BRAINTREE COMMUNITY HOSPITAL QUALITY ACCOUNTS 2010/11

BRAINTREE COMMUNITY HOSPITAL QUALITY ACCOUNTS 2010/11

Contents 1:

Statement from the Chief Executive

4

2:

Priorities for improvement

5

2. 2.1 2.2 2.3 2.4

5 5 6 6

2.5 2.6 2.7 2.8 2.9 2.10

3:

4:

Our Quality Priorities for 2011/12 Priority One Priority Two Priority Three Statements relating to the quality of NHS Services provided by Braintree Community Hospital Statement 1 – Review of services Statement 2 – Participation in Clinical Audit Statement 3 – Participation in research Statement 4 – Goals agreed with our commissioners Statement 5 – Care Quality Commission Statement 6 – Data Quality

7 7 10 10 10 11 12

Review of Quality Performance during 2010/11

13

3. 3.1 3.1.1 3.1.2 3.2 3.2.1 3.2.2 3.2.3 3.2.4 3.3 3.3.1 3.3.2 3.3.3 3.4 3.5

13 13 13 15 16 16 16 17 17 19 21 22 23 23 24

Review of performance during 2010/11 Patient safety Learning from incidents Safeguarding of children and vulnerable adults Clinical effectiveness and reduction of risk Audit Pathways of care Policies and procedures - following NICE/guidelines Infection protection and control Patient experience Surveys Internal Quality Improvement Group Suggestion Box Complaints Delivering same sex accommodation

Views of stakeholders

Braintree Community Hospital

26

Quality Accounts 2010/11

2

Introduction The establishment of Braintree Community Hospital follows years of campaigning from local GPs and families who wanted health services closer to where they live. The £16.5m Hospital has been designed with the patient in mind. It is a light and airy setting for our users, and this is created through the use of „sun pipes‟ and roof lights. It has been built using contemporary and traditional materials to create a unity with the existing listed buildings on site, whilst complementing the rural setting of Braintree. The unique aspect of this NHS hospital is that it brings together the best in public and private healthcare; the caring clinical expertise of the NHS partnered with private enterprise efficiencies. Clinical, surgical, nursing, diagnostic and catering specialists work together as one team with integrated care pathways to give patients an unprecedented level of personal care and attention. Our new building offers a state of the art, fresh environment in which we provide a seamless service of care that is highly valued and improves the health of the local community.

Braintree Community Hospital

Quality Accounts 2010/11

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1. Statement from the Chief Executive

I am very pleased to introduce the first set of Quality Accounts for Braintree Community Hospital (BCH), demonstrating that we are committed to delivering exemplary patient centered care. BCH is one of the first community hospitals to provide a wide range of day case surgery, outpatients and diagnostic tests alongside the services traditionally available in a community hospital such as rehabilitation, community beds and community nursing. Braintree Community Hospital opened its doors as scheduled on 19th April 2010 welcoming its first patients directly onto the ward. Patients from Braintree, Chelmsford and Maldon now have access to a full range of health services under one roof saving them time and extra journeys. Braintree Clinical Services Ltd (BCSL) was appointed by NHS Mid Essex PCT to manage the operation of the new Braintree Community Hospital, and was acquired by Serco Health in March 2011. A new management team is now in place to oversee the quality of services provided to patients. The new BCSL management team is now working with all staff with the aim of ensuring a thriving, high quality hospital that will:    

Offer the shortest possible waiting times for outpatient and day surgery Make the best use of the state of the art facilities Be an active partner in the local health community Become a centre of excellence for hospital based community services

We encourage our staff, patients, public and healthcare partners to look at these Quality Accounts to understand what we are doing well and where improvements in services are required. These Accounts outline our priorities for improvement in the coming year (2010/11) and we welcome comment on and involvement in determining future priorities for improvement. To the best of my knowledge, the information contained within these Quality Accounts is accurate. I am looking forward to working to create a bright new future for healthcare in Essex and pioneer a new type of community hospital in the UK. Paul Forden CEO Braintree Community Hospital

Braintree Community Hospital

Quality Accounts 2010/11

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2.

Our Quality Priorities for 2011/12

Part 2: Priorities for improvement and statement from the Senior Management Team (Board) This section contains information on the key quality priorities for 2011/12 and provides the nationally mandated information as required under Regulation 4 of the National Health Service (Quality Accounts) Regulations 2010, as a series of quality statements. 2.0

Our Quality Priorities for 2011/12

For 2010/11 we have agreed three key quality objectives aimed at improving our services. We developed these priorities through discussion with our staff and commissioner and will monitor them regularly through our internal governance arrangements at both board and subcommittee level. In particular these include our Joint Integrated Governance Board, our Clinical Risk and Information Governance Group and through our clinical performance reporting systems in liaison with our commissioner, Mid Essex PCT. 2.1

Priority One

Improve patient experience and increase service user involvement Quality priority Patient Improve patient experience experience through increased listening to and involvement of service users

Rationale Care should be organized around the individual, meeting their needs both clinically and in terms of their dignity and respect. We intend to actively seek patient‟s and service users views, to listen to their feedback and act on what we hear.

Objective for 2011/12  Develop patient user group.  Develop Internal CQC Patient Involvement Group.  Recruit Patient Liaison role.  Install plasma screen in Reception for public display of indicator achievements.

Completely eliminate risk of breaches – single sex accommodation

BCH submitted their „Declaration of Compliance‟ to Mid Essex PCT as required by the 31 March 2011. This declaration has now been placed on the BCH website. www.braintreecommunity hospital.com Following a compliance audit a number of actions have been identified that will further reduce the risk of breaches occurring

 Undertake all capital works planned to further improve accommodation provided for patients within all services.

Braintree Community Hospital

Quality Accounts 2010/11

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2.2

Priority Two

Reduce the number of preventable falls that occur within our services Quality priority Patient falls

Rationale

Objective for 2011/12

Monitoring throughout 2010/11 has identified that the level of falls occurring within our inpatient ward could be reduced.

   



2.3

Set as CQUIN target for 2011/12. Work with our Community Services provider to reduce the number of falls occurring in the in-patient ward. To monitor and report these incidents on a monthly basis through internal governance processes. To ensure that each fall is recorded as an incident and that a root cause analysis is undertaken to assess the reasons for each falls. To act on lessons learnt in order to prevent reoccurrence.

Priority Three

Improve the dissemination of lessons learnt identified through our comprehensive quality monitoring programme. Quality priority Dissemination of learning to improve services for patients

Incident reporting

Complaints

Braintree Community Hospital

Rationale A computerized incident monitoring system will standardize reporting practices across all subcontractors and assist in identification of trends and lessons to be learnt.

Although the level of complaints received during 2010/11 has been relatively low, improved systems to monitor and report on trends will assist in effectively disseminating any learning and thereby facilitate improved services for all users.

Objective for 2011/12  To install the Datix system within the hospital, so that comprehensive analysis of trends can be undertaken and lesson easily identified.  To ensure that these lessons are disseminated to all sub-contractors through internal governance reporting systems.  To ensure that all complaints received are thoroughly investigated and responded to in a timely manner.  To install the Datix system within the hospital, so that comprehensive analysis of trends can be undertaken and lesson easily identified.  To ensure that these lessons are disseminated to all

Quality Accounts 2010/11

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Internal clinical audit programme

All sub-contractors providing clinical services within BCH have in place a comprehensive clinical audit programme. Combining and standardizing practice across all service providers will provide the opportunity of enhanced reporting and sharing of lessons learnt across all services.

sub-contractors through internal governance reporting systems and service improvements are implemented where necessary.  To implement a hospital wide clinical audit programme that combines all sub-contractor audit programmes.

2.4 Statements relating to the quality of NHS Services provided by Braintree Community Hospital 2.5

Statement 1 – Review of services

During the reporting period from 1 April 2010 until 31 March 2011, Braintree Community Hospital provided 4 1 types of NHS Services. Braintree Community Hospital is one of the first community hospitals to provide a wide range of day case surgery, outpatients and diagnostic tests alongside the services traditionally available in a community hospital such as rehabilitation, community beds and community nursing. Our full range of services & facilities include: Outpatient departments New fully equipped treatment and consultation rooms enabling our medical specialists to meet all the treatment needs of the patient. Diagnostic services A full range of diagnostic services are available on-site including digital x-ray, ultrasound and endoscopy. MRI and CT scans can be booked and performed off-site.

1

The Health and Social Care Act 2008 lays down a number of „activities‟ (types o f services provided) which are regulated by the CQC. The CQC will register providers, like Braintree Community Hospital, to carry out registered activities if providers show that they are meeting essential standards of quality and safety. The 4 types of activities that BCH have been registered by the CQC to provide are:    

Treatment of disease, disorder or injury Surgical procedures Diagnostic and screening procedures Transport services, triage and medical advice provided remotely

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Rapid Assessment Unit A community based rapid access assessment service for elderly patients providing a multidisciplinary team assessment and diagnostics to avoid inappropriate acute hospital admission. The management of a care pathway to optimise recovery and promote independence closer to home. Day case surgery The hospital has two modern operating theatres in which a wide range of procedures can be performed; from minor skin lesions to laparoscopic cholecystectomys and orthopaedic procedures. Individual postoperative recovery bays are designed for maximum privacy and comfort. In-patient services There are twenty community in-patient beds, in mainly single rooms, available for patients who need nursing and rehabilitation. Single sex washing facilities are available. Therapies A full range of clinical assessment and treatments for patients within the community hospital and outreach clinics. This service focuses on a range of specific interventions, and is provided by specialist therapists. The team works co-operatively with all the service providers to provide an integrated pathway of care. Café The hospital Café offers a range of delicious dishes and sandwiches prepared using local and organic produce for in-patients, visitors and the whole hospital community. A seating area is available for dining and takeaway services are also on offer. A sample menu can be viewed on the website. During this reporting period, Braintree Clinical Services has reviewed all the data made available to them on the quality of care in the subcontracted services. The income generated by the NHS services reviewed in the 2010/11 reporting period represents 100 per cent of the total income generated from provision of the NHS services by Braintree Community Hospital during 2010/11.

Braintree Community Hospital

Quality Accounts 2010/11

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BCSL has joined together a unique partnership of provision of public and private sector organizations to deliver quality services to the local community. Subcontractors include:    

2.6

Central Essex Community Services (CECS) – local NHS specialists in community healthcare such as in-patient beds, physiotherapy, speech therapy, occupational therapy and rehabilitation Prime Diagnostics Limited (PDL) – a nationally accredited leader in community endoscopy services who have been delivering services within Braintree for the last 10 years Specialist Medical Imaging Ltd (SMI) – a nationally accredited diagnostic company offering expertise in x-ray and ultrasound Ashlyns Organics Ltd– a local catering company that specialises in using locallysourced and organic produce. The hospital Café complements patient services by providing food freshly prepared on site using local and organic produce for both patients and the whole hospital community

Statement 2 – Participation in Clinical Audit

During 2010/11 there was a national clinical audit and no confidential enquiries that covered the NHS services that Braintree Community Hospital provide. During 2010/11, as Braintree Community Hospital was still within its first year of opening, it elected not to participate in the national clinical audits or national confidential enquiries which it was eligible to participate in. BCH has confirmed with NCEPOD that of the national confidential enquiries undertaken in 2010/11, none were relevant to the services currently provided by the hospital. BCH has now registered with NCEPOD.

Braintree Community Hospital

Quality Accounts 2010/11

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The national clinical audits and national confidential enquiries that Braintree Community Hospital was eligible to participate in during 2010/11 are as follows:

Confidential enquiries/national audit

BCH participation

Reporting period

Number of cases submitted as a percentage of the number of cases required

National confidential enquiry into patient outcome and death (NCEPOD) No relevant enquiries National audits as advised by the National Clinical Audit Advisory Group (NCAAG) Elective procedures Not required by 2010/11 (national PROMS Commissioner for programme) 2010/11

2.7

Statement 3 – Participation in research

The number of patients receiving NHS services provided or sub-contracted by Braintree Community Hospital in 2010/11 that were recruited during this period to participate in research approved by a research ethics committee, numbered nil. Braintree Community Hospital has not participated in or undertaken any clinical research projects during 2010/11, however should this type of research activity be planned, a local Ethics Committee will be appointed to approve any research proposals put forward.

2.8

Statement 4 – Goals agreed with our commissioners

One percent of the annual contractual value of Braintree Community Hospital‟s income in 2010/11 was conditional on achieving quality improvement and innovation goals agreed with Mid Essex PCT through the Commissioning for Quality and Innovation (CQUIN) payment framework. Braintree Clinical Services Limited is currently in discussion with its Commissioner, Mid Essex PCT to agree the new CQUIN targets for 2011/12. Further details of the agreed goals for 2010/11 and for the following 12 month period are available on request from Paul Forden, Chief Executive, Braintree Community Hospital.

Braintree Community Hospital

Quality Accounts 2010/11

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CQUIN Indicator

To provide evidence of a clinical audit programme supported by action plans for changes to be made to services as a result of findings Health Promotion – staff are trained to deliver opportunistic health promotion advice and refer patients to relevant health promoting services Patient Satisfaction – the number of patient responses of „Excellent‟ or „Very Good‟ evidenced from patient feedback    Learning Disabilities – Routine systems are in place to collect data and information necessary to allow people with Learning Disabilities to be identified and their pathways of care tracked Audit Tool – Implement the use of a patient specific decision support tool that will enable staff to systematically determine the clinical appropriateness for admission, continued stay and discharge.

2.9

Target 2010/11

Assessment of achievement of target

>10 audits per contract year

100%

Corporate induction plans to include staff training with evidence that staff competencies in health promotion which leads to increased referrals to these services Provider to conduct a minimum of 2 patient satisfaction projects with 90% achievement of „Excellent‟ or „Very Good‟ for : Privacy and dignity Customer service Cleanliness Provider to identify 5 case studies to be presented

30% Intentions for 2011/12 include increased levels of staff training and onward referrals 100%

Clinical staff to routinely use appropriate review criteria for all patients. To implement an internal weekly reporting system

30% Intentions for 2011/12 include an improved system of monitoring and reporting outcomes of routine audits undertaken.

100%

Statement 5 – Care Quality Commission

Braintree Clinical Services Limited is required to register with the Care Quality Commission and its current registration status, awarded in April 2010, is unconditional. Braintree Community Hospital is subject to the periodic reviews by the Care Quality Commission. Braintree Community Hospital has not participated in any special reviews or investigations by the CQC during the reporting period 1 April 2010 to 31 March 2011. The CQC has not taken any enforcement action against BCSL during 2010/11.

2.10

Statement 6 – Data Quality

Braintree Community Hospital has not submitted records during 2010/11 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics, however will be submitting records to SUS from May 2011 onwards. Braintree Community Hospital

Quality Accounts 2010/11

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The Braintree Community Hospital‟s scores for 2010/2011, assessed using the information governance toolkit, are documented below:

Information Governance Management Assessment

Stage

Level 0

Version 8 Published (2010-2011) Target

Level 1

Level 2

Level Not Total Key Key Total Overall Grade 3 Relevant Req'ts Req'ts Req'ts Key Score Not Met Req'ts Met

0

0

1

4

0

5

0

4

4

93%

Satisfactory

0

0

1

4

0

5

0

4

4

93%

Satisfactory

Confidentiality and Data Protection Assurance

Assessment

Stage

Level Level Level Level Not Total Key Key Total Overall Grade 0 1 2 3 Relevant Req'ts Req'ts Req'ts Key Score Not Met Req'ts Met

Version 8 (2010-2011)

Published 0

0

3

4

1

8

0

6

6

85%

Satisfactory

Target

0

2

5

1

8

0

6

6

90%

Satisfactory

0

Information Security Assurance

Assessment

Version 8 (2010-2011)

Stage

Total Key Key Total Level Level Level Level Not 0 1 2 3 Relevant Req'ts Req'ts Req'ts Key Not Met

Met

Req'ts

Overall Grade Score

Published 0

0

0

13

0

13

0

11

11

100%

Satisfactory

Target

0

0

13

0

13

0

11

11

100%

Satisfactory

0

Clinical Information Assurance

Assessment

Stage

Level Level Level Level Not Total Key Key Total Overall Grade 0 1 2 3 Relevant Req'ts Req'ts Req'ts Key Score Not Met Req'ts Met

Version 8 (2010-2011)

Published

0

0

0

3

0

3

0

1

1

100%

Satisfactory

Target

0

0

0

3

0

3

0

1

1

100%

Satisfactory

Overall Level Level Level Level Not Total Key Key Total Overall Grade 0 1 2 3 Relevant Req'ts Req'ts Req'ts Key Score Not Met Req'ts Met

Assessment

Stage

Version 8 (2010-2011)

Published 0

0

4

24

1

29

0

22

22

95%

Satisfactory

0

0

3

25

1

29

0

22

22

96%

Satisfactory

Target

The Braintree Community Hospital was not subject to the Payment by Results clinical coding audit, by the Audit Commission, during 2010/11.

Braintree Community Hospital

Quality Accounts 2010/11

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3. Our Quality Review for 2010/11 3.

Review of performance during 2010/11

3.1

Patient safety

3.1.1 Learning from incidents Braintree Community Hospital recognises the importance of reporting all types of incidents and accidents as an integral part of how we identify and manage risk. This is one of the key measures we monitor closely. We are committed to improving the quality of care to patients, and the safety of staff and members of the public, through the consistent monitoring and review of all incidents. In all, there were a total of 191 incidents reported during 2010. There were a further 89 incidents logged, from January to March 2011. The increase in incident reports in 2011 is seen as improved reporting rather than the Hospital having increasing issues. The hospital is also becoming busier, with more patients and visitors attending the site as it becomes part of the local Health Community. Incidents are reviewed via the internal governance reporting systems. This includes a review by the management team through the Health and Safety Committee and the Clinical Risk and Information Governance Group. Summary reports are then reviewed at the Joint Integrated Governance Board and Medical Advisory Committee (MAC). No RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 which place a legal duty on employers, self-employed people and people in control of premises to report serious incidents and accidents to the HSE) were reported in 2010/11.

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The table below provides a breakdown of incidents by type, and reports this data by quarter.

Incidents By Type 90 14

80

3

70

Security

60

9

50 40 30

5 2 24

20 10 0

3 3 5 1st Quarter

37

Health and Safety

8 9 1 12

19

11

10

9

11

2nd Quarter

Medication

Communication + Clinical 22

3rd Quarter

Communication Clinical

13 4th Quarter

Graph 1: Number of incidents recorded by type during 2010/11

As detailed above, the highest number of incidents reported during 2010/11 fell into the category of Health and Safety. This category includes falls, which account for a number of the incidents reported. From research papers written, it is known that a higher patient fall rate is expected where there are old, infirm, confused patients as in the Community ward. The NHS National Patient Safety Agency report “Slips, Trips and Falls data 2010” indicates a mean rate of 8.6 falls per 1000 beds in Community Hospitals with higher rates in those wards where there are elderly patients or dementia sufferers, namely 82.2% of falls in those 65-100 years; 67.6% of falls 75 -100 years; 34% 85-100 years. The Community Inpatient ward caters for patients with high acuities (including E.O.L). The table below documents the number of falls occurring throughout the hospital, from May 2010 through until March 2011.

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No of Falls per Month 10 10

9

9

8

Total No of Falls

8

7

7 6 5

6 5 4

4

3

3

Total no

3 2 1

1 0

0

Month

Graph 2: Total number of falls, by month, as reported for 2010/11 Risk assessments are undertaken by staff on all patients alongside Falls Care Planning and cot-side risk assessments. Each incident is investigated by the senior nursing staff using root cause analysis to identify trends and risk factors. No fractures, head injuries or deaths occurred as a result of these falls and all were classified as no or moderate harm. However, Braintree Community Hospital is committed to reducing the number of preventable falls that are occurring on the inpatient ward. Actions plans for 2011/12 include a review of equipment used on the ward that assists in controlling the number of patient falls. The Central Essex Community Service‟s Matron has also joined the Mid Essex Hospital Trust‟s Falls Steering Group so that joint learning can occur. BCH has identified this key indicator as a CQUIN target for 2011/12, as additional focus on monitoring and prevention is a top priority for the hospital. 3.1.2

Safeguarding of children and vulnerable adults

Braintree Community Hospital is required to comply with the local Essex wide guidelines for Safeguarding Adults. The Safeguarding Adults Board for Southend, Essex and Thurrock have developed guidelines to set out clearly how concerns about vulnerable adults at risk of abuse will be managed. Braintree Community Hospital have adopted these guidelines and ensures compliance through both aligning internal policies and undertaking safeguarding awareness training for staff, using external specialist trainers. Safeguarding leads for both vulnerable adults and children have been identified. During 2011/12 the hospital will be delivering an enhanced training programme for staff in the area of safeguarding. On-line training modules have also been selected for inductees to complete over a 6 week period during their induction programme, to enhance awareness and understanding by staff.

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3.2

Clinical effectiveness and reduction of risk

Braintree Community Hospital has undertaken a range of quality improvement activities and initiatives to ensure the care we provide is clinically effective including: 3.2.1

Audit

A comprehensive audit programme is in place within the hospital. All subcontractors have their own individual annual audit plans and undertake regular monthly audits of both the care delivered and the environment in which this takes place. Each of the sub-contracted service providers have reviewed the outcomes of these audits within year and reported findings through their internal governance arrangements. It is intended that an overarching BCSL audit programme will be developed for 2011/12. The aim of this programme is to monitor that the individual subcontractor‟s audits have been carried out according to their annual plans and to ensure follow up action is undertaken. Shared learning will also enhance the opportunity to improve the quality of care across all services delivered within the hospital. 3.2.2

Pathways of care

Pathway development The Day Surgery Unit provides a surgical day care service which includes a patient pathway which commences at first outpatient appointment, continues through the surgical procedure and concludes with the required procedure specific follow-up. To support the documentation of patient care within the medical notes, BCH makes use of an Integrated Care Pathway (ICP) for Day case procedures. A project is now underway to further develop this ICP and to create 17 procedure specific surgical ICPs that cover the majority of surgical procedures being undertaken within the service. The second phase of this project will include the review and development of medical patient pathways. This is a six month project with the implementation of new ICPs being undertaken on a phased basis, to ensure that all new paperwork is trialled and adjusted where needed to facilitate accurate documentation of care. All clinical staff, including medical staff will be consulted with regard to these changes to ensure clear understanding and support is in place. Benefits to be realized through implementing procedure specific ICPs include the standardization of clinical care around best practice and the monitoring of variances from predicted pathways of care. Community ward inpatient pathway Central Essex Community Services (CECS), the service provider for the inpatient ward has developed a decision support tool to assist staff to determine the appropriate pathway for patients who access this service. Staff are now able to systematically determine the clinical appropriateness for admission, continued stay and final discharge. The Multidisciplinary team (MDT) then validates the assessment undertaken within the Rapid Assessment Unit (RAU) and reviews which pathway the patient has been placed on. This is further reviewed through regular audits. Audit findings from November 2010 through to March 2011, demonstrated that 93% of decisions made regarding assignment to inpatient pathways (rehabilitation, admission avoidance or end of life) were appropriate and accurate.

3.2.3

Policies and procedures - following NICE/guidelines Braintree Community Hospital

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A comprehensive library of hospital policies has been developed, based on current best practice and implementing the latest guidelines, including those published by the National Institute for Health and Clinical Excellence (NICE). Policy is targeted at both hospital wide level and at operational departmental level. Regular policy reviews are undertaken to ensure that staff have access to current guidance, and staff training ensures that practice remains current. 3.2.4

Infection protection and control

The main focus of infection prevention activity in our first year has been around setting up an accountability and responsibility structure within the hospital. This has included the implementation of an infection prevention and control committee, appointment/identification of an infection control doctor, infection prevention and control nurse specialist and named infection prevention link practitioners within every department. The hospital has successfully introduced the „Saving Lives‟ (DH) High Impact Interventions and hand hygiene rates to monitor good infection prevention practice. These results are presented monthly to the Clinical Quality Review Group (the clinical performance review mechanism in liaison with commissioners) and reported internally through the clinical risk committee, and at the quarterly infection prevention and control committee. The hospital has effectively implemented preadmission MRSA screening for all eligible elective admissions to the day surgery unit and MRSA admission screening within 2hrs for all intermediate care patients. The hospital has had no reported infection control outbreak during 2010/11 and within the same period has achieved excellent statutory reporting compliance by reporting a „zero‟ return to the Health Protection Agency against Healthcare Associated Infections (HCAI) statistics. This includes reporting against MRSA and clostridium difficile bacteraemias. The infection prevention nurse specialist and the infection prevention link practitioners have audited hand hygiene compliance, environmental cleanliness, and infection prevention audits and carried out risk assessments in all departments during the year. Infection control audits The annual infection prevention and control audit programme for 2010/11 included environmental audits. All audits were completed during the audit year using adapted versions of the Infection Prevention Society audit tools for monitoring infection control guidelines. Action Plans were incorporated into the audit. Infection prevention and control audits carried out in 2010-11 included the following:      

Hand hygiene and compliance with ‟bare below the elbows‟ Matron‟s environment audit for wards Theatre audit, theatre manager audit Endoscopy department audit Minor operations matrons audit Soft facility management environmental audits

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PEAT PEAT is an annual assessment, established in 2000 by the National Patient Safety Agency, for inpatient healthcare sites in England with more than ten beds. The PEAT assessments were undertaken in February this year working jointly with our Commissioners, NHS mid Essex. The results are excellent, as shown below and the aim is to continue to maintain these standards.

BCH

ENVIRONMENT excellent

FOOD Excellent

DIGNITY excellent

Hand Hygiene Protocols Hand hygiene procedures and the supporting policy was reviewed in 2010. The policy follows the World Health Organisation (WHO) and National Patient Safety Organisation‟s (NPSA), ‟five moments of hand hygiene‟. A drive to improve compliance with support from the link practitioners within each department has seen sustained monthly compliance throughout the year. The monthly hand hygiene observational audits have supported this compliance throughout the year, with breaches below 100% reported to the line manager.

2010/11 Hand hygiene audit:

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Outpatients department Endoscopy

No data

No data

93.2%

No data

100%

100%

100%

100%

100%

100%

100%

100%

Day surgery Wards Minor ops/endoscopy Overall % score

100% No data

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

No data

No data

100%

91%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

95%

94%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

96.6%

-

97%

100%

100%

100%

100%

100%

100%

100%

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On-going work for 2011/12 Braintree Community Hospital can celebrate a successful year, with very low infection rates and high levels of environmental cleanliness. However, Infection Prevention and Control remains a key focus and ongoing work for 2011/12 will include:  To continue with excellent Healthcare associated infection (HCAI) figures  To introduce the practice of Aseptic None Touch Technique (ANTT) supported by a robust policy and comprehensive staff training  To maintain infection prevention as a key priority within the integrated governance framework operating within the hospital  To enhance the infection prevention training programme for all staff at induction  To have all key infection prevention policies available for all staff on a central BCH site via a shared drive  To improve signage for hand hygiene awareness and cleaning schedules  To enhance the inter-department working and shared knowledge and learning across the hospital 3.3

Patient experience

Braintree Community Hospital places a great deal of emphasis on the views and feedback of patients; it is only with this feedback that we can identify areas for improvement, recognise where things are going well and share this good practice across the hospital, and truly understand more about what is important to our patients.

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Here are some of the views expressed by our patients and their relatives:

“Everyone involved with the Hospital is doing a marvellous job.” “Beautiful building, lovely decor, modern, bright, good ambiance, interesting artwork.” “I don‟t believe I would have a mother without the skill and care of many people in your Hospital. It is my belief that the services currently provided by BCSL are far ahead of the standards we have come to expect of our NHS.” “I was very impressed that there was plenty of parking and more importantly it was free.” “The Rapid Assessment Unit was unbelievably thorough and for something like four hours every conceivable test was carried out.” As someone who has regularly eaten at the Hospital cafeteria I have to say the quality is really high at very reasonable prices.” “Congratulations on making a trip to your Hospital as pleasurable an experience as a Hospital visit can be”

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3.3.1 Surveys In the drive for continual service improvement BCSL actively seeks the views of the service users on a regular basis. All outcomes are reviewed through the Quality & Audit Committee. Some sample summaries of surveys are shown below: Endoscopy During September 2010 the Annual Survey for endoscopy was carried out aiming to assess the effectiveness of the service and to measure the views of the patients and GPs. The sample size was 62 respondents from a total of 100 surveys distributed. There was a very positive response from patients regarding the service they received at the hospital. However, it was disappointing to note that 21% of patients still felt they were ill informed by GPs despite action followed up from the previous year in which patient information to GPs had increased. The action plan for the year focused on continuing to circulate information to GPs and to improve patient experience.

Food on the Ward During October 2010 the first food survey was carried out within the inpatient ward. Over 400 patients were sampled with a view to determining whether the menu devised was appropriate for both age/type of patients and appropriateness of content and required textures. Overall the quality of the food received very positive feedback. Suggestions from patients included requests for additional menu options/items and further information to be provided in order that all patients have a good understanding of the menu. An action plan was devised to implement these recommendations, and with discussion, changes have been made to the menu, with some of the more modern dishes being removed and replaced with more traditional fare. Ashlyns Caterers have always responded directly to individual requests made for particular types of food and have therefore been able to cope with individual patient needs. Nurses simply make additional requests at ordering time and these are always accommodated. An ad hoc assessment of the patient‟s view of food is taken on a daily basis. This determines which dishes have been particularly popular and why. Feedback to the Chef then influences the menu selection for the following week. Daycare Services Surveys have been carried out on a regular basis for daycare and outpatient services, however response have been limited. For the survey samples that were carried out in January, 18 patients responded in daycare and 26 in Outpatients. These surveys aim to measure the levels of patient satisfaction and to seek ways in which the service could be improved. Braintree Community Hospital

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Outpatients The majority of the respondents scored the department in the top two categories measured (excellent/good) and 21 of the 26 respondents stated that they would recommend the service to a friend. Day Surgery Unit The day surgery unit (DSU) scored much higher than Outpatients with all the patients unanimously stating that they would be happy to recommend the service to a friend. After reviewing the survey results it was found that the structure and form of the questionnaire needed enhancing to provide more in-depth information. An action plan has been devised that addressed the issues raised and includes a review of the questionnaire content. It was agreed to continue the circulation of the survey on a monthly basis in its present form until review was completed and signed off. As BCH has been in its first year of opening, the National Patient Survey has not been carried out this year, but will be undertaken in November 2011.

3.3.2

Internal Quality Improvement Group

An internal quality group was convened specifically with the aim to integrate and coordinate the feedback from patients and relatives attending the Hospital. In supporting compliance with the new Care Quality Commission (CQC) Essential Standards of Quality and Safety BCH supports increased patient involvement in all aspects of the patient pathway. The group agreed to provide a programme of surveys for the year with a view to determining whether they could be merged. Individual service specific reviews continue until an integrated programme is implemented.

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3.3.3. Suggestion Box A suggestion box has been installed in Main Reception, aimed at patients and staff who are able to offer ideas and comments to facilitate future improvement. Suggestions during the year have tended to be predominantly related to environmental issues. Subsequent changes that have been made include the following: Chairs with arms for cafe – new chairs have now been supplied Clock requested in reception – new clock installed on Reception wall Hooks requested in toilets – Hooks have been added to the backs of the toilet doors More directional signage requested – Internal and external signage has been ordered and some new internal signage has been installed  New seating in the atrium – seating altered to accommodate request for lower seating with arms    

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3.4

Complaints

BCH has in place a robust complaints management process that is compliant with the NHS Complaints process. Complaints are routinely monitored and logged. Analysis and reporting of this data occurs through the internal governance processes and has been discussed at Quality and Audit Committee meetings, and at a more senior level during the Joint Integrated Governance Board and finally at Medical Advisory Committee (MAC). During 2010/11 46 complaints were received at Braintree Community Hospital from a total of 40,091 patients attending within that period. This equates to only 0.11% which reflects the aim and ethos of BCH which is to provide exemplary patient care. Of these complaints, 35 were upheld and 4 were partially upheld, the remaining 7 were not upheld.

Closed Complaints 9

1

8 7

3

6

1

5

1

1

Not upheld

1

4 3 2 1

1 1

5

4 1

2

4 2

5

5

5

Partially upheld 2

Upheld

1

0 2010 2010 2010 2010 2010 2010 2010 2010 2011 2011 2011 May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Complaints have been categorised using the nationally recommended coding system as described within the NHS Data Model and Dictionary service provided by Connecting for Health. The chart below provides a breakdown of the complaints by type.

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Upheld Complaints by Type

Admission, discharge and transfer arrangements Aids and appliances, equipment, premises (including access)

1

All aspects of clinical treatment 4

5 6

Appointments, delay/cancellation (out-patients)

15 8 2

Attitude of staff Communication/information to PATIENTS (written and verbal)

11

Failure to follow agreed procedures Other

The highest number of complaints received during the year fell into the categories of delays/cancellations and communication issues. However, on investigation each complaint has highlighted different areas of concern, thus making trend analysis challenging. Each complaint has therefore been dealt with on an individual basis, and where lessons were learnt, these have been disseminated to staff and service improvements implemented.

3.5

Delivering same sex accommodation

Every patient has the right to receive high quality care that is safe, effective and respects their privacy and dignity. The Braintree Community Hospital is committed to providing every patient with same sex accommodation, because it helps to safeguard their privacy and dignity when they are often at their most vulnerable. We are proud to confirm that mixed sex accommodation has been virtually eliminated in our hospital. Patients who are admitted to our hospital will only share the room where they sleep with members of the same sex, and same sex toilets and bathrooms will be close to their bed area. As part of our mission and value statement we promise: „To deal with Patients as valued clients, responding to their needs and providing comprehensive treatment during the time they spend with us.‟ What does this mean for patients? Patients admitted to Braintree Community Hospital can expect to find the following: The inpatient area has been designed to provide a large number of individual rooms to accommodate personal needs with en-suite facilities. There are two 4 bedded bays where for only members of the same sex will be accommodated.

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There are also some communal areas such as the dining room and cafe which are used by both male & female patients and visitors. In day-care, individual cubicles are provided to ensure privacy and great care is taken on route to theatre to restrict any unnecessary encounters. All other areas of the hospital operate to strict protocols and guidelines to maintain compliance with single sex requirements. What are our plans for the future? Compliance with single sex accommodation forms only one part of the Hospital Development Plan. There are some physical environmental changes underway to further enhance patient privacy. Staff will continue to be proactive in the protection of patient privacy and will be routinely monitoring compliance against the standards.

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4 The views of Our Stakeholders Braintree Community Hospital Statement from Commissioning PCT NHS Mid Essex can confirm that the quality data contained within the Quality Account for Braintree Community Hospitals is in line with the information recorded by the PCT between April 2010 and end of March 2011. The PCT can also confirm that all statutory requirements have been included within the Quality Account. NHS Mid Essex recognises Braintree Community Hospital‟s commitment to patient safety and quality and has worked closely with Braintree Community Hospital to implement a series of programmes to facilitate the quality and patient safety agenda. NHS Mid Essex acknowledges the performance in relation to Health Care Acquired Infections (HCAI) such as MRSA and Clostridium Difficile and commends BCH in implementing a strong structure to support infection prevention activity. Braintree Community Hospital has achieved significant success in implementing the High Impact Interventions and has consistently achieved cleanliness and other infection prevention targets. In the forthcoming year, Braintree Community Hospital has chosen to focus on areas for improvement which offer the maximum opportunity to improve on patient safety, experience and outcomes. The PCT remains committed to assist Braintree Community Hospital in driving up quality and patient safety. Braintree Community Hospital acknowledges and appreciates the written statement from NHS Mid Essex and has made no further changes as a result of this statement.

This year the Quality Accounts have been submitted to both the Essex County Council Health Overview and Scrutiny Committee and the Essex and Southend LINk. Both organizations will be reviewing the Accounts however subsequent comments will not be received in time for consideration prior to publication of these Accounts.

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