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Fulwood Hall Hospital Quality Account 2018-19

Contents Contents

Welcome to Ramsay Health Care UK

Introduction to our Quality Account

PART 1 – STATEMENT ON QUALITY

1.1 Statement From The Hospital Director

1.2 Hospital Accountability Statement

1.3 Welcome to Fulwood Hall Hospital

PART 2

2.1 Priorities for Improvement

2.1.1 Review of clinical priorities 2018/19 (looking back) 2.1.2 Clinical Priorities for 2019/20 (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 using CQUINS 2.2.5 Statement from the Care Quality Commission 2.2.6 Statement on Data Quality 2.2.7 Stakeholders’ Views on 2018/19 Quality Accounts

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.1 The Core Quality Account Indicators

3.2 Patient Safety 3.2.1 3.2.2 3.2.3

Infection, Prevention & Control Cleanliness & Hospital Hygiene Safety in the Workplace

3.3 Clinical Effectiveness 3.3.1 3.3.2 3.3.3 3.3.4

Return to Theatre Learning from Deaths Staff Who Speak Up Priority Clinical Standards for Seven Day Hospital Services

3.4 Patient Experience 3.4.1 Patient Satisfaction Surveys

Appendix 1 – Services Covered by this Quality Account

Appendix 2 – Clinical Audit Program 2018/19

Quality Accounts 2018/19 of 55

Welcome to Ramsay Health Care UK Fulwood 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 thousands of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs, Clinical Commissioning Groups, NHS Trusts and NHS referral management and triage services.

Statement from Dr. Andrew Jones, Chief Executive Officer, Ramsay Health Care UK “The delivery of high quality patient care 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 and we remain committed to delivering superior quality care throughout our hospitals, for every patient, every day. As a clinician I have always believed that our values and transparency are the most important elements to the delivery of safe, high quality, efficient and timely care. Ramsay Health Care’s slogan “People Caring for People” was developed over 25 years ago and has become synonymous with Ramsay Health Care and the way it operates its business. We recognise that we operate in an industry where “care” is not just a value statement, but a critical part of the way we must go about our daily operations in order to meet the expectations of our customers – our patients and our staff. 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 our teamwork is a critical part of meeting the expectations of our patients. Whilst we have an excellent record in delivering quality patient care and managing risks, the company continues to focus on global and UK improvements that will keep it at the forefront of health care delivery, such as our global work on speaking up for safety, research collaborations and outcome measurements. I am very proud of Ramsay Health Care’s reputation in the delivery of safe and quality care. It gives us pleasure to share our results with you.” Dr. Andrew Jones Chief Executive Officer Ramsay Health Care UK


Introduction to our Quality Account This Quality Account is Fulwood Hall Hospital’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 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, developed by our Corporate Office, summarised and reviewed quality activities across every hospital within Ramsay Health Care UK. It was recognised that this didn’t provide enough in-depth information for the public and for 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.


Part 1

Statement on Quality

1.1 Statement on Quality from the Hospital Director At Fulwood Hall Hospital we appreciate patients are free to choose their healthcare provider and we are therefore consistently committed to offering the highest quality of care and clinical outcomes for our patients. Fulwood Hall Hospital has a long-established tradition of working closely with patients, external stakeholders including the NHS Clinical Commissioning Groups (CCGs) and General Practitioners (GP), as well as consultants to ensure the best quality healthcare is consistently being delivered. Our Vision is to be the leading local healthcare provider and the provider of choice, where clinical excellence, safety, care and quality are at the heart of everything we do. This Quality Account has been produced to demonstrate our continued commitment to measuring and acting on feedback from all our patients and customers about their experience, with the intention to continually learn and improve on all aspects of the services we provide. Fulwood's ‘Friends and Family’ patient satisfaction scores consistently achieve 100% for ‘would recommend to others’. This is consistent with the other local private hospitals and is higher than that of our local NHS Trust Hospitals. By analysing the results of this patient feedback and through a range of other patient feedback reports, we constantly seek ways to further improve the patient experience. Whilst patient feedback and involvement is extremely important to us, we also rely heavily on other measures of safety and clinical effectiveness which we use to satisfy ourselves that treatment is evidence-based and delivered by appropriately qualified and experienced doctors, nurses and other key healthcare professionals; examples of these are detailed in this Quality Account. Our Quality Account provides information for our patients and commissioners and provides assurance that we are committed to sharing our achievements and progress made from one year to the next. As a long standing and major provider for healthcare services across the world, Ramsay has a very strong record as a safe and responsible healthcare provider and we are proud to share our results. This Quality Account highlights areas where Fulwood Hall Hospital has improved the safety and quality of its services. It also highlights some areas where we need to continue to work on and improve upon. The development of this Quality Account was determined by the Executive Management Team within Ramsay Health Care UK. All professional and management teams at a local level have been represented in producing this account.

Margaret-Ann Worrell Hospital Director, Fulwood Hall Hospital


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.

Margaret-Ann Worrell

Hospital Director, Fulwood Hall Hospital Ramsay Health Care UK

This report has been reviewed and approved by:

• NHS Greater Preston Clinical Commissioning Group • Mr Ahsanul Haq, Consultant Urologist and Medical Advisory Committee Chair,

Fulwood Hall Hospital • Mr George McLauchlan, Consultant Orthopaedic Surgeon and Clinical Governance

Committee Chair, Fulwood Hall Hospital


1.3 Welcome to Fulwood Hall Hospital

Fulwood Hall Hospital is a private hospital situated near the M55/M6 motorway link in Fulwood in Preston, Lancashire. The hospital offers care to patients with private medical insurance, patients who wish to fund their own treatments and patients referred through the NHS Patient Choice Scheme. Fulwood Hall Hospital was opened as a purpose built facility in 1986. Independent patient satisfaction surveys show that 100% of our patients would recommend the hospital to family and friends and due to careful screening and rigorous infection control processes, the hospital continues to have a 0% MRSA incidence. Hospital Facilities Fulwood Hall Hospital can provide overnight en-suite inpatient accommodation for up to 29 patients, with 21 single rooms, 3 twin-bedded rooms and a dedicated two-bedded close care unit for higher risk patients. All bedrooms have TV/radio and telephone with WIFI being available throughout the building. Freshly prepared meals are prepared by in-house chefs and served directly to each patient in their room. Visitors are free to visit between the hours of 2pm and 4pm and from 6pm until 8pm. Extended visiting hours are available for our private patients. We also have a dedicated day care facility providing individual accommodation for up to 12 patients that are with us for less than a day. Our day care facility has been designed specifically to support patients in their recovery so they can be treated and return home as soon as they are clinically able and confident to leave. The hospital has 3 continually updated operating theatres with ultra clean, laminar air flow technology and a specialist endoscopy suite. A resident doctor is available on site 24 hours/day, 7 days/week. Our specialist ophthalmology suite and 9 private consulting rooms are supported by a fully equipped outpatient treatment room for minor procedures. Our pre-operative assessment unit screens and assesses patients prior to surgery.


Modern imaging facilities with ultrasound and mobile MRI and CT scanners are also available along with a physiotherapy and sports therapy department which includes a fully equipped gymnasium. Treatments and Services Fulwood Hall Hospital provides fast, convenient, effective and high quality treatment for patients of all ages (excluding children below the age of 19), whether medically insured, self-pay or from the NHS. Our full range of high quality services include, outpatient consultation, outpatient procedures, investigations/diagnostics, surgery and follow up care. Fulwood Hall Hospital has over 80 Consultants who work at Fulwood Hall Hospital through approved Practising Privileges providing a wide range of medical and surgical procedures and services including orthopaedic surgery, neurosurgery, general surgery, ENT, gastroenterology, gynaecology, neurology, ophthalmology, vascular surgery, colorectal surgery and urology. Competitively priced cosmetic surgery is also available from our specialist and highly experienced cosmetic surgeons - all of which hold substantive posts in NHS teaching hospitals. All patients at Fulwood Hall can be assured that they will only be seen and treated by their chosen operating Consultant throughout their treatment from first consultation to discharge. Fulwood Hall Hospital is BUPA accredited for gynaecology and colorectal cancer treatments and is one of the leading private providers for services in the North West. During the last 12 months the hospital has treated 9,431 inpatients, 89% of which were treated under the care of the NHS. Fulwood Hall Hospital employs 164 contracted members of staff and 94 members of bank staff. Free car parking and disabled access is available at Fulwood Hall Hospital.


Nursing and Medical Care All our patients are allocated a ‘named nurse’ at the beginning of each shift, the role of the named nurse is to provide co-ordinated care, support and treatment which is personalised to meet individual patient needs. The named nurse approach enables our patients to identify one nurse who is specifically and consistently responsible for their overall nursing care. In 1992 the Department of Health issued the Patients Charter in which the requirement for all inpatients to have a designated ‘named nurse’ was specifically mentioned. This has been re-enforced by the “hello, my name is…..” programme and all staff throughout the hospital will introduce themselves to patients. The Francis report into Mid Staffordshire (2013) also highlighted the advantages of having such a system in place but took the requirement further by stating that a ‘named nurse’ needed to be designated for each shift, this is the model used at Fulwood Hall Hospital. This was welcomed by the Royal College of Nursing that believes the ‘named nurse’ model provides a useful way to organise work around the needs of the patient (RCN 2014). Care and treatment provided at Fulwood Hall Hospital is Consultant led. We have looked at the Paterson conviction and looked at ways to give assurance locally as a hospital and corporately as an organisation to minimise the possibility of that recurring. All our Consultants have regular appraisals, are encouraged to submit data to PHIN and specialist services such as Orthopaedic, Neurosurgery and cancer services all use Multi-disciplinary team working to remove the potential for one Consultant to make key decisions in complex cases. We have an RMO (Resident Medical Officer) who supports the Consultants and together with the nursing team, providing round the clock medical support to all our patients. The hospital has built up excellent working relationships with our local Commissioners, Greater Preston CCG and the local Lancashire Teaching Hospitals NHS Foundation Trust in order to deliver a joint approach to patient care delivery across the patient economy. Our hospital staff are fully trained in the latest procedures and thus maintain all areas to the highest standards. Any patient who wishes to satisfy themselves on the quality of the hospital and it’s consultants can be reassured by the Care Quality Commission (CQC) Audits undertaken by the Department of Health which support the hospital’s excellent reputation. Working within the Department of Health guidelines, we screen patients for MRSA, and have a strong focus on patient safety. Cleanliness is vital to minimising infection. Fulwood Hall Hospital works with The Commissioning for Quality and Innovation (CQUINs) payments framework which encourages care providers to share and continually improve how care is delivered and to achieve transparency and overall improvement in healthcare. For the patient this means better experience, involvement and outcomes.

http://www.cqc.org.uk/location/1-128732946


Working with the Local Community Fulwood Hall Hospital continues to focus on delivering high standards of patient care in a friendly and approachable manner. Working with our partners, which include local GPs, consultants and other specialists, we deliver an individual personal service to patients, tailored to meet their needs.

Our GP Liaison Officer provides links to local General Practitioners to ensure that their needs and expectations are managed and through these links processes are developed in order to streamline processes. The GP Liaison Officer’s key role is to engage with local healthcare professionals within the community to ensure they are fully aware of the services on offer at Fulwood Hall Hospital and have access to any information that can assist General Practitioners and medical staff when referring into a secondary Care Provider. Part of the GP Liaison’s role is to coordinate the post graduate programme which runs on a monthly basis and covers a wide range of topics. Fulwood Hall Hospital also works closely with charities within the local community, hosting events in their support. The hospital supported ‘Little Teds – Baby Beat Appeal’ in 2016, managing to raise £1,788. We chose to support 'Defying Dementia' in 2017 and raised an amazing £2,417.49. In 2018 we supported the local charity ‘North West Blood Bikes’ raising a fantastic £ £2,159.54. This year, in 2019 we are supporting another local charity, ‘Cedar House Counselling Centre’ who are based in Preston. These are all either local charities or charities close to the heart of members of our staff and were decided by a vote through nominations received and discussed through our Staff Engagement Committee.


Part 2 2.1 Quality Priorities for Improvement 2018/2019

Plan for 2018/19

On an annual cycle, Fulwood Hall Hospital 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 ongoing at any one time. The priorities are determined by the hospitals Senior Leadership 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.

Fulwood Hall’s clinical strategy 2018-2019 was developed by the Hospital Head of Clinical Services (Matron), in conjunction with the clinical governance and medical advisory committees.


2.1.1 Review of clinical priorities 2018/19 (looking back)

Fulwood Hall Hospital had three clinical priorities during 2018/19:

1. Speaking Up For Safety (SUFS)TM Programme

2. Sign up to Safety

3. Safer Surgery and NatSSIP’s


1. Speaking Up For Safety (SUFS)TM Programme Across Ramsay Health Care we rolled out the ‘Speaking Up For Safety’ campaign which involved providing training for all staff and Consultants in the use of the ‘Safety Code’ which empowers all staff to speak up if they believe the safety of a patient is being compromised.

This has been successfully implemented at Fulwood Hall Hospital and we have been training peer messengers for the launch of the second stage which is ‘Promoting Professional Accountability’ which is being launched at Fulwood Hall on the 4th April 2019. This process has been well received throughout the hospital with staff feeling supported to challenge any behaviour which may affect safety.


2. Sign up to Safety

We are now in the second year of our safety improvement plan, the three areas forimprovement were:

1. Reducing Patient Falls

A review of the falls for the last three years reported on Riskman was carried out:

• In 2016/17 there were 25 reported falls (3 with harm to patient)



This is a greater than 50% reduction from 2016 to 2017 and a further 25% reduction from 2017 to 2018; this is a significant reduction year on year and shows evidence of implementation of robust processes. This means we have exceeded our target of reducing avoidable falls by 30% with a total reduction of greater than 60%

Absolute Numbers Rate per 100 discharges

2. Care of the Deteriorating Patient and Incident Reporting

There has been an increase in reported incidents on Riskman:

• In 2016/17 there were 217 reported incidents

• In 2017/18 there were 188 reported incidents

• In 2018/19 there have been 308 reported incidents

This shows a better understanding of the importance of reporting. During this time there has also been a decrease in incidents in incidents involving patients by

0

10

20

30

16/17 17/18 18/19

Falls

Fulwood Hall Hospital

0.00%

0.10%

0.20%

0.30%

16/17 17/18 18/19

Falls



almost 50% from 2016 to 2019 which is really positive news and shows the training and work on culture is really having a positive effect on patient care.

Whilst the number of Riskman incidents has increased the number of StEIS reported incidents have decreased year on year from 5 to 3 to 1 over the last three years, which is really positive and hopefully is showing the impact of all the collective measures that have been put in place.

This shows that incident reporting has become embedded throughout the hospital and it is now routine for staff to report incidents of any kind.

3. Information Security of Patient DataWe have not yet improved security of patient data to a level we are happy with.During the last 12 months there have been numerous changes within theoperational leadership team which has not allowed any new processes to becomeembedded. This will be an ongoing focus through the coming year.

3. Safer Surgery and NatSSIP’s

• The two key areas to focus on were the ‘surgical pause’ and the ‘debrief’ intheatre and the hospital is now fully compliant and audits will continue toprovide assurance that this compliancy is maintained.

• There were issues initially regarding other aspects of the WHO checklist withstaff members focussing purely on the two areas that had been identified asrequiring improvement which led to a lack of focus on other areas such as theoriginal sign in which has now been addressed with additional training andthrough team meetings and the involvement of the Medical AdvisoryCommittee.

• During 2018/19 there were zero never events in theatre and all staff havecompleted ‘Safety Code’ training so would speak up for the safety of theirpatient. This gives a high level of assurance within the department and thehospital and will help ensure that staff and Consultants are compliant withNatSSIP’s.


2.1.2 Clinical Priorities for 2019/2020 (looking forward)

Fulwood Hall Hospital’s Clinical Strategy for 2019/20, continues to be driven by our commitment to ensure that quality is at the core of everything we do. As a leading Independent Healthcare Provider we aim to continuously improve; quality, safety and patient experience.

• Speaking Up For Safety (SUFS)TM and Promoting ProfessionalAccountability

Speaking Up For Safety is an initiative that aims to promote safety by increasing the ease and motivation for clinicians to raise patient safety concerns with colleagues through graded assertiveness communication skills training. This is known as the ‘Safety Code’ and it is now mandatory for all staff to have attended training and will be part of the induction for new starters.

All clinicians will on occasion observe decisions or behaviours that cause them to consider whether the safest possible care is about to be delivered to a patient; whether observing the most junior or the most senior and respected clinician.

How a clinician responds to this dilemma is a reflection of:

• their training• their personal belief systems• their self confidence• the culture of their own professional group• the way their professional group interacts with other professional groups• the culture of the organisation they work in.

The barriers to a proactive response in such a situation are well known; fear of overstepping authority, expectations of negative consequences, or simply a lack of understanding of the framework and words to use when communicating concern.

Other industries have learnt that the ability to ‘speak up for safety’ is one of the most valuable resources they have to prevent errors of commission or omission.

Fulwood Hall Hospital and Ramsay Health Care are embracing the safety code and all staff will be encouraged to use it as appropriate to ensure patient safety and throughout 2019/20 this will be promoted and embedded throughout the hospital. When it is has been used it will be shared with the teams as example of how it can protect patients from risk of harm.


Promoting Professional Accountability Programme is an evidence-based framework that builds a high-performance culture of safety and reliability, and addresses individual behaviours that undermine it. The programme provides a system to identify, engage with and hold accountable staff who demonstrate repeated unprofessional behaviour.

The programme builds on the professionalism and commitment of the overwhelming majority of staff, while ensuring the actions of no one individual can undermine a culture of safety and quality.

It is built on respect for staff and acknowledges that the overwhelming majority of clinicians behave professionally and that all people make occasional errors.

It recognises that most observed incidents of unprofessional behaviour are uncharacteristic and unlikely to recur, particularly if brought to the individual’s attention.

Fulwood Hall will have Consultant key messengers and clinical staff key messengers to deliver the messages and support the process in practice. This will support our priority which is ensuring that we are delivering safe care to our patients.

Promoting Professional Accountability was launched at Fulwood Hall Hospital on the 4th April 2019 and is now available for all staff and Consultants via a portal. It is a confidential service which will be dealt with by a team outside of the hospital and any messages given will be done professionally and confidentially. It is anticipated that most people would only need one message to address their behaviour but if subsequent messages are required it can then escalate to the Chair of the Medical Advisory Service being asked to speak to the individual or the line manager depending on the individual concerned. There will be no way of tracking the number of individuals involved at hospital level, so there will be no published data at hospital level regarding the number of conversations that have taken place

The aim of Speaking up for Safety and Promoting Professional Accountability is to eradicate any instances of poor behaviour and to ensure that all patients are kept safe.


• Clinical Effectiveness

Looking at how we are performing and benchmarking against otherorganisations

Fulwood Hall has for a number of years participated in a number of studies to compare our performance against other hospitals but the engagement has been poor. This is particularly true for PROM’s, ICHOM’s and the British Spinal Register (BSR), until 2019 not all surgeons submitted data to the BSR.

For 2019/20 we aim to ensure that we improve our PROM’s submission data by 15% from the previous years so that we will have data that is more meaningful and reflective of what we are actually doing at the hospital.

We have commenced ICHOM’s recently but the pathway currently means that the patients do not have their post-op biometry at the hospital but go to different Optometrists so we are not capturing this data which invalidates the data that is being collected, during 2019/20 we endeavour to find a way to work with external services to capture this data.

All Orthopaedic Spinal Consultants and Neurosurgeons have agreed to have their data submitted and processes will be put in place to ensure this happens

We also now submit data to PHIN and it is essential that this information provides a true reflection of the services provided at the hospital so this will be a focus throughout 2019/20.

• Patient Experience

Fulwood Hall will continue to focus on patient feedback in order to build upon the patient experience at our Hospital. We pride ourselves as being the hospital of choice for all our patients and fully intend to continue to provide a first class service. Satisfaction has been monitored through patient feedback and complaints.

During 2019/20 we will look at how we can improve the patient journey by updating all the phone systems to make communications with the hospital better. We will develop the Autism Service to ensure any patients with autism have a good experience whilst under our care and we will look at how we can increase the percentage of patients completing patient satisfaction surveys to ensure our results are and accurate representative of the services we are providing.


• Well Led – Improving Staff Engagement

In one study of 200 hospitals, researchers found that the engagement level of nurses was the number one variable correlating to mortality.

Unfortunately, leaders often confuse employee engagement with employee appreciation or staff satisfaction; however, this is setting the bar too low. A satisfied employee may show up to work on time, do the minimum amount of work required, and be somewhat satisfied; however, true engagement is very different. True employee engagement is the emotional commitment employees have to the company and its goals. When employees are truly engaged, they care, give discretionary effort and go the extra mile.

For example:

• An engaged employee makes eye contact with patients, genuinely smiles, andwelcomes them

• An engaged employee escorts patients to their destination or helps family membersfind their loved ones

• An engaged employee listens to a patient, unrushed, and answers every questionregarding medications and discharge orders

• An engaged employee rounds on patients one last time before their shift is over• An engaged employee never forgets to wash their hands• An engaged employee makes fewer mistakes• An engaged employee puts patients first.

How will we engage our staff?

1. Articulate a clear vision to all employees and deliver this through ‘staff forums’.Senior leaders to role model our vision.

2. Ensure all staff are stakeholders in developing the hospital strategy.

3. Conduct employee engagement surveys and act on what staff say.‘You said we did’. Aim to receive >90% response in completion of staff survey.

4. Senior leaders will be trained about how to foster growth, trust, and healthyrelationships with employees through Compassionate Leadership - Leaders willhave an inspiring shared purpose, and strive to deliver and motivate staff to succeed.

Through compassionate leadership we will pay close attention to all staff and reallyunderstand the situations they face. Then respond empathetically and take thoughtfuland appropriate action to help.


2.2 Mandatory Statements Relating to the Quality of NHS Services Provided

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 2018/19 Fulwood Hall Hospital provided numerous NHS services.

Fulwood Hall Hospital 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 1st April 2018 to 31st March 2019 represents 100% of the total income generated from the provision of NHS services by Fulwood Hall Hospital for 1st April 2018 to 31st March 2019.

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 hospital’s senior managers together with Regional and Corporate 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 2018/19, the indicators on the scorecard which affect patient safety and quality were:

Human Resources

• Staff Cost % Net Revenue• HCA Hours as % of Total Nursing• Agency Cost as % of Total Staff• Cost• Ward Hours PPD• % Staff Turnover• % Sickness• % Lost Time• Appraisal %• Mandatory Training %• Staff Satisfaction Score• Number of Significant Staff Injuries

Patient

• Formal Complaints per 1000 HPD's• Patient Satisfaction Score• Significant Clinical Events per 1000

Admissions• Readmission per 1000 Admissions

Quality

• Workplace Health & Safety Score• Infection Control Audit Score• Consultant Satisfaction Score

2.2.2 Participation in Clinical Audit

During 1st April 2018 to 31st March 2019, Fulwood Hall Hospital participated in a number of national clinical audits.

The national clinical audits that Fulwood Hall Hospital participated in, and for which data collection was completed during 1st April 2018 to 31st March 2019, 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) 97%

Elective surgery (National PROMs Programme)

(figures from April 2017 – March 2018)

Hip 57.9%

Knee 56.3%

National Cardiac Arrest Audit (NCAA) Nil submissions

National Safety Thermometer 100% compliant

Medicine Safety Thermometer 100% compliant

British Spinal Register 45%

Serious Hazards of Transfusion (SHOT): UK National Haemovigilance

Nil submissions

Surgical Site Infection Surveillance Service 100% hips and knees

The reports of these national clinical audits were reviewed by the hospital’s Clinical Governance Committee and Fulwood Hall Hospital intends to take the following actions to improve the quality of healthcare provided.


Local Audits

The reports of local clinical audits from 1st April 2018 to 31st March 2019 (schedule attached in Appendix 2) were also reviewed by the Clinical Governance Committee.

Fulwood Hall Hospital participates in the Ramsay Corporate Audit Programme. The audit topic and schedule is set centrally by Ramsay Health Clinical Governance Committee to allow greater opportunity for benchmarking. Additionally Fulwood Hall Hospital also carries out a number of local clinical audits all of which go through the Clinical Governance Committee where actions are taken to improve the quality of the healthcare provided:

Summary of some of the local clinical audits undertaken from 1st April 2018 to 31st March 2019:

Medical Records: Initial audit score was 94%. This was due to incomplete documentation in care pathways and medical records, specifically handover sheet, operation notes not having times, and fluid balance not being balanced in recovery. It was evident that additional training was required to improve clinical record keeping and the completion of fluid balance charts. The final audit was also 94%, the areas previously addressed had all been improved but this low result was a result of low compliance to 48 hour pre-op phone calls. A review of the process was undertaken and we are looking at changing this to ensure phone calls are undertaken on a daily basis. There was also poor documentation regarding what information had been given to patients at pre-op assessment.

Patient Journey: Initial audit score 90%. There was incomplete information in the pre-operative assessment section which has been addressed with the team at the pre-op meetings. Disappointingly the most recent audit shows no real change with a result of 89%. However, all the action points from the initial audit have been addressed and we are now looking at issues relating to Consultants not completing all their documentation which will be addressed via Clinical Governance and Medical Advisory Committee meetings.

Ward Operational: Initial audit score was 100% and remained 100% at the end of the year so this is an excellent result for the ward team.

Theatre Operational: Initial audit score was 91%. Not all theatre staff had undertaken mandatory training or an appraisal within the last 12 months. Due to an increase in new staff within the department the training percentage had decreased. All staff have now been allocated a date for mandatory training and an appraisal where applicable to be undertaken between now and the end of June 2019. This is reflected in the slight increase in score when re-audited in March to 92%.


Theatre Observational: Initial audit score 92%. One of the main issues highlighted following the first audit was the low compliance of temperature monitoring during the perioperative phase. Additional work has been undertaken within the clinical teams and a Normathermia action group with members from both ward and theatre has been selected to undertake training and review of equipment available to drive best practice. Work continues and this has increased the audit score to 97%.

Infection Prevention and Control: The most recent IPC Environmental Audit, which was undertaken in March 2019, resulted in an overall score of 97%. This was a decrease from July 2019 audit score of 99%. Some areas within the hospital are in need of redecoration. A maintenance programme is now in place to rectify identified issues. Each Departmental Manager has undertaken a review of all clinical equipment and these will be replaced. A re-audit of the environment is planned for May 2019 which will see an improved score as the areas identified are currently being actioned.

Consent: The consent process is assessed in two stages. Stage one ensures that patients are provided with sufficient information to provide informed consent. Stage two confirms that the patient is happy to proceed having had time to consider the information provided. Our current hospital compliance is 99%.

Emergency Trolley Audit: To ensure that emergency equipment is ready for immediate use, a routine check of the defibrillator, oxygen and suction is undertaken daily. There is also a weekly audit of the content of the emergency trolley, this provides assurance that all emergency equipment is in date and there are sufficient numbers in each trolley as indicated by the Resuscitation Council (UK) 2017. These audit results are discussed and reviewed at our quarterly Resuscitation Committee Meetings. Our current hospital compliance to Emergency Trolley checks is 99%.

WHO – Surgical Safety Check Audit: Where any invasive procedures occur (out-patient department, theatre, radiology, endoscopy) we complete a monthly audit of WHO Surgical Safety Checks. The audit consists of review of the WHO checklist to ensure completion in full, and an observational audit of the process to ensure safety checks occur as set in policy. The audit assesses that clinical staff are routinely checking that the correct patient receives the correct surgery on the correct site, and the patient has been appropriately prepared and consented for the procedure planned. All departments scored >95% for WHO Surgical Safety Checks in March 2019.


2.2.3 Participation in Research

There were no patients recruited during 2018/19 to participate in research approved by a research ethics committee.

2.2.4 Goals agreed with our Commissioners using CQUINs

A proportion of Fulwood Hall Hospital income from 1st April 2018 to 31st March 2019 was conditional on successfully achieving quality improvement and innovation goals agreed by Fulwood Hall Hospital 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.

Fulwood Hall Hospital is currently awaiting final confirmation of our agreed CQUINs for 2018/19.


2.2.5 Statements from the Care Quality Commission (CQC)

Fulwood Hall Hospital is required to register with the Care Quality Commission and its current registration status on 31st March 2019 is registered without conditions

This is the summary from the recent report from the last inspection in August 2018:

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005. The main service provided by this hospital was surgery. Where our findings on surgery – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery service level. Services we rate our rating of this hospital stayed the same. We rated it as good overall. We found practice was good in relation to care in surgery, outpatients and diagnostic imaging services:

• The provider managed staffing effectively and services always had enough staff with theappropriate skills, experience and training to keep patients safe and to meet their careneeds.

• The hospital provided mandatory training for all staff and completion rates were high; thiswas up to date at the time of inspection.

• Staff were aware of hospital safeguarding procedures and followed these correctly.

• Staff were aware of the types of incident which could occur and reported these if theyoccurred. There was a good culture of incident reporting and learning was sharedfollowing this.


• Staff followed evidence-based care pathways for specific conditions; policies andprocedures were developed on national guidance.

• Seven-day services were available in case of emergencies and for responding toconcerns.

• Staff worked well together in multidisciplinary team approach to meet patients’ needs.

• The service responded well to different patient needs and had well established systemsfor supporting patients living with dementia or a learning disability.

• Leaders were visible and there was an open and positive culture amongst staff. Thehospital had developed a clear vision and strategy in engagement with staff.

• There was a clear governance system in place and this had been reviewed andstrengthened since our last inspection.

• The hospital engaged well with patients, staff, the public and local organisations to planand manage services appropriately, and collaborated with partner organisationseffectively.

However:

• Surgical safety and other theatre checklists were not always being carried out inaccordance with recognised best practice guidelines. The service did not always controlinfection risk well and we saw equipment and environmental defects which could presentan infection control risk.

• Managers did not always ensure staff received annual appraisals. Appraisal rates inoutpatients were poor and had been low in surgery.

• Pain scoring tools were used routinely in the physiotherapy department but not usedconsistently in the outpatient departments to manage patients’ pain levels.

We found areas of outstanding practice in surgery, outpatient and diagnostic care, including:

• Development of a working group for supporting patients who had autism.

• A focus on safety culture, with implementation of a ‘Speak up for Safety’ initiative andprovision of human factors training for all staff.

• Opportunities for staff development, and access to learning support funding for this,through Ramsay Healthcare.


We found areas of practice that require improvement in surgery and diagnostic imaging services, for:

• Improving practice in World Health Organisation (WHO) checklists.

• Maintaining robust systems for cleaning radiology equipment used in theatres.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two requirement notices that affected surgery and diagnostic imaging services.

As reported above it was identified during the inspection that Fulwood Hall Hospital did not always carry out surgical safety checklists in accordance with recognised best practice to ensure the safety of the patient during surgical episodes. This is a breach of Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (part 3) (as amended) parts 12 (1) and (2)(a). Fulwood Hall Hospital has now addressed this and are fully compliant in all aspects of the checklist and have been pro-active in simplifying the WHO checklist to ensure that it works in practice to ensure patient safety.

It was also identified that the provider did not ensure robust systems were in place for routine cleaning of radiology equipment used in theatre. This is a breach of Regulation 15 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (part 3) (as amended), parts 15 (1) (a). A process has now been put in place to ensure that equipment is cleaned and evidence is available that the equipment has been cleaned within the department.

We have had further meetings with our CQC inspector and a robust action plan has been completed to ensure all areas of improvement have been addressed

2.2.6 Data Quality

Fulwood Hall Hospital continues to take the following actions to improve data quality:

• Regular training to ensure staff understand the importance of accurate data input andhave sufficient technical competence.

• Spot checks completed by Senior Leadership Team to ensure data accuracy.

• Employment of a clinical coder to improve accuracy of recording.

• Supporting national Ramsay projects to ensure data accuracy.


NHS Number and General Medical Practice Code Validity

Fulwood Hall Hospital submitted records during 2018/19 to the Secondary Users 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 included:

The patient’s valid NHS number: • 100% for admitted patient care;• 100% for outpatient care; and• Accident and emergency care N/A (as not undertaken at Ramsay hospitals).

The General Medical Practice Code:

• 100% for admitted patient care;• 99.9% for outpatient care; and• Accident and emergency care N/A (as not undertaken at Ramsay hospitals).

Data Security & Protection Toolkit attainment levels (previously IG Toolkit)

Ramsay Group DSP Assessment Report overall for 2018/19 was 83% and was graded as ‘Standards Met.’ A score is no longer assigned.

This information is publicly available on the DSP website at: https://www.dsptoolkit.nhs.uk/

https://www.dsptoolkit.nhs.uk/


Clinical Coding Error Rate

Fulwood Hall Hospital was not subject to the ‘Payment by Results’ clinical coding audit during 2018/19 by the Audit Commission.

Hospital Site Next Audit Date

Primary Diagnosis

Secondary Diagnosis

Primary Procedure

Secondary Procedure

Fulwood Hall June 2019 96.4% 97.1% 100% 100%


2.2.7 Stakeholders’ Views on Fulwood Hall Hospital


Part 3: Review of Quality Performance1st April 2018 – 31st March 2019

Introduction

Statement from Vivienne Heckford

“This publication marks the ninth successive year since the first edition of Ramsay Quality Accounts. Through each year, month on month, we 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 assessments and opinions received from our doctors, our clinical staff, regulators and commissioners.

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, transparent 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


Ramsay Clinical Governance Framework 2019

The aim of clinical governance is to ensure that Ramsay develops ways of working which assure that the quality of patient care is central to 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

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.

3.1 The Core Quality Account Indicators

The following tables and graphs show comparisons regarding key data between the following:

• The best scoring hospital for this quality indicator based on all England hospitals providingNHS services

• The worst scoring hospital for this quality indicator based on all England hospitalsproviding NHS services

• The average score for this quality indicator• Fulwood Hall Hospital

Mortality

Period Best Worst Average Period Fulwood

Apr 16 - Mar 17 RKE 0.7075 RLQ 1.2123 Average 1 2017/18 NVC07 0.0001

Apr 17 - Mar 18 RJ1 0.6994 RE9 1.2321 Average 1 2018/19 NVC07 0.0000

SHMI Figures are not available for Independent Sector Hospitals. RiskMan data is used to find mortality rate.


0

1

2

3

16/17 17/18 18/19

Mortality


0.00%0.00%0.00%0.00%0.00%0.00%0.00%

16/17 17/18 18/19

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

Fulwood Hall has trained all ward and theatre staff on the NEWS2 observation chart and all staff completed Acute Illness Management training and a minimum of ILS with numerous staff completing ALS training. We have a robust process for pre-operative assessment and try to be as risk averse as possible which contributes to this year’s results.

Patient Reported Outcome Measures (PROMS)

Hernia Period Best Worst Average Period Fulwood

Apr16 - Mar 17 RJR 0.1618 RNA 0.016 Eng 0.089 Apr16 - Mar 17 NVC07 0.0840

Apr17 - Mar 18 RQM 0.136 RXK 0.029 Eng 0.089 Apr17 - Mar 18 NVC07 0.0583 REQUIREMENT is for ADJ. Health Gain. EQ-5D

Veins Period Best Worst Average Period Fulwood

Apr16 - Mar 17 RK9 1.3300 RTD -14.517 Eng -8.477 Apr16 - Mar 17 NVC07 *

Apr17 - Mar 18 RYJ -0.93 RWH -14.068 Eng -8.4501 Apr17 - Mar 18 NVC07 * REQUIREMENT is for ADJ. Health Gain. Aberdeen Score.

Hips Period Best Worst Average Period Fulwood

Apr16 - Mar 17 NTPH1 25.2044 RFS 17.838 Eng 22.019 Apr16 - Mar 17 NVC07 20.287

Apr17 - Mar 18 NTPH1 26.299 RBK 18.87 Eng 22.679 Apr17 - Mar 18 NVC07 22.770 REQUIREMENT is for ADJ. Health Gain. Oxford Hip Score. Primary Hip.

Knees Period Best Worst Average Period Fulwood

Apr16 - Mar 17 NTPH1 21.3485 RK5 12.647 Eng 16.877 Apr16 - Mar 17 NVC07 16.347

Apr17 - Mar 18 NT235 20.635 RAN 13.156 Eng 17.258 Apr17 - Mar 18 NVC07 16.804 REQUIREMENT is for ADJ. Health Gain. Oxford Knee Score. Primary Knee.


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

Readmissions


2010/11 Multiple 0.0 5P5 22.76 Eng 11.43 2017/18 NVC07 0.00181653

2011/12 Multiple 0.0 5NL 41.65 Eng 11.45 2018/19 NVC07 0.00163265 Data no longer reported.


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

The number of readmissions has decreased both in actual numbers and percentages over the last 12 months. This does not include any patients that present at the local trust rather than back at Fulwood Hall Hospital so measures are being put in place to attempt to capture this information as well as encouraging all patients to contact Fulwood Hall in the first instance if they have any complications following a procedure at our hospital.

We have 24 hour cover to review any patient and all patients are given the ward’s contact details. We will also now ask patients about any complications when they have the follow up call 4 weeks following hip and knee surgery to capture additional data.

0

5

10

15

20

16/17 17/18 18/19

Readmissions


0.00%0.00%0.00%0.01%0.01%0.01%

16/17 17/18 18/19

Readmissions



Responsiveness to Personal Needs


2012/13 RPC 88.2 RJ6 68.0 Eng 76.5 2013/14 NVC07 92.1

2013/14 RPY 87.0 RJ6 67.1 Eng 76.9 2014/15 NVC07 92.8

4b Patient experience of hospital care. No longer collected, data as last year.

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

Venous Thromboembolism (VTE) Assessment

Period Best Worst Average Period Fulwood 17/18 Q4 Several 100% NT490 0.0% Eng 95.2% 17/18 Q4 NVC07 99.5%

18/19 Q3 Several 100% NVC0M 14.7% Eng 95.7% 18/19 Q3 NVC07 97.0%

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

Fulwood Hall Hospital considers that this data is as described due to the robust processes in place to assess and report on all admitted patients as standard practice

0.8

0.82

0.84

0.86

0.88

0.9

0.92

0.94

0.96

0.98

1

80%81%82%83%84%85%86%87%88%89%90%91%92%93%94%95%96%97%98%99%

100%


Excellent

Fail

Actual

Target


C. Difficile Rate: per 100,000 bed days

Period Best Worst Average Period Fulwood 2016/17 Several 0 Q71 82.6 Eng 13.2 2017/18 NVC07 25.4 2017/18 Several 0 Q71 91.0 Eng 13.7 2018/19 NVC07 29.4

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.


Serious Untoward Incidents (SUIs): (Severity 1 Only)


Apr17 - Sep17 Several 0 RJW 0.64 Eng 0.15 2017/18 NVC07 0.00

Oct17 - Mar18 Several 0 RWD 0.55 Eng 0.15 2018/19 NVC07 0.00

No ind sector data, pulled from RM (Overall Sev 1). Acute Non-Specialist Data From NRLS, England Average based on these sites only


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.


Fulwood Hall Hospital has had no level 1 serious untoward incidents for the year 2018/19 and have only had one StEIS reportable incident. The hospital has introduced a ‘Speak Up For Safety’ process which aims to empower staff to intervene in any incidents where harm could potentially occur which could be a factor in this low number. The hospital is risk averse where possible and has strict pre-operative assessment processes which reduces the potential risk of incident.

0

2

4

16/17 17/18 18/19

SUIs (Severity 1 )


0.00%

0.02%

0.04%

16/17 17/18 18/19

SUIs (Severity 1)



Friends and Family Test


Jan-19 Several 100% RJR 71.0% Eng 96.0% Jan-19 NVC07 100.0%

Feb-19 Several 100% NVC12 70.0% Eng 96.0% Feb-19 NVC07 100.0%

Percentage Recommended.

This graph relates to: Q32 Please give your overall opinion of the quality of your care.

Friends and Family Test - Question Number 12d – Staff – The data made available by NationalHealth Service Trust or NHS Foundation Trust by NHS Digital ‘If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation' for each acute & acute specialist trust who took part in the staff survey.

4: Ensuring that people have a positive experience of care

Fulwood Hall Hospital is proud to maintain the high results for Friends and Family and will focus through 2019-2020 on increasing the response numbers.

97.7 97.8

0

20

40

60

80

100

2017 2018

Satis

fact

ion

Scor

es


Satisfaction Scores NHS/Private Patients


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.



0

5

10

15

20

25

16/17 17/18 18/19

Falls


0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

16/17 17/18 18/19

Serious Complaints


0.00%

0.00%

0.00%

0.01%

0.01%

0.01%

0.01%

16/17 17/18 18/19

Falls


0

1

16/17 17/18 18/19

Serious Complaints



3.2.1 Infection Prevention and Control

Fulwood Hall Hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 10 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 by 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.


0

5

10

15

16/17 17/18 18/19

Hospital Acquired Infections


0.00%

0.00%

0.00%

0.01%

0.01%

16/17 17/18 18/19

Hospital Acquired Infections


00.0010.0020.0030.0040.0050.0060.007

2016/17 2017/18 2018/19

Infe

ctio

n Ra

tes

(per

cent

age

of A

dmiss

iosn

s)


Infection Rates


Programmes and activities within our hospital include:

The Infection Control Link Nurse provides mandatory training in different areas of infection control on an annual basis to all staff. This year we have continued to encourage all patients to return to the hospital if they have any concerns regarding post-operative wound infections rather than using their own GP.

Hand hygiene awareness days are led by the Infection Control Link Nurse involving staff, patients and visitors and information in waiting areas.

Observational hand hygiene audits are also undertaken by the Infection Control Link Nurse.

As can be seen in the above graph our infection control rate remains very low.

An additional Infection Control Nurse has been recruited within Theatre to support the team.

Any patient presenting signs of an infection is reported on Riskman and then reviewed by the Infection Control Link Nurse and a root cause analysis completed to determine any possible trends. All results and any lessons learnt are presented at the hospital Health and Safety meetings, governance meetings and our quarterly infection control committee meetings. There have not been any trends identified in the period despite the increased reporting of infections in the reporting year.

3.2.2 Cleanliness and Hospital Hygiene

Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE).

The results for 2018 Audit were:

• National Average for Cleanliness was 98.47%; FHH 100%• National Average for Food and Hydration was 90.17%; FHH 95.40%• National Average for Organisation Food was 89.97%; FHH 92.50%• National Average for Ward Food was 90.52%; FHH 96.89%• National Average for Privacy Dignity and Wellbeing was 84.16%; FHH 95.12%• National Average for Condition Appearance and Maintenance was 94.32%; FHH 97.66%• National Average for Dementia was 78.89%; FHH 85.20%• National Average for Disability was 84.19%; FHH 91.76%

The results were again extremely positive, trending above the national average.

PLACE assessments occur annually at Fulwood Hall Hospital and provide a patient perspective and observation of the buildings and facilities, giving us a clear picture of how the people who use our hospital see it and how it can be improved. We are currently awaiting the date of our next planned PLACE Audit following a review of the programme, however PLACE are working towards the collection opening and we should receive the date of our next audit for 2019/20 very soon.


The scores for the 2018 PLACE Audit are shown below:

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 a 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 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.

In addition to mandatory training the Health and Safety Coordinator delivers a session on health and safety which is a revision for staff. There is a hospital Health and Safety board which covers a different topic every month helping to raise staff awareness and spot audits carried out monthly. The hospital Health and Safety coordinator is IOSH trained and we have an additional member of staff with the IOSH qualification.


3.3 Clinical Effectiveness

Fulwood Hall Hospital has a Clinical Governance team and committee that meet regularly through the year to monitor quality and effectiveness of care. Clinical KPIs, incidents together with patient and staff feedback are systematically reviewed to determine any trends that require further analysis or investigation.

More importantly, recommendations for action and improvement are presented to hospital management and the hospital’s Medical Advisory Committee to ensure results are visible and tied into actions required by the organisation as a whole.


0

5

10

15

16/17 17/18 18/19

Clinical Incidents


0.00%

0.00%

0.00%

0.01%

0.01%

16/17 17/18 18/19

All Incidents



3.3.1 Return to Theatre

Ramsay is treating significantly higher numbers of NHS patients every year as our services grow. The majority of 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.


Fulwood Hall continues to be pro-active through 2018-19 and has a process in place to capture any patients that require a return to theatre rather than them being admitted to the local trust. All patients are given the contact details for the ward on discharge and are asked to call the hospital if they have any concerns. Patients are also receiving a follow up call 48 hours following surgery. We have also asked all the Consultants that if they become aware of any patient that is admitted to a trust hospital to let us know so that we can maintain correct data for all our patients.

0

0.002

0.004

0.006

2016/17 2017/18 2018/19Retr

nn to

The

atre

(P

erce

ntag

e of

Adm

issio

sns)


Return to Theatre Score

0

5

10

15

16/17 17/18 18/19

Reoperations


0.00%

0.00%

0.00%

0.01%

16/17 17/18 18/19

Reoperations



3.3.2 Learning from Deaths

Fulwood Hall Hospital has had no deaths relating to hospital stays throughout the period 2018/2019. Ramsay Healthcare has a good process for sharing lessons learned across the organisation.


Ramsay Healthcare pro-actively looks at how we as an organisation can learn. Any SUI investigations are also shared across the organisation so that there is corporate wide learning from these incidents

3.3.3 Staff Who Speak Up

In its response to the Gosport Independent Panel Report, the Government committed to legislation requiring all NHS trusts and NHS foundation trusts in England to report annually on staff who speak up (including whistleblowers). Ahead of such legislation, NHS trusts and NHS foundation trusts are asked to provide details of ways in which staff can speak up (including how feedback is given to those who speak up), and how they ensure staff who do speak up do not suffer detriment. This disclosure should explain the different ways in which staff can speak up if they have concerns over quality of care, patient safety or bullying and harassment within the trust.

In 2018, Ramsay UK launched ‘Speak Up For Safety’, leading the way as the first healthcare provider in the UK to implement an initiative of this type and scale.

0

1

2

3

16/17 17/18 18/19

Mortality


0.00%

0.01%

0.01%

0.02%

0.02%

0.03%

16/17 17/18 18/19

Mortality



The ‘Speak Up For Safety’ programme, which is being delivered in partnership with the Cognitive Institute, reinforces Ramsay’s commitment to providing outstanding healthcare to our patients and safeguarding our staff against unsafe practice. The ‘Safety C.O.D.E.’ enables staff to break out of traditional models of healthcare hierarchy in the workplace, to challenge senior colleagues if they feel practice or behaviour is unsafe or inappropriate. This has already resulted in an environment of heightened team working, accountability and communication to produce high quality care centred on the best interests of the patient.

Ramsay UK has an exceptionally robust integrated governance approach to clinical care and safety, and continually measures performance and outcomes against internal and external benchmarks. However, following a CQC report in 2016 with an ‘inadequate’ rating, coupled with whistle-blower reports and internal provider reviews, evidence indicated that some staff may not be happy speaking up and identifying risk and potentially poor practice in colleagues. Ramsay reviewed this and it appeared there was a potential issue in healthcare globally, in response to this Ramsay introduced ‘Speaking Up for Safety’.

The Safety C.O.D.E. (which stands for Check, Option, Demand, Elevate) is a toolkit which consists of these four escalation steps for an employee to take if they feel something is unsafe. Sponsored by the Executive Board, the Hospital Senior Leadership Team oversee the roll out and integration of the programme and training at Fulwood Hall Hospital and across Ramsay. The programme is employee led, with staff delivering the training to their colleagues, supporting the process for adoption of the Safety C.O.D.E through peer to peer communication. Training compliance for staff and consultants is monitored corporately; the company benchmark is 85%.

Since the programme was introduced serious incidents, transfers out and near misses related to patient safety have fallen; and lessons learnt are discussed more freely and shared across the organisation weekly. The programme is part of an ongoing transformational process to be embedded into our workplace and reinforces a culture of safety and transparency for our teams to operate within, and our patients to feel confident in. The tools the Safety C.O.D.E. used, not only provide a framework for process, but they open a space of psychological safety where employees feel confident to speak up to more senior colleagues without fear of retribution. Ramsay UK is currently embedding the second phase of the programme which focuses on Promoting Professional Accountability, specifically targeted for peer to peer engagement for our Consultant users who work at Fulwood Hall Hospital and within Ramsay Health Care.


3.3.4 Priority Clinical Standards for Seven Day Hospital Services

Fulwood Hall Hospital only provides elective services and only accepts existing post-operative patients as emergency re-admissions. All our patients receive Consultant led care and practising privileges are only issued to Consultants that can get to the hospital within one hour and they arrange alternative Consultant cover for any occasions that they are not available. This ensures that we comply with seven day services clinical standards.

We have on-call radiology services and theatre to ensure that where appropriate our patients have access to the treatment required.

We have a service level agreement with the local trust for pharmacy, blood transfusion and pathology services which are all available 24 hours a day 7 days a week.

All of the above allows us to provide a seven day hospital service as required.

“The provision of ‘Seven Day Services’ is a requirement of the NHS Standard Contract and in essence requires providers of acute care to deliver high quality care and improve outcomes on a seven day basis for patients admitted to hospital in an emergency. There are ten separate Standards that providers must aim to achieve, with four of those being designated as being priority areas.

Ramsay Health Care has very few emergency admissions due to the nature of services provided to NHS patients (which is generally elective planned care in nature, rather than being emergency). As such many of the requirements of the Seven Day Services Programme are not applicable to Ramsay Health Care. Nonetheless Ramsay has been working to comply with the Standards and in line with national guidance a self-assessment process is being undertaken during spring/summer 2019.”


3.4 Patient Experience

All feedback from patients regarding their experiences with Ramsay Health Care is 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 fed back to the relevant staff directly. All staff are aware of our complaints procedures should our patients be unhappy with any aspect of their care.

Patient experiences are fed back via the various methods below and are standard agenda items on Local Governance Committees for discussion, trend analysis and further action where necessary. Escalation and further reporting to Ramsay Corporate and NHS England bodies occurs as required and according to NHS policy.

Feedback regarding the patient’s experience is encouraged in various ways via:

• Continuous patient satisfaction feedback via a web based invitation

• Hot alerts received within 48hrs of a patient making a comment on their web survey

• Yearly CQC patient surveys

• Friends and family questions asked on patient discharge

• ‘We value your opinion’ leaflet

• Verbal feedback to Ramsay staff - including Consultants, Matrons/Hospital Directors whilst visiting patients and Provider/CQC visit feedback.

• Written feedback via letters/emails

• Patient focus groups

• PROMs surveys

• Care pathways – patient are encouraged to read and participate in their plan of care.


3.4.1 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 patients’ 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 Director within 48hrs of receiving them so that a response can be made to the patient as soon as possible.


97.7 97.8

020406080

100

2017 2018

Satis

fact

ion

Scor

es


Satisfaction Scores NHS/Private Patients


Appendix 1

Services covered by this Quality Account

Regulated Activities – Fulwood Hall Hospital

Services Provided

Peoples Needs Met for:

Treatment of Disease, Disorder Or injury

Cardiology services, Dermatology, General Medicine, Haematology, Nephrology, Physiotherapy, Pain Management, Rheumatology, Sports Medicine

All adults 18 years and over

Surgical Procedures

Cosmetic/Plastic Surgery, Dermatological, Ear, Nose and Throat (ENT), Gastrointestinal, General Surgery, Gynaecological, Ophthalmic, Orthopaedic, Pain Management, Spinal and Neuro Surgery, Urological, Vascular, Ambulatory, Day and Inpatient Surgery

All adults excluding: • Patients with blood disorders (haemophilia, sickle

cell, thalassaemia) • Patients on renal dialysis • Patients with history of malignant hyperpyrexia • Planned surgery patients with positive MRSA

screen are deferred until negative • Patients who are likely to need ventilatory support

post operatively • Patients who are above a stable ASA 3. • Any patient who will require planned admission to

ITU post-surgery • Dyspnoea grade 3/4 (marked dyspnoea on mild

exertion e.g. from kitchen to bathroom or dyspnoea at rest)

• Poorly controlled asthma (needing oral steroids or has had frequent hospital admissions within last 3 months)

• MI in last 6 months • Angina classification 3/4 (limitations on normal

activity e.g. 1 flight of stairs or angina at rest) • CVA in last 6 months

However, all patients will be individually assessed and we will only exclude patients if we are unable to provide an appropriate and safe clinical environment.

Diagnostic and Screening

GI Physiology, Imaging Services, Phlebotomy, Urinary Screening and Specimen collection.

All adults 18 years and over

Family Planning Services

Gynaecology patient pathway, insertion and removal of inter uterine devices for medical as well as contraception purposes

All adults 18 years and over as clinically indicated


Appendix 2 Clinical Audit Programme 2018/19


Fulwood 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 Hospital Director using the contact details below.

For further information please contact:

Telephone: 01772 704 111 www.fulwoodhallhospital.co.uk

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