102 services/teams in the Community Provider. 23

24 The chart above shows the increasing engagement of teams from a baseline of 55 in April 2010 to the current number of 102. By March 2011, 83 services/teams were reporting full compliance. The IPC Team is continuing the work to ensure all the remaining services/teams will participate and importantly be fully compliant. Full compliance means that every aspect of hand washing was correctly performed on every occasion assessed-this includes both hand washing technique and compliance with uniform/nonuniform policy. For example, some people can fail the audit by having acrylic nails or wearing jewellery. Aseptic Non Touch Technique (ANTT) It is recommended that ANTT should be a part of all relevant clinical practices. NHS Bolton IPC Team commenced the rolling out of the ANTT programme to all relevant services. The Infection Prevention & Control Assistant Practitioner has worked exceedingly hard over the past 12 months to embed ANTT within Community practice. ANTT is now being included in all appropriate policies and protocols and with other good practices has been a key part of keeping the community HCAIs low. The following services have received training in ANTT in 2010/11: District Nursing Day & Evening Domiciliary Service Treatment Room Service BCU Darley Court Intermediate Care IV Therapy Team Imms & Vaccs team Podiatry Rheumatology Respiratory Team 24

25 Walk-In Centre Tissue Viability Accident and Incident Data The safety of people in our care and our staff is extremely important to us. Serious incidents in healthcare are uncommon, but when they do happen they can have a devastating and far-reaching effect. It is essential that all types of incidents including those that don t cause any harm or where prevented are reported, actively investigated and wherever possible the cause eliminated. The Trust uses a database to record incidents; this allows the Trust to look at the number, type and impact of the incidents reported and spot any trends that are developing. The graph below demonstrates the continuing success of the drive to develop a safety culture which is open and encourages staff to report incidents- this has lead to an increase in the number of incidents reported. Part of the reason for this success is the introduction in August 2009 of the web- based incident reporting form, which makes the reporting of an incident easier and quicker for staff; it also encourages the member of staff to get involved in developing a solution which should help prevent the incident happening again. It also facilitates the manager s investigation of the incident and enables feedback to the reporting member of staff. During 2010/2011 the Trust successfully reduced the number of incidents of serious harm to patients and staff whilst supporting an open incident reporting culture. The graph below shows a reduction in the impact of incidents over the last four years while the number of low harm incidents has increased. Not all of these serious incidents relate to harm to patients as there are other categories of serious incidents and these have seen a slight increase over time e.g. Information Governance. 25

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