Quality Account - NHS€¦ · Web viewThese are The Cataract Centre Ltd quality accounts to the public about the quality of services we offer. The Health Act 2009 and corresponding

Cataract Centre Ltd

Quality Accounts 2014 - 2015

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SECTION 1: INTRODUCTION AND STATEMENT FROM MANAGEMENT BOARD

WHAT IS A QUALITY ACCOUNT?

These are The Cataract Centre Ltd quality accounts to the public about the quality of services we offer. The Health Act 2009 and corresponding regulations place a legal obligation on providers of NHS healthcare services in England to publish these on an annual basis.

Our quality accounts are reviewed by our commissioning Clinical Commissioning Group and published electronically on NHS Choices website and a copy is also sent to the Secretary of State.

PURPOSES OF THE QUALITY ACCOUNT:

One of the key aims of the account is to:

Improve transparency and accountability to the public. Engage key stakeholders both internal and external in quality improvement Drive and enable providers to review services and identify where

improvement is needed. Create and share quality improvement plans Provide information on the quality of services to the public.

A requirement of the quality account is to include a statement from the management board summarising the quality of NHS services provided, the organisation’s priorities for quality for the forthcoming year, a series of statements from the board which are set out in the regulations and a review of the quality of services provided during the year.

In developing a quality account and setting priorities for the future there is an expectation that we will engage with staff, external stakeholders, commissioners, and patients including their carers and relatives.

Quality Account 2013-14

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QUALITY STATEMENT FROM THE MANAGEMENT BOARD

The Cataract Centre Ltd is pleased to present its second set of quality accounts for the year 2014-15. We are fully committed to fostering and continue to drive an organisational culture that puts the patient first and foremost and at the heart of everything we do.

The Cataract Centre was established by its founding surgeon in 1993 with the vision to demonstrate the highest levels of patient safety, quality, excellence in clinical outcomes and positive patient experience and satisfaction. This vision has formed the heart and soul of the Cataract Centre and is reflected in the dedication and the highest levels of quality shown by our team and reflected in the care received by our patients.

The Cataract Centre was registered with CQC in March 2012 with no conditions, as a provider who specialises in Ophthalmology services across the London Borough of Enfield, with a view to expanding our services further across London. As Clinical Director of The Cataract Centre, I am passionate about being committed to:

Delivering consistently high quality patient care Excellent patient outcomes with year on year improvement Excellent medical and clinical leadership Supporting all staff to ensure they are equipped to deliver continuously high

standards of service Involving patients in decision making so they can influence the delivery of

their care. Measuring and demonstrating the impact we make. Driving best practice by keeping up to date with new clinical and technological

developments in the field of Ophthalmology.

2014-15 was another significant year for The Cataract Centre, as we have progressed to expanding our range of services and clinics in the community and surgical capacity with our partner Trust namely Royal Free Hospitals NHS Foundation Trust. In 2014-15 we have seen over 9000 patients in community outpatient clinics, and undertaken over 3000 surgical procedures which include: Cataract surgery, glaucoma surgery, squint surgery, adnexal surgery, and YAG laser procedures for glaucoma and post cataract opacification.

The year has seen us transform our booking processes, and we have become a unified service with a single accountability and governance structure for patient pathways. This begins from referral to community service, management of chronic disease in the community to surgical intervention where required. In 2014-15 we


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have expanded our administrative structure from that implemented in 2013, as the demand for services continues to increase.

As part of good governance we have documented clinical and quality policies that are reviewed annually and we keep abreast of requirements from the CQC and other national regulatory bodies. We ensure our services are delivered by the most appropriate qualified clinicians and nurses with the relevant skills required.

An important part of this transformation is the establishment of quality meetings with Enfield Clinical Commissioning Group, where quality performance, service delivery and patient experience are all discussed and improvement plans assessed. Discussions are also afoot with local patient participation groups.

The Cataract Centres internal transformation ran parallel to significant changes within the local health economy and in line with ever increasing demand for the service. We are immensely proud in the determination and manner in which our staff have focused towards meeting the needs of the organisation in ever-changing dynamic and pressured times, ensuring excellence in patient service.

We continually monitor changes and review our performance so we can drive improvements for the benefit of all our patients.

The need to ensure clinical excellence is the role of all in the organisation and is not based on the reliance of solely one or two people. At The Cataract Centre we nurture an ethos of close team work and collaborative working and professionalism. We believe in investing in our staff, our clinics and equipment to ensure safe and consistent delivery of care at all times and to keep up with technological enhancements in service delivery.

We encourage staff, partners and commissioners to view our quality accounts to get an overview of what we do well and what we intend to improve in the coming 12 months.

Patient feedback is extremely important to us and we have continued to undertake patient experience programmes in 2014-15 and have also incorporated the national friends and family test questions into our programme.

The Cataract Centre is accustomed to the disciplines of regulatory compliance with the CQC and contractual requirements as set by our commissioners, to regularly report, where applicable: performance, complaints and serious incidents. The organisation maintains a log of all complaints and incidents with actions being undertaken to resolve issues or reduce risk.

To the best of our knowledge, the information contained within this quality account is accurate and a fair representation of the quality of services delivered.

Dr Raymond Lobo, Clinical Director - The Cataract Centre Ltd


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THE CATARACT CENTRE LTD

The Cataract Centre Ltd is a private Ophthalmology services provider situated in North London in the Borough of Enfield. The organisation offers services to NHS patients and those who wish to fund their own treatments.

The Cataract Centre Ltd provides a full range of ophthalmic services, including:

Community outpatient consultations and treatment Diagnostics Surgery Long term conditions management Follow-up care

During the period 2014-15 the service has seen over 9000 patients in the community through its community ophthalmology service and has carried out surgical procedures on over 3000 patients.

Currently 19 specialist ophthalmic consultants and specialist doctors work for the service and are supported by 37 clinical staff, a skills mix of Nurses, most of whom are ophthalmic specialty trained, Healthcare technicians, Orthoptists, Optometrists, 21 Administration staff and some dedicated facilities and housekeeping support.

The service has been commissioned by Enfield Clinical Commissioning Group to provide community ophthalmology services and has a partnership agreement with Barnet and Chase Farm Hospitals NHS Trust (BCFH) to undertake surgical procedures where required and they have been chosen by patients as their preferred choice of location.

The service has built excellent relationships with The Royal Free Hospitals NHS Foundation Trust following its acquisition of our original partner Barnet and Chase Farm Hospitals NHS Trust, commissioners and referring GP’s and clinical commissioning leads over the last 20years.

Our service manager recruited in 2013 with a background in ophthalmology nursing continued to provide and build vital relationships to the optometry community and GP’s to ensure their needs and expectations are being managed through a clear and effective referral process and streamlined pathways for subsequent patient choice referrals.


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SECTION 2

PROGRESS AGAINST 2014-15 IMPROVEMENT PRIORITIES

Our improvement priorities have been decided upon by evaluating and acting upon our governance processes and learning from our patients experience programme and staff feedback. We have a clear commitment to our patients and we work in partnership with the NHS both in terms of CCG, GP’s and Acute Hospital Trusts to ensure our services are safe and of high quality in meeting local requirements. We constantly strive to improve clinical safety and standards by a process of governance, including audit and feedback from all stakeholders participating and experiencing in our services.

PATIENT SAFETY

A. Never Events

These are serious and in most cases preventable patient safety incidents that should never occur if adequate preventable measures have been put in place. There are 25 nationally recognised never events of which 4 are core to the service.

Wrong site surgery –The service had no incidences of wrong site surgery on 2014-15. This is supported by the well embedded use of WHO surgical checklist by our surgical teams and the continued vigilance of all medical and nursing staff.

Wrong Implant – “Wrong intraocular lens implant; learning from reported patient safety incidents” (SP Kelly Feb 2011) showed that a large percentage of incidents of wrong implantation of IOL were due to wrong IOL selection. The Cataract Centre did not have any never events relating to this in 2014-15. The service has a thorough pre-operative setup with robust lens check protocol in place ensuring that all lenses are clearly available, identified and prepared the day prior to surgery and labelled appropriately with pre-surgery biometry information and patient details. Further to this lenses are double checked prior to being used in the operating for each patient. For clarity there are three separate checks in place before the lens is implanted in a patient’s eye.

Retained Foreign Object Post Operation - this rarely occurs due to the nature of our surgery. However due vigilance is undertaken due to the tiny microscopic sutures often used, most ophthalmic surgery is performed under


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a microscope which gives a good view of the operating field and thus prevents any foreign bodies from inadvertently entering the eye. This is also mitigated through the effective use the WHO Surgical Safety checklist process.

Overdose of Midazolam during conscious sedation – minimal invasive procedures require the need for sedation for some of the surgical care delivered by The Cataract Centre, particularly for anxious and nervous patients. No incident of this nature occurred in 2014-15, but the use will be monitored and reported under policy guidelines.

B. WHO Checklist Compliance

The WHO Surgical Safety Checklist is an effective tool used to improve the safety of surgical procedures by bringing together the entire surgical team, comprising surgeons, anaesthetists, and nurses. They are brought together to perform a number of key safety checks during vital phases of perioperative care, prior to the induction of anaesthesia, prior to skin incision and before the surgical team exits the operating theatre.

The Cataract Centre has implemented the World Health Organisation (WHO) recommendation for safer cataract surgery checklist. The checklist is a tool used throughout cataract surgery to improve the safety of surgery by driving good communication and setting out safety checks throughout the perioperative process. The service had achieved a 100% compliance rate for completion of the checklist in 2014-15.

C. Implementation and delivery of an Enhanced Community Patient administration system

The Cataract Centre has successfully implemented a new patient administration system in 2014-15 which has enhanced the way in which we monitor and deliver our services to patients. It has improved visibility of patient waiting lists and has streamlined administrative processes which also enhance the patient experience as it has made the answering of patient queries easier and quicker. This has been complemented by the increase of administrative staffing resource to further support the delivery of the service. Further embedment and development work will continue with the system to further enhance its capability in 2015-16.


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PATIENT EXPERIENCE

A. Overview

We have built on our patient experience programme from previous years and expanded the scope of patient experience to cover the entire pathway from outpatient phase to inpatient surgical phase and follow-up care. In addition to this we have incorporated the national NHS friends and family test (FFT) questions into our programme. Patient Experience feedback was one of the service CQUINs for 2014-15.

Overall, feedback was positive and results echoed the positive feedback and compliments clinicians and administrative staff received in person from patients (at the time of writing performance is based in Q1&2 2014-15). Results found that patient perception of the service is good and confidence in the service has been established and improved from 2013-14 with over 80% of community patients and 90% of surgical patients surveyed stating that they would use the service again and rating the service as either ‘Excellent’ or ‘Good’. In addition to this over 70% of community patients and 90% of surgical patients stated they would be ‘extremely likely’ or ‘likely’ to recommend the service to their friends and family.

The Cataract Centre Ltd received four formal complaints in 2014-15, of which three have been satisfactorily resolved with patients being satisfied with the outcome and one currently in the resolution process. The complaints were associated with the following:

1 complaint regarding the delay in booking a specialised diagnostic test. The delay was due to capacity constraints due to winter pressures and delays in the process of securing prior approval from commissioners for the provision of a specialised diagnostic test.

o We are currently reviewing the prior approval process to streamline it and make the decision making process with commissioners quicker.

o We have also learnt and re-iterated to administrative staff the importance of better communication with patients to keep them informed of progress and next steps.

2 complaints regarding delays in booking follow-up appointments. These were largely due to misunderstanding of when the patients should expect to be contacted for the booking of their follow-up.

o We have advised clinical staff to ensure that they clearly inform patients of a guide timeline for their follow-up and when they can expect to be contacted by our booking team to arrange their follow-up appointments.


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1 complaint regarding behaviour and professionalism of a member of staff. This complaint is currently under review and in the resolution process with the patient.

In light of the complaints received in 2014-15, communication is a key area of focus in 2015-16 and further insight into communication will be placed when collating feedback from patients as part of patient experience contact and surveys.

B. CQC Compliance

In 2014-15 we have developed and implemented a mock CQC inspection programme within our services to encompass the entire patient pathway from the community clinics to surgical services delivered at the Chase Farm Hospital site. This allows pro-active assessment of compliance against CQC Essential Standards of Quality and Safety and identifies key areas of focus where further action needs to be taken to maintain or improve compliance and ultimately the service and experience for our patients.

In 2014 The Cataract Centre Ltd had an unannounced inspection undertaken by the CQC and was found to be compliant with all standards assessed. Subsequent mock inspections undertaken by the service have shown continued compliance. This provided patients with a level of assurance regarding the quality of care they could expect to receive. Our mock CQC inspection programme is now a core component of governance within our service.

Further to this we have undertaken a compliance assurance exercise to ensure all our community partner practices where services are being delivered are compliant with CQC standards and where improvement is required sufficient plans are in place to deliver compliance and to mitigate against any impact to patients. Furthermore this assurance process will be continual through service delivery to ensure all satellite sites continue to be compliant and to ensure we deliver the best possible care to patients in the most appropriate environments.

C. Increased Access to Community Services

In 2014-15 we have increased our clinical resource and the level of services we offer. The community service now operates 7 days a week with additional clinics being run both midweek and during weekends, across multiple sites in the Borough of Enfield. This allows greater access to services both in terms of location and day of week, especially out of hours. This was a positive change made in response to patient feedback from 2013-14 patient experience programme. This has been well received from patients and is reflected from both positive comments from patients and by the positive uptake and utilisation of the extra clinics.


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CLINICAL EFFECTIVENESS

The Cataract Centre Ltd has Integrated Governance/Clinical Quality Review meetings with CCG: contractual, clinical and quality leads on a quarterly basis throughout the year to monitor quality and effectiveness of care.

All complaints, incidents, near misses, patient and staff feedback are reviewed to determine any trends that may require further root cause analysis investigations, and subsequent action plans for remedial action. Remedial action plans are presented to the group where lessons learned and progress is shared and disseminated. We also review and assess progress internally on a monthly basis.

In addition to this the service adheres to the governance and complaints policies/processes for services delivered on behalf of Royal Free Hospitals NHS Trust. The service now has Quarterly review meetings in place with the Trust to review and discuss clinical and operational matters and to ensure the continued delivery of service. We pro-actively share details of any incidents with the Trust and promote collaborative action and learning. We have found that this helps to promote our culture of being open and honest, patients safety incident reporting and aids in disseminating lessons learnt and aligning best practice.

Cataract surgery outcomes audit – The Cataract Centre Ltd undertook an internal audit of Cataract Surgery in Q1 to looking at activity undertaken in 2013-14. The audit showed positive outcomes for patient and did not highlight any areas of concern.

WHO surgical safety checklist audit – the service undertook and audit of 100 surgical patients in 2014-15 and found 100% compliance with the WHO surgical checklist.

Documentation audit – the service undertook a review of documentation and records management in 2014-15 and identified some areas for development. Following the review and with the support of the Quality Lead from commissioners, we have developed a new records management and storage policy which encompasses guidelines for good record maintenance and the fundamentals of a good medical record. This has now been disseminated across the service and is being pro-actively embedded to ensure all admin and clinical staff are adhering to it.

The service views documentation maintenance as essential to delivery of service and it is envisaged that by the adherence to this policy and by delivering an improved medical record it will improve both clinical practice of our clinicians but also the patient experience.


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The policy has also been reviewed and signed-off by commissioners prior to implementation.

PRIORITIES FOR 2015-16

The Cataract Centre Ltd have selected priorities for 2015-16 in line with the three Lord Darzi domains of quality and also in view of feedback from patients and internal review of areas for development.

PATIENT SAFETY

To reduce waiting times for patients from referral to 1st appointment in the community to ensure they receive they receive the most appropriate care in a timely manner as follows:

o Average Referral to 1st Community Outpatient appointment wait to be less than 28 days. (Baseline - 2014/15 Average = 34 days)

o To support this 1st attempt to contact patient should be within 5 working days of receipt of referral. (Baseline - 2014/15 Q4 Average = 8 days)

Reducing waiting times not only impacts on patient safety but also clinical effectiveness. Research has found that increased waiting times have correlated to increased risks for patients. Reducing waiting times supports the reduction in risk and the progression of a patient’s illness and prevents any clinical harm that could arise from untimely treatment. It also benefits patient flow through the patient journey and supports patients getting the appropriate care in an appropriate timeframe.

Furthermore, this can result in better outcomes for patients clinically with reduced risk of complications as well as improving the patients’ experience and overall wellbeing and quality of life.

Evidence continuous learning and change in clinical practice arising from the analysis of incidents, serious incidents and patient complaints.

Ensure all staff have received training in safeguarding and know how to escalate any safeguarding concerns.

To ensure continued compliance against the WHO surgical checklist.

PATIENT EXPERIENCE

To implement learning and actions from our 2014-15 patient experience programme feedback. Key actions include:

To run a series of Patient & Carer Focus groups to identify areas for improvement directly from both patients and their carers. This is to be done for both community and for acute care/surgical patients following initial review in the community.


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To recruit additional female medical staff to work in the community. To increase waiting room space for weekend clinics and Chase Farm Hospital

site. Review surgery booking schedule to reduce patient and carer waits during

surgery days. To improve FFT response rates and scores so that greater than 90% patients

state they would be ‘extremely likely’ or ‘likely’ to recommend the service to their friends and family. (Baseline - 2014/15 Q1-2 = 74.3%)

Rollout of New Patient Experience Survey Tool – the service has recently procured some patient experience software that allows surveys to be undertaken on the day both in community clinics and surgical ward via tablet and also patients will be able to complete the survey online. This is in addition to our current patient experience programme where patients are contacted via telephone for qualitative feedback. The software questions can be tailored by the service and will be based on existing questions used plus some additional new questions to be added following discussion and agreement with commissioners. This will enhance the level of feedback we get from patients and further allow us to make informed changes to improve services for our patients.

CLINICAL EFFECTIVENESS

Undertake a defined Clinical Audit for Cataract Surgery with Commissioners for external review and report the outcomes and improvements to quality in an Annual Report to the commissioner Clinical Quality Review Committee.

Ensure lead clinicians play an active role in clinical audit. Increase diagnostic capability to improve the patient journey. –

Implementation of OCT scanning diagnostic service. Ensure services are compliant with NICE guidelines. Maintain compliance with CQC Essential Standards of Quality and Safety.

STAFF DEVELOPMENT

The Cataract Centre Ltd appreciates the importance of staff development and voice in ensuring the continued delivery of a high quality service and care for our patients. Staff are also instrumental in the service improvement process, thus it is essential that we understand how our staff feel and any recommendations they may have. In view of this and following the changes in staffing structure in 2014-15, next year we aim to undertake the following:

Staff satisfaction survey.


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Staff Development Day – with key sessions on team building, sharing best practice, and ideas forum for staff to share ideas and agree goals for quality/service improvement.


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STATEMENTS OF ASSURANCE

In line with NHS requirements, the following are a series of statements that all providers must include in their quality account. In reflection of this The Cataract Centre Ltd make the following statements of assurance:

REVIEW OF SERVICE

During 2014-15 The Cataract Centre provided Ophthalmology services to the NHS through the agreed NHS Standard Acute Contract. It did not subcontract out any of those services.

The Cataract Centre has reviewed all the data available to them on the quality of care in all of these NHS services

The income generated by the NHS services reviewed in 2014-15 represents 100% of the total income generated from the provision of NHS services by The Cataract Centre Ltd for 2014-15.

PARTICIPATION IN CLINICAL AUDITS

During 2014/15 no national clinical audits or national confidential enquiry covered NHS services that The Cataract Centre Ltd provides.

However, even though there were no national clinical audits directly relevant to the service, The Cataract Centre Ltd plans to undertake a series of local audits in 2015/16 to identify areas and set actions for specific quality improvement.

PARTICIPATION IN CLINCIAL RESEARCH

The number of patients receiving NHS services provided by The Cataract Centre in 2014-15 that were recruited during that period to participate in research approved by a research ethics committee was zero.

USE OF THE CQUIN PAYMENT FRAMEWORK

The Cataract Centre LTD income in 2014-15 was conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework. The Cataract Centre Ltd achieved CQUIN goals for 2014-15.


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REGISTRATION WITH THE CARE QUALITY COMMISSION

The Cataract Centre Ltd is required to register with the Care Quality Commission and is currently fully registered with no condition to provide the following services for everyone:

diagnostic and screening procedures treatment of disease, disorder or injury, surgical services

The Cataract Centre had an unannounced CQC inspection on 10 th January 2014 and was found to be fully compliant against all inspected outcomes. The Care Quality Commission has not taken enforcement action against The Cataract Centre during 2014-15.

The Cataract Centre has not participated nor required to do so in any special reviews or investigations by the CQC during the reporting period.

Dr Raymond Lobo is the registered manager for the provision of the above and also the clinical director of the organisation.

DATA QUALITY

Statement on relevance of Data Quality and your actions to improve Data Quality

The Cataract Centre collates and tracks community patient data on a local system in line with the data protection act and NHS information governance toolkit.

For all activity undertaken on behalf of The Royal Free Hospitals NHS Trust (Formerly known as Barnet and Chase Farm Hospitals NHS Trust), our staff have completed the Trust statutory and mandatory training to include information governance. The service tracks and outcomes patient data using the Trust Cerner PAS system, in line with the Trust information governance guidelines. All staff have been suitably trained on all systems.

We will be taking the following actions to improve data quality:

The Cataract Centre Ltd has implement and will continue to embed and develop the enhanced patient administration database, which tracks patient referral status, appointment history and outcomes.


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PATIENT SAFETY INCIDENTS

The Cataract Centre has had no patient safety incidents in 2014-15. We acknowledge this to our continued vigilance and continual focus on patient safety underpinned by procedures relating to estate and equipment safety, effective patient record keeping and information. .


2014-15 – Overview of Performance against commissioned Quality KPIs


KPI No. KPI Threshold Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Comments

1 Patient’s waiting no longer than 4 weeks for an appointment <= 28 days 24 29 30 24 33 30 16 15 17 13 10 8

2100% of patient’s who cannot be contacted with choice of appointment automatically given an appointment within 5 working days of receipt of referral

100%

We have found this to cause some difficulty due to the elderly nature of the majority of our patients, of which a large proportiong require a chaperone. As a result we see a high level of reschedules and DNAs.

Following commissioner 'Walk the Pathway' visit, and a discussion around this The CC have shared letter templates for unable to contact and DNAs, which have been agreed and are in use. This requests the patient to contact the service within a given timeframe, otherwise they are discharged back to the care of their GP.

We are also in the process of reviewing DNAs and how we can work with primary care colleagues in reducing the occurance of this.

390% of routine patients, referred via SCAS, assessed and treated in the community service

90% 80.4% 78.5% 77.4% 77.3% 82.7% 76.8% 78.4% 81.1% 80.4% 82.3% 84.3% 79.1%

We aim to treat as many patients in the community as possible. Many patients elect to continue further treatment or on-going management with other acute providers, for which due to the right of patient choice we have limited control over.

Action: There are a number of treatements currently undertaken in secondary care, which we beleive can be undertaken in the community, with the added benefit of giving commissioner substantial cost savings. These are currently being proposed to you and are due for discussion.

4100% of routine referrals sent to the Enfield Referral Service triaged within 3 working days

100% Met Met Met Met Met Met Met Met Met Met Met Met

5100% of patients, where the community service is deemed to be inappropriate for the patients needs, returned to the Enfield Referral Service within 2 days of triage.


6Outcome of patient appointments (for 95% of patients) communicated to the referring healthcare professional within 5 days


This is largely the case. However as mentioned in previous correspndence we cannot account for postal delays. Action: We are currently scoping the possibil ity of emailing outcome letters to GP practices, but this does have a number of logistical challenges and also would require the buy in of GP practices. We will initially pilot this with a small cohort of practices and assess the benefits. We will inform you of progress in due course.

795% of provider performance reports produced to agreed format within 10 working days following the end of each month

We recognise and acknowledge the delays that the commisioners have experience in receiving the activity report. We have increased our adminitstrative resource and have made some investment into IT reporting processes that will improve the turnaround of this. The addition of diagnosis to the activity dataset is the key reason for delay. It is suggested that we review the target in l ight of this.

8 1st to Follow ratio capped to 1:1 ( Cumulative 2013/14) <=1 0.85 0.75 0.71 0.68 0.69 0.65 0.64 0.64 0.67 0.68 0.69 0.71

9Less than 10% of outpatients converting into a secondary care referral

< 10% 19.60% 21.50% 22.60% 22.70% 17.30% 23.20% 21.60% 18.90% 19.64% 17.66% 15.71% 20.90%

This is somewhat of a duplication of KPI.3, as those that are not seen and treated in the community service are referred into secondary care.

Action : We propose to commissioners that we have one indicator.

1090% of the patients rating the community service as good or excellent.

90%

We undertake patient experience survery as an on-going process throughout the year but form them as part of bi-annual patient experience exercises, where we group finding and develop action plans in responses to areas for development. We continue to make service improvements to ultimately improve the quality of care we deliver and the experience of our patients.

11 Provider to advise commsioners with details of any Care Quality Commission (CQC) visit within 48 hours of notification.

As our last CQC visit was almost a year ago, the service envisages a visit in the very near future. In particular as it is now post merger with regards to our partner organisation CFH, now Royal Free Hospitals NHS Foundation Trust. We will notify commissioners of if and when the CQC undertake any review.

12Provider to send commsioners a copy of any Care QualityCommission (CQC) inspection visit report within 48 hours ofpublication.

Reports are available via the CQC website. We will advise commissioners of when they are published and provide copies and a l ink the electronic report accordingly.

13Less than 5% of patients appointments cancelled by the provider(excludes patient cancellations and DNAs)

5%

It is extremely rare for the service to cancel appointments. We are aware that we have not cancelled any appointments in the last two months. Going forward we will include any cancelled appointments in our datasheet to allow for percentage calculations to be shown.

As per Q1&Q2 Patient Experience exercise : 79% rated the service as good or excellent ( Excellent = 55%, Good = 24%) 93% rated Excellent to Satisfactory.

Q3 - Q4 patient experience exercise currently in progress

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STATEMENT FROM COMMISSIONERS - NHS Enfield Clinical Commissioning Group

The Cataract Centre v3

NHS Enfield Clinical Commissioning Group (CCG) has reviewed the Quality Account for 2013/14 published by The Cataract Centre.

This statement has been reviewed by the chair of the CCG’s Quality and Safety Committee, to whom its approval has been delegated by the committee, having in turn been delegated the duty to review and endorse Quality Accounts by its Governing Body.

The Quality Account in general complies with governance as set out by both Monitor (for NHS Foundation Trusts) and the Department of Health (to all other NHS trusts and commissioned service providers).

Last year commissioners noted that not all priorities were focused on areas where deficient performance required improvement. Nor was there specific alignment of priorities to the core domains of quality; namely patient experience, patient safety and clinical effectiveness.

Commissioners are pleased to see that this feedback has been acknowledged this year, which has contributed to the priorities demonstrating more in terms of outcomes and meaning.

As regards the review of quality in 2014/15, commissioners acknowledge the positive benefit to patient care from increased access to community services and our joint partnership working in relation to records management and ongoing monitoring which is required to ensure compliance.

Commissioners also note that the provider was compliant with standards required by the Care Quality Commission having been subject to an unannounced inspection during the year.

The CCG looks forward to continuing to work in partnership with the provider to monitor its identified priorities and progress.

NHS Enfield Clinical Commissioning Group


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The Cataract Centre Ltd134 Lots RoadFulhamLondonSW10 0RJEmail: [email protected] Company Registered in England & Wales Number: 03336479CQC Registration Reference: 1-368009263Director: Mr Richard VaughanCQC Registered Manager and Clinical Director: Dr Raymond Lobo


mailto:[email protected]

Documents

Quality Account - NHS€¦ · Web viewThese are The Cataract Centre Ltd quality accounts to the public about the quality of services we offer. The Health Act 2009 and corresponding