One Ashford Hospital Quality Account 2018-19 - assets.nhs.uk · 2 Contents: Section TitlePage 1 Introduction to One Healthcare and One Ashford Hospital 3 2 Statement on Quality 6

One Ashford Hospital Quality Account1 April 2018 – 31 March 2019

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Contents:

Section Title Page

1 Introduction to One Healthcare and One Ashford Hospital 3

2 Statement on Quality 6

3 Accountability Statement 8 3.1 Statement 8 3.2 Quality Account Review 8

4 Quality Priorities for April 2018 – March 2019 9 4.1 Summary for 2018 – 2019 9 4.2 Update on planned quality and visions outlined in 2017-2018 Quality Account 9 4.3 Other key achievements during 2018 – 2019 12

5 Quality Priorities and Visions for April 2019 – March 2020 17

6 Statements from The Care Quality Commission 18

7 Statements on Data Quality 19 7.1 Data Quality 19 7.2 Information Governance Toolkit (IGT) attainment levels 19

8 Statements of Assurance and Compliance: Achievements 2018 – 2019 21 8.1 Goals agreed with Commissioners 21 8.2 NHS Service Provision 21 8.3 Audits 21 8.4 Key Performance and Quality Indicators 25

9 External Perspectives on Quality of Services 33

10 Closing Remarks 34

“First class service from start to finish! This is how healthcare should be delivered!”

March 2019

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1. Introduction to One Healthcare and One Ashford Hospital

Richard EvansChief Executive for One Healthcare

The One Healthcare Group was established in 2015, and is a UK based private healthcare provider in the South of England. Within the One Healthcare Group there are currently two sites; the first facility in Ashford, Kent, opened in March 2016, followed by the second site at Hatfield, Hertfordshire, in December 2017.

The primary objectives of One Healthcare are to provide exceptional care, delivered by specialist Consultants and experienced healthcare professionals, in a modern and well equipped hospital facility. The impact of their professionalism, decision-making, positive attitude and empathy is what makes the difference between good care and excellent care.

One Healthcare offers the newest purpose built hospitals with the latest theatres, a state of the art Endoscopy unit, luxury en-suite inpatient bedrooms, specialist rehabilitation physiotherapy, outpatient diagnostic facilities including fast-track access to X-ray, MRI and ultrasound. One Healthcare is unique in providing diagnostic care and treatment for all.

At One Healthcare our values are not just words, they are our corporate DNA, underpinning how we treat patients and those we work with.

• Care: we demonstrate care, compassion empathy and respect by listening - so we fully understand and deliver best advice, best treatment and best care for our patients.

• Quality: we inspire quality, continually assessing our actions and delivery questioning ourselves and seek out new innovative ways to deliver first class healthcare.

• Excellence: we consistently exceed patient expectations by delivering clinical excellence in an outstanding healthcare environment where safety is our number one priority.

• Leadership: we wish to inspire and impress our patients, partners and staff by serving our teams in way that we get extraordinary achievement from our people.

• Innovation: as an outcome driven organisation, we learn from best practice, latest research and key influencers to innovate and improve the way we deliver services.

• Honesty: if we feel we could do better we will say so and focus on making the right things happen.

• Value: we take pride in delivering quality and value for money by eradicating unnecessary waste, duplication or cost and passing on that efficiency to those who choose our services.

We use the above values to achieve our mission. At One Healthcare our mission is to provide:

• Safety as a priority – inspiring confidence and demonstrating accountability through our quality management systems and well trained resources

• Outstanding results – delivered by Consultants and experts working together in our modern hospital environment

• Quality you can trust – underpinned by the highest standards of governance delivered by our Consultant led teams

One Ashford HospitalThe site has been specifically developed with the customer in mind and benefits from ample parking. It provides access to purpose-built private facilities on a site that is just a short distance from the William Harvey NHS Hospital and situated off Junction 10 of the M20 Motorway.

One Ashford Hospital prides itself on high standards of clinical care, a friendly atmosphere and continual investment in staff, training and facilities.

“I have attended Ashford Hospital more than once now and cannot fault it.”

Inpatient July 2018

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Thehospitaloffers:• 20 inpatient en-suite bedrooms • Outpatient and inpatient Physiotherapy Services• 8 daycase patient bedrooms • On site Pharmacy• 7 outpatient consulting rooms • 24/7 Resident Medical Officer (RMO) on site• 3 outpatient treatment rooms • Free parking• 2 laminar flow theatres • Café with in house Baristas• Dedicated Endoscopy suite• MRI and diagnostic imaging suites

Wearepleasedtobeabletoofferthefollowingspecialtiesatourhospital:• Anaesthetics and Pain Management • General Medicine• Audiology • General Surgery• Cardiology Diagnostics • Gynaecology• Colorectal • Orthopaedic Surgery including Hand surgery• Cosmetic Surgery • Children and Young Persons Service (Paediatrics)• Dermatology • Physiotherapy• Diagnostic Imaging • Respiratory• Ear Nose and Throat (ENT) • Rheumatology• Endocrinology • Urology• Gastroenterology • Varicose Vein surgery

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2. Statement on Quality

Jo NolanHospital Director

I am pleased to be able to present One Ashford Hospital’s third Quality Account for April 2018 to March 2019. This Quality Account has been written to demonstrate One Ashford Hospital’s commitment to care and quality. In order to monitor and improve, we use measurements including feedback from patients, Consultants and staff, as well as audits, both national and local, and comparative benchmarking figures.

One Ashford Hospital is now in its third year, and has seen a change in hospital leadership. I joined as Hospital Director in October 2018. Having worked in Healthcare my whole career, I am able to bring a wealth of experience to the Hospital.

I have managed a number of hospitals, worked in the NHS, in the Pharmaceutical industry, and using my connections, the hospital has maintained and progressed exceptionally good

relationships with our team of Consultants. They all continue to have a strong commitment to work with us, ensuring we can all continue to provide the best quality healthcare to patients.

At One Ashford Hospital, we excel in the provision of the best standards of healthcare, and continue to work in close partnership with the NHS. We ensure the services delivered by us result in safe, effective, and bespoke care for each of our patients.

During our three years, we have established a robust audit programme, in which we continually build new ways of measuring outcomes. This includes measuring ourselves against external bodies’ criteria, such as the Care Quality Commission (CQC) and Clinical Commissioning Groups (CCGs) requirements. This ensures we meet and maintain the excellent standards which are expected of One Ashford Hospital.

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2. Statement on Quality

Our aim for our next inspection is to achieve an “Outstanding” rating. Measuring ourselves against the CQC Key Lines of Enquiry under each Domain (Safe, Well-Led, Caring, Effective, and Responsive) will ensure our ongoing progression towards an “Outstanding” rating.

Our staff are integral to the success of the hospital, and having a cohesive team approach to improve quality is vital. We adopted a strategic focus of ONE – Outstanding Needs Everyone – during 2018, so this becomes embedded in our daily culture and practice.

One Ashford Hospital is dedicated to leading the team effectively, to make certain our services are safe and compliant with all regulatory requirements, alongside meeting our customer expectations.

We recognise the importance of learning from patient feedback, incidents and complaints, ensuring we are open and honest, and continually review our processes and practices. We are proud to report 97% of patients would recommend One Ashford Hospital to their family and friends. This is a fantastic achievement to sustain throughout the year.

One goal for 2019-2020 is to uphold the emphasis on the safety of our patients, and delivering care in an effective way, with each patient being treated as an individual. We strive to ensure patients are informed and included in decisions about their care and treatment during their pathway. Our 2018-19 feedback results show 100% of patients felt involved in decisions about their care.

The business and strategic objectives have been identified during 2018-19. In addition to our values, we want to empower staff to recognise their role in facilitating One Ashford Hospital to achieve these key objectives during the next year.

Our Quality Account provides information for patients, staff, Consultants and commissioners, to assure them we are committed to sharing our progressive achievements from one year to the next. We remain committed to quality improvement of our services.

I am proud to lead the dedicated team, and look forward to another successful year.

“Care given before and after surgery was amazing - very professional and friendly, was made to feel very comfortable and relaxed.”

July 2018

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3. Accountability Statement

3.1 StatementTo the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate.

Jo NolanHospital Director Date: 14th May 2019

Note:Note: Directors of Organisations providing hospital services have an obligation under the 2009 Health Act, National Health Service (Quality Accounts) Regulations 2010 and the National Health Service (Quality Accounts) Amendment Regulation (2011), to prepare Quality Account for each financial year. This report has been prepared based in guidance issued by the Department of Health setting out these legal requirements.

3.2QualityAccountReviewThis account has been reviewed and approved by the following:

• Mr Richard Evans, Group Chief Executive Officer

• Mrs Jo Nolan, Hospital Director

• Mrs Sharon Takeda, Director of Clinical Services and Quality and Governance Committee Chair

• Mrs Shalini Gujral, Chief Pharmacist and Governance Lead

• Mr Brian Wise, Consultant Governance Lead (Consultant Uro-gynaecologist)

• Mr Helmut Zahn, Medical Advisory Committee Chair (Consultant Orthopaedic Surgeon)

“From my letter of consultant appointment to post-op - my treatment has been superb. Nothing has been too much trouble for reception, nursing and auxiliary staff. Plus an excellent surgeon/consultant, followed by excellent physiotherapy. In particular; explanation and advice was given clearly and concisely.”

August 2018

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4. Quality Priorities for April 2018 - March 2019

4.1 Summary for 2018 – 2019Our third year has seen us continuing to embed our governance framework and structure, to build on our data available for comparison and trend analysis. By having more data, our insight into areas requiring quality improvement can be targeted. The data we have will promote and support the adoption of best practice.

We are utilising the same framework, as this is embedded and is known throughout the organisation.

4.2 Update on planned quality and visions outlined in 2017-2018 Quality Account

a) Safe• Medicines Management NHS Safety

Thermometer – we have registered and commenced submissions at the end of 2018-2019. We will be able to provide comprehensive data in our next Quality Account.

• National Confidential Enquiry into Patient Outcome and Death (NCEPOD) – National report obtained during Patient Safety Congress, circulated to teams to embed learning and good practices where relevant. Ongoing monitoring of reports issues to adopt where applicable to One Ashford Hospital.

• Advanced Life Support (ALS) Course – our external Resuscitation Training Provider (AtoE Training and Solutions) delivered a two-day ALS course in December 2018. It was attended by 10 staff, who were all successful in passing this course. This qualification has enhanced the skills of our emergency team, and we hope to run a further course during 2019-2020.

The ClinicalAssurance

Board (CAB)

QualityGovernanceCommittee

Quarterly*

WaterGroup

*PLACE = Patient-Led Assessment of the Care Environment

Med

icin

esM

anag

emen

tCo

mm

ittee

Qua

rter

ly

Infection

Prevention

Control

Committee

Quarterly

Safety, Health & EnvironmentCommitteeBi-monthly

MedicalEquipment

Resuscitation

Comm

ittee

Quarterly

Inform

ation

Govern

ance

Group

Quarter

ly

Paediatric

Comm

ittee

Quarterly

*Quality Governance Committee Agenda includes:

1. Clinical Effectiveness: a) Incidents b) Service feedback c) Risk Register d) PREMS e) Audit

2. Infection Control

3. Health & Safety

4. INIRS

5. Medicines Management

6. National Registries

7. Documentation, policies and procedure management

8. Training

9. Information Governance

10. Resuscitation

11. Staff Engagement

12. Patient Focus

13. CQC Update

14. Safeguarding

Radiation

Protection

Comm

ittee

(INIRS)

Annually

ClinicalEffectiveness

GroupMonthly*

*Except for months with QGC meetings

NHS Trust BloodTransfusionCommitteeQuarterly

Closing the loopDatix Meeting

Weekly

SafeguardingHealth Leads

Staff ForumQuarterly

PLACE*

Inspection

Annually

CriticalCare

Network

Quality LocalIntelligence

Network(QLIN)

ControlledDrugs LocalIntelligence

Network(CDLIN)

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4. Quality priorities for 2018-2019

• Embedding of Quality Dashboard – the Dashboard is completed monthly by the Governance Team, with information being provided by departments across the hospital, who undertake several of the required audits. This ensures quality data is in one location, and results in comprehensive information being available to provide assurance to the Board, in addition to giving internal and external assurance when required. The collated data includes patient, Consultant and staff statistics, as well quality measures under three main headings of Key Performance Indicators, Quality and Compliance, and Audit requirements.

• Step Up to Safety initiatives – “Human Factors” training was provided to theatre staff in May 2018, and was well attended. Our Resuscitation Lead, who is a Senior Theatre Practitioner, has cascaded the key messages from this training to other clinical staff within the organisation. We are carrying forwards the plan to undertake a safety culture survey, as we made changes to the Datix system and these needed to be embedded. We have good levels of reporting with no severe, and low numbers of moderate harm incidents reported.

• One Ashford Hospital will provide key staff with training centred around “Human Factors” to promote awareness of patient safety. This programme will aim to explore safety behaviours and engage staff to understand their own role in our safety culture. A survey on the culture of patient safety at the hospital will also be undertaken by the Governance Team to obtain baseline data. This survey can then be carried out on an annual basis with action plans to effect a year on year improvement.

b) Well-led• Data Security and Protection Toolkit and

GDPR compliance – One Ashford Hospital has migrated data and completed the new Data Security and Protection Toolkit. Our CEO was acting Data Protection Officer whilst we sourced a company available to undertake this role for us.

• Review of new Key Lines of Enquiry (KLOEs) – for the independent sector the revised KLOEs were installed on our quality monitoring system HealthAssure. All Heads of Departments have been issued with their respective departmental data to analyse their service area against the KLOEs. This will be ongoing during 2019-2020. Our ONE – Outstanding Needs Everyone – initiative is incorporated into this.

• Chief Operating Officer (COO) open forum – our Group COO was promoted to Group Chief Executive Officer, and he has held several sessions of open forums for all staff during 2018-2019. Attendance has varied therefore the frequency of these has been reduced. He continues to schedule these forums regularly with several planned for the next year.

• Governance Structure – review initiated of requirements and meeting planner established to ensure yearly schedule for improvements in attendance. Timings of meetings were reviewed to promote the correct flow of information up and down the organisation. All meeting Chairpersons are required to review the meeting Terms of Reference on an annual basis.

• Cross-site Governance Board meetings – these meetings are occurring on a monthly basis and now firmly embedded as part of the One Healthcare Governance processes. These meetings are evolving as we continue to establish a cross-site Governance culture.

• The hospital participates within a Local Quality Intelligence Network (QLIN), a group consisting of private hospitals and NHS hospitals, which meet quarterly to review quality measures and learning to share best practice.

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c) Caring• Patient involvement and patient forum – we

have received limited response from notices in the hospital, therefore do not currently have a quorum to hold effective meetings. We do obtain patient feedback through questionnaires to analyse our performance and make changes based on comments received. During 2019-2020 our Director of Sales and Marketing is tasked with promoting this further.

• Fundamental Standards of Care – Highlighted to staff the importance of focusing on fundamental care practices and standards. This will be a key focus during 2019-2020.

• Patient menu redesign to include nutritional content information – due to priority changes within the Catering department, the initiative has been put on hold. We do have menu options for all dietary requirements, and the menu has been revised for both patients and staff to allow a greater choice. Staff are enthusiastic about the new options available to them, and are delighted when taster options are offered. We always get very positive comments with regards to the menu choices offered.

d) Effective• Review of Patient Satisfaction survey – In

January 2019 we changed our patient satisfaction questionnaire provider, this included a question review and survey redesign. This was relaunched with staff and we continue to receive excelled results. In 2019-2020 our response rates will be focused on with all teams to achieve more robust data. We are in the infancy of benchmarking against our sister hospital, and will request a comparison report with other similar sized private organisations.

• Training for staff, including induction – our mandatory training programme content and availability of face-to-face sessions across all subjects has been reviewed and availability increased where required. The HR Department are exploring additional options regarding our face-to-face and e-learning packages to assist staff to achieve competencies in key areas.

• Documentation and patient pathways – we launched a revised comprehensive inpatient surgical pathway in addition to a day surgery/23-hour pathway and blood transfusion pathway during the year. These have been well received by the clinical teams, as key information is in one document. There are plans to develop a minor procedure pathway for Outpatients for 2019-2020.

• National Breast and Cosmetic Implant Registry – The Deputy Theatre Manager oversees the reporting of data to the National Breast and Cosmetic Implant Registry.

e) Responsive• Consultant Survey – A Consultant Survey was

undertaken in June 2018 and results shared with Consultants and Staff. The feedback received was positive overall, and an action plan created by the Hospital Director.

• Back to the floor – The focus for this activity was changed to be a cross-site initiative to ensure good relationships and consistency in practice across both sites. This has allowed staff to share examples of good processes that both hospitals can implement.

• Early Warning Scores – A Patient Safety Alert to adopt the new national NEWS2 chart was issued in April 2017. One Ashford revised and amended the chart with the requirements and have provided clinical staff with the e-learning module. This launched in March 2019.

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4.3 Other key achievements during 2018-2019During 2018-2019 we increased staff involvement in various promotions of One Ashford Hospital, and supporting our local community. Keeping our visions at the heart of all activities, both clinical and non-clinical, we have achieved the following:

a) Safe

• MedicinesManagement: – Our internal pharmacy opened in February 2018 and has been extremely well received by Consultants, staff and patients. The quality of the Pharmacy Service has improved by decreasing medication-waiting times for discharge, provision of an outpatient Pharmacy service, more prompt delivery supply service to internal departments, and a safer management of Controlled Drugs by Pharmacy having greater control over distribution.

– The Pharmacy team have recruited a full time Clinical Pharmacist, allowing the Chief Pharmacist to focus on strategic development of the service across all One Healthcare facilities.

– Attendance by the Chief Pharmacist at the Independent Chief Pharmacist Network, has ensured current practice at One Ashford remains in line with national guidance and allows excellent relations with other Independent Providers to be formed.

– Extensive work is being undertaken to review ensure the new Professional guidance on the safe and secure handling of medicines issued in December 2018. This work is ongoing and will give us the assurance we are compliant with standards.

– Following the withdrawal of the NMC Standards for medicines management, the Royal College of Nursing (RCN) published a Professional Guidance on the Administration of Medicines in Healthcare Settings. These were circulated to all nursing staff along with local medicines management training to all clinical departments.

– A Controlled Drug Action plan was implemented and actioned following on from recommendations from the Gosport Enquiry report published in June 2018 and the annual CQC Safer Management of Controlled Drugs. Changes made include the storage and record keeping of Morphine Sulphate Solution and Tramadol, development of an opioid patch record document for inpatients, improved communication with GPs for opioid requests post discharge and Controlled Drug training for departments.

– The Hospital Director, as CDAO, attends the Quality CDLIN.

– Information given to patients on discharge has improved by the development of leaflets provided with medication at the time of dispensing. This includes antibiotic, pain and controlled drug information leaflets.

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• AntibioticAwareness – One Ashford continue to support and promote the World Antibiotic Awareness Week. This year’s awareness drive was from 12-18 November 2018. The aim of the campaign was to increase global awareness of antibiotic resistance and to encourage best practice by staff at One Ashford for infection control. The week consisted of an information stand, educational talks and staff quizzes.

• CQUINAchievement – At the time of publishing our last Quality Account, we had not received confirmation from our CCG of achievement of the agreed CQUINs. We are delighted to report that One Ashford Hospital achieved 100%, which included targets around improving staff health and wellbeing, timely identification of sepsis in acute inpatient settings, appropriate prescribing of antimicrobials and NHS e-referrals.

• DeputySafeguardingLead – During the year we appointed a deputy Safeguarding Lead, to assist the current Safeguarding Lead for One Ashford Hospital, who is the Director of Clinical Services. This will ensure a higher level of attendance at the local Safeguarding Network meetings and improved availability of advice.

b) Well-led

• HealthandWellbeingofstaff – One Ashford Hospital changed the provider for private medical insurance to ensure staff receive improved healthcare provision.

– Pension scheme revised in line with national requirements enhancing the benefits of our staff in preparation for retirement

– Support and training provided from external company to Heads of Department (HODs) regarding performance management, increasing the skills of the HODs to fulfil the management element of their role.

• OneAshfordHospitalHODsawaydays – Away days scheduled during the year for all HODs were for cohesive team working and organisational planning. This took place in an external environment to ensure protected time was dedicated to planning strategic company improvements.

• Employeenominations – Monthly staff nominations received to recognise outstanding contribution of team members, who have gone above and beyond their role duties.

• Reviewofjobdescriptions – To provide clarity and standardisation, revised job descriptions were issued to staff outlining their specific roles and corporate responsibilities.

• ControlledDrugaudits – Controlled Drug Accountable Officer (CDAO) undertaking the quarterly Controlled Drug audits in conjunction with Pharmacy, to ensure compliance is driven from the top down. This includes unannounced visits by the CDAO to departments to ensure ongoing compliance to Controlled Drug record keeping standards.

• Appraisals – Following feedback from the 2018 staff survey it was highlighted the appraisal process needed to be more robust. All HODs were requested to ensure each member of staff had an appraisal completed before April 2019. This was achieved and for 2019-2020 the appraisal documentation will be reviewed.

“Excellent care from start to finish, across all staff levels, and all in a modern and smart hospital environment.”

August 2018

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• Emergencyplanning – One Ashford Hospital has political awareness of the wider economy. With preparations for “Brexit” underway by the Government, our hospital participates in the Independent Hospitals Emergency Planning Group. This has been organised by the Independent Sector covering Kent, and NHS teams are invited to participate for collaborative working. These meetings review potential impacts to transport, medications, consumables and how we can support other health service provisions. We have links with the local NHS trusts for contingency planning for staffing levels should a major incident arise.

• Staffsurvey – We undertook our second Staff Survey in July 2018 to obtain staff views on how the hospital is performing, and how we can enhance our staff’s working experience. 93% of our staff would recommend the hospital to their relatives/friends if they needed care or treatment. The Hospital Director leads on the action improvement plan and regularly conducts feedback sessions for staff.

c) Caring

• Dataprotectiontrainingforstaff – We increased the training around information governance and the new requirements following the General Data Protection Regulations (GDPR) implemented in May 2018.

• Staffengagementandwellbeing – Staff red nose day – One Ashford Hospital raised an impressive £1200 for Comic Relief this year. Staff starred in a video to the song ‘The One and Only’ endorsed by Chesney Hawkes, and this was shown on local BBC news. We won the Comic Relief Squad Nosey award for our video chosen from multiple entries from across the country.

– Cycle to Hatfield – staff also participated in a “cycle to Hatfield challenge” which was another measure to raise money for this worthy charity.

– Massages for staff – We initially trialled an external qualified therapist attending site as a benefit for staff to have massages during the working day. This proved popular and is now a regular occurrence.

• FreedomtoSpeakUpGuardian – One Ashford Hospital continues to promote and support this key initiative, and all teams are aware which staff member is the Freedom to Speak Up Guardian. For 2019-2020, a review will be undertaken to have more than one staff member undertaking this vital role.

• Stafftraining – The application process for attending external training was revised and streamlined. Our Hospital Director and Director of Clinical Services, in conjunction with the HODs, are keen to ensure staff investment, and enhancement of their knowledge and skills. Examples of supporting staff include Leadership and Management courses, Paediatric Recovery Training, RCN Infection Control Course and Accountancy qualifications.

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• Dementiaawareness – Our Dementia Champion ensured One Ashford Hospital were involved with the national Dementia Awareness Week. During this period (Monday 21 May through to Friday 25 May 2018) short teaching sessions were held to raise awareness and highlight to staff what facilities, resources and support are available for patients with dementia.

• Communityevents– – Prostate awareness and support for the Urology foundation.

– Clinical Education events – we run a number of events for GPs and AHPs each year to promote awareness of our services. Such events have included a talk around cancer awareness including urology, bowel, dermatology, colorectal and sessions in relation to orthopaedics.

– Patient events – we have held a number of health promotion events for the public, including focus on women’s health and an evening on men’s health.

d) Effective

• InfectionPreventionandControl – One Ashford Hospital has Infection Prevention and Control as one of its top priorities. We appointed a new Infection Control Lead Nurse, who is undertaking the RCN qualification in infection prevention and control practice.

– The IPC Lead has rolled out a programme of Aseptic Non-Touch Technique (ANTT) and hand hygiene training to clinical staff, along with increased availability of face-to-face sessions relating to infection control practices.

– We have seen significant improvement with the 49 steps audit data collection. In addition, the IPC Lead has been successful in ensuring outstanding actions on the IPC Annual Plan have been achieved, by working closely with the IPC Link Practitioners, Consultant Microbiologist and Director of Infection, Prevention and Control.

– We undertook an additional audit specific to total knee replacements for the month of November 2018 in relation to SSI’s for further assurance of low infection rates.

– The national requirement to undertake PLACE (Patient-Led Assessments of the Care Environment) was achieved during June 2018, and an action and compliance plan recorded and submitted to the national NHS body. There are further developments to this programme in 2019, and it is expected new guidance is issued after September 2019.

– We have had no MRSA, MSSA or Clostridium Difficile bacteraemia infections reported.

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• Cross-siteHODsawaydays – Established by the CEO, 6 monthly cross-site meetings to be attended by Ashford and Hatfield HODs. This helps collaborative working for both sites where relevant, and sharing of lessons learnt to promote good processes and practices.

• RootCauseAnalysisinvestigations – Agreement over criteria for Root Cause Analysis investigations to be undertaken agreed at Cross-site Governance meetings. One Ashford Hospital reviewed all Moderate harm incidents reported in 2018-2019 to ensure correct categorisation and a concise RCA has been completed for these moderate harm incidents.

• PatientReportedOutcomeMeasures(PROMs) – We continue to collect outcome data for hip and knee procedures. Due to national requirements from PHIN and the NHS for groin hernias, we are no longer required to collected this data. After a review of patient procedure numbers, we stopped collecting other PROMs data (for example cosmetic procedures) as we were unable to submit meaningful data due to low numbers.

a) Responsive

• TeamEndoscopy

– We now have our very own purpose built Endoscopy suite, housing the latest endoscopy equipment. This enables One Ashford Hospital to offer a wide range of procedures in an environment which prioritises patient privacy and confidentiality.

– Our service is led and delivered by experienced Consultants in the fields of Gastroenterology and Gastrointestinal Surgery, with a dedicated manager.

• AdministrationTeam – To improve administrative processes and enhance our patient journey, we reviewed all our administration processes and appointed a Patient Administration Manager to ensure we remain responsive to patient enquiries.

• ISCAStraining – Managing complaints session attended by PA to Hospital Director who oversees complaints management to ensure updated information is implemented at One Ashford Hospital.

• PatientAdmissiontimes – The Hospital have reviewed the admission times for patients in response to feedback obtained via our patient satisfaction surveys. We have adjusted the arrival time according to the theatre list order, which means patients have less waiting times following their admission into hospital.

“Booklets sent prior to admission were very helpful and written in ‘plain’ English. All staff were very welcoming. Post-operative I was very unwell with nausea and dizziness and couldn’t eat. Kitchen staff came on many occasions to offer alternatives/suggest things I might like - nothing was too much trouble. Building was very open and airy and did not have the ‘feel’ of a hospital - it made an anxious time less stressful.”

September 2018

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5. Quality Priorities and Visions for April 2019 – March 2020

As part of our commitment to patient safety and providing an outstanding level of care, One Ashford Hospital continually seeks to improve our quality. Embedded in our practice is the drive to achieve the CQC “Outstanding” rating.

For the forthcoming year we have the following objectives and visions.

• Safe – We have an established audit programme, however with advice from an external Governance and Quality Specialist we are exploring options of additional audits that can be undertaken to add quality improvements to the hospital.

– We would like to undertake a safety culture questionnaire to gain an insight into staff attitudes to patient safety.

– We are continuing the work in ensuring our policies and SOPS are in line with The National Safety Standards for Invasive Procedures (NatSSIPs 2015) by changing our documents to the Local Safety Standards for Invasive Procedures (LocSSIPs) template. This is planned for completion within the first quarter of 2019-2020.

• Well-led – To follow on from the developments of our appraisal system, the Human Resources department plans to streamline the appraisal paperwork to ensure it is user friendly and appropriate for all staff.

– We remain committed to ensuring the correct staffing levels and undertake regular reviews around recruitment and retention, reduction of agency staff and sickness management. We have a large cohort of staff who have been in post from opening, indicating our staff retention is high. Analysis of sickness and absence data will continue to be carried out to determine any trends. Subsequent improvements will then be made to reduce occurrences.

– Provision of external Root Cause Analysis training to key senior team members, our Consultant MAC chair and Consultant Medical Governance lead.

• Caring – There are plans to explore increasing the availability of a Chaplaincy service.

– Customer care training is being delivered to all staff during the first half of 2019-2020 to ensure that we are providing a five-star service to all patients.

– We will identify another member of staff to undertake the Freedom to Speak Up Guardian training so we have an additional person available to listen and assist staff as needed in relation to patient safety.

• Responsive – We are exploring options to implement a telephone text appointment system for all Outpatient appointments.

– To improve falls prevention and management we will be auditing the revised falls prevention policy. This is in line with our 2019-2020 CQUIN CCG requirements.

• Effective – Implementation of Pain Working Group to improve practice for pain management and patient experience. This includes development of guidelines and more robust audits.

– Development of Lunch and Learn sessions for employees to promote continuous professional development in their roles.

– We will participate in a Kent-wide network group being developed around Infection Prevention and Control practices.

“I was welcomed by a very friendly and professional team of people. I was well informed, every step of the way, and my care was exceptional from each and every member of staff. It was a surreal experience and made my ordeal comfortable and easier to bare.”

September 2018

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It is a requirement of all hospitals to be registered with the national regulatory body the Care Quality Commission (CQC). One Ashford Hospital as a service provider is required to maintain registration with the CQC under the Health and Social Care Act 2008.

Certificate number: CRT1-3020775322

Certificate date: 27/10/2016

Provider ID: 1-2306619331

We are registered to provide the following services:• Diagnostic or Screening Procedures

• Family Planning

• Surgical procedures

• Treatment of disease, disorder or injury

The CQC have not issued any special reviews or investigations, and no enforcement actions have been placed on One Ashford Hospital.

One Ashford Hospital achieved a “Good” rating in our June 2017 Care Quality Commission (CQC) inspection. This rating was overall, and for each of the domains and service areas inspected. A copy of the report can be found here:

http://www.cqc.org.uk/sites/default/files/new_reports/AAAG7491.pdf

6. Statement from Care Quality Commission

“The comfort, the care, the privacy and the efficiency of all the entire team I had contact with. All carried out in clean spacious rooms designed to make recovery as pleasant an experience as possible. It certainly worked for me.”

January 2019

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7. Statements on Data Quality

7.1 Data QualityData quality remains exceptionally important to One Healthcare and at One Ashford Hospital we recognise that good quality information underpins the effective delivery of patient care and is a main driver for improvement. The CMA Order required hospitals to submit data to PHIN ‘at least quarterly’, however, to bring submission in line with standard processes in the NHS and provide our sites with the best opportunity to correct issues and continually improve data quality at regular intervals, prior to publication, One Healthcare submit data in monthly submissions. As a member of the PHIN Information Forum the Hospital has been working toward the PHIN requirements.

1. Episode Data: The Hospital has been working with our Patient Administration System (Compucare) providers to ensure this is fit for purpose and that our system is able to download directly to PHIN. We utilise Monmouth Consulting to extract and check our data on a monthly basis.

2. Patient Satisfaction: The Hospital uses the services of Howard Warwick to collect Patient Satisfaction data.

3. ICD 10 Coding: The Hospital contracted in the services of ICD 10 coders from Monmouth. The coding information is stored in Compucare assigned to the patient record or episode of care.

4. PROMs: The Hospital chose Quality Health to collect PROMs for hip and knee replacement surgery. The Hospital has been working with Quality Health to be in a position to provide this information to the NHS and PHIN directly.

7.2 Data Security and Protection Toolkit (DSPT)The Data Security and Protection Toolkit (DSPT) Toolkit is an online system which allows organisations to assess themselves, or be assessed, against NDG data security standards.

We have published our DSPT and attained all standards met grading. This means we are able to continue connectivity to the N3 and are currently in the process of moving over to the HSCN.

With the 2018 changes to Data Protections (DPA 2018 / GDPR 2018) we have now implemented encrypted emails to medical secretaries and consultants including other external contacts.

One Healthcare have also completed and been certificated for Cyber Essentials and IASME for GDPR compliance. Staff have had GDPR compliance Data Protection training, and completion rate for e-learning is 88%. Additionally, data protection is now explicitly added to contracts of employment and staff have signed and completed bring your own device and acceptable use policies.

Our Director of Clinical Services is our Caldicott Guardian and is passionate about our privacy and accountability of data. We have made further progress this year with meeting data standards and maintaining quality.

“The level of care was amazing - unlike most hospitals when nurses just do not have the time to give the care they would like. My nursing team were superb and no problem too much. My room was also great, the food was also good.”

January 2019

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7. Statements on Data Quality

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8.1GoalsagreedwithCommissionersOne Ashford Hospital were involved in undertaking the Commissioning for Quality and Innovation (CQUINs) scheme.

The CQUINs spanned two years and covered• Improving staff Health and Wellbeing

• NHS e-referrals

• Reducing the Impact of Serious Infections

Our submission schedule ran quarterly:• Q1 April – June 2018

• Q2 July – September 2018

• Q3 October – December 2018

• Q4 January – March 2019

The teams have continued to work hard towards completing the requirements. At the time of publishing this quality account, we have not yet received confirmation of our 2018-2019 achievement.

8.2 NHS service provisionWe will be continuing to work with NHS providing the following specialties under the NHS e-referrals system:

• Lower gastrointestinal (GI)

• General Surgery

• Gynaecology

• Orthopaedics

• Urology

8.3 AuditsAt One Ashford Hospital we participate in a number of National Clinical Audits.

a) National RegistriesSource: Local Audit data

We have been submitting data to the National Joint Registry since the hospital opened. The data is submitted by the One Ashford Hospital Theatre team, and the figures for April 2018 – March 2019 are below.

Name of Audit Number of Submissions (2018/2019)

National Joint Registry 622

National Breast and Cosmetic Implant Registry 5

8. Statements of Assurance and Compliance – Achievements 2018-2019

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b) Patient Reported Outcome Measures (PROMs)Source: Quality Health PROMs data reports

PROMs are a national programme implemented by NHS England and is a mandatory data collection system. The aim is to gather information around health improvements from the patient’s perspective following a surgical procedure. The methodology is to use standardised pre and post-operative questionnaires. The pre-operative questionnaire is provided to patients at pre-assessment and the post-operative survey is sent directly to patients between three and six months following their operation.

One Ashford Hospital we continue to submit Patient Reported Outcome Measures (PROMs) for NHS and private patients for hip and knee procedures. Our reports are administrated by Quality Health, who run this on behalf of NHS England.

We collect data from both private and NHS funded patients. Published data for NHS patients for the One Healthcare Group, on NHS digital indicates the following participation rates and post-operative issues and return rates for 2017/18. Data for 2018/19 was not available at the time of printing.

NHS PROMS

Group Pre-operative participation rate 2017/18

Eligible hospital procedures

Pre-operative questionnaires completed

Participation Rate

All Procedures 151 237 157.0%

Hip Replacement 59 96 162.7%

Knee Replacement 92 141 153.3%

*Average participation rate England is 86.7% (NHS Digital)

** Participation rates are greater than 100% due to sub-contracting to local trusts and double reporting. Additionally, patients may be pre-assessed and then not proceed to surgery.

Group Post-operative participation rate 2017/18

Pre-operative questionnaires completed

Post-operative questionnaires sent out

Issue RatePost-operative questionnaires returned

Response Rate

All Procedures 237 233 98.3% 142 60.9%

Hip Replacement 96 94 97.9% 58 61.7%

Knee Replacement 141 139 98.6% 84 60.4%

*Average response rate of England is 70.1% (NHS Digital)

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Ashford PROM Submissions 2018/19

Name of Audit Number of Submissions

NHS Hip PROMS 123

NHS Knee PROMS 232

Private Hip PROMS 93

Private Knee PROMS 85

c) NHS Safety Thermometer Compliance

i) Classic Safety Thermometer

One Ashford Hospital participate in the Classic NHS Safety Thermometer. Our submissions for 2018-2019 were consistent, meaning a submission percentage of 100% for the year.

Audit Overall submission percentage compliance

NHS Safety Thermometer (classic) 100%

There were no red flags for the year, however in March 2019 two of the 5 patients had an old UTI, which regrettably has resulted in a drop from our consistent 100% harm free care, as seen in the graph below.

ii) Medication Safety Thermometer

We have started submissions for the NHS Medication Safety Thermometer and in our next Quality Account we will provide comprehensive submission figures.

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d) Local auditsSource: Local audit data

Our Clinical Effectiveness Group is held on a regular basis, and is the forum to promote shared learning across the organisation. The results and areas of non-compliance evidenced by audits are discussed, with areas for improvement highlighted to help focus and drive improvements. Furthermore, any changes to practice and lessons learned from incidents and patient feedback, is disseminated to teams by attendees of this group.

Audit 2017-2018 percentage compliance*

2018-2019 percentage compliance*

Clinical Records Audit 69% 94%

Controlled Drugs 90% 84%

Early Warning Score (EWS) 65% 82%

Hand hygiene 99% 90%

Imaging safety and compliance 98% 99%

Infection Prevention and Control Environmental standards 95% 92%

Health Record keeping standards 79% 84%

Patient Consent 98% 100%

Physiotherapy record keeping 83% 86%

Peripheral Vascular Cannula Devices 85% 92%

Resuscitation 100% 100%

Sepsis 100% N/A – no patients met Sepsis audit criteria

Transfusion compliance 69%

Due to low patient numbers not undertaken to complete in 2019-2020

Urinary Catheter 91% 99%

World Health Organization (WHO) checklist compliance 93% 99%

* Based on average compliance for audits undertaken from April 2018 - March 2019. The frequency of audit varies from monthly to yearly and the overall compliance percentage reflects this.

“As a nurse I think we look at things in different way. The One Hospital totally exceeded my expectations of a hospital and has prompted a change of view towards private health care.”

August 2018

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8.4 Key Performance and Quality Indicators

a) IncidentsSource: Data obtained from Datix incident management and reporting system

During the year 1 April 2018 – 31 March 2019 there were a total of 524 incidents reported at One Ashford Hospital.

Prior to April 1 2018, the tiers that are standard in Datix for NHS organisations were used. A review of the categories and sub-categories for reporting were reviewed and streamlined in March 2018. They went live from April 2018, enabling staff to categorise incidents more easily and for data to be more meaningful.

The number of severe and moderate harm incidents remains very low, and our average of incidents reported compared to patient activity is 2%. We are continuing to work with staff to ensure all incidents and near misses are reported.

Information around complaints, incidents and key performance indicators are escalated to the Hospital Board through the Quality Dashboard. This was introduced in January 2018, and was fully embedded during the past year. The database provides us with a central resource of information to report on vital information easily and transparently.

“From the initial diagnosis at One Ashford through to my operation I was treated professionally by every member of the team - from reception team, through surgery & aftercare. Excellent facilities made my stay.”

March 2019

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Criteria Number % against activity Comments and actions to improve quality

Patient deaths (unexpected and expected)

1 0.03% 1 patient death was reported in February 2019. This was not reportable to the CQC as it was outside of the relevant timeframe. The cause of death was not related to the surgical intervention the patient underwent.

Serious incidents and never events

0 0% We will continue to monitor incidents reported via Datix for any trends and keep staff aware via regular updates at Clinical Effectiveness and governance meetings.

Unplanned readmissions within 28 days

7 0.20% Each incident is reviewed by a senior clinical team member to identify learning and actions to prevent reoccurrence. 2 incidents related to pain, 2 related to urinary retention, 2 related to post-operative nausea and vomiting, 1 required evacuation of haematoma (see below). Each incident was managed according to the clinical intervention required, appropriate action taken with good clinical practice undertaken with no indication for concerns or change in practice.

Unplanned returns to theatre (within 7 days)

6 0.20% We continue to work with the Consultants to ensure low levels of returns to theatres. All instances are reported on Datix to evaluate. 2 evacuation of haematoma, 2 corrections following dislocation of joint, 1 bleeding post-operatively, 1 pain not alleviated by first surgery. These were all known complications of surgery as identified through RCA investigation.

Unplanned transfers to another hospital*

2 0.06% Reviews undertaken to establish any trends. 1 patient required a CT scan. CT service not provided at One Ashford therefore unable to perform on site. 1 patient required level 2 care and transfer to the local NHS Hospital. Level 2 care facilities not available at One Ashford hospital.

Patient falls 14 0.45% A full review was undertaken of all falls incidents to ensure all possible measures are in place. Falls prevention policy revised and new guidelines for the management of Vaso Vagal episodes developed. “Call don’t fall” signs are on display in all patient bedrooms and bathrooms.

Venous Thromboembolism (VTE) cases

4 0.10% Investigation of the potential 4 VTE’s showed all were unavoidable and precautionary measures were undertaken correctly.

Safeguarding Referrals to local Safeguarding team

0 0% No safeguarding incidents needed to be reported to the local safeguarding team.

* At One Ashford Hospital we do not have high dependency or intensive care facilities. Any patient requiring level 2 or 3 care, will require a transfer out. We have an excellent affiliation with the local NHS Trust, which is opposite our site.

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Key learning and changes to practice from incidents:• New policy for external visitors – with clear identification and sign in procedures to ensure security of

site and individuals entering the building.

• Enhance GDPR training – provided to all employees and ‘how to guides’ developed to help staff support accurate data entry and confidentiality of patient information. Crib sheets disseminated to identify examples of data breaches.

• Medicine management training – this included training on controlled drugs to ensure good medicine practice across the organisation and a reduction in medication related incidents.

• Prescription pad storage – improved secure storage and logs of prescriptions used to maintain compliance with prescription storage requirements and risk of theft.

• Staff carpark surface – approval of plan to resurface carpark in response to slips, trips and falls on current surface.

• Review of medication administration chart – format of chart reviewed to allow easier administration for nursing staff and less risk of error.

• Introduction of new Patient Own Drug lockers (POD) – existing lockers were within patient bedside cabinet, therefore not being utilised correctly. New lockers purchased and located within patient rooms with specific digital combination locks.

• Non–slip device for bedroom chairs – to ensure safety and prevention of furniture from slipping when patients mobilising.

• Enhancing imaging referral form – to identify funding stream to support correct patient billing process.

• Review and update of RMO handbooks – to include clarity of processes and requirement of the role, in line with changes in local and national guidance.

• Review of falls prevention policy – updated in relation to actions to undertake post fall. Management of low blood pressure post operatively and before mobilisation (vasovagal management). Purchase of further equipment for mobilising patient from the floor.

• Purchase of medical record racking – Specific racking for medical records allowing for appropriate storage and ease of record location.

b) Infection Prevention and ControlSource: Local Infection Prevention and Control databases and Datix incident managing and reporting system

Our work continues in complying with all mandatory reporting requirements; including Public Health England (PHE) for reporting of alert organisms. We had no reports of MRSA, MSSA and Clostridium Difficile Bacteraemias in this reporting year and are working to ensure that we continue to have zero cases. Mandatory surveillance for orthopaedic joint surgical site infections occurs on a quarterly basis as required. We have low rates of infection across all specialties.

We scrupulously monitor any hospital acquired or surgical site infections (SSIs). There were a total of 25 superficial infections and 2 deep infections in the year 2018-19 across all specialities. This equates to 0.9% of all surgical procedures undertaken during the year. This remained the same as the previous year despite an increase in activity.

We have been successful in appointing a new Infection Prevention and Control Lead Nurse with the full support of the Executive Team. This was a gap in service provision which was an important factor in prioritising Infection Prevention and Control within One Ashford Hospital. The Lead Nurse along with the Director of Infection Prevention and Control and Link Practitioners has made significant progress against the annual plan. The plan is designed to effect improvements in performance and practice across the site.

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The Lead Nurse has brought to fruition the face-to-face rolling programme of training for hand hygiene, aseptic non-touch technique (ANTT) and sepsis. This has allowed more staff to be trained and updated throughout the year supported by e-learning general infection control modules.

The embedded audit programme continues for infection control, including hand hygiene, 49 steps, mattress, environmental and sharps bin audits. With the appointment of the Lead Nurse for infection prevention and control there has been improved analysis of data, more support for the departments undertaking the audits and implementing any changes to practice. We continue to work closely with the Consultant Microbiologist and Hospital IPC Link Practitioners.

c) ComplaintsSource: Datix incident reporting and management system

One Ashford Hospital is committed to providing all patients with the best possible experience, but recognise there are occasions where expectations are not met. We welcome and encourage any feedback, both positive and negative, from patients or relatives, and report this via Datix. We capture compliments, comments, concerns and formal complaints.

For patients or family members who raise formal complaints, we support through our structured complaints procedure. The stages are as follows:

• Stage 1 – Local resolution

• Stage 2 – Internal review by Group Chief Executive Officer

• Stage 3 – Referral to Independent External Adjudication service run by ISCAS

Between 1 April 2018 – 31 March 2019, 41 formal complaints were reported. This amounts to 0.13% against the number of patients seen (n=31049), a decrease compared to last year. 2 complaints were escalated to Stage 2, and none have been reported to Stage 3.

The complaint process we adhere to is to acknowledge all complaints within 3 working days, and respond within 20 working days. For our acknowledgments 94% of the time we met this requirement, and for responses this was 96%.

In April 2018, we introduced subjects to the Service Feedback module, to allow us to complete trend analysis on common areas of complaints and concerns. Analysis of these trends show the top 3 areas of complaints as 1) communication (written and verbal), 2) attitude and behaviour of hospital employees, and 3) finance and charges. For most complaints, there is more than one subject noted.

This has enabled us to review key areas for improvement, particularly around clear communication, in particular around hospital and consultant charges, as well as ensuring staff come across in a helpful and friendly manner.

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Key learning and changes to practice following Complaints:• Pre-assessment team have been expanded and relocated to a designated area with readily available

consultation rooms and improved working environment. All ensuring a more efficient, quality of service and smoother patient pathway.

• Clearer documentation and signage for patients in relation to hospital charges and consultant fees, avoiding unexpected incurred cost for patients. Displayed in outpatient areas and consulting rooms.

• Appointment of reservation manager – streamlining reservation process leading to improved patient communication and booking experience.

• Increased administration support in imaging department to allow enquires to be dealt with more efficiently and booking made promptly.

• Implementation of a ‘This is Me’ meetings for any patient with identified special requirement including, special needs, dementia, deaf patients.

• Process improvement and training of reception staff to take payments at the reception desk to enhance patient experience and convenience

d) Patient Experience and SatisfactionSource: Quality Health and Howard Warwick Associates Patient Satisfaction Reports

An excellent patient experience is a key objective at One Ashford Hospital, and patient feedback is high on our agenda to identify how we are performing and to highlight how we can improve the patient journey. Our patient survey provider was switched in January 2019 with a full review of the questions and format of the survey. These changes included combining the day surgery and in-patient survey. Surveys remain available on paper and on-line.

Response rate for in-patient surveys

Q1 April – June 2018

July 2018

Aug 2018

Sept 2018

Oct 2018

Nov 2018

Dec 2018

Jan 2019

Feb 2019

Mar 2019

55% 73% 73% 55% 50% 54% 74% 26% 32% 32%

More work is required to increase response rates as this has declined with the implementation of the combined surveys.

“I cannot praise too highly the general atmosphere of One Ashford. It is warm & welcoming & spotlessly clean. Everyone I came into contact with was friendly & helpful. The staff gave of their time in their busy schedules to chat & reassure me. I really appreciated the fact that they all seemed to have an understanding of my needs, nothing was too much trouble & made me feel they were all personally involved in my care - I was not just a number on a tick list”

January 2019

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The table below highlights a selection of the results. Our Friends and Family Recommendation average score for 2018-19 was 97% would recommend One Ashford Hospital.

Q1 July 2018

Aug 2018

Sept 2018

Oct 2018

Nov 2018

Dec 2018

Jan 2019

Feb 2019

Mar 2019

Friends and Family Test 97% 97% 98% 94% 92% 98% 98% 100% 100% 100%

Involved in decisions 99% 100% 100% 100% 98% 100% 100% 100% 98% 100%

Treated with Dignity and Respect 99% 100% 100% 100% 98% 100% 100% 100% 100% 98%

Privacy given 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Worries and Fears addressed 100% 100% 97% 100% 100% 98% 100% 100% 100% 96%

Medication side effects discussed 96% 98% 96% 91% 93% 96% 96% 97% 97% 97%

Discharge process smooth 100% 98% 100% 98% 100% 98% 100% 100% 100% 96%

Summary of results in 2018/19

Following feedback and comments on the patient satisfaction surveys, we have made the following changes:• New hospital gowns sourced to ensure dignity and respect maintained.

• Toilet flush system reviewed and flushes changed to allow easier flushing of toilets in all areas.

• Further signage for parking outside hospital made clearer so patients able to identify car park easily.

• Internal signage reviewed and improved on staff and patient feedback.

• Staff encouraged to park in staff car park to ensure ample parking on site for patients.

• Increased discharge information for medication provided by pharmacy including analgesia and antibiotics.

• Reviewed patient menu launched in April 2018 due to feedback with regards to requirement for increased variety of choice. Including gluten free options and availability.

• Review of patient admission times according to theatre list order.

• Customer care training developed to assist with clarity of ensuring all staff provide a high level of communication and 5-star service to patient, visitors and staff to be rolled out in new financial year.

• Establishment of pain management group to improve patient experience and effective pain management.

“Every aspect of my care and treatment was carried out professionally by everyone who dealt with me, without exception.”

January 2019

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e)StaffSatisfactionSurveySource: Howard Warwick Associates Staff Satisfaction Reports

At One Ashford Hospital, we aim to provide an excellent working environment for our staff, ensuring they feel valued and motivated within their roles. Staff engagement and satisfaction helps us meet our key objective of providing safe, exceptional levels of care to our patients. We focus on promoting and maintaining good levels of staff health and wellbeing thereby reducing sickness. We undertake a yearly survey to measure key areas to indicate staff satisfaction, including health and well-being. The latest survey was undertaken in June 2018. We were delighted that 87% of our staff completed the survey (an increase of 8% from 2017/18), giving integrity to the results.

Following the results of the survey the Hospital Director created an action plan for improvement and has led workshops with staff involvement.

Changes made included:• Standardised meeting templates implemented to ensure clarity and consistency of meetings and

sharing of information.

• Employee of the month nominations and awards continued.

• Yearly Christmas award staff nominations. The following awards were issued; employee of the year, extra mile, customer service, personal development, staff support and team of the year.

• Thank you cards sent by Hospital Director for special recognition of hard work.

• Birthday card and lunch voucher for staff birthdays.

• Open house meetings with the CEO on a regular basis to increase staff confidence in suggesting improvements in their area of work in line with governance and business development.

• Flexible working policy and staff can request flexible working hours if in line with the service. 100% of requests have been granted in 2018/19.

• Ad hoc training sessions for staff in relation to clinical and non-clinical subjects, for example health and safety.

f)StaffTurnoverandAbsencesSource: Local HR database

As an organisation we closely monitor staff absences and turnover to ensure that we have healthy and stable workforce. This data is collated by our HR Team.

During 2018-19 our average turnover was 1.2%, which has decreased from the previous year. Reviewing this against the updated skills for care document from September 2018, we are significantly below the NHS average of 30.7%*1.

For 2018-2019 our average sickness and absence for the year equated to 6.86%. The data from NHS digital*2 for the whole of 2018 identified an average of 4.22% for England.

*1 https://www.skillsforcare.org.uk/NMDS-SC-intelligence/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-state-of-the-adult-social-care-sector-and-workforce-2018.pdf

*2 https://digital.nhs.uk/data-and-information/publications/statistical/nhs-sickness-absence-rates

g)StaffTrainingSource: Local HR database

One Ashford Hospital continues to provide a variety of training modules for staff, both through e-learning and face-to-face modules. Frequency of completion has been reviewed in line with national guidance.

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Showing our dedication to staff continuous professional development, we have invested in specific courses relevant to staff roles. This ensures we maintain a competent and capable workforce. Examples include:

• Strategic Leadership and Management• Operational Management - Becoming a Successful Leader• Advanced Life Support• Health Assure Annual User Group Conference• Legionella – role of the responsible person• Caldicott Guardian Training• Accounting Association Training• Patient Safety Congress• Human Factors training for theatres and cascaded to other clinical staff• RCN infection prevention and control module• Cervicogenic dizziness and vestibular rehabilitation• Safe and Secure Handling of Medicines• Further RADAR training• Symptom Management for End of Life Care• Pain Management• Dermatology study days• Clinical Pharmacy Technician Diploma

For face-to-face training we have increased the infection control sessions, including ANTT, hand hygiene and going forwards sessions will include Sepsis. Furthermore, there has been a re-launch of the medicines management training in response to new national guidance.

Overall our training compliance currently for e learning is at 93%, this can fluctuate throughout the year. The Focus for 2019-2020 will be to ensure they remain at high levels.

h) Health and SafetySource: Local Health and Safety data and audit

During this reporting year we identified a new Health and Safety Lead and as part of their role one of the first priorities in early 2019 was to undertake a thorough review of all our health and safety processes. The Lead is working closely with an external specialist in health and safety. All our policies are in date, and we have developed a new COSHH electronic register. Within the action plan is to review our risk assessment templates to gain maximum consistency across all departments. To help us to achieve this we use an electronic system, Health Assure, to manage all the risks and link associated actions. This allows the hospital to ascertain risk levels and areas for action and any significant risks escalated to the Company board on a monthly basis for review and required intervention.

We have engaged health and safety link members in each department supported by the Lead, who carry out monthly audits and meet quarterly as a group to discuss priorities.

The hospital has undertaken 2 emergency scenarios: unexplained suspicious package in reception and a fire scenario in theatre where the local fire service attended in addition to local hospital involvement. These were dealt with in a satisfactory manner and action plan for areas of improvement developed. We will continue to keep health and safety high on the agenda for 2019-20.

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9. External perspectives on Quality of Services

We invited our local Clinical Commissioning Group (CCG) to provide comments and an external perspective on our Quality of Services.

We received a letter from the Chief Nurse for East Kent CCGs on 23 May 2019. We provided our draft version of the One Ashford Quality Account for them to review. We can confirm no content revisions made to the data provided subsequent to receiving the comments below.

The East Kent CCGs recognise the draft of One Ashford Hospital 2018-19 Quality Account and welcome the transparency of success and clarity of areas for improvement including Step Up to Safety initiatives and human factors training, patient involvement and patient forum, fundamental standards of care, and documentation and patient pathways.

The CCGs acknowledge the positive Care Quality Commission (CQC) ratings of “Good” and are supportive of One Ashford’s aspiration to achieve an “Outstanding” rating for your next inspection.

We welcome the 2019-20 priorities and visions and recognise these will build on the work started in the previous year such as undertaking a safety culture questionnaire to gain insight into staff attitudes to patient safety and provision of external Root Cause Analysis training to key senior team members.

We look forward to our continued collaborative approach to improving the service provision for our population including participation in the Kent-wide network group being developed around infection prevention and control practices and improving falls prevention and management in line with the 2019-20 CQUIN.

Yours sincerely

Sarah Vaux Chief Nurse for the East Kent CCGs

“The whole atmosphere when you walk into One Ashford is reassuring & uplifting. Calming decor & attentive staff at the desk & it only gets better - as one friend commented - the rooms make you think you are in a holiday spa!”

March 2019

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10. Closing remarks

Thank you for taking the time to read One Ashford Hospital’s Quality Account for the year 1 April 2018 – 31 March 2019.

Your views are always welcome, and we would be pleased to hear from you if you have any comments, questions or wish to provide feedback.

Youcancontactusinavarietyofways:

Via email: [email protected]

Via telephone: 01233 423000 (ask for the Governance Lead)

Write to us: One Ashford Hospital Kennington Road Willesborough Ashford TN24 0YS

One Ashford Hospital, Kennington Road, Willesborough, Ashford TN24 0YS. 01233 423000.

One Hatfield Hospital, Hatfield Avenue, Hatfield Business Park, Hatfield AL10 9UA. 01707 443333.

Documents

One Ashford Hospital Quality Account 2018-19 - assets.nhs.uk · 2 Contents: Section TitlePage 1 Introduction to One Healthcare and One Ashford Hospital 3 2 Statement on Quality 6