Quality Account 2016-17 1. Introduction 2. Looking back 3. Other areas of quality 4. Patient and public empowerment 5. Looking forward 6. Quality and effectiveness 7. Appendix 1
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Quality Account 2016-17
1. Introduction 2. Looking back 3. Other areas of quality 4. Patient and public empowerment 5. Looking forward 6. Quality and effectiveness 7. Appendix
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Introduction
Foreword
Who we are
Our approach to quality
What is the quality account?
Foreword
Delivering excellent services and high quality care to people in the communities we serve is the prime motivation for all our clinical and support staff alike. Producing our quality account allows us to reflect on how well we have delivered that during the year. We also consider the extent to which we achieved the improvements we set out to make, and decide on priorities for the next 12 months. Our quality account demonstrates that we take seriously the monitoring of the safety of our care, the quality of patient experience, and effectiveness of our services.
We are pleased that staff feel able to report incidents so that they can be investigated and improvements can be made. This year, our Board and senior management team have taken part in visits across the organisation to provide our staff with opportunities to raise any issues they have, and hear about how our teams are ensuring safe, effective care, and good patient experience.
We are also proud of our progress on the amount of staff compliant with their training, increased amount of patient feedback, and our achievements against our CQUIN and quality priorities. However we are not complacent and recognise that in some areas, while still at relatively low levels, there has been an increase in avoidable harm to patients – particularly medication errors and pressure ulcers. We believe this is in part due to increased activity and to increased complexity of the patients under our care. We will not be satisfied until this trend is reversed and we eliminate avoidable harm altogether. That is why these two areas remain priorities for this year.
Well supported staff who are happy at work provide the best care and supporting staff remains a key priority for us. We are renewing efforts this year to provide staff with easy to use, fit for purpose information technology to provide them with accurate and up to date information and to reduce the burden of administrative tasks and data entry on clinical staff. We recognise staff turnover is too high and we are continuing to look at ways to improve staff experience. Work on safe staffing standards supported by a new e-rostering system will help us ensure safe staffing levels and better match our resources to demand.
In our quality account you can find information on incidents and complaints as well as compliments and compliance levels, and information on how successful each of our quality initiatives were last year. We hope you find it informative, open and reassuring.
Julia Clarke - Chief ExecutivePaul Kearney - Chair of the Board
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Who we are
Bristol Community Health is a staff-owned community interest company, focusing on providing NHS community and prison health services in Bristol and surrounding areas. Our dedicated and compassionate teams have a reputation for high quality, person centred care.
Our organisation spun out from the NHS in 2011, and has been employee owned ever since. Any surplus we make is invested back into our services and community, and our shareholders who are our staff, do not benefit financially. This helps to keep our focus on maintaining high quality patient care.
Our vision is improved health and wellbeing across the communities we serve.
Our mission is to provide person-centred patient care.
Our values are demonstrated in everything we do, and reflect our four strategic themes:
• Making their day: touching lives and partnership.
• Time to care: one team and innovation
• Managing our money: sustainability and invest wisely
• Being the best: aim high and learning
2015-16 has been an exciting year for us, as we were preparing to launch two services. The first, InspireBetterHealth, is a new partnership providing offender healthcare in five prisons in the South West - HMP Bristol, HMP Eastwood Park, HMP Ashfield, HMP Leyhill and HMP Erlestoke. We were also preparing to provide children’s community health services in Bristol for a year, with Sirona Care and Health CIC (lead provider) and Avon and Wiltshire Mental Health Partnership NHS Trust. As both services launched on 1 April, the statistics within this document do not reflect these new staff members or services. To find out more about our achievements, visit page…
Our approach to quality
The three key strands of our quality model that reflect the Department of Health approach include patient safety, patient experience and clinical effectiveness.. Our clinical governance aims to ensure that we continually improve quality within our services – and we retain the gold standard of NHS governance frameworks. Here, you can see our governance framework (fig. 1) and clinical governance framework (fig. 2).
Operationally, our quality model means that staff:
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• Deliver the fundamental elements of good care – compassion, dignity, respect and safety – first time and every time and to everyone whom we serve, making every contact count.
• Aspire to provide the highest quality of care, focused on achieving the best outcomes for our patients, by supporting the adoption of best practice and promoting innovation.
Clinical governance is delivered through a structure of focused working groups that monitor the outcomes from our work-streams for;
• Patient and public empowerment, which includes complaints and compliments• Patient safety and risk management, – which includes quality and harm free care
meetings and complex case reviews• Information governance • Prisons governance groups• Clinical audit, effectiveness, research and innovation• Safeguarding adults and children• Medicines management and our non-medical prescribing groups• Supervision and competency of clinical staff• Infection prevention and control
Each of the key areas are monitored under the clinical governance structure through reviews of data including audits and incidents and comparing our performance against national and local standards. This is overseen by the Quality Assurance and Governance Committee which reports directly to the Board, who also receive a monthly report on all areas of quality. We aim to group clinical outcomes to provide evidence that assures our services are:
▪ Safe▪ Effective▪ Caring▪ Responsive▪ Well-led
As an independent sector provider of NHS funded services our main mechanisms for accountability for quality and assurance include;
• Corporate and individual accountability• Contractual relationships with Clinical Commissioning Groups and NHS England• Regulatory relationships with the Care Quality Commission, the Health and Safety
Executive and the Community Interest Companies Regulator• Scrutiny by local Healthwatch supported by the publication of Quality Account.
What is the Quality Account?Our dedicated and compassionate staff are committed to providing the highest quality healthcare, and our fifth Quality Account demonstrates this.
A Quality Account is an annual document which reports on the quality of care under three key elements as outlined by the Department of Health; these are patient safety, patient experience and clinical effectiveness. Each year, providers of healthcare are expected to outline their areas of quality improvement for the year ahead, and reflect on the areas from the past year. All activity is drawn together and is subject to considerable internal consultation shared with a variety of external stakeholders prior to incorporating their feedback in the published version. This will help you, as a patient, carer, family member,
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or other key stakeholder, to understand the key areas we have improved on as well as those areas that we have identified where quality or safety can be further improved and why.
Within this document, you will find an update on last year’s quality priorities, as well as the priority areas for 2016-17. Sometimes our priorities are driven by national healthcare priorities, like the ‘Sepsis 6’ tool. Other times they are shaped around what our patients think, such as our pledge to collaborate more closely with voluntary sector organisations . You will find that the bulk of this document ‘looks back’ at our achievements over the last financial year (April 2015 – March 2016).We have also outlined our future priorities which we will deliver in the next financial year of April 2016 to March 2017.
The members of staff who lead on delivering our quality priorities, set up work plans to achieve the aims of the priority, and progress is reported to the clinical cabinet and to our Quality Assurance and Governance Committee which reports to our Board.
A Quality Account is not only aimed at patients and carers, but also our commissioners (Bristol and South Gloucestershire CCGs and NHS England) and other healthcare providers and Trusts. We understand that some of the terms within this document may not be easily understood by those who do not work in healthcare. To make this information as accessible as possible, you will find explanations within these boxes.
Thank you
We would like to thank the patients, carers and voluntary sector organisations who have helped us shape this Quality Account. Your views are important to us, and by attending our events or getting in contact in other ways, we have chosen our future Quality Account priorities with you at the centre. Look out throughout this document to see exactly where your thoughts and views have made an impact in this format.
Every improvement we have made that is demonstrated in this document is for the patients of Bristol and other areas we serve, so in the context of this document, 'you' refers to the patient first and foremost.
The following have also helped us shape our 2015/16 Quality Account
This is a public document and is therefore available in a variety of media, formats and on our website. To access the document in another format, call 0117 900 2198 or email [email protected].
2. Looking back
Our QA priorities over the past 12 months
In this section, you will find information relating to our quality priorities of 2015-16. The numbering of these priorities is for ease of navigation in this section, rather than an indication of priority. In section xx, you will find our quality priorities for the year ahead.
Clinical effectiveness:
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Priority 1: implementation of a Sepsis tool to identify patients with sepsis earlier
Priority 2: Implementation of accessible care plans to ensure shared decision making for all.
Patient experience:
Priority 3: Develop a framework for the production of patient stories using patient, carer and family feedback in a meaningful way.
Priority 4: Improve our equalities monitoring data to ensure all patients who use our services experience equality.
Patient safety:
Priority 5: Improve medicines management to ensure clinical, cost effectiveness and safe use of medicines.
Priority 6: Development of a methodology for safe staffing to deliver effective, safe and compassionate care.
Priority 7: Continuing pressure ulcer prevention by taking further proactive steps through continued learning.
Priority 1: Implementation of the sepsis screening tool to identify patients with sepsis earlier.
What we said we would do
Our Advanced Nurse Practitioners (ANPs) in the Rapid Response Teams developed a sepsis screening tool which they planned to introduce. We planned to design a teaching programme for all clinical staff so they could all use the tool effectively, and to disseminate the tool more widely across our clinical teams.
<< pull out box>> Did you know: 150,000 people develop sepsis per year in the UK, with 44,000 of these people dying from sepsis.
The early recognition of patients with sepsis and the reporting of these findings to GPs or medical teams in the hospital is crucial to reducing the risk of a patient’s condition deteriorating further. The sepsis screening tool helps clinicians to do this. It enables staff to recognise a diagnosis of sepsis early so that patients are given the right treatment to stop their condition from worsening.
What we did
We piloted our sepsis screening tool within the three Rapid Response Teams, the Out Of Hours Team, the In-Reach and REACT Teams (based in the Bristol Royal Infirmary (BRI)
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and Southmead hospitals) and the Community Respiratory Team. To do this, we designed a sepsis teaching programme for all our clinical staff, which was validated by a geriatric consultant from the BRI.
We completed monthly audits, the findings of which were used to educate and up skill staff within these teams to ensure sepsis was being recognised, treated and documented correctly.
We also rolled the tool out to the prisons, within which we provide healthcare, and we are in the process of rolling it out to all our community staff. We gathered sepsis related case studies to identify how the sepsis screening tool was put into practice during the pilot.
We have also spread the word on sepsis more widely on World Sepsis Day by communicating the signs and symptoms to all staff.
<<add in image of sepsis signs card>>
How we will continue the work
We will continue to audit the Sepsis Tool on a monthly basis, using the findings to update our staff to ensure they are documenting cases of sepsis accurately on our patient record system, EMIS. We will continue to educate all new staff around the importance of recognition and escalation of sepsis. As we changed clinical system this year we were unable to measure if we have increased the numbers of patients identified with sepsis but we are now in a position to monitor this in 2016/17 to see if the improved training and tools will ensure patients receive early treatment for sepsis. New guidelines for the diagnosis of Sepsis will be released in July 2016 and we will ensure we update our processes and our staff.
What this means for patients
Sepsis is a life threatening condition and in order to reduce morbidity our patients will continue to be screened for sepsis. If sepsis is suspected you will be treated in a timely manner by the right person in the right place at the right time.
Priority 2: Implementation of accessible care plans to ensure shared decision making for all.
What we said we would do
Our aim was to ensure that accessible personalised care plans were available ready for use by our staff, and rolled out across our services, to make sure all our patients with communications or language needs were empowered to make decisions about their own healthcare.
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We planned to launch the tool to our staff, and other healthcare providers, and support them to use it well.
It was important to us to consider our varied range of patients, and to reflect this we had plans to pilot the care plan in one of our prisons
What we did
The care plan has been printed and it is being held within our Community Learning Difficulties Team (CLDT) as they are the team who have the highest proportion of patients in need of the plan.
We made the accessible care plan available on our staff website, which is used by our whole staff team.
We launched our accessible care plan through training and education for GPs, practice nurses and our own staff and gave advice on how to use it. In the last 14 months, 350 accessible plans have been used within CLDT. The team have rolled out shared decision making using the accessible care plan to therapy teams within the Disabled Children’s Service with the goal of enhancing transition processes.
The tool was introduced to Ashfield Prison where it was adapted to meet the needs of prison patients. So far 40 patients with respiratory conditions across Ashfield and Leyhill prisons have completed accessible personalised care plans with staff adopting the shared decision making approach. They reported that patients engaged better and identified the support they needed to achieve their health goals, especially around smoking cessation.
We have identified care plan champions in teams across the organisation as well as introduced the ‘Care Plan Buddy’ volunteer role as a pilot within community health teams to improve implementation even further. A cohort of ten volunteers were recruited and trained in order to support patients and carers to develop their own care plans. Of this cohort, five buddies remain active and within six months of training, they had supported 22 patients with their care plans.
<<include excerpt from Gemma Smith’s case study>>
How will we continue the work?
We believe that shared decision making is significant in enhancing the experienced quality of patient care we deliver. In continuing our commitment to this, we aim to roll it out to our wider services with appropriate support. Our aim is that all patients and service users who wish to develop their own care plan are supported and enabled to do this. Our new clinical system now has codes which will enable future measurements of percentages of our patient population who use a personal care plan.
What this means for patients
More than ever we are ensuring that we are meeting the needs of our diverse range of patients and keeping them feeling empowered and involved in decisions about their
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healthcare. This is just one of the ways we are recognising how diverse our city is. For more on this, check out the patient and public empowerment section of this report.
Priority 3: Develop a framework to ensure we use feedback in a meaningful way, including patient and carer stories, to continue to improve patient experience.
What we said we would do
We said we would further develop our feedback system, called Meridian, to alert team managers in real-time of any areas of concern. We also said we would listen to and gather patient stories in order to truly understand how the care we provide impacts on people who use our services. By hearing the patient’s thoughts and feelings on the care and treatment we provide, we can understand whether we are making a meaningful and positive impact on their healthcare.
What we did
The work we did for this quality priority can be grouped into three areas, as follows:
- Real-time feedback, real-time action
Through our real-time feedback system team managers are instantly alerted to areas of concern raised by patients – this is when a score is less than 50%. During the past year, we have received 316 concerns from patients. All of these have been responded to within five working days, and all were resolved.
All of our surveys now give our patients the opportunity to leave their name and contact number should they have a concern. If they do leave their details, a member of our PPE Team contacts the patients to talk through their experience – both the positive and the areas in which we can improve.
- Patient Stories
In May 2015, we launched an exciting pilot with the aim of understanding the best approach to gathering patient stories. Our Patient and Public Empowerment Team (PPE) visited ten patients being seen by our Community Nursing and Community Respiratory Teams who had consented to sharing their story with us. The patient names were suggested by the services.
We used a best practice toolkit1 for gathering stories to make sure that we did not ask any leading questions which may have skewed the response from patients. We then transcribed the stories, got them approved by the patients, and sent them to service managers as case studies to facilitate service improvement. We also gathered our first patient story video which can be found on our website <<add link>>.
From this pilot, we learnt that we would get a more balanced view of patient experience by randomly choosing patients, rather than asking the teams to contact patients on our behalf.
1 “A toolkit for collecting and using patient stories for service improvement”, October 2008, Western Australia Department of Health.
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The success of the pilot meant we recruited and trained three feedback volunteers who are now meeting with a random sample of patients from across our services as part of an ongoing programme of work. By working with volunteers in this way, we believe that patients are more willing to share a true reflection of their experience of our services. We will increasingly use patient stories to inform action plans which help us improve the quality of our services (see below), and in staff training to help support staff to reflect on how their work impacts on the experience of patients. You can find many examples of our patient stories in our Patient and Public Empowerment Review 2015, available at www.briscomhealth.org.uk
- Action Planning
Improving patient experience relies on our services implementing real service change, which is why we support team managers to review feedback and develop achievable actions. We extended this across our community health services, and considered:
• using a template developed with leading experts in this area, Picker Institute Europe,
• including as many sources of patient feedback as we could. For example, real-time feedback from Meridian, complaints, compliments, patient stories and feedback from focus groups.
• looking at what we were doing well and where we could do better. Team managers can use Meridian to view how their service compares to other services across the organisation to help them with this.
• updating plans every three months which provided our services the opportunity to discuss the latest patient feedback data with their team and see whether they were focusing on the right areas
What this means for patients
You can feel more confident than ever that when you share their feedback with us, it is taken seriously and something meaningful is done with it. You can be more assured that your feedback is being sent to the right people at the right time to continue to improve the your experience and that of others using community health services.
Priority 4: Improve our equalities monitoring data to ensure all patients who use our services experience equality.
What we said we would do
We said we would focus our efforts in 2015/16 to better understand who our patients are, specifically in relation to the protected characteristics defined in the Equality Act 2010. These include, for example, ethnicity, sexual orientation and disability. The reason we wanted to focus on this was because our recording of this data was generally poor.
What we did
In line with our Equality and Diversity Strategy ‘Valuing All’ we took a number of steps to improve the recording of protected characteristics (equality) data from patients.
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• We reviewed the way that our new patient record system, EMIS, was set-up to record this data and found that the system could not record disability status or sexual orientation. We therefore submitted a request to the national EMIS group so they could prioritise adding these categories.
• We developed guidance for staff to support them to understand why they need to ask equality related information and suggested some ways they might best do this.
• We developed a new paper based template for patients to record their equality data.
• We developed EMIS so that that it automatically prompts our clinicians to ask patients to provide their equality data if it is currently missing.
• We commissioned cultural competence training to further support staff in this area (see CQUIN review for further detail).
• We continued to monitor patient feedback and complaints by the equality groups to allow us to identify and take action on any trends to improve patient experience.
• We reviewed our existing Equality Impact Assessment framework, so our teams could simply use protected characteristics data to understand whether our services are accessible and promote equality of opportunity.
This has been a challenging priority for us to deliver during the year, mainly due to the obstacles of recording data and supporting staff. Despite this we are pleased with the progress we have made so far and will continue our focus on this area in the year ahead.
The table below shows the progress we have made against the protected characteristics.
Protected Characteristic
At a 31/03/2015
New referrals received 1 Feb to 1 April 2016
Variance
Age 100% 100% 0%
Sex 100% 100% 0%
Ethnicity 54% 70.28% 16.28%
Religion 11% 6.29% -4.71%
Disability 0.1% 9.38% 9.28%
Sexual Orientation 0% 9.73% 9.73%
Marital Status 0% 8.57% 8.57%
Gender Reassignment
0% 0% 0%
Pregnancy and Maternity
0% 0% 0%
The information shows the year-end position of recording the protected characteristics data for patients newly referred to Bristol Community Health. It shows that we have
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maintained 100% recording against the age and gender over the year and made good progress in improving recording relating to patients' self-reported disability status, sexual orientation, ethnicity and marital status. We have not currently prioritised recording of gender reassignment or pregnancy / maternity but will review this in the future. We believe that the lower percentage recorded against religion / belief is a temporary reduction and we expect this to improve over the year ahead.
What this means for patients
We are now beginning to see a big improvement in the recording of protected characteristic data. This allows us to increase our understanding of the profile of patients across our services. We will soon be able to compare this to what we know about the local population as a whole to understand whether our services are representative of the communities we serve. This helps us to take action to make our services more accessible and culturally appropriate for you.
Priority 5: Improve medicines management to ensure clinical, cost effectiveness and safe use of medicines.
What we said we would do
The priority of our Medicines Management Team is to improve patient safety when using medicines. Our efforts have been focused on promoting a culture of reporting medicines related incidents with all our staff and patients, and sharing the learning from these incidents across our clinical teams in our organisation. We have ensured that these incidents were appropriately reviewed, discussed and reflected in a timely manner, and that changes were implemented to avoid incidents re-occurring and improve patients’ care outcomes. Most of these incidents do not cause harm to patients but they are important in identifying problems or gaps in our processes where we can learn to improve safety of care.
What we did
Our main success is that syringe driver devices, which are used to deliver drugs to people with symptoms of pain or nausea, were changed to simplify the process for nurses and this significantly reduced the numbers of reported problems in this area.
This year, following a national campaign to reduce antibiotic resistance and super infections resulting from antibiotic misuse, our Medicines Management Team has undertaken extensive work to promote Antibiotic Stewardship. For example, we have reviewed our antibiotic prescribing on a quarterly basis and run a broad spectrum antibiotic audit to gain some understanding on the areas that we would need to focus on. To complement this work, we have organised several educational talks for our clinical teams to raise awareness on ways to help them prescribe antibiotics responsibly. Our continued work in Antibiotic Stewardship has resulted in a significant reduction of the total amount of antibiotic prescribing in our organisation. This is a relevant step in our commitment to work towards reducing antibiotic resistance and superinfections such as Clostridium difficile infections, which are difficult to treat with existing antibiotics.
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During the last year, we decided to focus specifically in three main areas of medicines related incidents: insulin, syringe drivers and patch medication, as these types of incidents showed an increase from the previous year. Although all were classified as minor or no harm they identify areas where processes can be improved.. Different group meetings were arranged to tackle specific concerns around this type of medicines related incidents, for example, an Insulin Task and Finish Group, Community Healthcare Teams Incident Group and a Quality and Harm Free Care Group. As a result of the review and discussions of incidents by these groups, several improvements were implemented in our practice, such as a mandatory training for all nurses and health care assistants that administer medications. This training is currently being developed and piloted with test groups.
From our recent review of medicines related incidents, we have found several trends. There has been a slight increase in medication related incidents during year 2015/16 in comparison to year 2014/15. This increase has mainly occurred in our Community Healthcare Teams and Out of Hours Teams. When reviewing the type of incidents occurring during year 2015/16, incidents in missed doses, record management and controlled drug balance have increased from year 2014/15. However the level of harm from these incidents has remained low. By contrast, on a positive note, incidents such as wrong doses, wrong drug, missing medication and syringe drivers medicines related incidents have been reduced from last year’s records. This improvement in our performance was a result from our improvement work undertaken in this area.
How we will continue this work
We are aware that we still have scope for improvement on the use of broad spectrum antibiotics including co-amoxiclav. For this reason, Antibiotic Stewardship will be still high in our priority list and we plan to carry on auditing the use of co-amoxiclav, a type of broad spectrum antibiotic, and promote best practice when prescribing antibiotics.
In order to set clear objectives in our Medicines Management framework for this coming year, we are going to establish specific Commissioning for Quality and Innovation (CQUIN) targets. We will ensure that these CQUIN targets are tailored to our commitment to reduce our medicines related incidents, specifically missed doses, record management and controlled drug type incidents. These CQUIN targets will take into account measures around specific activities. For example, the optimisation of mandatory training for nurses to ensure it is relevant, practical and efficient, and the implementation of processes to ensure nurses are up to date with their training needs in medicines handling. Another CQUIN target will be around the optimisation of our processes of keeping patients’ records including EMIS electronic system, T-card handover systems, the drug authorisation charts and controlled drug registers. And finally we will carry out audits to monitor the outcomes of the implementation of these new recommendations.
What this means for the patients
We believe that by a continuous improvement process of monitoring incidents involving medications we can continue to improve the safety of our services and the experience of our patients. The early targeting of areas where we notice any gaps in processes help us
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to prevent future mistakes and avoid serious harm. We are keen to join national campaigns like the Antibiotic Guardians to ensure future safety of patients through appropriate use of antibiotics
Priority 6: Development of methodology for safe staffing to deliver effective, safe and compassionate care.
What we said we would do
Our aim was to work with community teams, our Urgent Care Centre and Rapid Response Team to develop criteria to measure staffing skill levels that are safe. NICE guidance on standards for this area are due to be published in 2016.
The key aims of the priority were:
- To work with the Department of Health and NHS England as part of a national expert group.
- To seek out best practice from other community organisations and share learning from our own developments through the National Benchmarking Network.
- To source an e-rostering tool which will help to assess the number of staff needed across the organisation and to flex our resources to meet the needs of our patients.
- To understand and measure demand for planned and unplanned care across services by developing data collection methods which could be used to apply to systems to manage workload.
- To agree a tool that could be used to measure the complexity and needs of patients on the caseload of our services.
What we did
We revised the programme definition, which was approved in December 2015 through a series of consultations and ground work. A newly elected programme board has been tasked to deliver a safe staffing standard which sets out what is required to deliver high quality care, taking into account the demand and capacity of the service. five work streams have been created:
- Right resource
- Workforce planning
- Monitoring and reporting
- Systems consolidation
- Communications and involvement
How we will continue this work
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Work will continue throughout the course of 2016-17 with a clearly defined programme scope. The programme will be expected to produce a standard for each service that sets out what is required to deliver high quality patient care, taking into account the demand and capacity of the service.
Systems will be procured to support the safe staffing standard to generate key evidence required to inform decision making.
Using a phased approach the programme will prioritise the Community Nursing Teams, Out Of Hours, the Urgent Care Centre and End of Life Services before rolling out to all services by the end of the financial year. This will introduce new ways of working that will improve the quality and safety of patient care through co-ordination and ability to be flexible in allocating staff to better meet the needs of patients..
What this means for patients
Patients will be assured that the right people with the right skills are in the right place at the right time. One of the prominent requests from patients is to have timed appointments. With an effective rostering solution it is hoped that this may be facilitated more readily to patients as services will have a much clearer view of their working day and allow customisation of visits based on patient needs. It will also provide an organisational view of resource versus demand and address any risk of the delays in providing services when demand is at a peak.
Priority 7: Continuing pressure ulcer prevention by taking further proactive steps through continued learning.
What we said we would do
Our aims were to focus on staff education, shared learning, and training around pressure ulcers to take a more proactive approach to pressure ulcer prevention. We wanted to work with other healthcare organisations including home care agencies, and continue to educate patients and their carers to be aware of techniques to safeguard the skin.
Our vision is to develop a culture whereby every member of staff inherently considers pressure ulcer risk at every interaction with every patient. We have been implementing the SSKIN bundle for four years alongside our project ‘Pressure Ulcers – Everybody’s Business’, enabling us to continue to engage with our staff about prevention. Our plan for the last year was to be more proactive around pressure ulcer prevention than ever before.
What we did
In addition to our current portfolio of educational leaflets to share with patients, we have developed a postcard to give to patients which identifies why they may be at risk and what they can do to prevent skin damage. This postcard also acts as a reminder for health and social staff of the key elements of risk.
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<<add in image of the postcard>>
We have increased training for our healthcare staff and for our partners in social care to monthly sessions to ensure regular access. Working with our social partners by offering them training on pressure ulcer prevention is extremely important as carers are in a unique position to identify any early warning signs. We have extended this offer of training to private family carers as well as social care agencies and residential organisations.
In support of International Stop the Pressure Day in November, our Wound Care Service ran a campaign to encourage staff, family and carers to moisturise and check area at risk of ulcers. The campaign which was called ‘moisturise, protect and prevent’, promoted moisturising skin to prevent pressure ulcers. All the Integrated Community Teams and Rapid Response Teams were visited to promote the simple idea of moisturising the three most common areas which are the sacrum, the buttocks and the heels. We also encouraged the regular inspection of these areas, as well as the use of our SSKIN care bundle with all patients.
We were granted funding this year for a new pressure mapping sensor unit which has been used regularly with our high risk patients to identify if they have ‘hot spots’ of pressure when sitting or lying that could potentially cause skin damage in the future. This has proved to be invaluable in visually demonstrating to patients and staff where at risk areas are and what changes need to be made to reduce that risk. It has also enabled us to proactively change equipment or refer to wheelchair services for reassessment of wheelchairs or cushions.
We are participating in the ‘Stop the Pressure Programme’ which is a joint partnership initiative working across the health economy involving local primary care, community services and commissioners. The aim is to share learning, standardise best practice and drive a collaborative approach to pressure ulcer prevention
We investigated any incident of significant pressure damage to identify if there were any aspects of care that could have been improved or changed to have prevented the damage occurring. Themes are drawn out from the investigations to inform learning and are shared with our healthcare staff through a variety of communication channels. We also continue to conduct an annual audit of the implementation of our SSKIN protocols for our at risk patients.
Some of the key issues and actions have been:
Equipment issues- A tool has been designed to assist staff correctly to choose pressure relieving
mattresses.- Safety measures have been put in place to ensure appropriate pressure relieving
mattresses are supplied with hospital beds.- Funding has been supplied to provide more innovative aids for pressure relief including
heel lifts and wedges.- Mirrors have been issued to healthcare staff as an aid to heel inspection.- Patient safety messages have been sent out regularly to remind staff of key points to
remember.
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Inexperience of very new staff in pressure ulcer prevention- SSKIN awareness training is now linked to induction of our new staff in order to ensure
they have a heightened awareness of pressure ulcer prevention and the importance of implementing SSKIN and skin checks.
Pressure ulcer prevention documentation needs to be improved- A diary sized flash card for all staff was launched in December 2015 as a visual
reminder of key aspects of our SSKIN campaign that must be actioned with every patient and must be documented correctly.
- An EMIS SSKIN template has been designed and launched in January 2016 to aid staff in completely essential documentation succinctly.
Working collaboratively with social care agencies and teaching them to recognise early warning signs of pressure damage when providing hygiene needs has proved to be very successful and the awareness of health and social staff is much higher when measured through our annual audit.
Our focus on heels, a particularly high risk area for pressure ulcers, has been very positively received and staff routinely advise patients to reduce pressure on this area by the use of equipment as well as encouraging regular changes of position. A pilot on the use of waffle boots has contributed to a reduction in heel pressure damage and our Bristol CCG have now agreed to include these within the equipment available to community nursing.
How we will continue this work
Our integrated healthcare teams are becoming increasingly proactive in managing the pressure ulcer risk of our patients. This has been demonstrated by increasing requests for pressure mapping and advice around prevention. Our occupational therapy and wound care service are working increasingly collaboratively to ensure patients risk is minimised.
We have plans to implement a new education drive with the agencies to capture their new staff and continue momentum.
Listening and learning from patients who have been affected by pressure damage to inform our care is a new initiative and a focus group with patients is planned for May 2016.
Extra resource allocated to the Wound Care Service will enable a new project of working closely with the ICHTs to further embed SSKIN in their everyday patient care. This will commence in May 2016 and will continue our drive to protect our patients and eliminate all avoidable pressure ulcers.
What this means for patientsOur work in this area means we are doing more than ever to equip healthcare staff with the knowledge they need to prevent pressure ulcers from occurring. Pressure ulcers are avoidable, and by teaching carers how to check for them, we hope we will see less and less of them that need treating.
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3. Other areas of quality
Within this section you will find information on other areas of quality improvement which sit outside of the quality priorities. You will find more detailed information on each of the areas in the appendix.
Safeguarding adults and children
Incident reporting
Staff experience and learning and development
Infection prevention and control
Clinical supervision
Our performance against national priorities
Our performance against our contract
Our awards and achievements
Safeguarding adults and children – extract
There have been a number of changes within safeguarding over the past year, with the introduction of changes within the Care Act and updates from the Female Genital Mutilation Act and the Counter Terrorism and Security Act. We have been working hard to ensure that we are compliant with the care act, which has included updating training, establishing some Safeguarding Link Practitioners, and helping staff understand their duty to report concerns. We have seen an increase in safeguarding adults referrals by 77% in this year, showing the effectiveness of our training and support for staff. We have also achieved good compliance with our Safeguarding Children training, and now have a named nurse and named doctor in post.. We are continuing work in this area to ensure we are playing an active part of keeping children safe in Bristol. Training and information on safeguarding children continues to be tailored to suit the needs of our staff, following an audit, and to make it applicable to more staff, as many mainly work with adults.
Staff experience – extract
Our annual staff survey gives a us a good indication of how our staff feel about lots of different areas of working within our organisation. Staff told us that they felt confident reporting incidents and reporting unsafe clinical practice. our highest scoring theme was teamwork, which tells us staff value their teams and understand their role in their team, and their team’s role in the organisation.
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Amongst the lowing scoring areas included pay, staffing levels and IT, so we put in place plans to improve these areas. We also launched our Happiness and Wellbeing Programme, aimed at improving the mental and physical wellbeing of our staff and finding ways for them to be happier at work. The programme, which launched in early 2016, has seen 25% of staff take advantage of one or more of the schemes and benefits on offer, including a range of salary sacrifice benefits, the ability to buy and sell leave, and a range of fitness and resilience interventions. We are also working on other areas for improvement as identified in our 2015 staff survey and other staff forums, including staff capacity and allocation.
We continue to invest in the development of our staff – from offering apprenticeships to both new and existing staff, to enrolling staff on fast track Community Matron and extended skills programmes. We also successfully secured funding from the West of England Academic Health Science Network to train Band 2-4 staff in improving communication skills.
Incident reporting – extract
We have been working over the past year to improve staff engagement with incident reporting, and refining our reporting tools to ensure we can learn from themes that may be occurring. We are really pleased that a higher percentage of our staff compared to the NHS responded positively to the questions on knowing how to report an incident and feeling informed of learning from themes that appear. We have been working on further refinement of our incident reporting system, Ulysses, and developments to ensure it sits in line with current legislation.
Engaging with our staff
All incidents regarding patients and staff continue to be reported in the incident reporting system Ulysses. All members of staff are being encouraged to incident report, through inductions and other training opportunities. We know staff are more aware of their responsibilities to report incidents as 94% responded positively to the question “, “If I was concerned about unsafe clinical practice, I would know how to report it” in our 2015 staff survey. This compares favourably to the NHS response to the same question which is 85%. There continues to be an upward trend in reporting incidents as shown in the graph below and this represents a maturing incident reporting culture for our organisation.
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BCH Patient Safety Incidents April 14 to March 16
As an organisation, we can continually learn and prevent further harm to patients by reporting clinical incidents. Demonstrating this learning takes time, but we can report that we score 12% higher on the 2015 staff survey question: “we are informed about errors, near misses and incidents that happen in the organisation and we learn from them”, compared to the NHS response. We will continue to build on this by communicating key learning across our organisation. This can sometimes be challenging with many staff based across the city, but we have so far published six patient safety messages ranging in topics from the importance of clinical documentation to reminding patients to float their heals to prevent pressure ulcers and learning themes after each of our monthly complex case review meetings. These are sent to all clinical teams directly and made available on our staff website.
Improvements to our incident reporting system, Ulysses
Our Quality and Patient Safety Team continued to work with the HR Team, over the past year to monitor staff compliance in registering to use the online incident system which was managed as a risk to service on a monthly basis. This has now been reduced to managing the registrations on a quarterly basis as confidence has grown.
There has been further refinement with the management and use of Ulysses during the past year which includes:
• A medication list to improve data quality and provide an accurate record of medicines that have been involved in incidents,
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• Updates to the equipment schedule, which remains work in progress, and
• Images are now uploaded on to the incident reporting to aid the correct classification of pressure ulcers which are our most frequently reported cause group and cause of serious injury.
The system continues to develop in line with new legislation changes and this year saw the introduction of new cause groups for safeguarding incidents including FGM and PREVENT. This has coincided with our organisation raising awareness of this type of incident so that if it is identified it might be referred to the appropriate agency.
Addressing non-concordance
Concordance (or agreement) with care can be challenging in the community as when patients are in their own home, they have greater flexibility on how and when they will comply with advice given by clinical teams who may only visit once or twice a week. When moderate harm and above has occurred and the incident is identified as a Serious Incident Requiring Investigation (SIRI) - during the subsequent investigation run by the clinical teams our Non-Concordance Policy might be used to determine what our Organisation’s approach was to patients who refuse treatment and/or care and provides guidance for clinicians when patients are not concordant with treatment and/or care plan. Where it is clear that the patient’s involvement has been unhelpful, the Clinical Commissioning Group has supported the view that Root Cause Analysis (RCA) investigation will not be required. On submission of the 72 hour report where this is clearly evidenced, we will ask for the incident to be removed from STEIS. We continue to develop the supervision of Shared Decision making between the clinician and the patient for the management of the care with the aim of non-concordance to be avoided.
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PSI
The Complex Case meeting continues monthly for the review of SIRIs and BCH incident reviews. This meeting has developed over the year and where it is possible it is supported by those community nurses who have been involved with the care of the patient who supply helpful narrative to the issues highlighted with the care. Pressure ulcers grade 3 and 4 continue to be the most frequently reported SIRI over the last year and the reporting of them has increased from 33 to 52. At first glance this may not appear to be a good position but the organisation is now more confident that it is picking up on each one, reporting it openly and working with the family or the care agencies for their management. Pressure ulcer development is a national problem and BCH is part of the Pan Avon Pressure Ulcer group and it is hoped that any new learning from this group will be introduced into management of pressure ulcer at BCH.
The organisation has signed up to the Sign up to Safety campaign and is an active member of the West of England Academic Health Science Network. This work programme has helped to develop the standard reporting of observations particularly when a patient has deteriorating health. The use of Early Warning Scores (EWS) across the community with the other providers means we are now all speaking and using a common language when assistance is sought. Staff working in HMP healthcare settings as well as our Rapid Response and Urgent Care Centres have all been trained in the use of these assessments which is particularly useful for screening for sepsis and delirium which require timely and urgent medical interventions for survival.
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Total PSI and SIRI from April 2014 to March 2016
We made a successful application to bid for funds to implement a standard communication format (SBAR) and Human Factors training for the staffing groups within the bands 1 – 4 in order to support this group of staff with communication issues. BCH has also involved Bristol City Council with this training programme as it would be particularly useful for where joint provision of service is delivered such as in the intermediate care services.
At the Voices for Health conference held in November 2015 a breakout table for patient safety was set up to open up the discussion of patient safety in the community. At the table were mainly carers and one of the main themes coming about was how difficult it is for the service users to navigate their way across the providers available and to know where responsibility starts and stops for each organisation.
Clinical Supervision - extract
In 2015 we continued our commitment to ensuring that clinical staff across the organisation received clinical supervision sessions where they were observed delivering patient care in line with organisational policy.
The policy, which is a response to the Francis Report recommendations, promotes a culture of openness, reflection and shared learning. With the awareness and skills of clinical supervision already established through training within the workforce, we worked to improve the number of clinical supervision sessions accessed by our clinicians.
We identified areas of good practice in a number of teams where the practice is embedded and staff engaged with clinical supervision and used it to identify learning needs and set personal goals.
We also identified other areas of service where additional work is required to improve engagement and embedding of clinical supervision to a satisfactory level. We will work concertedly with the teams who require more support and their management to ensure the required improvement and compliance with standards.
Our performance against key national indicators
Indicator 2014/2015 2015/2016
Serious Incidents Requiring Investigation 38 57
Never Events 0 0
Incidence of Falls 41 25
Incidence of Pressure Ulcers 426 578
Medication Incidents 291 344
All Patient Safety Incidents 1119 1442
Infection Control pre 48 0 (we were informed of 0 (We were informed of 23
hour MRSA bacteraemia
2 MRSA bacteraemia cases from our caseload but did not identify any deficiencies in care)
2 MRSA bacteraemia cases from our caseload but the infections were not related to our care)
Infection prevention and control Clostridium difficile infections leading to death or colectomy 0 0
Review of CQUIN Goals for 2015-16
The Commissioning for Quality and Innovation (CQUIN) payment framework is an incentive scheme between providers and their commissioners aimed at fostering innovation and improving quality in service delivery. In 2015/16 2.5% of Bristol Community Health’s contracts were linked directly towards the achievement of these CQUIN targets.
Our year end position shows that we have achieved some significant successes during 2015-16, which is particularly pleasing considering that we implemented a new patient records system, EMIS Web, part-way through the year. This was a substantial project which required a lot of hard work and time commitment from our clinical teams, and led to some temporary challenges in reporting and recording data. Some of our key achievements are as follows:
• We have continued our focus on the rapid assessment and referral of patients with dementia. 100% of patients in our Rapid Response and Community Nursing teams were appropriately screened and 97% of our staff are trained at Level 1 for Dementia awareness and assessment (both measures against a 90% target);
• We have continued and built upon the support we provide to the wider local health system by working collaboratively with cross-organisation teams to enable flow of patients through the system and support discharges from acute care into the community;
• We have responded to the implementation of the Care Act 2014 by fully reviewing our Safeguarding Level 1 and 2 training provision and increasing the percentage of our staff trained in safeguarding to 91%.
• We ran a series of focus groups during the year to build upon our relationships with primary care and ensure that healthcare is consistent and joined up. Our stakeholder survey showed 77% people likely or extremely likely to recommend our services –
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a 3% increase on 2014-15. 62% scored us 8 to 10 on our commitment to patient care , compared to only 16% in 2014-15. 88% of respondents felt that we were a good employer or improving. This compares to 57% of respondents in 2014-15, who had concerns about us as an employer or felt we were not a good employer.
• Designed and implemented a health navigator programme for our Learning Disabilities patients;
• We finalised a new tool to support early diagnosis of sepsis, and rolled out new training on National Early Warning Scores to increase awareness across our staff teams. At the end of the year, the percentage of patients at risk of sepsis in our Rapid Response and COPD teams who had been screened was 100%.
In some areas, despite making good progress, we did not meet all the targets set at the start of the year:
• Care plans: Our target was for 80% of patients of our community matrons to have urgent care plans documented. This is one area where the implementation of EMIS Web has had a substantial impact on data gathering and reporting, and between October and March 60.5% of patients who had been seen regularly by the Community Matrons had an urgent care plan documented.
• Antibiotic prescribing: We successfully delivered a reduction in the percentage of antibiotics prescribed by our clinicians during the year to 26% against a target of 28%,however we did not achieve our target for a reduction in the prescribing of broad spectrum antibiotics. Outturn for the year was 18% against a target of 11%. We are continuing work to reduce the proportion of antibiotics prescribed which are broad spectrum, and this will feed into our Medicines Management CQUIN for the forthcoming year.
• Health inequalities: We have successfully delivered cultural competency training widely amongst our staff group and completed a review to investigate and understand DNA (Did Not Attend) rates within our BME patient group. The introduction of EMIS Web, (where key demographic data now has to be manually entered into EMIS, which previously was fed through from the Spine automatically), the collection and reporting of data on protected characteristics of our patients has been affected during the year. Outturn for the year shows;
▪ Ethnicity recording at 70.27% against a target of 80%▪ Religion recording at 6.31% against a target of 11%▪ Sexual orientation recording at 9.69% against a target of 1%
However, monitoring of all three indicators evidences an improvement in recording percentages in all three areas, since processes have been put in place this year. Monitoring, training and awareness raising is continuing and it is envisaged that recording will continue the upward trend.
We have yet to finalise the percentage of the total funding we have achieved in relation to CQUIN objectives.
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Areas of Consistently Good or Improved Performance in 2015-16
We have yet to finalise the percentage of our quality and innovation incentive schemes we have achieved, but details are below:
Our Therapy services including MATs, Spinal and MSK Physiotherapy have performed well throughout the year and exceeded all national Referral to Treatment Time targets whilst managing higher levels of demand;
• We have maintained high service standards in those areas that have also experienced growth in demand including Podiatry, Musculoskeletal Physiotherapy services, Bladder and Bowel, Wound Care, Tuberculosis and long term condition services such as Chronic Obstructive Pulmonary Disease and Heart Failure;
• Our Learning Disabilities service has exceeded national targets for patients seen within 18 and 13 weeks (97.9% against 95% target and 92.1% against 85% target, respectively) and whilst there is no target for patients seen in 4 weeks, this was achieved for 59.8% of all patients;
• The Learning Disabilities service has seen a large increase in the amount of activity with the total number of contacts exceeding year end targets;
• Over 70% of our patients seen by the enhanced Palliative Care Home Support Service were supported to die in their preferred place;
• Our Dermatology Service has increased the number of surgical procedures performed in year.
• Our Urgent Care Centres have exceeded the national waiting time standard of 95% seen within 4 hours (98.4% for Urgent Care Centre and 100% for Walk In Centre);
• The latest Prison Health and Justice Indicators or Performance (HJIPs) have been successfully reported and a new scorecard developed for the service;
• The Health Assessment and Review Team (HART) has seen improvement to timescales for reviewing patient eligibility to Continuing Healthcare and Funded Nursing Care – including a reduction in the incidence of overdue reviews and improvement to timescales for reviewing retrospective applications and appeals;
Our awards and achievements
Shortlisted for Best Patient and Public Involvement Award at the first Bristol Health and Care Awards.
One of our nurses, Karen Crane, is featured in the Nursing Standard’s centenary edition.
Our healthcare staff feature in the Skills for Health #OurHealthHeros campaign.
Bristol Community Health was shortlisted for two awards at the 2015 Social Enterprise UK Awards, which took place in London on 26th November. The categories are Health and Social Care and the flagship award, UK Social Enterprise of the Year. Over 300 organisations applied to this year’s Awards, which recognise organisations for both their business excellence and contribution to society.
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Our organisation was also shortlisted for Employee-Owned Business of the Year in the 2015 UK Employee Ownership Awards. These annual awards are the most sought after accolades for employee-owned organisations across the UK. The ceremony took place on 23rd November in Birmingham and we were recognised as highly commended in the category. Our Dermatology team was also shortlisted as Clinical Team of the Year in the 2015 General Practice Awards, announced at the end of November.Lynne Skrine became President of the British Dermatological Nursing Group.
We celebrated ten years of our COPD and DESP Services.
Claire Madsen, our Deputy Clinical Director, won an award at the end of December from the Chartered Society of Physiotherapy. The award, ‘Demonstrating Leadership’, recognises Claire’s outstanding leadership within physiotherapy.
Many of our staff have published articles on their specialist areas and spoken at national conferences
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4. Patient and Public Empowerment
Our patients are at the heart of what we do, and our Patient and Public Empowerment (PPE) Team work hard to engage and empower our patients to work with us. Here, we go through the areas of most impact from our (PPE) work, but you can read much more on our website, where you will find a download of our recent PPE Review.
We also take a look at complaints and compliments, and how they shape the work that we do.
Working with our patients
2015/16 was the second year in the delivery of our three-year Patient and Public Empowerment strategy ‘Your Healthcare, Your Way’.
Our main areas of focus have been to make best use of patient feedback to improve the quality of care, extend the role and impact of our participation community, develop our plans for patient leadership and grow our volunteer programme.
To review all of our work, we published our first annual report in October 2015, with lots of case studies and examples. To take a look visit www.briscomhealth.org.uk, or call 0117 900 2146 for a paper copy. Here, we highlight some of our achievements grouped under the objectives within our original strategy.
1) To place what’s important to patients at the centre of every decision
We made sure that the accessible care plan we had developed was offered to patients in prison healthcare - a patient group that would benefit from it.
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Please refer to the review of this year’s quality priorities for more information on this.
2) To make it simple for patients and carers to share their experiences
• We continued to embed the use of our real-time patient feedback system ‘Meridian’, extending it to new services and provided individual support and at team meetings to make sure that our clinical staff are working with a ‘how are we doing?’ approach.
• We introduced benchmarks to enable services to compare their performance with one another. We also introduced real-time alerts so that poor patient feedback is instantly emailed to the right team manager who can take appropriate action to resolve any issues (please refer to the review of this year’s quality priorities for more information on this).
• We reflected on the findings from our patient stories pilot and have now recruited three feedback volunteers to meet with patients to listen to their thoughts and feelings on their experience of our services.
• We worked with the Carers Support Centre to hold two focus groups with carers. We did this to establish whether we are providing them with the right level of support and are involving them in decisions about the care and treatment for the person they are caring for.
Listening to more patients than ever
Between April 2015 and March 2016, we are delighted to report that we have had 4,938 responses to surveys by patients and carers. This represents a 100% increase on the number of responses received in 2013 in the annual survey. This means we are now listening to feedback from TWICE as many patients.
We have now rolled out our real-time feedback approach to almost all of our community health services which means patients can tell us what they think in a way and a time that suits them.
2464
4938
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Chart x: patient experience survey comple-tions
Completed surveysNumber of services taking part
Com
plet
ed su
rvey
s
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Friends and Family Test
We continued to ask patients to respond to the Friends and Family Test (FFT) in line with contractual and national requirements.
We received 4850 responses to FFT during the year and overall:
• 96.5% of 3809 respondents seen in clinic or home based services would recommend our services to friends and family should they require similar care or treatment. Less than 1% would not recommend our services.
• 81% of 1041 respondents seen at our Urgent Care Centre or Walk in Centre would recommend our services, with 12% stating they would not recommend our services.
Patient Experience Score
Our overall patient experience score for the 2015/16 year is 89.7 out of a maximum 100. This represents a positive picture of patient experience across our range of services.
We continued to monitor patient experience by key themes of person-centred care. The position against the 2014/15 data is shown below.
87.02
90.8
94.47
85.74
82.41
90.01
92.13
95.14
90.57
84.21
Chart x: Patient Experience Score
by Theme
2015/16 2014/15
We are pleased to report we have made improvements to patient experience in every theme, with the most significant increases in access and appointments (+ 3%) and involvement in decisions and respect for preferences (+4.8%). These improvements have been made possible thanks to the feedback provided by patients and the hard work of staff in making changes to the way they work.
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Comments received from patients and carers
• “I get alot from the visits from the associate community matron. I look forward to these visits as they help me in caring for myself. Thank you for everything. – Patient, Community Nursing Service 15/05/2015
• “It was very helpful and the nurse was friendly, approachable, patient and great with our son. We felt reassured and left feeling confident about managing our son's eczema and having further support if we needed it.”- Parent of Patient, Dermatology Service 28/05/2015
• “I could not have had better service and support. This was delivered in a caring and professional manner. I was able to stay in my own home because of their care. I could not have received more excellent and timely treatment. Many thanks . Patient, Rapid Response 23/06/2015
• “Myself and my two daughters would like to thank everyone for the excellent help we were given which enabled us to keep my husband at home which was our wish”– Carer, Palliative Care Home Support Service 30/07/2015
• “The clinician was very understanding of my condition he made me feel very relaxed. I gave a few problems that may all relate to the initial referral. I now feel able to manage my care but I know I can contact him if I need to”. – Patient, Podiatry Service 25/08/2015
•• “I was treated with the best care and attention and I was informed of all the things I
need to make my condition better. Thank you!”. – Patient, Bladder and Bowel Service 30/09/2015
• “It was great! I feel very inspired to do all I can to improve my health and maintain my independency as long as I can.” Patient, MSK Physiotherapy Service 26/10/2015
• “Thank you for helping us to think about things differently.” Carer of service user, Learning Disability Service 21/10/2015
• “Th(e)re is nothing that could have improved this journey from scared and challenged to confident and healthier. Leanne and her team have been fantastic in their support and guidance and encouragement..” Patient, COPD Pulmonary Rehabilitation 12/11/2015
• “To be honest the help and understanding I have received by the Bristol community health and the community therapy team has been so good that I can not see anything that can improve on my personal experience, the way the team approach the patient in a correct humanitarian way and the ability to listen and understand not only the physical needs but also the mental state of the patient after going through a major operation is remarkable. The team is doing their job not only to get their weekly wages but more important of all they are doing it because they really care for other human beings”. – Patient Community Therapy Beds, December 2015.
• “I appreciate all the help offered to me my life has transformed for the better since I started going at Haven. Patient, The Haven, December 2015.
•• “Nothing could have improved my experience today! I was given accurate info
from reception when I rang prior to visit, a warm, professional reception; was see(n) quickly by an excellent HCA was greeted by the nurse who had previously treated me. Both treatment and advice could not be faulted. Thank you all :-)”. Patient, Urgent Care Centre, February 2016.
• “Myself and husband have nothing but praise for the respect and quality of the service provided by your teams, after over 100 days in hospital which I as a
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patient is fully thankful for the expertise given to me, was astounded by your service after coming home”– Patient, COPD Hospital at Home, February 2016
3) Make it simple to inform patients and carers how their feedback is leading to improved services
• We published even more examples of how patient feedback is making a real difference to the services we provide. We provided examples and case studies on our website, in our community newspaper, on clinic noticeboards and within our first ever PPE annual review to demonstrate what actions we are taking to continue to improve our quality of care.
• Matthew Areskog, PPE Lead and Claire Madsen, Deputy Clinical Director appeared on BBC Radio Bristol to discuss patient involvement and shared decision making with Dr Phil Hammond on his Saturday morning show.
What have we changed following feedback from patients?
• We have developed a carers survey and an action plan to improve carers experience following feedback from focus groups in February.
• We now include information on expected waiting time to treatment on letters to patients of our Community Therapy Service.
• The patient-led heart failure support group has doubled in size following a request to promote the group via a leaflet given out by our Heart Failure Service.
• Our REACT Service now provides clear information to patients about the service they have been referred on to.
• Our Diabetic Eye Screening Programme is trialling Saturday clinics.• Our Bladder and Bowel Service is aiming to improve patient experience of
arranging appointments by increasing the range of time slots available and reviewing clinic locations.
• Our healthcare service at HMP Ashfield are aiming to involve more patients in decisions about their care and treatment by ensuring all patients receive a My Personal Care Plan and are supported to complete it.
4) To work together with patients and carers to develop services around their needs
• In September 2015 we took a big step forwards in our shared aspirations for Patient and Community Leadership by being accepted on the Kings Fund Collaborative Pairs programme. The aim of the programme is for patients and clinicians to work together on a shared challenge and by doing so redefine their relationship together. Our pair, Claire Valser, patient participant and Gayle Bryant, Advanced Intermediate Care Practitioner, were brought together by their common belief that shared decision making is an invaluable tool for empowering patients to have real control over how their health and care is provided in a way that best meets their needs.
• On October 2015 70 members of our participation community came together for the first time at our ‘Voices in Health’ event to share experiences of how they have been involved in developing community health services in Bristol.
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• We continued with our rolling programme of focus groups by meeting with patients and carers who had experience of our Urgent Care Centre, Community Nursing and Diabetic Foot Care services.
• In February 2016, our participation community met again at our annual priority setting event to help shape the areas of focus for the year ahead in terms of quality priorities and budget setting. The ideas from this event have directly shaped the content of this Quality Account.
5) To work alongside volunteers to strengthen the care we provide and our bonds with the community
• During the year we have invested significant effort in growing our volunteer programme. We now have over 20 volunteers working with us in a range of exciting roles that complement the care we provide for the benefit of patients.
• Our roles include feedback volunteers, welcome volunteers at our Urgent Care Centre, volunteers supporting patients seen by our Macmillan cancer survivorship service as well as exercise buddies in Pulmonary Rehabilitation.
• We are especially proud of our Exercise Buddy volunteers, many of whom are our former patients. They provide practical and emotional support and encouragement to patients with COPD attending our six-week pulmonary rehabilitation course. This role has been shown to improve patient experience, increase the proportion of patients who attend the full course and provide a confidence boost to the volunteers themselves.
6) To work collaboratively with the voluntary and community sector to improve outcomes for patient and carers
• In January 2016, Bristol Community Health and Voscur launched a joint survey that aimed to increase our understanding of how well we currently work with the local voluntary and community sector. We are pleased that 81% of respondents would recommend our services to friends or family, and we received some very positive feedback. The results also show there is plenty of room for further collaborative working and as such, we plan to work with Voscur to hold a community health and wellbeing forum with the local VCS in the year ahead.
Learning from complaints We strive to ensure that each and every patient will be happy with the care they receive. However, we understand that sometimes things go wrong, and appreciate it when patients and families raise issues with us so that we can make them right. We value all patient and family feedback and use comments and concerns to learn, and improve our services for others.
Our Comments and Complaints Service has three core elements :-• Listening – to hear and take seriously all feedback that is acquired, whether that
be a formal complaint, a compliment or a patient story.• Responding – to provide a full written response to complaints. All responses are
investigated by a senior manager, signed off by the service and sent via the Chief Executive.
• Improving – our Complaint Service to not only provide an investigation and formal response to the complainant but to identify gaps in service provision and changes
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that may need to be made to improve services for patients. This is achieved through the investigation process.
Learning from our complaints is currently reported to the Senior Management Team’s Risk Group every month, to our Board via the Quality Assurance and Clinical Governance Committee’s scrutiny of the previous quarter’s report and to our Commissioners via the monthly Integrated Quality and Performance Report.
Below are some changes that have been made to services following complaints in the last financial year:-
• The Urgent Care Centre now has one member of staff who has six hours of dedicated time per week to audit every x-ray that is taken ensuring that if a nurse initially misses something this is picked up quickly.
• We produced guidance on the required documentation in the patients home following the introduction of EMIS.
• The Urgent Care Centre produced an abdominal protocol for patients with increasing and / or changing abdominal pain
What we have done in the last 12 months and what are our plans for the coming 12 months?
A key part of our work during the last financial year has been focused on strengthening the systems and processes for gathering learning from complaints and evaluating the service. This happens as standard practice for each and every complaint received. We send evaluation forms to complainants so they can let us know how they found our complaints process. Unfortunately, the response rate is low at 12% - we will be exploring ways for complainants to feed back in other ways, such as online, to try and increase this. Our complaints leaflet, called ‘How are we doing?’, has been revamped and is now available on our website and in all of the clinics in which our teams work. As well as providing details for how to make a complaint, the leaflet explains how to get more involved in the work we do around patient engagement, and how to provide general feedback. We also display posters in waiting areas and other places to raise awareness with more patients.
We will be working with our colleagues in the Migrant Health Service, and the Learning Disabilities Team to better understand what steps can be made to ensure our complaints process is accessible to service users using these particular services, We will also be working more closely with our Patient Experience Team and Patient Safety Team to better share information and note emerging themes and issues to take early positive action where necessary on any ‘hot spots’.
The numbers
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Service Number of Complaints
Contacts Per Year
Monthly Average
Podiatry 5 33741 2812
Urgent Care Centre 21 32354 2696
Continuing Healthcare South Glos
10 1820 152
Continuing Healthcare Bristol
3 2267 189
Musculoskeletal Assessment and Treatment Service
6 6068 506
Community Nursing 23 207635 17303
Bladder & Bowel Service 3 2454 205
Specialist Community Neurology Service
2 7006 584
Occupational Therapy 1 4817 401
Physiotherapy 2 19791 1649
Diabetic Eye Screening 3 31988 2666
Offender Health 8 No data available until April 2016
No data available until April 2016
Rehab 2 17214 1435
Learning Disabilities 2 20833 1736
Walk in Centre 1 17495 1458
CDCC 2 2500 208
There were 94 complaints received between April 2015 - March 2016, an increase from last year’s 80. We conducted some work to compare these figures with other similar organisations and services and we are receiving a similar number of complaints. Additionally we believe increases are due in part to greater internal promotion of the complaints system and greater external awareness of the quality of services that patients receiving NHS Services are entitled to, following the publication of high profile reports.
Of the 94 complaints received, 98 % were acknowledged within three working days, and 94% were responded to fully within 28 working days.
By 31 March 2016, four complaints remained open, but none are expected to exceed being responded to within 28 days.
Reasons for delay in response to the 6% complaints that were closed beyond timescale of 28 days:
Reason for delay Number of cases affected
Delayed whilst waiting for a response from another organization
3
Key staff on leave delaying investigation or delays in contacting staff
1
Complexity of investigation 2
Referrals to OmbudsmanTwo complaints were referred to the Health and Parliamentary Ombudsman (HPO) during the financial year. The HPO decided to discontinue their investigation into one complaint and the other is still under investigation.
Complaints by Service
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Themes
Subject Number of cases
Attitude and behaviour of staff – i.e. when a patient or relative has been unhappy with the level of professionalism displayed by staff
15
Clinical Care – i.e. when a patient or relative feels either the quality of care delivered was not of the standard expected or they did not agree with clincial plan followed
30
Provision of care – i.e. the way a service is made available
7
Communication / Information provided to patients – i.e. patients or relatives did not believe that staff / service communicated appropriately or communication was misleading
9
Waiting Times / Appointments – i.e. long waits or delays for appointments
14
General Process – i.e. when a patient or relative is unhappy with the processes in
17
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place by services
Equipment Delays – i.e. when there has been a delay to equipment that is clinically required
2
Complaints by Subject
Appointment DelaysAttitude of StaffClinical CareProvision of CareGeneral ProcessCommunicationEquipment Delays
Examples of complaints received and how these were responded to :-
• A patient’s husband was referred to the Occupational Therapy by his GP. Patient has multiple issues including stroke and NPH. The patients family wanted some help to support patient to sit out of bed in the daytime safely NPH. tafftaffby staffed to discontinue their investigation into one comatient has been bed ridden for some time, which had led to muscle wastage. The family were concerned that there was a delay to patient receiving an OT appointment.After a 3 month wait, an OT visited and recommended a review of the chair either to add supports for patient to stay in his chair and a suitable sling for him to sit in, or for a different chair. Complainant was aware that it was likely to be another two months, before issues were resolved.
A response was sent apologising that we were not able to reach the 8 week target on this occasion and explained that staffing had been increased to address this shortfall in the short term, and that funding has been procured to increase the staffing permanently within the occupational therapy.
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• A complainant was unhappy that although the district nurses were supporting his father, following his cutting his foot whilst stumbling. The wound deteriorated over the month the team were proving support and ended with his having three toes amputated.
The complaint was investigated, and investigation found that although the team provided appropriate support i.e. visited regularly, involved GP as and when appropriate and involved wound care specialists, the team failed to complete notes stored within the home, which may have provided the family with some reassurance as to care being provided, and to take regular photographs of wound and upload to EMIS.
A letter of explanation was sent and an action plan re learning developed, which resulted in guidance being produced on required documentation in the patients home following the introduction of EMIS (electronic patient records system)
• A patient attended UCC suffering from abdominal pain. Following triage she was assessed by a nurse who carried out tests and observations, which were all normal. The nurse stated she did not feel it necessary to refer patient for further testing, despite patient's pain.
Patient attended a GP appointment the following day and was referred to the RUH where an emergency appendectomy was performed and the patient was found to have a ruptured cyst on her ovary.
An investigation took place which found that the patients observations and urinalysis tests were normal, she did not appear to have presented with a definitive acute abdominal pain, and was advised to seek a GP appointment within 2 days if the symptoms did not improve or if pain worsened.
The Investigator recommended that clinicians refer any patients presenting with increasing abdominal pain to secondary care and an Abdominal Protocol was produced to this effect
Learning from compliments
Compliments are just as useful a tool for measuring the quality of services as complaints, as they help to provide a really balanced view of our performance.165 compliments were received and logged this financial year.A breakdown can be found below, along with some examples of thanks received throughout the year
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Compliments
Community NursingContinuing HealthcareCOPD NursingDiabetic NursingIntermediate CareLearning DisabilitiesMATSOccupational TherpayPalliative CareMcMillan NursingPhysiotherapyPodiatryRehabilitationSPA OOH NursingUrgent Care Centre
“On behalf of my mother and wider family I would like to thank you and your team for the excellent care and support that you provided my father X with over the past 2 months. My parents have been full of praise for the work of your team specifically with regards to your professionalism, dedication and use of humour during his time in your care. It is clear to his family that your care has had a positive impact on him; we have all seen a huge improvement in his condition. Thank you to each and every member of your team for your hard work”
“I have recently had to have the Rapid Response Team in to administer antibiotics. I feel compelled to write, they proved to be an extraordinary caring, professional friendly group of women.
Some near the end of their shift when tiredness generally breaks through, they arrived in my home with smiles and laughter. I am so grateful to each and everyone from this team who went out of their way to assist and help through a very difficult time.
During the treatment I was told my mother was dying. Their response overwhelmed me. All went out of their way bring comfort and when I asked some questions about mums palliative care they told me what it was. Although I have been unwell myself it has been of enormous help. I feel honoured and privileged to have met these very wonderful women. I shall not soon forget them.”
“Thank you for your well written discharge letter received today – you have absolutely encapsulated our problems and concerns perfectly and I thank you for just ‘getting us’. Your problem solving has got us out of a deep dark pit and we are very grateful to you both, not only for your ability to problem solve but just your friendly demeanour and un judgemental approach.
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The biggest help has been your support in getting us extra respite care which has absolutely changed our lives from total despair to real hope. X anxiety has virtually gone, he is so much happier and loves going out with X. It has enriched his life so much and he how feels very much a part of society, it is lovely to witness. I feel more rested and able to pursue different interests and go to work, and as a result I now feel that my life is worthwhile instead of always having felt worthless. Thank you so much for your intervention, it has truly benefited us all as a family.”
“X after a long, debilitating, tortuous illness which he stoically bore with quiet dignity died peacefully this morning at 07.50.
I, as his Civil Partner, wish to express my profound gratitude to the absolutely superb Nursing Team who acted with the greatest gentleness and genuine compassion who's efforts did much in easing his terminal pain and discomfort. Their caring went far beyond the bounds of mere duty.
To say I was touched by such caring, which went well beyond merely being a job is a profound understatement. I simply do not have the words to express my gratitude.
Thank you, i will never forgot such tender humanity and kindness”
“I would like to say that when I attended the urgent care centre for treatment, I was treated very kindly by the medical staff. The care and consideration that was shown to me was wonderful, also several of my friends have been treated there and they were very pleased with the way they were treated. Thank you once again”
5. Looking forward
Quality Account priorities 2016-17
Here we map out our areas of focus for the next 12 months (2016-2017). We also consider what we would like to achieve and the impact it could make. We worked collaboratively with patients to present priorities not only aligned with national and local health priorities, but also to reflect what patients feel is important to them. You will see that one of these priorities has been chosen by patients.
When patients told us we had too many priorities and that we should narrow our focus, we listened, and this year we have less priorities.
We will measure the outcome of these priorities through patient stories and feedback, so we can understand the areas of most impact.
Clinical effectiveness
Improving outcomes for patients with sepsis
Improving Care at End of Life - Anticipatory prescribing
Improving outcomes for the acutely unwell patient
Patient experience40
Making Information More Accessible
Delivering person centred care together with the Voluntary Sector
Patient safety
Optimising Medicines Management
QUALITY ACCOUNT PRIORITIES 2016-17
Clinical Effectiveness
Improving outcomes for patients with sepsis
Why this priority is important
There are indications that sepsis is easily missed during initial contacts with health services. Prompt recognition, escalation and treatment is key to improving patient outcomes from sepsis. These factors increase the chance of survival from sepsis and the reduction in complications associated with it.
Reasons why sepsis is easily missed is usually due to deficiencies in taking vital signs such as temmparatures and pulse to highlight subtle signs of deterioration in a condition at an early stage. One reason for the difficulty with identification is that the symptoms of sepsis often suggest less serious illnesses such as influenza and this can lead to delays in seeking or receiving treatment.
What we are hoping to achieve
Patients said they wanted us to develop a focus on identifying patients most at risk of developing sepsis.
We hope to improve the identification, escalation and treatment of sepsis in patients. This will build on previous work around the use of the Early Warning Score System, and initial introduction of the Sepsis 6 tool.
The key milestones we will aim to achieve include:
• Continue embedding the Early Warning Score system in the integrated community healthcare teams (May 2016 onwards).
• Continue embedding and monitoring implementation of the Maternity Early Warning Score system in the female prison service (May 2016 onwards).
• Introduce and implement the National Early Warning Score (NEWS) across our clinical services to replace our current system. Also introduce and implement NICE clinical guidelines on Sepsis (June 2016 onwards).
• Disseminate training to clinical staff in the use of Sepsis 6 and roll out the tool in all appropriate clinical teams especially prison services (June 2016 onwards).
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Patients said they wanted to see training on sepsis identification available to all staff.
• Roll out the use of our screening algorithm as an indication of the care pathway for the acutely ill or deteriorating patient (July 2016 onwards).
• Promote the uptake of the seasonal flu vaccination by pregnant women in the female prison (August 2016 onwards).
• Audit implementation of sepsis screening and identification through the use of Sepsis 6 and NICE guidelines in at least two prison teams (after October 2016 and annually).
What this means for patients
If sepsis is recognised, escalated and treated in a timely manner, you will be more likely to get the right treatment, for the right condition at the right time, in the right place and by the right professional. Furthermore this will increase the chance of survival and ensure reduction in the complications associated with sepsis. It is likely to reduce emergency department admission as treatment will be initiated sooner rather later. If you however need to be assessed and treated in hospital, the use of our screening tool and pathway will ensure a good handover to emergency and hospital services thereby promoting a shorter admission and joint working between hospital and community services to get you home as quickly as possible. We hope that the consistency of care will increase, ensuring that your care is seamless between our teams, your GP and any hospitals you may receive care from. By promoting the uptake of flu vaccination, we hope that the pregnant women within our female prison service will be better protected against opportunistic infections which can lead to sepsis.
Improving Care at End of Life -Anticipatory Prescribing of ‘Just in Case’ medication for symptom control in end of life care
Why this priority is important
There has been widespread introduction of anticipatory prescribing in community-based palliative care in the UK. This usually means that GPs or non-medical prescribers (with appropriate training for patients nearing the end of life) issues a prescription before it is needed, in anticipation of managing symptoms of dying (pain, secretions, nausea and vomiting, agitation and shortness of breath), that can be experienced near the end of a patient’s life.
Anticipatory prescribing is a process and not an event and should be tailored to the individual patient and circumstances, taking into account risks and benefits of prescribing in advance. The prescriptions are often activated by nurses working in the community who also play a key role in the process.
Patients in the community with a terminal illness who have been assessed by a qualified healthcare professional as actively deteriorating often experience new or worsening symptoms as they approach the last days of life and may be unable to swallow oral medication. It is therefore considered good practice to prescribe and provide ‘Just in
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Case’ (JIC) medication in the home in anticipation of managing symptoms such as pain, nausea and vomiting which are common near the end of a patient’s life. Individualised prescription (FP10) for JiC medications is thus recommended. For patients unable to swallow oral medication, a range of subcutaneous (SC) medication should be prescribed and authorised on the Community Palliative Care Drug Chart to allow administration by a registered nurse working in the community. Those patients who deteriorate and develop uncontrolled symptoms will require a full clinical assessment to ensure there is appropriate treatment of any reversible factor and a clear management plan.
What we are hoping to achieve
We will ensure:
- Those patients with a need for anticipatory prescribing of JIC will be identified ahead of time by our community healthcare teams involved in provision of end of life care to patients.
- Ensure that patients and carers understand the plan of care, the purpose of the JIC medication and are given information leaflet on JIC medication.
- That all JIC medication are prescribed on an FP10 form and written (authorised) on the Community Palliative Care Drug chart.
- The patient or carer is able to get the JIC medicines dispensed from the pharmacy, even if the medicines are needed urgently.
- That the GPs and our non-medical prescribers complete and update respective Patient’s Community Palliative Care Drug Chart.
- Our staff team will work to the CCG’s prescribing guidance for JIC Medication.
- Those JIC medicines are prescribed in advance, stored in the patient’s home and clearly labelled so that healthcare professionals can easily identify.
What this means for patients
Anticipatory prescriptions are increasingly used to ensure symptom relief is readily available for patients nearing the end of life. Anticipatory prescribing of JIC medicine ensures that possible symptoms in the last days of life are anticipated and if they occur, they are treated promptly, thereby improving the quality of care to palliative patients in the community. Furthermore, anticipating patient’s needs and providing appropriate medication in the home ensures the avoidance of the distress which can be caused by delayed access to medicines.
Improving Outcomes for the Acutely Unwell Patient - Implementation of a training course to ensure staff use systematic assessment for early response (SAFER).M
Why this priority is important
Evidence has been identified by the National Patient Safety Agency (NPSA), the National Institute for Clinical Excellence (NICE) and others that delays in recognising deteriorating
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patients and in escalating findings has resulted in delayed treatment and in some cases, unnecessary deaths.
Clinicians from across our services have developed the SAFER course to support our staff in maintaining and improving their competence in responding in an emergency situation.
The course is aimed at our qualified staff, and reinforces the need for a systematic and structured approach to managing an acutely unwell patient by recognising deterioration and escalating findings to an appropriate health professional. It includes identifying who is in charge of the emergency and includes a practical assessment of each member of staff’s competence in managing an acutely unwell patient.
We have developed a ‘screening an unwell patient’ flowchart to support the training which incorporates an Early Warning Score, and sepsis and delirium screening tools. It asks ‘does your patient look unwell?’ then guides the staff on actions to take, who to inform, including documentation of findings (using the SBAR tool- situation, background, assessment and recommendation).
When a patient has been identified as being acutely unwell or at risk of deterioration it is essential that a thorough assessment is completed, reviewed and repeated regularly. If the assessment is performed by every member of staff in a methodical and consistent manner, this will ensure patients receive a high level of care that will quickly identify their needs and lead to the best outcome for the patient. This course will help staff to identify patient who are acutely unwell and what actions to take to keep them safe.
What we are hoping to achieve
We aim for all our qualified staff to be trained and assessed in the management of acutely unwell patients enabling them to use a structured and systematic approach to ensure timely and safe treatment for the patient.
We will provide all staff with a training manual that supports the programme to familiarise themselves prior to the training and to use as a reference guide for updating themselves.
We aim to make the training mandatory for all our nurses, assistant practitioners, physiotherapists and occupational therapists, and will manage and record their attendance.
What this means for patients
Deteriorating patients will be recognised earlier with escalation to the appropriate professional for timely treatment by the right person in the right place at the right time.
We are all passionate about the safety of our patients and we know that the level of competency of our clinicians to respond in an emergency situation can make an enormous difference to whether people survive a life threatening event.
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Patient experience
Meeting the diverse needs of our patients by implementing the Accessible Information Standard
What this priority is important
The Accessible Information Standard (AIS) is a new legal requirement for providers of NHS funded services.
Nationally, patients who have a sensory impairment, for example those who are deaf, partially sighted or blind, have difficulty in accessing services. Patients with some neurological conditions also experience difficulty in communicating with healthcare professionals. Healthcare organisations have not always provided information in an accessible way to these groups, nor have they met their communication needs in a person centred way.
The AIS requires us to meet the communication needs of people with a disability, impairment or sensory loss. The standard applies to all patients and service users who have information or communication needs relating to a disability, impairment or sensory loss. By capturing their communication needs correctly, we can then ensure that their needs are accommodated for. This may be ensuring appointment letters are in large print, or creating a leaflet in braille. It may also mean providing face to face interpretation support such as a British Sign Language interpreter, or making reasonable adjustments to the length of an appointment to ensure that communication between patient and healthcare professional is effective.
We are committed to implementing the AIS, ensuring we advance equality for these patient groups and continue to work towards our mission of providing person centred patient care.
Did you know that 2 in 3 of British Sign Language users did not get an interpreter and 28% of patients with a hearing loss did not understand their diagnosis after visiting their GP? (Action for Hearing Loss)
What we are hoping to achieve
There are five areas of the AIS that we will work towards during the year.
• ASK patients if they have any information or communication needs.
• RECORD these needs in a clear and standardised way.
• HIGHLIGHT a patients electronic record so it is clear that they have information or communication needs, and explain how those needs should be met (based on the preference of the patient).
• SHARE information about a person’s needs with other healthcare and adult social care providers, when they have permission to do so.
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• ACT and take steps to ensure that individuals receive information which they can access and understand. This will include adapting appointment letters, patient information and face to face communication.
We will develop new, simple, workable processes to make our compliance with the new standard as easy and as seamless as possible. We will seek opportunities to involve patients, carers and the voluntary sector in supporting us to implement the AIS, for example in providing training for our staff. We will also look at collaborating with other healthcare providers in city where possible.
What this means for patients
Implementation of the AIS will make it easier to access our services if you have a disability, impairment or sensory loss.
It also has the potential to improve outcomes by providing effective, person-centred communication which may mean you receive earlier diagnosis or treatment or feel more involved in decisions about your care and therefore feel more confident to manage your health.
The AIS may also bring some benefit to our organisation too, by reducing ‘did not attend’ (DNA) rates, for example. This means you will attend appointments that may have missed previously.
The 2013 Action on Hearing Loss report, Access all Areas?, reported that 14% of people with hearing loss had missed an appointment due to not hearing their name being called in the waiting room.
Delivering person centred care together with the Voluntary Sector
This priority was chosen by our patients.
What this priority means
Some of our services already make referrals to specific Voluntary and Community Sector (VCS) organisations like the West of England Care and Repair, for support for patients. Our nurses and therapists visit thousands of patients in their homes each month, providing care and treatment at home, helping them to live life well and often reducing isolation. To truly deliver person centred patient care we need to recognise that patients would often benefit from other services to support other aspects of their lives, not just the healthcare we provide.
We plan to embed our connections with the VCS by working as part of the Bristol Ageing Better (BAB) Partnership on an exciting pilot project. BAB is leading on developing a ‘first contact checklist’ that our healthcare staff will use to refer a patient on to a list of agreed VCS organisations who together will meet their need in a holistic way.
What we are hoping to achieve
We will sign up to be part of the first contact checklist pilot as a referring agency. We will trial the approach in one of our community nursing locality teams. This means that;
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1. When a community matron, community nurse or healthcare assistant visits a patient, they have the opportunity to go through some brief questions with the patient should they the patient wish to.
2. These questions will help to identify what support might be needed for the patient, for example, a fire safety check, some financial advice or referral to a befriending service to reduce isolation.
3. The patient has the opportunity to consent to their information being shared with other agencies.
4. The healthcare professional sends off the form electronically to the BAB first contact checklist hub and leaves a card with the patient so they know which agencies they have been referred to.
5. A member of staff at the hub processes the form and makes contact with the relevant agencies.
6. The patient receives contact from the relevant agencies who then visit the patient to meet the identified need.
We will then evaluate the pilot together with BAB and the other VCS organisations and determine whether to roll-out to our other services.
What this means for patients
You will benefit from the first contact checklist pilot by having your needs met in a holistic way. Meeting both your wellbeing needs as well as your health needs may also increase your ability to self-care and manage long-term conditions. As the checklist is completed by one of our staff and the referrals are managed by BAB, the pressure of contacting multiple agencies is taken away from you and our staff.
Patient Safety
Optimising Medicines Management
Patients told us they wanted us to focus on providing training for healthcare professionals.
Why this priority is important
There are 3 specific areas of focus for this priority;
The prevalence of antimicrobial resistance is said to have risen alarmingly in recent years, leading to increased pressure on existing antibiotics and greater challenges in treating patients. This rise is said to be linked to the inappropriate use of broad spectrum antibiotics, for example overusing this type of antibiotics when they are not clinically necessary eg for viral illness.
Some patients discharged from hospital are referred to our services when they are at risk of re-admission to hospital. For example, patients that would need intravenous antibiotics
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or other medicines such as insulin and would benefit from a home care plan. Currently, our staff would need authorisation from the patient’s GP in order to administer medicines post hospital discharge with the exception of intravenous antibiotics. Currently these intravenous antibiotics could be administered following an appropriate hospital drug chart with a hospital consultant authorisation. The process of obtaining this authorisation during working hours (Monday to Friday) has not been an issue. However, out of normal working hours, obtaining GP authorisation (e.g. via BrisDoc) is not always timely and safe. We believe that by expanding the number of medicines that could be administered by our staff using an authorised hospital drug chart, when patients are discharged from hospital in out of hours, will have a positive impact on patient care.
We have always aimed to provide our staff with appropriate training to ensure the safe and effective use of medicines. As our medicines related incident reports indicate that we still have a scope for improvement, we would like to include in our priorities a further commitment in improving clinical staff training in relation to safe medicines handling.
What we are hoping to achieve
During 2016/17 we will aim to achieve a reduction in the inappropriate prescription of broad spectrum antibiotics through antibiotic stewardship; a reduction in missed medication doses immediately following hospital discharge through the use of hospital drug chart by the out of hours clinical service; and a reduction of medicines related incidents through an improvement in our availability of training resources
Antibiotic Stewardship:
We will:
• raise awareness of antibiotic stewardship, with a focus on the implications of routine use of broad spectrum antibiotics.
• provide staff (especially non-medical prescribers) with clear and evidence based best practice guidance on the use of antimicrobial agents.
• provide the general public with clear information (e.g. patient leaflets) on the natural course of self-limited infections and when antibiotics would be of benefit
Patients told us they wanted more information to be available to the general public.
• monitor and audit the prescribing of broad spectrum antibiotics by our non-medical prescribers.
Use of hospital drug chart post discharge:
We will:
• build on our current experience of administering intravenous antibiotics post hospital discharge from the drug chart authorised by consultants.
• put in place an appropriate and safe system to allow the Out of Hours service teams to administer medication prescribed by the hospital during the period post discharge until
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the next working day when a community prescription chart can be obtained from the patient’s own GP.
Better training on safe medicines handling:
Patients told us they wanted to see better training on handling medicines safely.
We will:
• increase our training opportunities for all healthcare staff within the organisation regarding safe handling of medicines.
• Optimise and update current training resources taking into account our current need to minimise medicines related incidents including missed doses.
• Design appropriate face-to-face workshops and online courses.
What this means for patients
The safer use of antibiotics will result in less adverse effects for you. These adverse effects could include potential admission to hospital due to a resistant super-infection that fails to respond to standard treatment. Good antibiotic stewardship will also ensure the preservation of the effectiveness of current antibiotics for future generations.
3By facilitating post-discharge systems, you will receive better continuity of care following hospital admission. Also the risk of harm from medicines related incidents will be reduced. For example, missed doses would be prevented as authorisations would be obtained in a timely manner.
By ensuring that our healthcare professionals are appropriately trained in safe medicines handling, you will receive safer and more effective healthcare.
Our CQUIN Objectives for 2016-17
In 2016/17 the CQUIN scheme is worth 2.5% of our contractual income from commissioners. CQUINs are priority areas, chosen by commissioners, clinicians, patients, which impact on quality of care. These are areas chosen for improvement or development in the coming year - some are national, some are local and some can be across systems involving hospitals and community services working together
The headline CQUIN goals are as follows:
CQUINS (Commissioning for Quality and Innovation) is a framework which enables commissioners to reward excellence by linking a proportion of healthcare providers’ income to the achievement of local quality improvement goals.
(i) National Mandated Objectives
• Health and wellbeing of staffAccess to physical activity schemesAccess to physiotherapy servicesIntroducing Mental health initiatives
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Improving uptake of influenza vaccination.
(ii) Bristol Community Health Organisational Objectives
• Frailty: Piloting an approach, based on the use of a ‘frailty index’, to identify and instigate preventative care that targets components of frailty before a health crisis occurs.
• Domestic abuse support for Learning Disabilities patients: Ensuring that all BCH staff working in Learning Disabilities are fully up to date, trained and equipped to work with service users who are experiencing or potentially experiencing domestic abuse. This vulnerable group are very much at risk of suffering abuse and often do not have the same access to support on issues relating to domestic violence.
• Medicines Management: Continuing our work to design and implement a cross-organisation framework to improve consistency and safety in the management of medicines. This will include targets on reducing medicines management incidents and improved antibiotic stewardship.
• Pressure ulcer prevention: This objective builds on our existing work in this area, which particularly affects the patients of our Community Nursing teams. We will be building on work already completed to establish a culture within which all staff consider pressure ulcer risk in every interaction with patients.
• Staff development: we will ensure that staff are given protected time for reflective practice, supervision and learning
Service Improvement Priorities for 2016-17
Based on our end of year performance outturn we have identified the following areas as service improvement priorities in 2016/17:
• EMIS Web – Across all Services to ensure that EMIS Web data is reported to the highest quality standard and improves operational efficiency by (wherever possible) replacing workarounds in previous systems (RiO/spreadsheets etc.);
• CQUINs – Programme management of all schemes to maximise opportunity for innovation and improvements to the quality of services we provide;
• Waiting lists – Managing the capacity of our services to reduce waiting times, despite the pressures of increasing demand on community services that are evidenced year on year;
• Neuro and Elderly services – Improving 18 week waiting times for neurological and elderly care pathways
• Podiatry Service – improve waiting times so that at least 40% of “Non-Urgent” patients are seen within 4 weeks of their referral being received.
• Prisons Service – Further implementation of the Health and Justice Indicators of Performance and additional reporting scorecards;
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• Equalities Monitoring – Improving our equalities monitoring across the nine protected characteristics and making better use of this information to improve accessibility to our services.
6. Quality and effectiveness
In this section we present the structures, systems and processes which underpin how we will deliver our quality priorities and other areas of work.Monitoring is carried out by reviewing our data from audits, incidents and complaints through our quality and harm free care group. We compare our policies and performance against national and local standards set by NICE or by bodies such as the Safeguarding Boards. This is reported both to commissioners and to our quality sub committee of our Board who are responsible for ensuring the quality of our services.
1. Data quality2. Statements of assurance 3. Audit and research4. Our participation in clinical audits5. Clinical effectiveness6. CQC7. Continuous learning and improvement 8. What other organisations say about us – to be completed after consultation
1. Data Quality
A high level of data quality underpins the effective use of information in decision making to improve the quality of Bristol Community Health services. In 2015-16 a data completion and data validation exercise showed the following for services that use the EMIS Web clinical system:
• 99.93% of our patient records have an NHS number recorded;
• 99.85% of our patient records have a GP Practice recorded;
• 93.1% of appointments had an outcome recorded (i.e. the result of the appointment were recorded);
• Where recorded outcomes suggest that the patient should be discharged (not left as “Active”) recording has improved from 0.42% down to 0.21%,
• Our average waiting time between referral and first appointment is 3.2 weeks
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Data quality is also systematically reviewed as part of ongoing monthly reporting arrangements to commissioners and the Bristol Community Health Board. This includes the following:
• A programme of performance and finance reviews with service leads and budget-holders to review areas where under-performance is linked to data quality;
• Monthly sense checking of activity information and key performance indicators against data quality key lines of enquiry;
• Regular meetings with IT suppliers to review data quality issues either from an inputting ‘front-end’ or reporting ‘back-end’ perspective; and
• Ongoing peer review of coding scripts and data collection processes as part of the overall Bristol Community Health reporting framework.
As part of our strategy to improve data quality Bristol Community Health has implemented processes to demonstrate compliance with the Information Standards Notice in 2011. This informed all community providers funded or provided by the NHS about the introduction of the Community Information Data Set (CIDS).
CIDS is a patient-level, output-based, secondary uses data set. ‘Secondary use’ functions include use for commissioning, clinical audit, research, service planning, inspection and regulation and performance management. The data set itself outlines required data items, national definitions and associated values to be extracted or derived from local systems.
Bristol Community Health is fully compliant with mandatory CIDs information for the main clinical system, EMIS Web.
Information governance toolkit – attainment levels
As a result of improvement plans carried out in 2015/16 and a review of the toolkit comments and evidence the score has now increased to 82% (Level 2) with a target of 86% for 2016/17. This is an improvement from 2014/15 when score was assessed at 78%.
2. Statements of assurance
Would you recommend us to a friend or family member? Staff feedback.
84% of staff would recommend Bristol Community Health to friends and family if they needed care or treatmentThe result to this question puts us in the top 10% of health organisations nationally – we score higher than our local trusts too (North Bristol Trust scored 52% and University Hospitals Bristol scored (71%)63% of staff would recommend Bristol Community Health to friends and family as a place to work.
Patient feedback
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We received 4850 responses to FFT during the year and overall:• 96.5% of 3809 respondents seen in clinic or home based services would
recommend our services to friends and family should they require similar care or treatment. Less than 1% would not recommend our services.
• 81% of 1041 respondents seen at our Urgent Care Centre or Walk in Centre would recommend our services, with 12% stating they would not recommend our services.
3. Audit and research
Participation in National Clinical Audits, National Confidential Enquiries and local Clinical Audits
IntroductionWe monitor clinical audit activity through our clinical audit framework. The framework sets out our priority areas for clinical audit, and the areas that specific teams and services would like to focus on. All clinical audits are closely linked to the priorities identified within our Quality Accounts, our CQUINs, performance targets set by our commissioners, and the National Institute for Health and Care Excellence (NICE) quality standards. Progress against the framework is monitored quarterly by the Quality Assurance Group, and sub-standard audit results are reviewed in the Quality and Harm Free Care Group.
4. Participation in National Clinical Audits
National clinical audits refer to a group of audits which form part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). This is a set of national clinical audits, registries and outcome review programmes which measure healthcare practice on specific conditions, against accepted standards, and give healthcare providers benchmarked reports on their performance.
During 2015/16, four national clinical audits and zero national confidential enquiries covered NHS services that we provide, as follows:
Audit Name Participated?
National Chronic Obstructive Pulmonary Disease Audit
Yes
National Parkinson’s Audit Yes
Sentinel Stroke National Audit Yes
National Audit of Intermediate Care Yes
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During the period 2015/16, we participated in 100% national clinical audits and 100% national confidential enquiries which we were eligible to participate in.
Participation in Local Clinical AuditsThe ‘local’ clinical audit plan is made up of our organisational priority audits (mandated audits), and audits that are carried out on topics which are chosen by individual healthcare professionals and/ or teams. Evaluating aspects of care that individual and/ or teams themselves have selected as being important helps us to learn about the quality of our clinical interventions, and study the impact of any changes in relation to quality improvement.
Mandated (priority) Audits
Name of Audit Services Undertaking the Audit
Documentation (including consent) All
Infection Prevention and Control All
Health Care Assistant (HCA) Insulin Audit Community Health Teams (CHTs)
Doppler Audit CHTs, Wound Care Team
Handover Audit CHTs, Prison Healthcare Teams (HMPs)
Safeguarding Children Audit All
Catheter Audit CHTs, Bladder & Bowel Service
Syringe Pump Audit CHTs
Care Plan Audit CHTs, Rehab & Reablement Teams, Community Learning Difficulties Team (CLDT), HMPs
SSKIN Audit CHTs, Wound Care Team, Rehab & Reablement Teams
Early Warning Score Audit CHTs, Rehab & Reablement Teams, HMPs
Falls Audit Rapid Response, Rehab & Reablement Teams, and Neuro Therapy Teams
Health Navigators Audit CLDT
Sepsis Screening HMPs
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We have completed 196 clinical audits (to report stage) during 2015/16. Of these, 2 were audits against a NICE guidelines / quality standard, and 4 were interface audits with other NHS providers, as follows:
Type of Audit Total to Report Stage
National Clinical Audits• Chronic Obstructive Pulmonary Disease Audit• National Parkinson’s Audit• Sentinel Stroke National Audit• National Audit of Intermediate Care
4
Audits of NICE Quality Standards• Diabetes• Falls (via CQUIN)
3
Interface Audits (with another trusts/healthcare provider)• Non-mobile babies injury audit (NBT, UHB & Sirona)• Appropriateness of paediatric presentations (UHB)• Referrals to / from Brisdoc (Brisdoc)• Medical syringe pump audit (pan-Avon guidelines)
4
Other local audits• across all Bristol Community Health teams / services
146
Total 156
LearningBy engaging in clinical audit activities, we are able to demonstrate how we improve patient care and outcomes, through the systematic review of care against explicit criteria. By auditing our performance, we are ensuring that what should be done is being done, and if not, there is a framework in place to enable improvement to be made.
Frequently, as in the case of the record keeping audit, findings can be benchmarked across teams and/or services. This enables the learning from good practice to be shared, further driving up our quality of care.
Case Study 1Positive Learning from audits!
The REACT Team recently undertook an audit of the falls process they were following. The results showed that there had been little or no improvement on the previous year’s audit, so they decided to use the learning to look at how the falls processes and associated documentation could evolve.
A review found that the majority of referrals had gone to one service, causing long waiting lists of up to six months. .
Working with our acute partners (UHB and NBT), the REACT Team produced a Falls Pathway document to assist clinicians to streamline patients based on their clinical assessment into the most appropriate referral option. This, in line with a new
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assessment structure that prompts the clinician to consider and record specific aspects of assessment, was designed to improve the data captured as well as the onward referral process.
The new procedures have been put in place, and the re-audit is expected to show that the referral methods are more proficient, leading to a clearer picture of the management options available, and shorter waiting lists for future management.
The REACT Team reflected that “the audit process has opened our minds to changes that we needed to make to move forward as a service. Early indicators show that the impact of the changes has benefited our patients greatly. This has been a stimulating and positive experience – and we expect encouraging results from the changes we have made!”
5. Clinical effectiveness
All of the guidance released during 2015/16 by the National Institute for Health and Care Excellence (NICE), which is relevant to services providing NHS care by Bristol Community Health, is reviewed by our Clinical Cabinet, and checked for compliance by our service leads. Compliance is then tested via routine Clinical Audits.
The following is a breakdown of the NICE guidance reviewed by the Clinical Cabinet during 2015/16:
Type of Guidance Total
Clinical Guidelines (CGs) 28
Public Health Guidance (PH) -
Quality Standards (QS) 33
Technology Appraisals (TAs) 9
Medical Technology Guidance (MTGs) 2
NICE Diagnostics 5
NICE Interventional Procedures (IPGs) -
NICE Safe Staffing Guidelines (SGs) -
NICE Medicines Practice Guidelines -
NICE Social Care Guidelines 1
NICE highly Specialised Technology Appraisals -
Total 78
Participation in clinical research
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We are an research active organisation. We engage in research studies, discuss research opportunities with researchers, and encourage our staff to access research training opportunities. We work hard to increase the level of participation in clinical research, recognising the part that this plays in the wider health improvement of the nation. We work closely with our research partners, People and Research West of England (PRWE), Bristol University, the University of the West of England, and the Avon Primary Care Research Collaborative.
The Avon Primary Care Research Collaborative provides us with a research governance service, via a service level agreement. In addition to this, our Clinical Cabinet reviews all research projects that involve our staff or patients, prior to the being given formal approval by the Avon Primary Care Research Collaborative.
During 2015/16, we were involved in seven research studies, which were approved by a Research Ethics Committee. The research projects are as follows:
Research Title Service Involved Research Author
Shared decision making within goal setting in Intermediate Care
Intermediate Care Alice Rose
The implementation of a Mobile Working App. in a COPD team increases productivity and improves the recording of documentation & quality outcome measures.
Chronic Obstructive Pulmonary Disease Team
Anthony Troman
A risk assessment for Domestic Violence within a Learning Disability Population
Community Learning Disabilities Team
Rosie Banting
Telehealth for patients living with COPD and coexisting conditions: experiences of healthcare andimplications for the design of acceptable and appropriate home-based telehealth systems
Chronic Obstructive Pulmonary Disease Team
Patrick Kierkegaard
Domestic Violence perpetrators in CLDT
Community Learning Disabilities Team
Charlotte Swift
Fathers with learning disabilities and their experiences of Adult Social Care
Community Learning Disabilities Team
Daryl Dugdale
A novel, theory-based intervention to promote engagement in physical activity in early rheumatoid arthritis (PEPA-RA): Proof of concept study.
Musculoskeletal physiotherapy
Fiona Cramp
In addition to this, we are involved in the HITs programme, the Bristol Health Partners Health Integration Teams. HITs are cross organisational and interdisciplinary groups, set
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up to harness strengths in research, innovation, education, healthcare and prevention, to improve health outcomes.
HITs we are involved in, with a brief summary of their work, are listed below:
HIT Name Brief Summary of the HIT
Dementia The Dementia HIT aims to achieve the best quality of life for people and families living with, and/or affected by, dementia. The Dementia HIT brings together providers of dementia care across Bristol and South Glos, (local universities, Councils, NHS, voluntary and community organisations). The dementia HIT has five workstreams: Research, Education, patient & Public Involvement, Transforming Care and Dementia Friendly Communities, which all ensuring that HIT’s vision can be achieved.The Research workstream have just begun a new project looking at the needs of people from Black and Ethnic Minority communities, whilst the Education workstream have been busy distributing the National dementia Core Skills Education and Training Framework.
MOVE The main objective of MOVE HIT is to evolve, over the next 10 years, a high quality, high impact, internationally-recognised system for Parkinson's and other movement disorders. This will incorporate and integrate all aspects of clinical and social care, translational research and competency based education, supported by first class management and commissioning.The focus on work for the MOVE HIT is around developing a regional advanced treatment service, whilst striving to transform services for local Parkinson’s patients by developing an interactive, comprehensive care pathway.
ITHAcA The Integration to Avoid Hospital Admissions HIT focus their aims on reducing complexity within the urgent care system and developing the capacity to use data in evaluating changes and optimising the productivity of existing and new interventions. The HIT covers 3 main areas; chronic obstructive pulmonary disease (COPD) of the lungs, dementia with additional illness and asthma in children, and focuses on tackling the high rate of emergency hospital bed days for long-term conditions, improving treatment outcomes and reducing the need for long-term care.
6. CQC
We are required to register with the CQC for the regulated healthcare services we provide. You can find more details in our “statement of purpose” on our website.
We have a CQC nominated individual and registered managers who work together with the CQC and staff in our organisation to monitor and report ensuring we are compliant with the CQC Essential Standards of Safety and Quality.
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During 2015 / 16 the CQC has not taken any enforcement action against us. However the organisation has participated in a CQC Thematic Review of two patient pathways in December 2015. This was done with other health and social care providers and concentrated on patients who have either had a stroke or fractured their hip. The final report will be published in April 2016.
The following table outlines the notifications we have made during the reporting period:
Subject of notification (community services) Total Number 2015 / 16
Total number 2014/15
Death of a person using a service (including palliative care)
25 18
Incidents reported to or investigated by the police
3 1
Loss or disruption to services 1 1
Serious Incidents 81 37
Allegations of Neglect 9
Subject of notification (prisons) Total Number 2015 / 16
Total number 2014/15
Death of a person using a service (including palliative care)
6 9
Incidents reported to or investigated by the police
1 1
Loss or disruption to services 0 0
Serious Incidents 0 0
Please note that ‘death in custody’ refers to all deaths in a prison including expected deaths for palliative patients and death that occurs up to 30 days after release. Deaths in the community include all expected deaths when our staff are present including those within our palliative care service.
The majority of serious injury incidents reported are pressure ulcers and include those ulcers that patients already have when they come into our service.
This year we had a formal visit by CQC and Her Majesty’s Inspector of Prisons at Ashfield Prison in August 2015. The visit went well and the organisation was praised for its patient focus and excellent care provision. Areas of notable practice were our patient
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feedback systems and approach together with a system that helps staff to effectively manage patients in a deteriorating condition. The inspectors held the prison up to be that against which others will be benchmarked in future. Final report is yet to be published.
We continue to work hard to ensure our services meet the quality standards requested by CQC. We have maintained our support to teams to help them prepare for CQC inspections with a rolling programme of quality and safety checks.
7. Continuous learning and improvement
How we critically appraise our services and ensure continuous learning and improvement
In 2013/14 we reviewed all our systems and processes to develop more robust mechanisms to ensure we were capturing learning to continuously improve. There are a number of mechanisms in place to ensure critical appraisal of the quality of our services.
Patient feedback: We use real time feedback to identify the key areas of patient care that are scoring well or where we need to improve. The system was introduced in 2014, and this year is a Quality Account priority to demonstrate how we will use the feedback to improve services. To find out more about real time patient feedback, see our patient and public empowerment section.
Patient complaints As well as investigating and responding to each complaint, we use this learning to implement service improvements. For the prisons within which we supply healthcare, we organise specific events for our Patient and Public Empowerment Team to visit to ask for feedback to ensure they are represented.
Harm free care learning. Our structure for learning and improvement includes a Quality and Harm Free Care Group led by the Clinical Director and attended by the leads of all service areas, complaints officer and safeguarding leads. In this meeting, all patient safety incidents are reviewed for themes arising and any learning that can be shared with other services.
Complex case reviews. A complex case review meeting is convened to review any serious incidents that occur and this follows an extensive root cause analysis investigation. This meeting brings together senior clinicians and managers with front line staff to ensure that learning is disseminated throughout the organisation but also to ensure that obstacles to good care e.g. lack of equipment can be addressed swiftly. Some examples from this framework that have improved quality are the provision of heel supports in the community for patients at risk of pressure ulcers, and the introduction of handover guidelines and safety briefings in the prison setting. Other areas of ensuring quality include:
- Each year we carry out an extensive review of the quality of all our services during our preparation phase to prepare the Quality Account. An additional programme of work-streams relating to quality is the CQUIN programme which includes both local and national priorities for quality of care.
- We carry out ad-hoc quality and safety visits for all our services – this involves Board members, clinicians and managers visiting services and assessing against agreed criteria including assessing for knowledge of current safety messages to ensure our communication methods and learning dissemination are working well.
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- We have an annual audit and survey plan for an organisation wide approach to the audit cycle – learning and improving from results.
- a number of professional conferences to showcase our own work – the details of these are included in our awards and achievements section.
- a number of local and national expert strategic groups focused on improving quality of care and patient safety. This includes the West of England Academic Health Science Network and the Sign up to Safety Campaign. We contribute to the National Reporting and Learning System to monitor trends on safety incidents. We participate in the annual audits of practice with both Safeguarding Adult and Children Boards, believing that transparency, an open culture and peer review, in addition to regulatory oversight, is critical to appraising the quality of our services
8. What other organisations say about us
To be completed after consultation
7. Appendix
Safeguarding adults and children - full
It has been a busy year in Safeguarding Adults and Children due to the introduction of new key pieces of legislation. In particular The Care Act 2014, The Female Genital Mutilation (FGM) Act 2003 and The Counter Terrorism and Security Act 2015.
This year we have also worked closely with our CQC managers, Patient Safety Team and operational teams to have in place a clear system in recording and reporting any harm that we have caused. We now have a more robust database of all safeguarding referrals we have sent as a result of any harm caused by our services and we work closely with the CQC managers and Patient Safety to ensure we appropriately report this to Bristol City Council Safeguarding Team, CQC and the CCG.
The Counter Terrorism and Security Act 2015 introduced a new duty under the prevent strategy. This strategy aims to reduce the threat to the UK from Terrorism by preventing people becoming terrorists or supporting terrorism. In April 2015 it became a duty for organisations to report concerns of anyone who is at risk of radicalisation or demonstrating this behaviour. We have started to ensure that we are compliant with this duty, which has mainly included reviewing our training. All new staff now receive training on their induction. Alongside this we targeted specific teams which we identified as priority areas for Level 2 training, this included Migrant Health, Prison Healthcare, Community Learning Disability Teams and Urgent Care Centre. We have now achieved training for these areas and have started to roll out a programme of training to deliver to the rest of our clinical workforce. We also updated our incident reporting system to ensure that staff could report incidents relating to prevent. We have already seen that this training has been beneficial to staff increasing their awareness and reporting concerns as we have had our first 2 referrals.
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The FGM Act 2003 introduced a new duty to report to the police from October 2015. In order to be compliant with this we have updated our safeguarding adult and Children policies, released new reporting guidance for FGM and also updated our training for level 1 and level 2 safeguarding children. We have also identified a FGM Lead for our organisation which is the Named Nurse for Safeguarding Children and updated our website with key information about the duty. We hope over the next year we can offer more targeted supervision to our children’s services to ensure they receive the support they require in identifying concerns and reporting in line with the duty.
Safeguarding Adults
The Care Act has been the biggest change in Adult Social Care legislation in 60 years and this has now put safeguarding adults on a statutory footing. This has meant that as an organisation we have had to ensure our staff are aware of the key changes in the Care Act and their responsibilities in their duty to report concerns. We have worked hard this year to ensure that as an organisation we are compliant with The Care Act, this has included reviewing and updating our existing training programme alongside updating our Safeguarding Adult Policy and, incident reporting system and reporting guidelines for staff. We now have a well-established group of Safeguarding Link Practitioners to support the work of Safeguarding Adults who are able to offer support to their colleagues in their teams. This group has met quarterly and it has gone from strength to strength. We also saw our first Safeguarding Adult conference for our staff in April last year. The conference was a great opportunity to work with other partners in safeguarding and we had specialist speakers from University Hospitals Bristol on Domestic Abuse and Bristol City Council on Mental Capacity. This was very well received by all who attended and we hope that we can achieve this again in 2016. as an organisation, we were also well represented at the Bristol Safeguarding Adult Board conference which was held in November; it is great to see how committed our staff are to safeguarding adults at risk of abuse and learning more about this area with our partnership agencies. We continue to be heavily involved with the Bristol Safeguarding Adult Board and our organisation is well represented on all sub-groups of the board, this is really important to us to ensure we are working with partners across Bristol to safeguarding adults at risk of abuse.
Following the change in our reporting process last year we have seen an incredible rise in the numbers of safeguarding adult referrals. This has increased by 77% and this has been a great indication that our training and support has been effective in enabling staff to recognise signs of abuse and report them appropriately. We also responded to concerns raised by staff regarding lack of feedback from Bristol City Council following submission of safeguarding referrals. We decided to audit this and took a random sample of cases to check how many of our staff received feedback. We are in the process of compiling the results of this audit.
Safeguarding Children
Most of our services are provided to adults. However the children that we do see in the Urgent Care Centre, the Haven and the Community Learning Disabilities Services are a
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vulnerable group. In the last few years we have had problems in recruiting a Safeguarding Children Lead and in retaining them in post. Despite this we have achieved good compliance levels with Safeguarding Children training matrix, have provided regular supervision sessions to our staff who do work with children through our safeguarding team and Think Family approach. This year we conducted an audit of our newly formatted Safeguarding Children training. Last year this was updated to a blended model of e-learning and face to face. Following the audit we have now changed this training back to face to face as our staff reported difficulties in achieving the blended approach. We also had feedback that staff wanted more information on Prevent, FGM and more case studies applicable to a wider range of roles, particularly as predominantly our staff work within adult services. These changes have already been made to improve our training in response to this feedback. We now have an experienced named nurse in post from March 2016 who is embedded within our safeguarding team. We have also reviewed the resource available to this team to ensure that we can continue to improve in this area to meet the standards and to ensure we are an active and engaged partner in the work of the Safeguarding Children’s Board improving the wellbeing of children and families in Bristol.
Staff experience – full appendix
During 2015/16, we continued to prioritise improving the experience of our staff, to ensure the continued delivery of high quality patient care. We again offered staff the opportunity to hear about and feed into our key business priorities as well as share their views on the things that are great in our organisation and our areas for development in our ‘Shape Our Future’ open forum events. Issues that we covered in these sessions included staff capacity, staff allocation and resource planning, and happiness and wellbeing.
Measuring staff satisfaction
Our third annual staff survey gave staff the opportunity to share their views on a whole range of subjects relating to their employment. The survey helps us to understand what we do well, and where we need to improve in order to enhance the experience of staff. The survey covers key areas such as patient and staff safety, recognition of success and Information Technology. We conducted our survey in April 2015 and received a 71% response rate – a 5% increase compared to 2014.
What we are doing well
We are pleased to share the following five highest scoring questions:
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% Positive % Neutral %Negative
57Bristol Community Health encourages me to report errors, near misses or incidents.
94 5 1
61If I was concerned about unsafe clinical practice, I would know how to report it
94 4 2
2I understand how my work contributes to the success of the organisation
93 5 2
19I understand how my role contributes to meeting my team’s goals
93 5 2
51Bristol Community Health has made how I am expected to behave at work clear to me
93 6 1
The highest scoring three overall themes were:
• Section 4 – Team work – Average score of 76% positive responses • Section 7 – Patients / customers and continuous improvement – Average score of
74% positive responses • Section 8 – Communications – Average score of 70% positive responses
As part of our 2015 survey, we also undertook the Staff Friends and Family Test (FFT), in line with guidance from NHS England. The Staff FFT measures how happy staff would be to recommend their organisation provides to friends and family.
The two questions within the staff FFT are:
• How likely are you to recommend Bristol Community Health to friends and family if they needed care or treatment?
• How likely are you to recommend Bristol Community Health to friends and family as a place to work?
The results of the Staff FFT were:
84% of our staff would recommend Bristol Community Health to friends and family if they needed care or treatment
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The result to this question put us in the top 10% of healthcare organisations nationally – we scored higher than our local trusts too (North Bristol Trust scored 52% and University Hospitals Bristol scored 71%).
63% of our staff would recommend Bristol Community Health to friends and family as a place to work.
Areas for improvement
Our 2015 staff survey also indicated the areas in which staff felt we could make improvements. As a result of some of the below, we have implemented real change within our organisation.
The following were the questions with the lowest score:
% Positive % Neutral %Negative
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There are enough staff at Bristol Community health for me to do my job properly
33 25 42
36 I am satisfied with my level of pay. 36 28 36
7When things go wrong with my technology I get good support to fix things quickly.
37 29 34
26There are opportunities for me to progress my career at Bristol Community Health.
38 31 31
81I believe the Staff Council has the ability to influence Board decisions.
38 50 12
The lowest scoring three overall themes were:
• Section 11 – Our organisation – Average score of 53% positive responses • Section 9 – Management and leadership – Average score of 55% positive
responses • Section 10 – Change – Average score of 57% positive responses
We made it a priority to address the lowest scoring areas of the survey. Below, we have included the improvements we made in response to the concerns staff raised.
Information technology• 39% were satisfied with the IT equipment.
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• 37% felt that they got support quick enough when they did have IT problems.
So we took action…
• We created a new informatics strategy to develop the IT we really needed.
• We restructured the Informatics Team and appointed a new Chief Information Officer (CIO) who is starting soon and will undertake a complete review of our IT infrastructure
Staff capacity• 33% felt that there were enough staff at Bristol Community Health to do their jobs properly.
• 44% felt that that there was enough time to do their jobs effectively.
So we took action…
• Our Safe Staffing Programme is working to identify a staff resource and allocation model based on the acuity, dependency and complexity of patients and the availability of staff, taking into account essential non clinical activity such as appraisals and one to ones, training, expense claiming etc. An e-rostering system is being procured and implemented as part of this.
Visibility of the Board• 41% felt that our Board was sufficiently visible. Following our focus on Board engagement with teams as a result of the 2014 results, this increased from 32%,but we still have work to do.
So we took action…
• The Board and Senior Management Team have continued to attend sessions with every team. These sessions were about listening to our staff, to find out how they felt about working at Bristol Community Health and to hear about the key issues they face.
• Non-executive Board directors attended the 2016 Shape Our Future events to hear staff feedback first-hand and to reflect this in their work.
• Board members have been part of CQC mock inspections.
Pay• 36% were satisfied with their level of pay.
So we took action…
• We became a Living Wage employer and continued to match or exceed Agenda for Change terms and conditions.
Staff Happiness and Wellbeing Programme – see more on this below
• 64% were happy at work
• 35% said that they may leave Bristol Community Health in the next 12 months
• 54% considered our benefits package (annual leave, flexible working, pay, pensions etc.) to be fair
• 32% had been unwell due to work related stress.
So we took action…
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One of our most innovative areas of work has been the launch of our Happiness and Wellbeing Programme, which aims to put the physical and mental wellbeing of our staff at the heart of our organisation.
All staff were given the opportunity to feed their ideas into the project during a staff consultation prior to launch. Our Staff Council were also closely involved in the development of the physical health element of the programme. The success so far reflects the positive feedback we received during the consultation.
Over the past four months, we have launched:
• an employee benefits platform with access to salary sacrifice and holiday trading
• fitness classes
• sponsorship for Bristol sporting events
• an employee assistance programme (a confidential support service)
• preventative and emergency mental wellbeing support
• physiotherapy for staff
In the first two months of launching the project, over 25% of staff had taken advantage of one or more of the benefits listed above.
Learning and Development - full appendix
Staff within Bristol Community Health have access to a wide range of development opportunities to ensure that they are able to deliver the best possible care to our patients. This includes a portfolio of training that is divided into essential skills development for clinical and non-clinical staff, continuing professional development, leadership and management.
Human Factors
We were successful in securing funding from the West of England Health Science Network (WEAHSN) to enable a training programme for all staff in the organisation that are Band 2-4 (clinical and non-clinical). The training programme looks at raising awareness of human factors and improving communication through use of the SBAR (situation, background, assessment and recommendation) communication tool and will start in June 2016.
Training programmes
We are running several training programmes for clinical staff:
Seven of our staff are currently on a fast track district nurse programme (run with the University of West of England) and are due to complete in two years. Seven more staff are due to start the programme later this year.
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Staff from our Community Matron and Rapid Response Teams continue to enrol onto our Advanced Practitioners programme. Prison healthcare staff will have access in 2016. The programme enables practitioners to develop their clinical reasoning and decision making through reflective practice, action learning, completion of competency frameworks and face to face training.
Nine staff are so far undertaking our Fast Track Community Matron Programme. Those on the Programme are supported to get the skills and experience they need to work at Community Matron level in approximately 6 months.
51 healthcare assistants (HCA) have attended the Extended Skills Programme since September 2014. We extended the programme to prison healthcare staff in September 2015. . Each HCA is allocated a mentor in practice who supports the HCA to complete the 35 competencies (27 competencies for HCAs working in prison healthcare) over 12 months. In addition, two clinical supervisors have been recruited who will further support the HCAs in the community nursing teams to achieve their competencies.
Non-registered staff continue to have the opportunity to access apprenticeships.
Apprenticeships
Bristol Community Health support both existing staff and new staff to undertake apprenticeships. In 2015/6 we supported 24 staff on different apprenticeship programmes (see chart).
Business and Admin L2Business and Admin L3Clinical Healthcare Support L3Higher Apprenticeship Health and Social CareFoundation degree Care Management in the Community 2nd Year
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Chart showing different apprenticeship programmes that staff are currently undertaking.
Level 3 apprenticeships provided staff with the opportunity to develop their literacy and numeracy to functional skills level 2. Business and administration apprenticeships additionally undertook IT functional skills.
This year we offered the higher apprenticeship to clinical staff for the first time. This is a 12-18 month programme with one day a work out of the office for formal training. , involving The apprenticeship focuses on the consolidation of learning and on embedding consistently good practice in core areas, as well as the development of additional knowledge and skills.
Three staff have successfully completed the first year of the foundation degree in Care Management in the Community and are now in their second year, due to complete December 2016.
We continue to look at opportunities for staff to develop in line with the national Talent for Care Strategy and Widening Participation Agenda.
Preceptorship
All newly qualified Registered Practitioners (less than one year since qualification) were invited to join the preceptorship programme. Preceptorship is recommended by the Department of Health (2010) as a way to support newly qualified healthcare staff at Band 5 to transition from student to confident practitioner. New guidance has been issued by Health Education England on the content of preceptorship programmes. The current programme is being adapted to incorporate these recommendations. The programme promotes networking and multi-professional working to support patient care. All newly qualified staff are allocated a preceptor in their workplace to support them to develop their skills and identify individual learning outcomes to become confident practitioners delivering quality care.
Return to Practice
We have continued to recruit to the Return to Practice Programme for adult nursing in partnership with the University of West of England (UWE). In 2015/6 we recruited seven people onto the programme, all of which successfully completed it.
Students
We are committed to investing in learning, and providing placements for a wide range of students. We offered placements to a number of adult nursing students accessing 22 different placement areas. We also offered placements in physiotherapy, speech and language and learning difficulties nursing. With the recent addition of the interim CCHP contract we will also be offering more child nursing, health visitor and school nurse placements, All student placements have dedicated mentors/clinical educators to support their practice. Placement audits are carried out on an annual basis to monitor the quality of the placement and ensure we provide a good learning environment. UWE students are able to access information about their placement through the portal that is
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updated by the key mentor in the placement area. This enables students to prepare for their placement and maximise their learning opportunities.
Essential skills compliance
Below is a graph charting the increase in compliance of our staff around essential skills training. We have recently achieved 95% compliance – the highest it has ever been. We will continue to ensure our staff are keeping their statutory training up to date by recording it in performance reviews.
Incident reporting – appendix
The chart below shows the number of patient safety incidents and all other Bristol Community Health incidents including information governance, health and safety and patient safety incidents. The monthly average of patient safety incidents reported during the course of the year is 120 and this has increased since 2014/15 when it was 93.
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April May June July Aug Sept Oct Nov Dec Jan Feb Mar0
50
100
150
200
250
300
350BCH Incidents Reported During
2015/2016
BCH Patient Safety In-cidents
Num
ber o
f Inc
iden
ts
Analysis of Most Frequently Reported Bristol Community Health Patient Safety Incidents
Analysis of our patient safety incidents revealed that pressure ulcers were the highest reported cause group, accounting for 40% this is up from 38.07% of incidents reported during 2014/15. Grade one and two pressure ulcers made up for 91% of this figure this year which is a slight decrease in comparison to 2014/15. Grade one pressure ulcers accounted for 26.82% of all pressure ulcers, with grade two pressure ulcers accounting for 64.19%. Few healthcare organisations report grade one pressure ulcers as this type of pressure ulcer appears on the skin as a non-blanching red mark.
This increase in reporting during 2015/16 helps to demonstrate how reliable Bristol Community Health is now at reporting this type of harm and that its work in validating correctly the grade of pressure ulcer is being sustained. This increase in reporting during 2015/16 is built on the work from 2014/15 where increased awareness was promoted with nurses’ routinely assessing and reporting skin damage to patients on their first visit.
Validation exercises of pressure ulcers continue to be undertaken by the Wound Care Service and the team uses this information to feedback to the clinical teams on accurate reporting and learning. This year has also seen the collaboration with other services, such as podiatry services, who may not have traditionally inputted into the reporting of pressure ulcers but through joint investigations and further training this knowledge and awareness has increased.
Also in February 2016, Bristol Community Health was able to add to their incident reporting system images of the different types of pressure ulcer developed in order to assist with correct categorization. During 2015/16 there was a rise in the number of moisture lesions and wounds of other origins being incorrectly reported as pressure ulcers. This is demonstrated in the chart below; 67.9% of injury ill health to patient incidents in 2015/16 were originally reported as pressure ulcers but were later reassessed by the Tissue Viability Specialist Nurse as a moisture lesion or wound of other origin.
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Pressure Ulcers Medication In-cidents
Staffing issues Injury ill health to patient
Clinical As-sessment and
Review
0
100
200
300
400
500
600
Most common cause of patient safety incidents 2015/2016 in comparison to 2013 to 2015
2015/2016 2014/2015 2013/2014
The reporting of medication incidents has increased during 2015/16 in comparison to 2014/15 for both community and prison healthcare services.
The increase in incident reporting during 2015/16 in the community was attributed to missed doses, record management and controlled drug balances. Different group meetings were arranged to manage specific medication concerns raised as a result of these incidents and several improvements were implemented in practice. During 2015/16, a reduction in medication incidents was realised in wrong dose, wrong drug, missing medication and syringe driver incidents. This improvement was directly linked to work undertaken regarding medicines related incidents.
There has been a year-on-year increase in medicines-related incidents in HM prison sites since 2013/14. HMP Bristol in particular has increased reporting significantly for 2015/16 as a direct result of focus by nurse managers on improving incident reporting rates. The majority of incidents reported were classed as ‘near misses’ i.e. did not reach the patient and were resolved by minimal or brief intervention.
The highest cause groups for medicines-related incidents were wrong dose and records management. Variations in practice and knowledge of medicines and medicines management standards were identified as contributing to medicines-related incidents. A medicines management workbook and competency set has been developed and provided to all clinical staff. This now forms part of induction for new staff, and all existing staff are expected to complete the workbook and be assessed as competent in as aspects of medicines management. In addition to this, a new electronic prescribing and medicines administration (ePMA) module has been implemented in the clinical IT system,
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SystmOne. It is anticipated ePMA will contribute to higher levels of safety in medicines management across the prison sites as the system continues to embed and staff become more familiar with its use.
There has been an increase in the number of staffing level incidents reported from 86 in 2014/15 to 111 incidents in 2015/16. Bristol Community Health is undertaking a Safe Staffing Project which has resulted in increased awareness with staff that unsafe staffing levels should be reported. Community teams have seen a rise during the year in the number of unplanned urgent call-outs. In addition one community nursing locality changed the structure of its team and locations which was challenging for staff but which in the end improved integration of processes and practice. HMP staffing incidents have also increased. However many of these incidents were related to issues beyond the control of Bristol Community Health. These incident reports are shared at the Prison Partnership Board and managed through escalation meetings and a Quality and Safety Assurance Review.
Clinical assessment and review was a new cause group introduced onto the Ulysses incident reporting system in January 2015. This new cause group enabled staff to report incidents concerning clinical assessment, implementation of care and on-going monitoring and review. Previously these incidents had been captured under other cause groups. Some historic incidents were easily reallocated to this new cause group whilst others which were previously captured under another cause group “referral” were left under their original cause group as they were not as easy to reallocate. True comparisons against this cause group will be seen in 2016/17.
Reporting on Harm
Since September 2014, each incident is assessed against the National Patient Safety Agency’s rating definitions to determine the actual impact of harm upon the patient involved with the incident. In addition all incidents have a level of harm being identified prior to being uploaded to the National Reporting Learning System (NRLS) data set.
Analysis of our patient safety incidents shows that whilst our encouragement to staff to report incidents has increased incident numbers, the majority 92.65% of these incidents resulted in minor or no harm to patients. This increase from 84.36% in 2014/15 to 92.65% in 2015/16 is a good thing to be reporting within the patient safety area and would suggest that as an organization we are a safe and reliable organization in reporting our harm. 2.77% were logged as “near miss” which means that an incident which may have caused harm was avoided. 4.58% of incidents resulted in moderate harm with 78.79% of these being pressure ulcers with a grading of three or four.
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At present there are 56 incidents that have been reported as Serious Incidents Requiring Investigation (SIRI) through to the respective Commissioner. Of these the main themes are:
Pressure Ulcers 45
Medication Incidents 4
Information Governance 2
Communication 1
Delay in treatment leading to harm 1
Delay failure to monitor 1
Injury/Ill health to patient 1
Medical Equipment 1
Furthermore, to the 45 pressure ulcer incidents identified as SIRIs, there are a further 14 incidents, of which 13 were pressure ulcers, that on review of the evidence within the 72 hour report BCH were able to challenge the commissioner and request that they were downgraded from the SI status. Examples of this includes where it is clear that there has been evidence of non-concordance by the service user and also where the report is clear enough to demonstrate that nothing more could be provided.
From review of the outcomes of the complex case reviews which helps to determine whether the pressure ulcers were avoidable or not this work remains work in progress but to date 13 pressure ulcers have been identified as avoidable with 16 being identified as unavoidable and 1 being underdetermined.
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In addition the Quality and Patient Safety team have commissioned an additional 12 Bristol Community Health internal reviews on incidents where they are not SIRI or where there has been low or no harm but on initial assessment it looks like there is useful learning for the organization. This is a challenge to the service involved but it has been undertaken with the willingness and curiosity to learn.
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