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Rowley Hall Hospital Quality Account 2016/17

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 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.


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


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.


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.


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

[email protected]

mailto:[email protected]


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



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)


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,


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.


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.


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.


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


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.


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


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


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


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.


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

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.


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.


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 -


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


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.

.


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).


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.

https://www.igt.hscic.gov.uk/


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.


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.


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 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


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

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


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 *


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 *


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


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


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.


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


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


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.


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%


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


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.


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 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.


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



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


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%


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.


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.


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)


Infection Rates


Our annual assessment took place during May 2016 and the results are as follows:


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.


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.


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)


Return to Theatre Score


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.


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


Satisfaction Scores NHS/Private Patients


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.


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


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.


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.


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




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

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