Contents
Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1 Statement from the General Manager
1.2 Hospital accountability statement
PART 2
2.1 Priorities for Improvement
2.1.1 Review of clinical priorities 2016/7 (looking back)
2.1.2 Clinical Priorities for 2017/18 (looking forward)
2.2 Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2016/17 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1 The Core Quality Account indicators
3.2 Patient Safety
3.3 Clinical Effectiveness
3.4 Patient Experience
3.5 Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Statement from Staffordshire Health Watch
Appendix 3 – Clinical Audits
Quality Accounts 2016/17 Page 4 of 54
Welcome to Ramsay Health Care UK
Rowley Hall Hospital is part of the Ramsay Health Care Group
The Ramsay Health Care Group was established in 1964 and has grown to
become a global hospital group operating over 100 hospitals and day surgery
facilities across Australia, the United Kingdom, Indonesia and France. Within the
UK, Ramsay Health Care is one of the leading providers of independent hospital
services in England, with a network of 31 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to
the NHS in the UK. Through a variety of national and local contracts we deliver
1,000s of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs and Clinical
Commissioning Group.
CEO and Director of Clinical Services Statements
Introduction
Statement from Mark Page
Statement from Mark Page, Chief Executive Officer, Ramsay Health Care UK
“The delivery of high quality patient care, service and outcomes remains the highest priority to Ramsay Health Care. Our clinical staff and consultants are critical in ensuring we achieve this across the whole organisation. We remain committed to delivering superior quality care and services throughout our hospitals, for every patient, every day. Everyone across our organisation is responsible for the delivery of clinical excellence and our organisational culture ensures that the patient remains at the centre of everything we do. At Ramsay we recognise that our people, staff and doctors, are the key to our success and that teamwork and communication is critical to meeting the expectations of our patients Whilst we have an excellent record in delivering quality patient care and managing risks, the Ramsay Health Care UK continues to focus on improvements that will keep it at the forefront of health care delivery.
Quality Accounts 2016/17 Page 5 of 54
I am very proud of Ramsay Health Care’s reputation as a global leader in the
delivery of safe and quality care. It gives us pleasure to share our results with
you.”
Mark Page
Chief Executive officer
Ramsay Health Care UK
Quality Accounts 2016/17 Page 6 of 54
Introduction to our Quality Account
This Quality Account is Rowley Hall’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment
centre within the Ramsay Health Care UK. It was recognised that this didn’t
provide enough in depth information for the public and commissioners about the
quality of services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group now
develops its own Quality Account, which includes some Group wide initiatives, but
also describes the many excellent local achievements and quality plans that we
would like to share.
Quality Accounts 2016/17 Page 7 of 54
Part 1
1.1 Statement on quality from the General Manager
I was extremely pleased to be appointed as General Manager at Rowley Hall
Hospital in April 2017. I have spent the last 28 years working in healthcare both in
the NHS and Independent sector prior to joining Ramsay. I firmly believe that
patients are at the very heart of everything we do and as such ensuring a high
standard of care is what we must be delivering on.
The patients that continue to choose our facility via the electronic referral system
continue to grow year on year. The service continues to promote high standards
of care and deliver on excellent clinical outcomes across all specialties. Our work
involves working with the CCG’s, local Trusts as well as patients directly in order
to ensure efficient and effective care and treatment.
Providing holistic care for all our patients starts with the first contact with the
hospital. We know that any sort of contact with us can cause anxiety for patients
and their families so providing that reassurance and time is an important part of
the treatment pathway. All our staff are trained to a high standard so that all
patients and their families receive a service that is compassionate and caring of
all of their needs.
The hospital continues to see us being rated as five star with NHS choices and
our Friends and Family survey indicates 100% of both in and out patients would
recommend us. This is a great achievement, but we certainly don’t sit on our
laurels about this. All concerns and complaints are taken seriously and acted
upon immediately. The resolution of these is important to us and the learning from
them supports us in shaping and evolving the hospital.
The hospital continues to run a number of services 7 days a week to ensure that
patients are not only seen in a timely way, but that we can also offer flexibility to
them in their treatment and recovery. Our effective recruitment of consultants and
management of waiting lists means we can do this is a way that meets the needs
of the patient.
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Rowley Hall has seen its high standard of care confirmed with a recent CQC
inspection which rated the hospital as GOOD. This was a fantastic achievement
and gives us the solid foundation to work towards the outstanding we want to
achieve.
Ramsay Health Care UK continues to promote high quality care and invests in its
facilities and staff to provide this. This has been seen within the hospital over the
last 12 months and will continue to be seen going forward.
I am in an extremely privileged position to be the GM and see the level of care the
hospital provides and feel these quality accounts really demonstrate our
commitment to positively impacting on people’s lives.
If you would like to comment or provide feedback please do not hesitate to contact me on the following number or email.
Lisa Powell, General Manager
Rowley Hall Hospital
01785 328607
Quality Accounts 2016/17 Page 9 of 54
1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Lisa Powell
General Manager
Rowley Hall Hospital
Ramsay Health Care UK
This report has been read and approved by –
James Beech – Reginal Director
Ishan Bhoora – Orthopaedic Surgeon and Medical Advisory Committee Chair
Rebecca Turley – Matron
Clinical Commissioning Group (CCG)
Quality Accounts 2016/17 Page 10 of 54
Welcome to Rowley Hall hospital
The Rowley Hall Hospital is situated in the centre of Stafford with easy access to
public transport.
The main hospital is housed in a listed building, with a smaller building adjacent
to the rear car park which houses our administration team and physiotherapy
service.
Our Services
The hospital consists of two operating theatres both with laminar flow and 11
inpatient bedrooms (13 overnight beds) with en-suite facilities, and a 10 bay Day
Surgery Unit (DSU). 5 additional DSU pods were commissioned in November
2015 to support the increase in DSU activity across all specialities. This has been
a welcome addition to the site to support and treat patients in a stand-alone unit
safely and effectively.
Our Staff have been carefully selected for their friendly and caring approach as
well as their efficiency and professionalism. A Resident Doctor is available 24
hours a day. The restful atmosphere and high level of personal attention combine
to aid patient recovery. The first patients were admitted in August 1987 and the
hospital has continued to grow and develop since this date.
In 1999 the first floor was converted to accommodate our outpatient services
including the X-ray and physiotherapy departments.
In 2007 due to growth of our services refurbishment of “the old schoolhouse”
allowed us to re house the business office and our physiotherapy department.
This also allowed us to locate our non-invasive cosmetic services within this
environment, with a dedicated consulting room for our cosmetic nurses to deliver
laser hair removal.
In 2016/2017 we admitted a total 6,303 patients with 5653 being NHS patients
(1st April 2016 to 31st March 2017)
The hospital provides a comprehensive range of services. These include;
Podiatry,
General Surgery,
Urology,
Spinal,
Orthopaedic,
Quality Accounts 2016/17 Page 11 of 54
Cosmetic services,
Ophthalmology,
Gynaecology,
The Hospital has mobile CT and MRI service which is offered to both privately
insured and NHS patients. We offer a direct access service for both MRI service
and CT for NHS patients referred by their GP.
Our Staffing
To ensure that patients are at the centre of everything we do and receive the
highest standard of care, we have 78 dedicated Consultants, working alongside
113 permanent staff and 60 Bank members including nursing, radiology,
physiotherapy, supported by administration, housekeeping, and maintenance and
catering staff.
Our senior management team consists of the General Manager, Matron,
Operations Manager, Marketing and PR Exec and a Finance Manager
NHS Partners and GP Communication
At Rowley Hall Hospital we work closely with our colleagues at the Clinical
Commissioning Groups and local NHS Trust to ensure our services meet the
needs of the patients we serve, including shared services such as: pathology,
pharmacy, and some diagnostic services.
We also work in partnership with our GPs in the area supporting them with
educational needs by organising specialist training sessions with the help of our
Consultant body. At Rowley Hall Hospital we feel it is important to maintain
excellent links with local GPs and work together for the benefit of all our patients.
We have a dedicated GP liaison officer to foster these links and relationships.
Supporting Charities
Rowley Hall Hospital supports several charities including Katherine House
Hospice and McMillan Hospice.
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Part 2
2.1 Quality priorities for 2016/2017 Plan for 2016/17
On an annual cycle, Rowley Hall develops an operational plan to set objectives
for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us, result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives on going at any one time. The
priorities are determined by the hospitals Senior Management Team taking into
account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2016/17 (looking back)
Embedding new E-learning platform
The new mandatory training platform E2 system was taken up well and the
feedback was very positive with the modules easy to follow.
The compliance to E-learning is an ongoing process with the Heads of
Department and Matron ensuring staff are up to date with their mandatory
training.
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Development of Rowley Hall Senior Management Team (SMT)
The SMT at Rowley Hall has continues to develop with the employment of a new
Matron in November 2016 now working alongside the General Manager (GM) and
Operations Manager.
The new General Manager came in post in April 2017.
This new team will form the most senior decision making group with regard to
operational management issues.
Together, as a team, there will be a collective responsibility to ensure the most
effective running of our hospital in order to optimise the experience of patients in
our care.
The Ramsay Clinical Audit Programme
The current Clinical Audit Programme enables us to bench mark and measure
our compliance with best practice and clinical care. It also enables us to take the
learning from it and shape practice,
Since the employment of our Quality Improvement lead we have successfully
achieved our goal set out in 2015/2016 report of 100% compliance.
We have seen a significant improvement in our compliance to completing the
audits in a timely manner. Looking back we can see that every audit within the
programme has been completed.
The results/outcomes and actions are cascaded to the department’s monthly in
the Clinical Governance and Leadership meetings.
Action plans are devised setting out clear objectives and time scales given to
review the progress. This allows us to measure the quality of care and service
against agreed standards and make improvements where necessary.
Development of the workforce During 2016-2017 Rowley Hall assisted in the development of our Health Care
assistance (HCAs) through the apprenticeship scheme and through developing
the HCA competencies.
Quality Accounts 2016/17 Page 14 of 54
This has allowed our HCAs to increase their own knowledge and skills within our
organisation to assist in their job role.
Some of our HCAs work primarily in one department but due to the HCA
competencies improving their knowledge and skills as well as their confidence
this has allowed them to work across other departments and also to assist others
in clinics, theatres and other procedures i.e X-ray
Preparedness for Revalidation Consultants and Nurses
The NMC revalidation came into effect in April 2016 and was developed to
demonstrate safe and effective practice. It encourages refection on practice and
the Code of Practice in the workplace.
Revalidation takes place every 3 years to renew nurse’s registration.
Rowley Hall has assisted nurses’ successfully through the revalidation process.
In addition there is a process in place to ensure all our practitioners are safe and
in date with their registration.
To fulfil one of the requirements of 35 hours of continued professional
development and 20 of those hours being participating learning, Rowley have
advertised and offered many study days both on and off site in order for staff to
achieve this requirement
Increasing the day case capacity by driving the day surgical pathway
Our aim for 2016-2017 was to increase the day case activity by driving the day
surgery pathway.
The benefits of day surgery include
Increased capacity (more bed days available) Improved utilisation of operating theatres Speedier recovery Increased patient satisfaction and experience Day cases have minimum disruption to patient lives
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Patient satisfaction from the Friends and Family survey in our Day Surgery Unit
(DSU) over the year range from the lowest at 96% up to 100% for extremely likely
to recommend.
From our previous year (2015-2016) our day case activity was 4.636 patients
making 82% of our business. We have seen an increase in 2016-2017 up to
5,308 day case patients making it 84% of our activity.
Establishment of a patient care review committee meeting with the existing medical advisory committee (MAC)
Our MAC meetings are held every 2 months with the nominated lead from each
speciality, the General Manager, Matron and the MAC chairman.
The purpose of the MAC is to impose stricter rules on consultants over issues
such as audit, note keeping, patient experience and clinical practice.
The role of the MAC is to be the formal organisation structure that ensures clinical
services, procedures or interventions are provided by competent medical
practitioners.
The matron compiles and delivers a report during these meetings discussing
clinical topics that include number of incidents and trends, reporting staffing
vacancies and establishment including agency use, audit outcomes and action
plans, external audits and visits including CQC outcomes.
Working with local Optometrists and our ophthalmic consultants to reduce follow ups in hospital and refer direct to list for second eye
The aim of this CQUIN is to reduce the number of appointments within the
Cataract Pathway - to reduce consultations and improve patient experience by
eliminating unnecessary hospital appointments.
The introduction of the new pathway for Cataract patients went live on the 29th
September 2016. Staff at Rowley Hall have embedded processes that are driving
improvements to meet the requirements of this CQUIN.
An improvement target of 98% was agreed with the Commissioners. The results
below confirm that this target was not met during quarter 3 achieving 47% overall.
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We have carried out an audit to determine the reasons why patients are returning
to Rowley Hall for their follow up appointment and have found the following the
main reasons:
Patient Choice
Consultant Request
Non-compliance with the Standard Operating Procedure (namely not
consenting for both eyes at the 1st initial consultation).
Actions taken -
Rowley Hall Hospital is committed to providing assurance for all patients
receiving treatment and has designed and information leaflet for the
Cataract patients that will be cared for in the community. It explains that
their post op care will be managed in a safe and timely way and ensures
any issues are escalated in a robust and timely way.
Clearly written Standard Operating Procedure implemented with a robust
auditing process and contingencies in the event of non-compliance with
the process.
Duty of Candour
Duty of candour is a requirement from the Care Quality Commissioners (CQC)
regulation 20 and this was also a recommendation 18 from the Francis Enquiry
Report into Mid Staffs NHS Foundation Trust.
Here at Rowley we are dedicated in delivering duty of candour. As a provider we
are open and transparent with those that use our service and other ‘relevant
persons’ in relation to care and treatment if things go wrong.
In the main corridor we have a display board highlighting the importance of Duty
of Candour, the legal requirements and our duty as employees. This is also
reinforced with our staff team so they are aware of its importance and to promote
a positive, open culture.
During 2016-2017 we have continued to discuss and share our complaints and
incidents at our monthly clinical governance meetings. Our HOT alerts from the
QaResearch are also shared via, meetings, emailed to relevant departments and
Quality Accounts 2016/17 Page 17 of 54
displayed on the Quality notice board. We use the learning from this to help
shape the service and clinical practice.
2.1.2 Clinical Priorities for 2017-2018 (looking forward)
Joint Advisory Group (JAG) Accreditation
The JAG Accreditation Scheme is a patient centred and workforce focused scheme based on the principle of independent assessment against recognized standards. The scheme was developed for all endoscopy services and providers across the UK in the NHS and Independent Sector. What is JAG Accreditation intended to accomplish? • Stimulate continuous improvement in processes and patient outcomes • Strengthen endoscopy services • Provide a knowledge base of best practices • Increase patient confidence in services • Improve the management and efficiency of services • Provide education on better/best practices • Provide comparison with self and others • Enhance the workforce, retention and satisfaction • Increase chances to add to and grow services To achieve full JAG Accreditation an endoscopy service must provide clear
evidence that they have met all of the standards. The endoscopy team at Rowley
are currently working hard towards achieving JAG accreditation.
Training and development
Rowley Hall Hospital continues to commit to supporting all staff in their continued
professional development by offering them training days and courses both on and
off site.
These are offered and encouraged to staff by way of email, adverts, on the
training notice board and in the quarterly quality newsletter.
Some training sessions are mandatory which are recorded and monitored by our
Training & Development Co-ordinator and by our HODs. Other training sessions
Quality Accounts 2016/17 Page 18 of 54
include accredited further education courses, Continued Professional
Development (CPD) courses and professional conferences.
With the assistance of the newly appointed Quality Improvement Lead and the
new Matron to assists the Training & Development co-ordinator, we aim to drive
the increase in percentage of staff with all the mandatory training requirements.
Audit Programme and local audits
Due to the success of last year’s compliance in completing 100% of the audits in
the Clinical Audit Programme in a timely manner, we aim to continue this success
moving forward.
Alongside these audits Rowley Hall will be carrying out local audits to monitor the
outcomes of the clinical care. This will take in to account current NICE guidance
to ensure practice is safe and current.
Action plans will be devised, actioned and followed up.
The outcomes of the audits are discussed at monthly clinical governance and
leadership meetings as well as displayed and quality notice board.
PROMS (Patient Reported Outcome Measures)
PROMs enable health care professionals to measure the overall benefit of clinical
effectiveness of undertaking surgical procedures. PROMS measures a patient’s
health status or health related quality of life at a single point in time and are
collected through short, self-completed questionnaires. This health status
information is collected before and after a procedure and provides an indication of
the outcomes or quality of care delivered.
Currently cover four procedures but at Rowley we only cover three – hip, knees
and groins
Moving forward Rowley aims to improve our response rates with PROMS and
look into increasing our percentages
Quality Accounts 2016/17 Page 19 of 54
Increasing Day Unit capacity
During 2016-2017 we saw an increase of 2% in activity compared to 2015-2016.
We aim to drive activity in day case surgery at Rowley further with the possibility
of an off-site standalone Day Surgery Unit.
This would enable us to have dedicated operating theatre rooms, more patient
pods and increase in activity resulting in a reduction in waiting list for patients.
An increase in case activity also allows for beds on the ward to be freed up for
more complex cases.
CQUIN ( Commissioning for Quality and Information)
Clinical Commissioning Groups (CCG’s) in the UK introduced the CQUIN system in 2009. This framework makes a proportion of healthcare provider’s income conditional to the achievement of local quality improvement goals. Our agreed goals for 2017/18 are
1. Offering Advice and Guidance (A&G) 2. E-referrals
These are discussed further in section 2.2.5.
2.2 Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2016/17 Rowley Hall Hospital provided and/or subcontracted 11 NHS
services. The income generated by the NHS represents 81.6% of Rowley Hall
Hospital’s total income from the provisions for 1 April 2016 to 31st March 2017
Rowley Hall Hospital has reviewed all the data available to them on the quality of
care in all of these NHS services.
Quality Accounts 2016/17 Page 20 of 54
The Balanced Scorecard
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard
are reviewed each year. The scorecard is reviewed each quarter by the hospitals
senior managers together with Regional and Corporate Senior Managers and
Directors. The balanced scorecard approach has been an extremely successful
tool in helping us benchmark against other hospitals and identifying key areas for
improvement.
In the period for 2016/17, the indicators on the scorecard which affect patient
safety and quality were:
Human Recourses
Staff Costs as % Net Revenue 31.8%
HCA Hours as % of Total Nursing 20.8%
Agency cost as % of Total Clinical Staff Costs 16.2%
Ward Hours PPD 4.25
Staff Turnover rolling 12 month % 17.8%
Sickness rolling 12 months % 4.77%
Lost time (includes annual leave, study leave and sick leave %
17.4%
Appraisal % 55.55%
Mandatory Training 67.9% face to face 61% e-learning
Staff engagement Score Not carried out in 2016/2017
Number of significant staff injuries 0
Patient
Formal Complaints per 1000 HPD’s (Hospital Patient Days)
3.7
Patient satisfaction score 96 QaResearch
Significant Clinical Events per 1000 Admissions 0
Readmission per 1000 Admissions 0
Quality Accounts 2016/17 Page 21 of 54
Quality
Workplace Health and Safety Score 92%
INFECTION CONTROL AUDITS:
Hand Hygiene Audit 80%
Environmental Audit 87%
Surgical Site Infection’s Audit 90%
PVCCB 85%
2.2.2 Participation in clinical audit
During 1 April 2016 to 31st March 2017 Rowley Hall Hospital participated in 3
national clinical audits and zero national confidential enquiries.
The national clinical audits and national confidential enquiries that Rowley Hall
Hospital participated in, and for which data collection was completed during 1
April 2016 to 31st March 2017, are listed below alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of registered
cases required by the terms of that audit or enquiry.
Name of audit / Clinical Outcome Review Programme
cases
submitted
National Joint Registry (NJR) 100%
NHS Safety Thermometer
100%
Elective surgery (National PROMs Programme) (April 2016- September 2016 – most recent data available)
50%
The reports of three national clinical audits from 1 April 2016 to 31st March 2017
were reviewed by the Clinical Governance Committee and Rowley Hall Hospital
intends to take the following actions to improve the quality of healthcare provided-
National Joint Registry (NJR)- Rowley Hall Hospital has seen a continued
compliance in the completion of National Joint Registry. Current percentage
scored for compliance is 100% and we will continue to monitor and act upon the
results from our corporately generated monthly NJR reports.
Patient Reported Outcomes (PROMs) - The most recent data available dates
from April 2016- September 2016 form the NHS Digital. The participation
percentage for these dates is at 50% from the total number of eligible hospital
episodes. This can be from the patient declining to take part in the PROM and
completing the pre-op questionnaire.
Quality Accounts 2016/17 Page 22 of 54
NHS Safety Thermometer- we will continue to use the Safety Thermometer as a
point of care instrument. It will be used alongside our other patient measures and
risk assessments to provide a care environment free of harm for our patients
Local Audits
The reports of 107 local clinical audits from 1 April 2016 to 31st March 2017 were
reviewed by the Clinical Governance Committee at Rowley Hall Hospital. Action
plans are devised at the end of each month and action put in place where scores
are below 90%. These are then followed up with 1 month for update on progress
and actions implemented. The clinical audit schedule can be found in Appendix 2.
2.2.3 Participation in Research
There were no patients recruited during 2016-17 to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Rowley Hall Hospital’s income in from 1 April 2016 to 31st March
2017 was conditional on achieving quality improvement and innovation goals
agreed and any person or body they entered into a contract, agreement or
arrangement with for the provision of NHS services, through the Commissioning
for Quality and Innovation payment framework.
Each commissioner agrees a number of different CQUIN’s at the beginning of the
finical year with each of their providers. These include quarterly reviews of the
milestones set as well as final outcome targets.
The agreed goals at Rowley Hall Hospital for 2017/18 are focused around the e-
Referral system ensuring the numbers of e-referrals are appropriate for your
hospital, working with the local CCG, GP practices and Clinicians to enable the
most effective patient pathway; and around offering advice and guidance to GP in
all specialties.
Quality Accounts 2016/17 Page 23 of 54
Indicator 1 - NHS E-Referral
This relates to GP referrals to consultant led first outpatient services and the
availability of services and appointments on the NHS e-referral. All providers to
publish all services and make their first appointment slots available on the NHS e-
referral service
Indicator 2 – Advice and Guidance (A&G) in all Specialties
To set up an A&G service for non-urgent GP referrals, allowing GPs to access
consultant advice prior to referring patients into secondary care, whether this
leads to refer being made or not.
Both CQUINs will be developed with the local Commissioners in order to provide
the best care for patients.
2.2.5 Statements from the Care Quality Commission (CQC)
Rowley Hall Hospital is required to register with the Care Quality Commission and
its current registration status on 31st March is registered without conditions
The Care Quality Commission (CQC) visited Rowley Hall Hospital to undertake
an announced inspection on the 12th October 2016. Staff, patients and clinical
departments were visited along with an investigation into all elements of our
Hospital.
The final report was issued in January 2017 as follows -
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Rowley Hall Hospital has made significant progress towards the safety
improvements that the CQC recommended. These include;
Surgical First Assistants (SFA)
Staffing in theatres was not in line with surgical first assist perioperative care
collaborative guidelines. Staff undertaking the role had not completed the
recognised training requirements and undertook dual roles for procedures greater
than a minor operation.
Actions
X2 fully qualified SFA employed in theatre at present
X 4 due to qualify August 2017
Risk assessment undertaken at weekly activity planning meeting for
effective staff planning & matron and theatre manager risk asses daily and,
if needed, agency SFA’s are requested.
Both theatre and matron have a copy of The Association of Preioperative
Practice (AFPP) guidance to refer to when needed.
Advanced Life Support (ALS)
Not all staff who worked in recovery were trained in Advanced Life Support (ALS)
which meant good practice guidelines were not being followed
Actions
Theatre manager ALS qualified.
X 3 recovery staff to undertake training x 1 Operating Department
Practitioner (ODP) currently enrolled on course, x 2 RN to commence Sept
2017. Resuscitation lead nurse to offer support sessions before course is
undertaken.
Responsible Medical Officer (RMO) who is on site 24 hours per day is ALS
trained & is remains part of the ALS team response. This will continue
alongside the further training of the recovery staff.
World Health Organisation (WHO) Checklist
Surgical safety processes were not embedded in theatres
Quality Accounts 2016/17 Page 25 of 54
Actions
Being undertaken & spot checked & audited weekly
Emergency Scenarios including on the ward and MRI van
Mandatory Training
Compliance improving month on month however still not at target of 85%
Intermediate Life Support (ILS)/ Basic Life Support (BLS) ad hoc sessions being
held between us and West Midlands
Intravenous (IV) & cannulation training held across sites to ensure learning is
wider than the hospital.
Areas of Good Practice
Incidents were reported, investigated, feedback given and learning applied.
Infection control and prevention processes were in place and recoded
rates of infection were low.
NHS safety thermometer data measured harm free care.
Staffing levels were planned an implemented to keep people safe.
Medical cover for patients was appropriate.
Hand Hygiene results achieved 93% overall
During March 2017 the CCGs Head of Nursing Quality and support manager from
the Clinical Commissioning group undertook an unannounced inspection of the
site.
The visit provided a high degree of assurance with regards to Rowley Hall’s
response to the CQCs recommendations.
.
Quality Accounts 2016/17 Page 26 of 54
2.2.6 Data Quality
The annual audit program reviews the quality of our data via clinical systems
together with medical and paper records (appendix 2). All audits are discussed at
the MAC, clinical governance committee, leadership and health and safety
meeting. Action plans are put in place and reviewed monthly against compliance.
Rowley Hall Hospital will be taking the following actions to improve data quality.
Continue to provide comprehensive reports for the MAC and CGC
regarding clinical audit results.
Improve engagement with consultants regarding the importance of accurate patient data collection on written records. For example improving comprehensive completion of consent forms e.g. requests for additional tests.
Review and improve the PROMS data collection process to ensure all patients eligible to participate in the questionnaire are provided with a questionnaire.
Continue to input into the British Spinal register, NJR and NHS Safety Thermometer.
NHS Number and General Medical Practice Code Validity
Rowley Hall Hospital submitted records during 2016/17 to the Secondary
Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which
are included in the latest published data. The percentage of records in the
published data which included:
The patient’s valid NHS number:
98.98% for admitted patient care;
99.96%for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code:
100% for admitted patient care;
99.99% for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
Quality Accounts 2016/17 Page 27 of 54
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall score
for 2016/17 was 82% and was graded ‘green’ (satisfactory) meeting level 2 and 3
for all requirements.
This information is publicly available on the DH Information Governance Toolkit
website at https://www.igt.hscic.gov.uk
Clinical coding error rate
Rowley Hall Hospital was not subject to the Payment by Results clinical coding
audit during 2016/2017 by the Audit Commission.
No clinical coding audit was carried out during 2016/2017 at Rowley Hall Hospital.
The last audit was 17/11/15 as the data below shows.
Quality Accounts 2016/17 Page 28 of 54
2.2.7 Stakeholders views on 2016/17 Quality Account
NHS Stafford and Surrounds Clinical Commissioning Group (CCG)
NHS Stafford and Surrounds Clinical Commissioning Group (CCG), as Co-ordinating
Commissioner for Rowley Hall Hospital, are pleased to comment on the Rowley Hall
Hospital Quality Account 2016/17.
Local CCGs are committed to working closely with Rowley Hall Hospital to maintain the
organisation’s high standard of quality and safety. Formal monitoring of quality and safety
is undertaken through quarterly Clinical Quality Review Meetings (CQRM) where
representatives from Rowley Hall Hospital and local CCGs meet to scrutinise a
substantial amount of both quantitative and qualitative data. CQRMs are the primary
forum for the CCG and Rowley Hall Hospital to discuss quality and safety however staff
from both organisations also work closely on a day-to-day basis. The CCG looks forward
to continuing to work with Rowley Hall Hospital in 2017/18.
Review of 2016/17
The CCG is pleased to note Rowley Hall Hospital’s commitment to the monitoring and
improvement of quality and safety and this is evident throughout the Quality Account. Of
particular note are the following achievements –
Patient feedback is consistently very positive and monthly results from the Friends and
Family test often reveal that 100% of surveyed patients would recommend the
organisation.
A recent CQC inspection rated the hospital as GOOD overall.
Although the CQC inspection resulted in a ‘good’ overall rating the rating for the Safety
domain was ‘requires improvement’. The organisation responded positively to CQC
recommendations that were received following inspection and developed an action plan to
address these. The CCG is engaged with Rowley Hall Hospital to monitor delivery of the
action plan.
No Serious Incidents (SI) were reported in 2016/17. Patient Safety Incidents which do not
meet SI criteria but nonetheless do require investigation are discussed at CQRM, any
trends are identified and resulting actions are considered and discussed.
Work is ongoing to strengthen links with local General Practitioners and a dedicated GP
Liaison Officer is in place to drive these efforts.
A new E-learning platform was launched and it is expected that this will help to encourage
staff access to training.
The Senior Management Team has been strengthened with the appointment of a new
Matron in November 2017 and new General Manager in April 2017. These new team
members are committed to the monitoring and improvement of quality and safety at
Rowley Hall Hospital and work closely with the CCG.
A robust clinical audit programme is in place and this information is regularly reported to
CQRM.
Quality Accounts 2016/17 Page 29 of 54
Two CCG visits were undertaken in 2016/17, one unannounced and one announced.
Rowley Hall Hospital staff were happy to engage with the visiting CCG representatives
and the visits provided a high degree of assurance.
Evidence of the JAG accreditation process has been shared with Commissioners and
progress towards accreditation has been noted.
Priorities for 2017/18
The CCG support the 2017/18 priorities that Rowley Hall Hospital have laid out in the
Quality Account. The CCG notes that some actions are outstanding to address CQC
recommendations and will continue to support the completion of these actions.
Quality Accounts 2016/17 Page 30 of 54
Part 3: Review of quality performance 2015/2016
Statements of quality delivery
Matron, Rebecca Turley
Review of quality performance 1st April 2016 - 31st March 2017
Introduction
“This publication marks the eighth successive year since the first edition of
Ramsay Quality Accounts. As we have previously done through each year, we
continue to analyse our performance on many levels, we reflect on the valuable
feedback we receive from our patients about the outcomes of their treatment and
also reflect on professional opinion received from our doctors, our clinical staff,
regulators and commissioners.
I am pleased to say that whilst the numbers of patients choosing Ramsay for their
care continues to increase, quality continues to also improve as demonstrated by
improved clinical outcomes and measures.
We listen where concerns or suggestions have been raised and, in this account,
we have set out our track record as well as our plan for more improvements in the
coming year. This is a discipline we vigorously support, always driving this cycle
of continuous improvement in our hospitals and addressing public concern about
standards in healthcare, be these about our commitments to providing
compassionate patient care, assurance about patient privacy and dignity, hospital
safety and good outcomes of treatment. We believe in being open and honest
where outcomes and experience fail to meet patient expectation so we take
action, learn, improve and implement the change and deliver great care and
optimum experience for our patients.”
Vivienne Heckford
Director of Clinical Services
Ramsay Health Care UK
Quality Accounts 2016/17 Page 31 of 54
Ramsay Clinical Governance Framework 2016/2017
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care,
clinicians are enabled to provide that care and the organisation can satisfy itself
that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
management systems, clinical, financial, estates etc, are inter-dependent with
actions in one area impacting on others.
Several models have been devised to include all the elements of Clinical
Governance to provide a framework for ensuring that it is embedded,
implemented and can be monitored in an organisation. In developing this
framework for Ramsay Health Care UK we have gone back to the original Scally
and Donaldson paper (1998) as we believe that it is a model that allows coverage
and inclusion of all the necessary strategies, policies, systems and processes for
effective Clinical Governance. The domains of this model are:
• Infrastructure • Culture • Quality methods • Poor performance • Risk avoidance • Coherence
Quality Accounts 2016/17 Page 32 of 54
Ramsay Health Care Clinical Governance Framework
National Guidance
Ramsay also complies with the recommendations contained in technology
appraisals issued by the National Institute for Health and Clinical Excellence
(NICE) and Safety Alerts as issued by the NHS Commissioning Board Special
Health Authority.
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
Quality Accounts 2016/17 Page 33 of 54
3.1 The Core Quality Account indicators
Mortality
Prescribed Information Related NHS Outcomes Framework Domain
The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to— (a) the value and banding of the summary hospital-level mortality indicator (“SHMI”) for the trust for the reporting period; and (b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period. *The palliative care indicator is a contextual indicator.
1: Preventing People from dying prematurely 2: Enhancing quality of life for people with long-term conditions
Mortality: Period Best Worst Average
Period Rowley
Oct 14 - Sep
15 RKE 0.652 RVW 1.18 Average 1 2014/15 NVC17 0
Oct 15 - Sep
16 RKE 0.689 RLQ 1.16 Average 1 2015/16 NVC17 0
Rowley Hall Hospital considers that this data is as described for the following reasons
There were no deaths at Rowley Hall Hospital during this reporting period
This is the most recent data available. Rowley Hall hospital has taken the following actions to maintain this rate and so the quality of its services by
Completion of corporate audits, statuary notification, incident investigation, root cause analysis of care episodes and continuous evaluation of clinical risk.
Robust mandatory training programme
Anaesthetic review of all high risk patients pre-operatively.
Information sharing at Clinical Governance monthly meetings and Infection Prevention quarterly meetings
Quality Accounts 2016/17 Page 34 of 54
RROMS (Patient Reported Outcome Measure)
The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the trust’s patient reported outcome measures scores for— (i) groin hernia surgery, (ii) varicose vein surgery, (iii) hip replacement surgery, and (iv) knee replacement surgery, during the reporting period.
3: Helping people to recover from episodes of ill health or following injury
PROMS: Period Best Worst Average
Period Rowley
Hernia Apr15 - Mar16
NT438 0.157 RVW 0.021 Eng 0.088 Apr15 - Mar16
NVC17 *
Apr16 - Sep16
RJR 0.162 RNA 0.016 Eng 0.089 Apr16 - Sep16
NVC17 *
PROMS: Period Best Worst Average
Period Rowley
Hips Apr15 - Mar16
RYJ 24.973 RBK 16.892 Eng 21.617 Apr15 - Mar16
NVC17 21.052
Apr16 - Sep16
NTPH1 25.204 RFS 17.84 Eng 22.018 Apr16 - Sep16
NVC17 *
PROMS: Period Best Worst Average
Period Rowley
Knees Apr15 - Mar16
NTPH1 19.920 RQX 11.960 Eng 16.368 Apr15 - Mar16
NVC17 15.722
Apr16 - Sep16
NTPH1 21.349 RK5 12.65 Eng 16.877 Apr16 - Sep16
NVC17 *
Rowley Hall hospital considers that this data is as described for the following reasons
Patients at Rowley hall Hospital have reported in line with the national average for hips and knees for Apr 15- March 16
Our response rate for the period Apr 16-Sept 16 was too small to quantify outcome measure
Rowley Hall hospital intends to take the following actions to improve this score by
Engaging staff and raise importance awareness of PROMs to encourage a greater participation rate
Share progress/ updated information with all departments at regular intervals to encourage this engagement
Quality Accounts 2016/17 Page 35 of 54
Readmissions
The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the percentage of patients aged— (i) 0 to 14; and (ii) 15 or over, Readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period.
3: Helping people to recover from episodes of ill health or following injury
Readmissions: Period Best Worst Average
Period Rowley
2010/11 Multiple 0.0 5P5 22.76 Eng 11.43 2010/11 NVC21 7.12
2011/12 Multiple 0.0 5NL 41.65 Eng 11.45 2011/12 NVC21 0
Rowley Hall hospital considers that this data is as described for the following reasons
These are the most up to date figures from HSCIC at present.
All readmissions are reported to our CCG’s through our monthly quality reports and logged on to our reporting system Riskman
As demonstrated in the table above Rowley Hall Hospital is below the national average for readmissions. This can be explained by our thorough clinical practice ensuring that patients are not discharged home too early and that patients/carers/relatives receive correct discharge information
Rowley Hall hospital has taken the following actions to improve this score and so the quality of its services, by the following actions;
Completion of clinical reports with incident investigation and root cause analysis if required for all readmissions
The sharing of information through our monthly clinical governance and Leadership meetings
Reinforcement of discharge policy.
Quality Accounts 2016/17 Page 36 of 54
Responsiveness
The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the trust’s responsiveness to the personal needs of its patients during the reporting period.
4: Ensuring that people have a positive experience of care
Rowley Hall Hospital considers that this data is as described for the following reasons
This is the most recent data available as we were not invited to complete the NHS inpatient survey last year.
Feedback from patients regarding their experience at Rowley Hall Hospital is encouraged and is essential to inform our staff how acre can be enhanced or adjusted to meet individual patient satisfaction.
Similar data available can be found in our QaResearch where the patient is asked
‘overall opinion of the quality of your care’. This data is shown below-
Responsiveness: Period Best Worst Average
Period Rowley
to personal 2012/13 RPC 88.2 RJ6 68.0 Eng 76.5 2013/14 NVC17 93.7
needs 2013/14 RPY 87.0 RJ6 67.1 Eng 76.9 2014/15 NVC17 93.8
Quality Accounts 2016/17 Page 37 of 54
Rowley Hall hospital has taken the following actions to improve this score, and so the quality of its services
Participating in regular internal audit/ inspection process
Acting upon CQC and CCG inspection feedback
Addressing written feedback via letters/emails/complaints
Continue to participate in annual PLACE audit
Continue to proactively promote patient satisfaction surveys.
Quality Accounts 2016/17 Page 38 of 54
Venous Thromboembolism (VTE)
The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.
5: Treating and caring for people in a safe environment and protecting them from avoidable harm
VTE Assessment:
Period Best Worst Average
Period Rowley
16/17
Q2 Several 100% NV302 0.0% Eng 95.5% 16/17Q2 NVC17 97.0%
16/17
Q3 Several 100% NT490 65.9% Eng 95.6% 16/17 Q3 NVC17 99.7%
Rowley Hall hospital considers that this data is as described for the following reasons
We have a robust patient assessment process coupled with the co-operation of all of our consultants this has ensured that we always aim to reach full compliance for VTE assessment thereby minimising the risk for all patients. The VTE assessment documentation is now issued at pre-operative assessment where the assessment is instigated by the nurse and then completed by the admitting consultant.
Rowley Hall hospital has taken the following actions to improve and maintain this score, and so the quality of its services
VTE assessment forms part of the Ramsay patient pathway, these are completed on admissions for all patients.
The completed discharge medical record check for all patients forms an additional system check for the documented VTE assessment this is then marked accordingly within the patients cosmic record.
Monthly checks of corporate report for VTE assessments are completed
Quality Accounts 2016/17 Page 39 of 54
Clostridium Difficile Rates
The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the rate per 100,000 bed days of cases of C difficile infection reported within the trust amongst patients aged 2 or over during the reporting period.
5: Treating and caring for people in a safe environment and protecting them from avoidable harm
C. Diff rate: Period Best Worst Average
Period Rowley
per 100,000 2014/15 Several 0 RPY 62.2 Eng 15.1 2014/15 NVC17 0.0
bed days 2015/16 Several 0 RPY 66.0 Eng 14.9 2014/15 NVC17 0.0
Rowley Hall Hospital considers that this data is as described for the following reasons
Rowley Hall has had no incidents of clostridium difficile in this reporting period and shows a lower than average rate.
Rowley Hall Hospital has again achieved a zero rate of clostridium difficile from April 2016- March 2017
Infection Prevention and Control (IPC) polices are revised and developed every two years. IPC programs are designed to bring about improvements in performance and practice.
An annual strategy for infection prevention and control is developed at a corporate level by the group.
A network of specialist nurses and infection control link nurses operate across the Ramsay organisation to support and networking best clinical practice.
Rowley Hall Hospital employs an IPC nurse and has link nurses in every department.
Rowley Hall Hospital has taken the following actions to maintain this score and so the quality of its services, by
Maintain high standards of Infection Prevention and control practice to minimise the risk of occurrence of clostridium difficile.
Report any incidents of clostridium difficile infection to the appropriate Public Health bodies, responsible microbiologist, consultants. clinical commissioning groups and enter onto Riskman.
Implement the correct treatment and nursing interventions for any confirmed or suspected clostridium difficile infections.
Follow national and corporate guidance in infection prevention and control standards, audits and processes.
Quality Accounts 2016/17 Page 40 of 54
Serious Untoward Incidents (SUI’S)
Rowley Hall Hospital reports any type of incident on an internal reporting system.
Any serious untoward incidents are reported to external bodies accordingly.
The following data can be found at:-
http://www.nrls.nspa.nhs.uk/resourses/
The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death
5: Treating and caring for people in a safe environment and protecting them from avoidable harm
Rowley Hall hospital considers that this data is as described for the following reasons
There were no SUIs for the reporting period April 15 - March 16.
The data has not been updated since March 2016
The Riskman system reports incidents directly to the corporate Risk Management Team allowing the identification of trends at Rowley Hall Hospital.
Rowley Hall hospital has taken the following actions to maintain this score and so
the quality of its services, by
Maintaining a robust staff induction and mandatory training programme.
The senior management team ensure that incidents are investigated and with lessons are learnt from these events. They are shared with staff across the hospital so that we can prevent the same type of incident occurring again.
All incidents are reviewed by the General Manager and the Matron and an investigation process, Root Cause Analysis and action plan implemented where appropriate.
Falls assessment tool implemented as well as the use of a comprehensive risk assessment to identify and minimise risk.
SUIs: Period Best Worst Average
Period Rowley
(Severity 1 only)
Apr 15 - Sep 15
Several 0 RY3 2.39 Eng 0.21 Apr 15 - Sep 15
NVC17 0.00
Oct 15 - Mar 16
Several 0 RY6 4.45 Eng 0.21 Oct 15 - Mar 16
NVC17 0.00
Quality Accounts 2016/17 Page 41 of 54
Friends and Family Test
Friends and Family Test – Patient. The data made available by National Health Service Trust or NHS Foundation Trust by NHS Digital for all acute providers of adult NHS funded care, covering services for inpatients and patients discharged from Accident and Emergency (types 1 and 2)
4: Ensuring that people have a positive experience of care This indicator is not a statutory requirement.
F&F Test: Period Best Worst Average
Period Rowley
Jan-17 Several 100% RJ731 61.1% Eng 95.7% Jan-17 NVC17 100.0%
Feb-17 Several 100% NT3X3 72.7% Eng 95.8% Feb-17 NVC17 100.0%
Rowley Hall hospital considers that this data is as described for the following reasons
In this reporting period Rowley Hall Hospital achieved higher than the national average for patient satisfaction score.
All patients that attend Rowley Hall Hospital are invited to take part in this anonymous survey asking simply whether they would recommend our hospital to their friends and family.
Rowley Hall hospital has taken the following actions to maintain this percentage and so the quality of its services, by
Encouraging our patients to take part in the survey
Use the friends and family feedback to continuously monitor patient feedback in all departments and disseminate to individual departments.
Review the corporately generated Friends and Family results to analyse and act upon any trends identified.
Quality Accounts 2016/17 Page 42 of 54
3.2 Patient safety
We are a progressive hospital and focussed on stretching our performance every
year and in all performance respects, and certainly in regards to our track record
for patient safety.
Risks to patient safety come to light through a number of routes including routine
audit, complaints, litigation, adverse incident reporting and raising concerns but
more routinely from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of
key indicators as illustrated in the graphs below.
3.2.1 Infection prevention and control (IPC)
Rowley Hall Hospital has a low rate of hospital acquired infection and has had no
reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme
to reduce incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed at a corporate level Infection Prevention and
Control (IPC) Committee and group policy is revised and re-deployed every two
years. Our IPC programmes are designed to bring about improvements in
performance and in practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:
Hand hygiene is high on our agenda with the monthly audits and local audits along with the non-touch hand gels across the facility
MRSA screening as per IPC policy
Infection incidents reported on Riskman
Mandatory training on IPC
Report monthly on all aspects of infection control to our Clinical Governance meetings and in the monthly reports to corporate.
Quality Accounts 2016/17 Page 43 of 54
Our infection rates remain relatively low here at Rowley Hall Hospital in
comparison to the nation average despite the increase noted in 2016/17.
Encouragement to enter all SSI’s onto Riskman may have resulted in this
reporting year appearing higher as well as in increase in activity and complexity of
cases.
Rowley Hall has just re-introduced a local Infection Prevention and Control
committee quarterly meetings. With our newly appointed Infection Prevention and
Control Lead nurse this will involve clinical engagement and will actively work
hard to identify any trends during 2016/17 to assist in reducing the number of
infections.
Root Cause Analysis (RCA’s) are carried out where necessary to determine the
cause of the SSI’s so we can learn and respond accordingly.
3.2.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE) PLACE assessments occur annually at Rowley Hall Hospital, providing us with a patient’s eye view of the buildings, facilities and food we offer, giving us a clear picture of how the people who use our hospital see it and how it can be improved. The main purpose of a PLACE assessment is to get the patient view.
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
2014/15 2015/16 2016/17
Infe
ctio
n R
ates
(p
erce
nta
ge o
f A
dm
issi
osn
s)
Rowley Hall Hospital
Infection Rates
Quality Accounts 2016/17 Page 44 of 54
Our annual assessment took place during May 2016 and the results are as follows:
Rowley Hall Hospital
Ramsay Average 2016
National Average 2016
Cleanliness 98.76% 98.45% 98.1%
Food 85.52% 90.5% 88.2%
Privacy, dignity and wellbeing
80.49% 81.86% 84.2%
Disability 55.59% 80.66% 78.8%
Dementia 68.10% 80.66% 75.3%
3.2.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring our staff have high
awareness of safety has been a foundation for our overall risk management
programme and this awareness then naturally extends to safeguarding patient
safety.
Our record in workplace safety as illustrated by Accidents per 1000 Admissions
demonstrates the results of safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every
month and these are sent in a timely way via an electronic system called the
Ramsay Central Alert System (CAS).
Safety alerts, medicine / device recalls and new and revised policies are
cascaded in this way to our General Manager which ensures we keep up to date
with all safety issues.
Our safety initiatives for 2016/17 include –
All incidents reported onto Riskman in a timely manner and are reviewed by the senior management team, in clinical governance and health and safety meetings.
Sharing of lessons learnt with clinical teams.
Quality Accounts 2016/17 Page 45 of 54
Ongoing training programme for staff at mandatory training and on induction covering topics Manual Handling, Riskman reporting system and Fire safety.
Health and safety committee meetings to ensure systems are in place and to review of safety concerns or issues.
CCTV covering external areas to the Hospital.
Panic alarm system in place at Reception
Replacement of carpet on ground floor.
Lighting improved in outside areas.
3.3 Clinical effectiveness
Rowley Hall Hospital has a Clinical Governance team and committee that meet
monthly to monitor quality and effectiveness of care.
Clinical incidents, patient and staff feedback are systematically reviewed to
determine any trend that requires further analysis or investigation.
More importantly, recommendations for action and improvement are presented to
hospital management and medical advisory committees to ensure results are
visible and tied into actions required by the organisation as a whole.
Regular national and local audits are undertaken at Rowley Hall Hospital to
monitor our clinical effectiveness in all departments. From this, action plans are
devised and disseminated to all departments’ for action and follow up.
3.3.1 Return to theatre
Rowley Hall Hospital is treating significantly higher numbers of patients every
year as our services grow. Our patients undergo planned surgical procedures and
so monitoring numbers of patients that require a return to theatre for
supplementary treatment is an important measure.
Every surgical intervention carries a risk of complication so some incidence of
returns to theatre is normal. The value of the measurement is to detect trends that
emerge in relation to a specific operation or specific surgical team. Ramsay’s rate
of return is very low consistent with our track record of successful clinical
outcomes.
Quality Accounts 2016/17 Page 46 of 54
The graph above shows that Rowley Hall Hospital’s return to theatre activity has
had an approximate increase of 0.04% during 2016/17.
This could be explained by the increase in complex cases during this period as at
Rowley Hall as well as the increase of awareness to report on Riskman.
With every return to theatre that occurs an RCA is completed to investigate the
causes and to understand the lessons learnt with the aim to reduce the number of
occurrences.
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and inform service development in various ways dependent on the
type of experience (both positive and negative) and action required to address
them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
notice boards. Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experiences are feedback via the various methods below, and are regular
agenda items on Local Governance Committees for discussion, trend analysis
0
0.01
0.02
0.03
0.04
0.05
0.06
0.07
2014/15 2015/16 2016/17
Ret
rnn
to
Th
eatr
e
(Per
cen
tage
of
Ad
mis
sio
sns)
Rowley Hall Hospital
Return to Theatre Score
Quality Accounts 2016/17 Page 47 of 54
and further action where necessary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
Hot alerts received within 48hrs of a patient making a comment on their web survey
Friends and family questions asked on patient discharge
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient views and opinions in PLACE assessments
Shared experiences and learning through our monthly complaints meetings
and in our monthly clinical governance meetings
PROMs surveys
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently of
the hospital so we receive a true reflection of our patient’s views.
Every patient is asked their consent to receive an electronic survey or phone call
following their discharge from the hospital. The results from the questions asked
are used to influence the way the hospital seeks to improve its services. Any text
comments made by patients on their survey are sent as ‘hot alerts’ to the Hospital
Manager within 48hrs of receiving them so that a response can be made to the
patient as soon as possible.
The graph below shows an increase of 0.6% during this reporting period. This
increase has been due to the excellent nursing care our patients receive and the
excellent patient outcomes.
During 2017/18 Rowley Hall Hospital aims to ensure that our feedback remains
above 90%, with a drive to increase the scores from 2015/16.
Quality Accounts 2016/17 Page 48 of 54
3.4 Rowley Hall Hospital Case Study
In September 2016 Rowley Hall Hospital collaborated with the Local Optometrist
and the LOC to introduce a new pathway for a vulnerable and elderly cohort of
patients that underwent Cataract surgery at Rowley Hall.
The main purpose of the scheme is to allow accredited Optometrist to use their
skills to perform the check-up following day case cataract surgery meaning that
the patient does not require another appointment at the hospital. This allows the
ophthalmologist more clinical time to attend to more serious cases and the
patients are able to attend their usual optometrist where they are more
comfortable and the service more accessible, especially for those with mobility
issues.
Since going live with the new scheme almost 500 patients have benefited from a
convenient and comfortable cataract surgery follow-up which includes
Being discharged from hospital the same day as the cataract operation
Being able to make appointment with an accredited optometrist of their
choice directly
Appointments taking place within 4 weeks after surgery and no later than 6
weeks
And no need to return to Rowley Hall Hospital unless there are any
problems
95.4 96.0
0
20
40
60
80
100
120
2014/15 2015/16
Sati
sfac
tio
n S
core
s
Rowley Hall Hospital
Satisfaction Scores NHS/Private Patients
Quality Accounts 2016/17 Page 49 of 54
The response from both patients and Optometrist has been positive and Rowley
Hall Hospital plans to continue with the scheme during 2017 so that we continue
to see an improved experience for our patients and continue to support the Local
Health Economy.
Quality Accounts 2016/17 Page 50 of 54
Appendix 1
Services covered by this quality account
This hospital provides NHS and private inpatient and outpatient facilities for:-
Dermatology
Cosmetic surgery
Diagnostics
General Surgery
Gastroenterology
Gynaecology
Ophthalmology
Orthopaedics
Pain Management
Podiatric surgery
Physiotherapy
Spinal
Urology
Quality Accounts 2016/17 Page 51 of 54
Appendix 2
Staffordshire Health Watch
Introduction
Healthwatch Staffordshire was pleased to have been invited to comment on the Quality
Accounts of Rowley Hall Hospital. We recognise the work that has taken place over the past year
to deliver the services and it is very pleasing to note that the Hospital is clearly committed to
continual service improvement. A clear overview of services is also detailed within the report.
Healthwatch Staffordshire are pleased that the Hospital is continuing to focus on improving
patient experience and would commend the NHS Choices 5-star rating together with the
attainment of a 100% score from the Friends and Family survey indicating patients would
recommend Rowley Hall Hospital.
The report outlines the key areas which the Hospital has focused on over the last year, and the
format of the report clearly outlines where further work is required, particularly where targets
have been missed. There is a clear explanation of improvements made as a result of missed
targets.
The report format ensures that the priorities for the year ahead are easily identified as the
ongoing programme of work. We note the six clinical priority areas for 2016/17- JAG
Accreditations; Training and Development; Audit Programme and Local Audits; PROMS;
Increasing Day Unit Capacity and CQUIN. Defining timescales for the JAG Accreditation Scheme
would be beneficial together with more detailed information regarding how the PROMS
response rates will be improved and the desired percentages.
The Hospital has implemented a Clinical Audit Programme and a local clinical audit programme
and we acknowledge the level of resource this must involve. The evidence presented within the
report includes the results and creation of action plans in a timely manner. The Goals agreed
with Commissioners using the CQUIN Framework are detailed, including actions to be taken
where improvements are required again demonstrating continual improvement. The Balanced
Scorecard provides an overview of audit results, it would be helpful to define if the scores
represent areas for improvement or are areas of success.
The importance of clinical governance is recognised together with the integration of this. There
is a continual theme throughout the report of the desire to increase the PROMS participation
rate. A clear definition is provided of the positives that this will bring in addition to the positive
impact a greater response rate would have on continual improvement and reporting on the Care
Quality Account Indicators.
The report includes an explanation of the variety of ways that the Hospital engages with patients
to encourage feedback. Details of how the Hospital will aim to ensure that feedback remains
above 90% would be informative.
Quality Accounts 2016/17 Page 52 of 54
Conclusion
Healthwatch Staffordshire looks forward to having the opportunity to review the 2017/18
Quality Account next year and particularly to be able to assess how the quality initiatives have
impacted on the Hospital’s staff and the residents of Staffordshire.
Quality Accounts 2016/17 Page 53 of 54
Appendix 3 – Clinical Audit Programme 2016/17. Each arrow links to the audit to be completed in each month.
Audit Programme v9.0 2016/17 Hospital Name: Implemented: July 2016
Authors: S. Harvey / A. Hemming-Allen / N. Carre / A. McDonald For review: June 2017
Use arrow symbol to locate required audit
JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN
Medical Records Med Rec VTEDet Pt Med Rec VTE N & H Med Rec VTE Det Pt Med Rec VTE N & H
ConsentConsent Consent Consent Consent
Pre admission / DischargePA & Dis PA & Dis
Green 100%
Care Pathways and Variance
Tracking CP & VT CP & VT
Cool
Amber 90 - 99%
Controlled DrugsControlled
Drugs
Controlled
Drugs
Controlled
Drugs
Controlled
DrugsAmber 80 - 89%
PrescribingPrescribing Prescribing
Hot
Amber70 - 79%
Medicines Management Medicines
Management
Medicines
ManagementRed 69% and under
Radiology
NMR / Referral FormsReferral
Forms - IP
Referral
Forms- OP
Referral
Forms-NMR
Referral
Forms- TH
Referral
Forms- MRI
Referral
Forms- CT
Referral
Forms- IPReferral
Forms-OP
Referral
Forms-
NMR
Referral
Forms- TH
Referral
Forms- MRI
Referral
Forms - CT
Radiology
NRR / Post Exam / IRMERNRR
Post Exam Post Exam NRR
IRMER /
IRR99 Post Exam Post Exam
Radiology - MRI
MRI Report MRI Report MRI Safety
MRI
Report MRI Report
Radiology - CTCT Report CT Report CT Report CT Report
PhysiotherapySafe
Service Learning Partnership
Records
Keeping Consent Evaluation Treatment Promotion
Surgical Safety for Invasive
ProceduresSurgical
Safety - TH
Surgical Safety
- Rad
Surgical
Safety - OP
Surgical
Safety - TH
Surgical
Safety - Rad
Surgical
Safety - OP
Surgical
Safety - TH
Surgical
Safety - Rad
Surgical
Safety - OP
Surgical
Safety - TH
Surgical
Safety - Rad
TheatreOrganisati
onal Mgt Anaesthetic
Peri op Pt
Care Clin Effect
Organisatio
nal Mgt
Anaesthetic Peri op Care Clin Effect
Infection Prevention and
Control*Isolation Hand
hygiene PVCCB UCCB
Hand
hygiene SSI CVCCB
Hand
hygiene PVCCB UCCB
Hand
hygiene SSI
IPC - Environmental / Hand
Hygiene ActionEnviron
Monthly
Hand
hygiene Environ
Monthly
Hand
hygiene
Monthly
Hand
hygiene Environ
Monthly
Hand
hygiene
Monthly
Hand
hygiene Environ
Monthly
Hand
hygiene
TransfusionCompliance
Allogeneic
Traceability
Auto logous
Traceability
Traffic light score
Quality Accounts 2016/17 Page 54 of 54
Rowley Hall Hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
Hospital phone number
01785 238608
Hospital website
www.rowleyhallhospital.co.uk