Quality summary report: Intermediate Care Wards CLCH Barnet

Transcription

1 Quality summary report: Intermediate Care Wards CLCH Barnet CLCH Quality Report Jan Dec 2011 Location RYXY9 & RYXZ1 Service exact name Intermediate Care Wards CLCH Barnet Address line 1 Edgware Community Hospital Address line 2 Burnt Oak Broadway Town/city Edgware County Middlesex Postcode HA8 0AD No. beds 65 (across two sites) Website Main telephone Completed by Patricia Hill Divisional Manager for Intermediate Care Services & AHP Professional Lead (CLCH Barnet) Approval Fiona Jackson Associate Director of Operations CLCH Barnet

2 CLCH Quality Report 2011 Summary report for Intermediate Care Wards- CLCH Barnet Directorate Service area Adult Operations- Barnet Intermediate Care Wards Boroughs Barnet Kensington & Chelsea Hammersmith & Fulham Westminster CQC statement of purpose for this service The intermediate care wards: Jade, Ruby and Marjory Warren, act as a step up facility, enabling patients to be admitted from the community; and as a step down facility where patients can be admitted following periods of care in an acute hospital. All patients must: Be medically stable and not requiring acute medical care or investigations. Have identified rehabilitation goals and be able to participate in the rehabilitation process. Be a UK resident. Be registered with a GP in Barnet or the surrounding area. A multidisciplinary approach to rehabilitation and patient care is used. Core care pathways include: Intensive Assessment: Multidisciplinary assessment to identify rehabilitation potential prior to embarking on the general rehabilitation pathway. General Rehabilitation: Rehabilitation interventions to help patients regain independence and confidence at home or improve their level of function for a community setting following acute hospital care or following referral to the unit by a GP as part of an admission avoidance initiative. We aim to prevent avoidable dependence on long term care by supporting patients to recover and respond to nursing care and therapy

3 intervention in order to avoid long term residential or nursing home placement. Stroke Rehabilitation: Designated rehabilitation beds with specialist nursing and therapy staff to optimise recovery following stroke is provided in all the wards except Marjory Warren ward. The wards works closely with acute hospitals, GPs, the day hospital intermediate care teams, district nurses, community matrons, social care and voluntary services and are able to admit patients throughout the day or night. A single point of access provides a bed management function and coordinates referrals and admissions. The wards are managed by a modern matron as well as a senior member of the nursing team who is always on duty to ensure that appropriate care of the patient is maintained at all times. General medical cover is available Monday to Friday to with out of hours medical cover provided by the out of hours GP co-operative. Therapy interventions are provided 7 days/ week. A total of 37 beds are available. One ward comprises 17 beds split into two 4 bedded bays and nine side rooms. The bays and side rooms have en-suite toilet and shower facilities. Bays and side rooms are single sex only. The second ward comprises 20 beds, split into three 4 bedded bays and eight side rooms. The bays and side rooms have en-suite toilet and shower facilities, and are single sex occupancy only. The unit has sufficient staffing levels and systems & processes to ensure privacy and dignity are maintained at all times. The wards may provide care to the following clients groups: Learning disabilities or autistic spectrum disorder. Older people. Adults. Physical disability. Sensory impairment. Dementia. People who misuse drugs and alcohol. People with an eating disorder. The Edgware Community Hospital intermediate care wards are registered with

4 the Care Quality Commission (RYXY9) and the Finchley Memorial Hospital intermediate care ward is registered with the Care Quality Commission (RYXZ1) to deliver rehabilitation, community healthcare and doctors treatment services. The following regulated activities are provided: Treatment of disease, disorder or injury. Diagnostic and screening procedures. Overall summary of quality performance and next steps CLCH Barnet delivers inpatient rehabilitation services across two sites, Edgware Community Hospital (37 beds across two wards including 14 stroke beds) and Finchley memorial Hospital (28 bedded ward). Evidence-based care is delivered along three identified care pathways; assessment, general rehabilitation and stroke. As a result of innovative service redesign in Autumn 2010, an enhanced rehabilitation model of care (ERMC) has been developed to support patient need. Care is provided on each ward by a team of experienced, specialist, highly skilled and competent staff. The model of care supports multi-disciplinary (MDT) working whereby joint assessments are undertaken within 48 hours of admission, in order to ensure all patient goals are identified and optimum rehabilitation goals achieved. The MDT comprises a medical consultant, staff grade doctor, social worker, physiotherapists, occupational therapists, dieticians, speech & language therapists, nurses, rehabilitation support workers, healthcare assistants and administrators. On the stroke unit, assessment tools include use of the Northwick Park Dependency score while the Barthel, Goal Attainment Score (GAS) and FIM/FAM outcome measures are used. On the rehabilitation pathways, SMART goals have been introduced in addition to FIM. Focus is placed on patient-centred care delivered 7 days a week where the patient safety, clinical effectiveness and patient experience are fundamental to the success of the service. Emphasis is placed on robust discharge planning, delivery of high quality goal-oriented care and returning patients to optimum function in order to support independent living in their own homes. To prevent hospital acquired infection while supporting independence, patients are

5 discharged into the community resulting in an average length of stay of 20 days for rehabilitation and 32 days for stroke. Patients are accepted depending on clinical need, while triage is supported by use of an MDT assessment form. Tracker nurses assess patients in neighbouring hospitals to ensure appropriateness to the service. Our patient population is diverse ranging from affluent to deprived, with often complex needs associated with co-morbidities and long term conditions. A robust social care team assisted by the placement officer (supporting privately funding patients requiring care), in addition to the discharge advisor ensure that all patient needs are met, regardless of ethnicity, religion, sexual orientation, age, gender or marital status. Data collection includes mandatory information on ethnicity to ensure an equitable and accessible service is being provided to all our multicultural urban population. An advocacy service is also available while many of our clinical staff are multi-lingual further supporting cultural inclusion. A chaplaincy service is also available while special dietary requirements are available including vegetarian and Kosher options for patients. A Protected mealtime policy is also in place and there is also a robust Patient Advisory & Liaison Service to support patients and carers. A service user focus group has been established to gather information on patient experience resulting in a responsive service. Patient information is also available. Patient satisfaction surveys and patient stores are undertaken. A robust process for clinical audit has been introduced including emphasis on infection control and patient safety. Clinical risk assessments are undertaken on admission including Falls, Skin Integrity (Waterlow) and a nutritional assessment tool (MUST) within 6 hours of admission. Focus is placed on ensuring best practice with benchmarking of clinical standards against National Institute for Clinical Excellence (NICE), Essence of Care and High Impact Actions standards. Areas that we addressed last year to improve quality included collaborative working within the MDT teams, increased clinical competencies for unregistered

6 staff (rehabilitation support workers) through targeted education, introduction of 6 day working for therapists, implementation of the Productive Ward programme, introduction of risk assessments for falls, nutrition and skin integrity on admission, development of breakfast clubs and daily exercise classes and group activities, working towards a paper-lite system of work with the implementation of RiO, introduction of comfort rounds for patients, acting on patient feedback from focus groups, patient feedback, focusing on patient information and family involvement with discharge planning. A robust process for incident reporting is in place to ensure patient safety while root cause analyses have been undertaken for serious incidents while action plans have been implemented. Areas for future development include the full introduction of clinical supervision for all staff, introduction of clinical competencies for all nursing staff, development of focus groups and patient feedback, use of volunteers on the wards, robust clinical audit cycles, development of a specific falls groups on each ward, standardisation of working shift patterns for nurses and therapists to support MDT working and improved productivity, introduction of Patient Group Directions (PGD) for nursing staff and standardised use of outcome measures including Patient Reported Outcomes (PROMs) and Patient Reported Experience Measures (PREMS) for all patients. Furthermore development of the RiO system for all staff use, improved documentation and implementation of E4E (Nursing standards) will also be undertaken. Safety Overview We aim to make our service as safe as possible at all times. A robust system for incident reporting is in place while reporting of incidents has increased over the past year. Most incidents relate to falls on the ward which is

7 consistent with findings from other trusts due to the nature of the patient cohort. Introduction of MUST (nutritional assessment tool), falls assessment and Waterlow assessments on admission has also supported patient safety. In the event of any serious incidents, root cause analyses have been undertaken and action plans implemented and monitored by the Learning from Experience group. Manual handling training is an integral component of ward safety with on the ward manual handling training provided for staff using the ward based specialist equipment. Monthly infection control audits are undertaken on each ward while annual environmental inspections are undertaken to ensure cleanliness and safety. Clinical competencies have been introduced for rehabilitation support workers while mandatory training is undertaken by all staff. All staff have accessed Safeguarding training are aware of the correct process for raising an alert which has been compounded by the introduction of Mental Capacity training on site. Information Governance training and staff appraisal have also been undertaken by all staff. A culture of no blame is engendered while staff learns from experience in the event of untoward issues. A process for clinical supervision is also in place. Audit has also been introduced with robust action plans put in place to address issues identified which are monitored by the senior manager. Areas for further development include ensuring audit is embedded in clinical practice to assure patient safety. Clinical supervision is also being introduced for all members of staff. A specific falls group will be set up at each site to target fallers and improve patient safety. Furthermore development of clinical competencies for registered nursing staff will also be undertaken.

8 Key achieveme nts this year We identified the following safety improvement actions in our 2010 Quality Report. This section outlines the progress we have made on each of them: 1) Improve our risk assessment of patients in our care: Ongoing with use of MUST, Waterlow and Falls monitored monthly as part of one of our CQUIN indicators. 2) Improved reporting of incidence of UTI s in patients with in-dwelling urinary catheters; complete. Datix form completed on every patient who develops UTI. 3) Deemed compliant by CQC inspection at Finchley in Dec and at Edgware Community Hospital in February Key results Total incidents Jan-Dec 2011 by severity Degree of Harm Low Minor Medium High Catastrophic Total incidents Jan-Dec 2011 by category

9 Level of reporting: In this incidents recorded in case. Near are in most service, are every misses recorded cases. Themes arising Through the analysis of incident reporting for the year ended Falls consist of just over 50% of all incidents reported between January 2011 and December with this in mind a number of initiatives have been introduced. The General Rehabilitation Wards are engaged with patients and clinicians in carrying out a service wide audit on falls to identify key indicators of high risk and to develop and action with subsequent service changes to provide education and intervention to patients, cares, families and staff. To develop this further Falls related competencies have been implemented in the core competencies of the rehabilitation support workers to raise awareness and improve staff engagement.

10 Our staff have also engaged with our central London colleagues in developing the Assessment and Intervention on Admission for Falls tool for audit and the Best Practice following Falls which is also piloting across a number of Inpatient sites across CLCH. Safety Action Expected Named Improveme completion lead nt Actions date for 2012 Training for all staff in incident reporting, Falls October Patrick assessments and Mental Capacity Act 2012 Harding Ensure infection control standards are in place for February Patrick cleaning of commodes 2012 Harding Ensure all medical charts are completed fully when January Patrick administering medication Harding Ensure comfort rounds are undertaken and a robust January Patrick process in place for recording to promote patient 2012 Harding safety and comfort To introduce specific falls groups at each site to March 2012 Patrick target fallers identified by falls risk assessment, to Harding optimise patient safety and rehabilitation. Effectiveness Overview We aim to achieve the best possible outcomes for patients. To do this, we regularly check to see that we are delivering care and treatment according to best practice standards, and we increasingly look to measure and improve clinical and patient reported outcomes.

11 A competency framework for unregistered staff has also been introduced specifically for the rehabilitation support workers. Furthermore, emphasis is placed on addressing patient and family expectation by arranging early family meetings soon after discharge to agree management plans, treatment goals and discharge plans. A robust framework is in place while emphasis is placed on training and staff development supported by use of annual appraisal and training needs analysis. Clinical courses are available within the organisation and there is a system in place to support external courses. Opportunities for work shadowing and mentoring are also available. The library resource centre at Edgware Community Hospital also supports clinical research. Additionally, some of our clinicians have or are undertaking masters qualifications in clinical practice. Areas of key priority for the intermediate care wards this year are include the full introduction of Patient Reported Outcomes (PROM) with the use of Goal Attainment Scores (GAS) supported by use of SMART goals (Specific, Measureable, Achievable, Realistic and Timely) for our rehabilitation patients excluding stroke as these are already in place. Another area for development is ensuring all staff access clinical supervision. Development of clinical competencies for all registered nurses will also be introduced to optimise clinical effectiveness. Focus will also be placed on the implementation of Energising for Excellence (E4E) to ensure clinical effectiveness for nursing staff which will also be extended to all disciplines. Key achievements this year Development of our clinical staff to deliver a therapeutic relationship with our patients and clients that is built upon compassion, dignity and care benchmarks. 1) Development of our clinical staff to deliver a therapeutic relationship with our patients and clients that is built upon compassion, dignity and care benchmarks- Ongoing. 2) Access clinical specific training- Ongoing 3) Measure the patient experience in change in practice- Ongoing

12 Next steps 1) Clinical supervision to be implemented in all areas 2) Implementation of PROMs and PREMS to establish patient feedback to care 3) Ensure audit is embedded in practice to demonstrate clinical effectiveness 4) Introduce nursing competencies for all registered staff 5) Introduce journal clubs and reflective practice to learn from experience and to keep abreast of evidence based practice 6) Ensure all patients have goals and treatment plans in place to support MDT working and goal attainment. Key results Patient Reported Outcome Measures (PROMs) GAS scores have been used on the stroke unit. Clinical Outcomes The Northwick Park Dependence Score and Barthel score have also been used on the stroke unit. FIM has been used on one of the rehabilitation wards while there are now plans in place to roll this out across al the CLCH Barnet bedded areas. Other measures of effectiveness Other measures of effectiveness include documented goals obtained such as increased walking distance, independence with sitting or feeding, swallowing, communication, mobility, tone, mood and activities of daily living. Furthermore, discharge destination (own home or care home) are also recorded. Clinical Audit Participation in Trust-wide audits during 2011 The Service took part in the Health Records audit and achieved a mean compliance rate of 81% against the standards. The Service audited 31 records.

13 This year our clinical audit plan has focused on the following audits: Falls Stroke management in line with NICE guidelines The General Rehabilitation Wards are engaged with patients and clinicians in carrying out a service wide audit on falls to identify key indicators of high risk and to develop and action with subsequent service changes to provide education and intervention to patients, cares, families and staff. To develop this further Falls related competencies have been implemented in the core competencies of the rehabilitation support workers to raise awareness and improve staff engagement. Our staff have also engaged with our central London colleagues in developing the Assessment and Intervention on Admission for Falls tool for audit and the Best Practice following Falls which is also piloting across a number of Inpatient sites across CLCH. With the reduction in length of stay a potent piece of work was done on our Stroke ward around the FIM/FAM scores on admission and again on discharge demonstrating improvements are continuing to be made in patients functional scores even with the reduction on length of stay Series2 Series1 FIM+FAM Scores

14 In the grapy above the blue line demonstrates the admission scores with the green contrasting line demonstrating the FIM/FAM score on discharge. This clearly shows significant improvements are being made with multi-disciplinary intervention. Discharge Destinations from Jade ward 80 77% % 16% 4.7% Home Resi Home Nursing Home Other 0 Home Resi Home Nursing Home Other Further work was carried out on this patient cohort to analyse their discharge destination. Please see graph below. Discharge destination values Frequency Percent Valid Percent Cumulative Percent Discharge Destination Home Resi Home Nursing Home Other

15 Total Again it can be clearly seen that 77% of these patients are returning to their own homes validating the increased FIM/FAM scores and improvements in patients overall functional ability. Further Audits were carried out in relation to patient participation; Community Rehabilitation audit of clinical records to establish client engagement 2012 Service Area and borough of notes being audited: Barnet ICS bedded service- Jade Ward, Specialist Stroke Rehab Number of participants; 5 Name of Auditor: Hubert Sakkariyas- Clinical Specialist OT in Stroke Lousie Penny- Senior OT Date of audit 28/03/2012 Question YES NO Action

16 Is the client s functional ability comprehensively documented? For example: Do you feel you have a clear picture of the clients function and how they came to be where they are now? 3 2 Need for review of current paper work. With the change in LOS time frames and priorities have to be revisited with the team. Was the client asked what they would like to work on and achieve 4 1 Item for review For example: Is this documented in the clients records? Was the client asked about their expectations of therapy For example: Is there documentary evidence that the above answer was discussed in terms of what was possible and how it would be achieved (or not) 3 2 Documentation does not distinguish between expectations and goals Do the goals reflect what the client wished to work on 4 1 Family and patient meetings For example: Are the goals around the areas the client had identified they wanted to work on

17 Is there evidence that the therapists and client have decided on the goals together 5 Family and patient meetings- provides a good opportunity to do this. Are the goals written in clear language that the client can understand 5 Family and patient meetings- provides a good opportunity to do this. Is there evidence of a timeframe for intervention 5 Family and patient meetings- provides a good opportunity to do this. Is there evidence the timeframe has been discussed with the client For example: Is there a statement stating that explanation was given to client regarding length of intervention and importance of reviewing goals / assessing progress Is there a treatment plan 2 3 Lack of documentation Does the treatment plan relate to the goals 2 3 Treatment plan reflects more on discharge than goals. Is there evidence the treatment plan has been shared with the client 5 Family and patient meetings- provides a good opportunity to do this.

18 Is there evidence of review of goals 3 2 Is the review done with the client 4 1 Is there evidence of education of the client to manage their condition 5 Is their evidence of information given to the client ie leaflet regarding the service or their condition 1 4 New leaflet introduced and staff made aware Is their evidence that discharge is discussed prior to discharge 5 How soon prior to discharge did the discussion take place 5 Between 4-20 days notice Is their evidence of discussion with client regarding any issues they may have with discharge 5 If there are issues is there evidence they were addressed 5 Is there evidence of goals reviewed with client at discharge 2 3 Findings: % of patients had evidence that the therapists and client have decided on the goals together. 2. There is 100% compliance to setting time frames for treatment and intervention % of patients audited had a family meeting and discharge plans and treatment plans have been shared with patient and family Recommendations: 1. Evidence of leaflet regarding the service and condition need to be documented regularly. With the release of the new Stroke Handbook

19 these figures should have improved by the next audit, thus improving patient participation and patient knowledge and understanding into their condition. 2. To improve patient involvement with review of their goals prior to discharge. 3. To improve documentation of patient expectations and goals. NICE compliance The following NICE guidance is either fully or partially relevant to this service: CG68 CG2 CG21 CG91 To ensure that we are complying with these best practice guidance, we have carried out the following actions in 2011: NICE guidance baseline assessment conducted and guidance implementation NICE related education for staff has been organised with the aim to improve quality of the service including BMJ e-learning Research and innovation Reviewing length of stay and dependency levels on admission and associated implications. Use of special stockings to reduce onset of DVT and increased tone will shortly be piloted in conjunction with Barnet & Chase Farm NHS Hospitals Trust Innovative use of band 3 rehabilitation support workers to engender a culture that is rehabilitation focused. Review of use of rehabilitation beds. Full implementation of Productive Ward programme Full implementation of RiO and paperlite system of work

20 What the patients say about the outcomes of their care and treatment To all the team involved in looking after RG, Thanks is just a little word but still it s meant to show your kindness is appreciated more than you could know To all the staff on Marjory Warren Ward, we join our mother in expressing our sincere thanks for the care, dedication and kindness you displayed. Your sensitivity to all her needs was really appreciated and we are so grateful for all that you have done To all the Nurses, Physios and Care Helpers that have helped and cared for me during my stay at Finchley Memorial a big thank you you have been brilliant Clinical Action add or delete rows to this table as Expected Named Effectiveness needed completion lead improvement date actions Clinical supervision to be implemented in all March 2012 Patrick areas Harding Implementation of PROMs and PREMS to June 2012 Patrick establish patient feedback to care Harding Ensure audit is embedded in practice to Oct Patrick demonstrate clinical effectiveness Harding Introduce nursing competencies for all Sep Patricia Hill registered staff Introduce journal clubs and reflective practice May 2012 Patrick to learn from experience and to keep abreast of Harding evidence based practice Ensure all patients have goals and treatment February Patrick plans in place to support MDT working and 2012 Harding

21 goal attainment Experience Overview We care about treating everybody with kindness, dignity and respect at all times. Staff members were selected to undertake an Excellence in Customer Care training programme last year. Learning from this training was fed back to the teams. Care plans are developed in conjunction with the patients and their family/carers in order that the individual patient needs are met. A multi disciplinary team approach is adopted where possible to enable the most appropriate care to be delivered along the patient pathway. All staff work collaboratively with other members of the multi disciplinary team in primary care, secondary care and third sector agencies. A number of patient focus groups and patient stories were undertaken on the ward with resulting action plans implemented following patient feedback. Patient feedback questionnaires have recently been introduced on the wards and we are currently awaiting feedback from collators. Key achievements this year We identified the following patient experience improvement actions in our 2010 Quality Report. This section outlines the progress we have made on each of them: 1) Continue to gather detailed understanding of patient experience to improve quality - ongoing 2) Aim to gather 5 patient stories - completed 3) Action plans achieved following feedback from patient stores - completed

22 4) Action plans completed following feedback from patient user focus groups- completed 5) Introduction of Patient Reported Experience Measures (PREMS) - ongoing 6) Action plans put in place following trend analysis of patient complaints- ongoing 7) Audit undertaken of impact of 6 day working on staff and patientscomplete 8) Facility put in place to support patients feedback via comments box on each ward - complete 9) Deemed complaint by CQC in December 2011 following an inspection at Finchley Memorial Hospital. Next steps 1) Ensure robust patient experience is being gathered from all wards 2) Ensure patient - user focus groups are established to capture the patient experience and ensure our services are fit for purpose and meet patient s needs. 3) Further develop patient information on all wards 4) Establish more activities by using volunteers on the wards. Patient survey results Patient surveys (known as Patient Reported Experience Measures PREMs) Summary of results for core patient experience measures (Aug-Dec 2011) Question Result for this service Trust-wide average % patients/carers rating overall experience good or excellent 90% 93% % patients saying they were definitely involved in planning their treatment 36% 56%

23 % patients saying they were always treated with dignity & respect 100% 92% % patients saying they definitely understood explanation 64% 88% % patients satisfied with waiting time 90% 74% Interpretation of PREM results The service received exceptional results with regards to patients reporting that they were treated with dignity and respect, with 100% of patients reporting that they were treating with dignity and respect. However, the service receive low results for patients reporting that they were involved in planning their treatment, with only 36% reporting that they were definitely involved in planning their treatment. PREM methodology The following table summarises the number of patients that responded to a PREM this year, and shows this as a percentage of all referrals during the survey period (August December 2011). Our aim was to achieve a representative view of patient feedback, so we set out to survey patients on discharge. PREM volume targets Total (Aug-Dec 2011) Number of patients who responded to a PREM 11 Total new referrals 200 % of new referrals who responded to a PREM 5.5% Target % of respondents 15% Target achieved? No.

24 Compliments and Complaints Compliments and Complaints Number of compliments Jan 2011 Dec 2011: 34 Number of complaints Jan 2011 Dec 2011: 8 Patient user groups and focus groups Focus groups were held earlier in the year with service users as part of the development of the enhanced rehab model of care (EMRC). Following these, action plans were put in place to address issues identified which included access to hot drinks, large portion sizes, access to newspapers and response time to call bells. Plans are underway to establish these once again with the communication and PPE lead for CLCH. Other qualitative feedback Feedback from patients and their relatives have also been considered and action plans put in place where appropriate. What the patients say To all the team involved in looking after RG, Thanks is just a little word but still it s meant to show your kindness is appreciated more than you could know To all the staff on Marjory Warren Ward, we join our mother in expressing our sincere thanks for the care, dedication and kindness you displayed. Your sensitivity to all her needs was really appreciated and we are so grateful for all that you have done To all the Nurses, Physios and Care Helpers that have helped and cared for me during my stay at Finchley Memorial a big thank you you have been brilliant Patient Action Expected Named experience completio lead Improvement n date Actions Ensure robust patient experience is being gathered from all wards Ongoing Patrick Harding

25 Ensure patient-user focus groups are established to capture the patient experience and ensure our services are fit for purpose and meet patient s need May 2012 Patricia Hill Further develop patient information on all wards July 2012 Patricia Hill Establish more activities by using volunteers on the wards. April 2012 Patrick Harding