board report summary sheet€¦ · catering services (food hygiene & safety) the trust’s...

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BOARD REPORT SUMMARY SHEET

Meeting:

Date:

Trust Board

29 August 2019

Title:

Annual Report 2018/19

Functional Support Services

Lead Director:

Melanie McClements,

Interim Director of Acute Services

Purpose:

For approval

Key strategic aims:

This report has been prepared to meet the requirements of the Trust’s

Controls Assurance Standards relating to Food Hygiene and Safety,

Environmental Cleanliness, Decontamination of Reusable Medical

Devices and Security Management. This report also provides an update

on the other services within Functional Support Services and it

summarises the key issues/achievements for each service area in

2018/19 and sets out their key objectives for 2019/20.

Key issues/risks for discussion:

Catering Services (Food Hygiene & Safety)

The Trust’s 2018/19 self-assessment score against the Food

Hygiene and Safety Controls Assurance Standard was

Compliant at 88%.

All 48 of the Trust’s registered food premises are rated 5 which

is the top rating under the National Food Hygiene Rating

Scheme.

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A new hot drinks vending machine is now available in

Craigavon Area Hospital main foyer, which provides hot drinks

24/7 and it has been very well received by patients and visitors.

Catering Services representatives were involved in groups

established to take forward the implementation of the new

International Dysphagia Diet Standardisation Initiative (IDDSI)

descriptor levels for dysphagia meals and dysphagia awareness

training was received by Catering Services staff.

In January 2019 issues regarding the texture of certain

dysphagia meals had been identified and raised with BSO.

Catering Services along with the Dieticians audited the items

sold in all of the Trust Dining Rooms and Coffee Bars against

the Minimum Nutritional Standards for Catering HSC which will

assist in prioritising the work required to implement the

Standards.

During 2018/19 Managers had to keep their Catering

Contingency Plan under constant review due to the United

Kingdom’s plans to leave the European Union.

The recycling of waste commenced in the Dining Room at

Craigavon Area Hospital in February 2019, in conjunction with

Estates Services and there are plans to roll out recycling to the

other Dining Rooms and Coffee Bars.

Domestic Services (Environmental Cleanliness)

The Trust’s 2018/19 self-assessment score against the

Environmental Cleanliness Controls Assurance Standard was

Compliant at 88%.

As a result of new inpatient beds introduced in the Trust the bed

cleaning sections of the Terminal and Discharge Cleaning

Standard Operating Procedures were updated and trained out

to all ward-based Domestic Services staff.

Domestic Services were involved in trialling the new Micad

Cleaning Monitoring System and 8 new i-pads were secured to

run the new system.

Domestic Services are addressing the actions in relation to

environmental cleanliness to meet the objectives of the Infection

Prevention Control Strategy 2018-21.

Portering, Security and Car Parking Services

The Trust’s 2018/19 self-assessment score against the Security

Management Controls Assurance Standard was Compliant at

84%.

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Work continued during 2018/19 to extend the network’s access

control system at Craigavon Area Hospital.

The external security contract is being retendered and the new

security contract should be in place by 1 September 2019.

Support Services have been working closely with Estates and

IT Services in relation to the new CCTV infrastructure. Capital

funding of £100k was secured to upgrade the CCTV

infrastructure and replace faulty cameras at Craigavon Area

and Daisy Hill Hospitals, and also Carrickore Respite Unit.

Support Services, Estates Services and Emergency Planning

have been involved in finalising lockdown plans for Craigavon

Area and Daisy Hill Hospitals.

At Daisy Hill Hospital access to the hospital at night has been

reviewed and additional lockdown arrangements have been

implemented to restrict access to the main block at night.

Following some significant security incidents in the Emergency

Department and Acute Medical Unit, Craigavon Area Hospital,

and subsequent concerns raised by staff work began to develop

plans to enhance security in these areas.

A new Pay and Display Car Park opened at the main entrance

at Daisy Hill Hospital for the convenience of patients attending

Outpatients Department following its relocation to Bernish

House and parking enforcement was extended to cover pay

and display parking.

Decontamination Services


Decontamination of Reusable Medical Devices Controls

Assurance Standard was Compliant at 91%.

Both the Trust’s Sterile Services Departments were externally

audited by the British Standards Institute (BSI) in January 2019

and they were successfully re-accredited to the BS EN ISO

13485:2016 Quality Management Standard and the Medical

Devices Directive (MDD) 93/42/EEC.

Radiology, Thorndale Unit and Integrated Maternity and

Women’s Health Services are all using the Trophon semi-

automated system for the decontamination of specialised

probes in line with the Department of Health Decontamination

policy best practice guidance.

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The trans-oesophageal (TOE) probes used in the Cardiac Cath

Lab are not yet being processed through a semi-automated

decontamination process in an Endoscope Washer Disinfector

(EWD) as staff training has not yet taken place but this is

planned for the Autumn and this risk is logged on the Medicine

and Unscheduled Care Divisional Risk Register.

The two interim endoscope decontamination facilities in Day

Surgery Unit and Theatres, Craigavon Area Hospital do not

meet the requirements of the Department of Health

Decontamination Strategy and this risk is logged on the Acute

Services Directorate Risk Register.

The endoscope washer disinfectors (EWDs) on the Craigavon

Area Hospital site have past their life expectancy and funding

for replacement EWDs has been included in the Trust’s Capital

Priority List and this risk is logged on the Acute Services

Directorate Risk Register.

Laundry Services

During 2018/19 the Laundry started a programme of

modernisation and reform. Capital investment of circa

£330,000 was secured for the replacement of a new calender

and two new washing machines, which were installed on the 1

April 2019.

Equipment maintenance/breakdown problems are still a major

issue for the Laundry and this risk is logged within the broader

Capital risks on the Board Assurance Framework..

Laundry Services were externally audited by National Quality

Assurance (NQA) in February 2019 and they were successfully

re-accredited to the ISO 9001:2015 Standard.

Switchboard Services

The new iMessage bleeping system is now operational

throughout the Trust.

Capital investment of £50,000 was secured for the purchase of

a new Avaya Equinox Switchboard system for both Craigavon

Area and Daisy Hill Hospitals which will provide a more

modernised call answering system.

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Chaplaincy Services

Since Functional Support Services took over responsibility for

the Trust wide Chaplaincy Services, regular meetings of the

Chaplaincy Teams at Craigavon Area and Daisy Hill Hospitals

have been established, which has improved information sharing

and communications.

Patient information supplied to the Chaplains has been

reviewed to ensure that it is line with General Data Protection

Regulations (GDPR).

Health Records, Ward Clarks, Emergency Department Admin & Data

Validation Admin

As a result of the centralisation of the Ophthalmology Service to

the Belfast HSC Trust, Health Records had to pull and

photocopy over 4,000 records.

A proposal was submitted and approved for iFIT technology for

locating patient charts and this is on the capital list for

consideration of funding.

The requesting of blood via Ordercomms from the core wards is

now carried out by Ward Clerks on both the Craigavon Area

and Daisy Hill Hospital sites which has freed up Junior Doctors’

time to enable them to provide more face-to-face care for

patients.

The Ward Clerks have worked with the Medicine and

Unscheduled Care Division to set up the Direct Assessment

Unit at Daisy Hill Hospital.

The Ward Clerks have been involved in implementing a new

ward attender process for Cardiology patients, which will ensure

that all patients seen by Cardiologists while on a ward will be

captured on the Patient Administration System (PAS).

Scanning of Emergency Department documentation for under

four year old patients in Craigavon Area Hospital Emergency

Department has commenced.

Admin staff have been involved in setting up virtual wards at

both Craigavon Area and Daisy Hill Hospitals.

Admin staff have been involved in the setting up of the

Pulmonary Embolism (PE) Service ensuring patient information

is recorded accurately.

A new system of registering patients for a Major Incident has

been implemented.

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Referral and Booking Centre & Secretarial Support

The Referral and Booking Centre has supported the

implementation of the E-Referrals system within Northern

Ireland Electronic Care Record (NIECR) across the Trust with

sixteen Specialities now live across Acute Services.

The Referral and Booking Centre has re-introduced the sending

of acknowledgment letters to patients advising them that their

referral has been received.

Admin staff have played an important key role in establishing

the new elective centres, in particular the Regional Cataract

Service at South Tyrone Hospital.

Admin staff were involved in the transfer of the Ophthalmology

Service to Belfast HSC Trust.

Admin staff worked alongside Health Records as a joint project

to try and introduce ‘chartless’ clinics.

Admin Managers have rolled out Voice Recognition in Geriatric

Specialty.

The roll out of EDT (Electronic Document Transfer) was

completed during 2018/19 with the result that the Trust now

sends letters electronically to GPs.

Data quality remains a big issue for Admin Managers who have

continued to work alongside other departments to enhance the

quality of information throughout the Trust, and additional

support is now in place to support this work.

Admin Managers have worked with the Information Department

and the Data Quality Team on virtual recording of information

for most of the Specialities.

The increased introduction of biologics therapies has meant a

change to admin processes as the recording requirements are

different for these treatments and Admin Managers have been

involved in developing Standard Operating Procedures along

with the Consultants/Specialist Nurses and PAS team to ensure

that the data is captured accurately for these patients.

Admin staff in Antenatal Dept have facilitated the roll out of the

electronic sign-off of results and this has now been extended to

Dermatology as a pilot.

A review of booking processes was completed for RACP (Rapid

Access Chest Pain) and procedures have been written up

resulting in the Admin staff now providing a more centralised

booking system which ensures equity for patients using this

service.

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Admin Managers in conjunction with the Information Team have

been involving in reviewing patients that have an Open

Outpatient Referral Registration on the Patient Administration

System (PAS).

Summary of SMTdiscussion:

Breadth and depth of work acknowledged and commended. Some

discussion re capital requirements for consideration by CAG. Discussed

change to Controls Assurance Standards approach.

Human Rights/Equality:

No Issues

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Annual Report 2018/19

Functional Support Services

Functional Support Services August 2019

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1.0 INTRODUCTION

The Functional Support Services Division sits within the Acute Services

Directorate and it has responsibility for a range of essential services including

Catering, Domestic, Portering, Security, Car Parking, Decontamination,

Laundry, Switchboard, Chaplaincy, Health Records, Ward Clarks, Emergency

Department Admin, Data Validation Admin, Referral and Booking Centre and

Secretarial Support.

Following the cessation of the DHSSPSNI Controls Assurance process on 1

April 2018 the Southern Trust along with the other Trusts in the region agreed

Assurance Standard templates relating to Food Hygiene and Safety,

Environmental Cleanliness, Security Management. The Decontamination of

Medical Devices and the Medical Devices and Equipment Management

Standards were amalgamated to form a Medical Devices Management

Governance Framework and a regional template will be developed

amalgamating both of these Standards, however for 2018/19 each Trust has

completed the same self-assessment templates as previously used. This

report has been prepared to meet the requirements of the Trust’s Controls

Assurance Standards relating to Food Hygiene and Safety, Environmental

Cleanliness, Security Management and Decontamination.

This report also provides an update on the other services within Functional

Support Services. It summarises the key issues/achievements for each

service area in 2018/19 and sets out their key objectives for 2019/20.

2.0 CATERING SERVICES (FOOD HYGIENE AND SAFETY CONTROLS

ASSURANCE)

Catering Services operate out of four main production kitchens which supply

meals for in-patients, clients and staff, within the Southern Trust, namely

Craigavon Area Hospital, Daisy Hill Hospital, South Tyrone Hospital and

Lurgan Hospital.

Catering Services is also responsible for the in-patient meal service at

Bluestone Unit and Mullinure Hospital, and for the Ground Floor Coffee Bars

at Craigavon Area Hospital, Daisy Hill Hospital, Bluestone Unit, Portadown

HCC, Banbridge HCC and St Luke’s Hill Building.

A total of approximately 860,000 patient/client meals were served during

2018/19 (based on 3 meals per day) compared to approx. 800,000 in 2017/18.

Catering outlets serviced circa. 1.1 million customers during 2018/19

compared to circa. 1 million in 2017/18. There are circa. 117 whole-time

equivalent staff employed in Catering Services.

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2.1 Key Issues / Achievements 2018/19

2.1.1 New Tea and Coffee Vending Facilities at Craigavon Area Hospital

In March 2019, a hot drinks vending machine was installed at

Craigavon Area Hospital main foyer which provides hot drinks 24/7.

The new hot drinks vending is in response to a need that was identified

by patients and visitors and it is in line with the Trust’s strategic

direction for out-of-hours catering services and addresses complaints

from service users about the lack of facilities out-of-hours, and the new

machine has been very well received.

2.1.2 Dysphagia Meals

Catering Services representatives were involved in groups established

to take forward the implementation of the new International Dysphagia

Diet Standardisation Initiative (IDDSI) descriptor levels for dysphagia

meals and dysphagia awareness training was received by Catering

Services staff.

In January 2019 issues regarding the texture of certain dysphagia

meals had been identified in the region and as a result of this, audits

were completed by Nursing and Speech and Language staff which

raised concerns regarding inconsistencies with the texture of some

products. Nursing staff and community facilities were alerted to the

issues and for the need to remain vigilant when serving meals. The

issues were raised with Business Support Organisation (BSO) who

worked with the company to identify and address the problems.

2.1.3 Controls Assurance

The Trust’s 2018/19 self-assessment score against the Food Hygiene

and Safety Controls Assurance Standard was Compliant at 88%.

2.1.4 National Food Hygiene Rating Scheme

All 48 of the Trust’s registered food premises are rated 5 under the

National Food Hygiene Rating Scheme. 5 is the top rating. Ratings

are published on the Food Standards Agency website.

Under the National Food Hygiene Rating Scheme all food premises

registered with the Council are given a rating after an inspection visit.

Food premises are rated according to the level of compliance with:-

Food hygiene and safety procedures i.e. food handling practices

and procedures and temperature control.

Structural requirements i.e. cleanliness, layout, condition of

structure, lighting, ventilation etc.

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Confidence in management requirements i.e. Food Safety

Management System (HACCP) and training.

2.1.5 Minimum Nutritional Standards for Catering HSC

Audits were conducted by Support Services and Dietitians in the Dining

Rooms and Coffee Bars as part of the work of the Trust’s Nutrition in

the Workplace Group and these were completed in June 2018. These

audits provided a snapshot of the level of compliance with the Minimum

Nutritional Standards. There are 43 Standards in total and the Trust

Catering outlets were Fully Compliant in 13, Partially Compliant in 26

and Non-Complaint in 4 Standards. 26 Recommendations were

identified during the audit to improve compliance against the

Standards, which will provide healthier menu choices and products

offered to promote healthier eating for staff and visitors in the Dining

Rooms and Coffee Bars.

Catering Departments have been working alongside the Nutrition in the

Workplace Group to make realistic changes in the Dining Rooms and

Coffee Bars based on the results from the audit. Work is ongoing to

implement the Recommendations but Catering Departments will need

support in order to progress some of the Recommendations. This will

require training, marketing and promotion and increased customer

education with regards to nutritional information. Investment in

Catering Services will therefore be required to deliver many of the

Recommendations.

Regionally a Project Lead has been funded by the Public Health

Agency (PHA) to assist Trusts with implementing the Minimum

Nutritional Standards. The PHA expects Trusts to deliver training from

their Health and Well Being budget and within the Southern Trust,

Dietitians have been identified to deliver training to Catering staff.

2.1.6 EU Exit

During 2018/19 Managers had to keep their Catering Contingency Plan

under constant review due to the United Kingdom’s plans to leave the

European Union. Representatives from the Trust attended Regional

Catering Group Meetings with Business Support Organisation (BSO)

regarding contingency plans in preparation for EU Exit.

2.1.7 Recycling in Dining Rooms

The recycling of waste commenced in the Dining Room at Craigavon

Area Hospital in February 2019, in conjunction with Estates Services

and there are plans to roll out recycling to the other Dining Rooms and

Coffee Bars.

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2.2 Key Objectives 2019/20

2.2.1 New Dysphagia Descriptors

From 1 April 2019 Catering Services will require to roll out the inpatient

menu changes in line with the new dysphagia descriptors under the

IDDSI Framework and work with the Dieticians and Nursing to ensure

that the new menus are embedded at ward level.

2.2.2 Allergens

Complete review of Grab & Go and pre-packaged food that is sold in

the Dining Rooms and Coffee Bars in preparation of the new legislation

regarding the labelling of pre-packed food for direct sale that will be

introduced in 2021.

2.2.3 Recruitment

Complete the ongoing recruitment exercise for Catering Assistants to

help regularise Catering Services which is highly reliant on Agency staff

and identify the need for further recruitment.

Develop a plan to address the recruitment difficulties for Cooks and

Supervisors in the main production kitchens.

2.2.4 Saffron Catering Management Information System

To appoint a Project Lead from within existing resources with the

support of a Band 4 Information Officer to progress implementation of

the Saffron Management Information System and secure funding for

the replacement of tills at Catering outlets which will allow the sales

data to be linked to Saffron.

2.2.5 Food Vending Service

There are plans to roll out healthier vending services in all locations

across the Trust. All stock in vending machines will be critically

reviewed to promote healthier choices and this will be enabled by the

new regional vending contract due to be implemented in February

2020.

2.2.6 Hot Drinks Vending Service

There are plans to roll out hot drinks vending services in other areas

where visitor feedback and footfall indicates need.

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2.2.7 Minimum Nutritional Standards for Catering HSC

To have Catering managers and staff trained in Level 2 Award in

Nutrition for Health (Royal Society for Public Health) by March 2020 to

help progress implementation of the Minimum Nutritional Standards

and the Recommendations from the Southern Trust audit.

2.2.8 Review of Patient Menus Daisy Hill Hospital

Following feedback from patients a review of patient menus was

undertaken at Daisy Hill Hospital. This review has involved

engagement with the Dieticians and Nursing and it is aimed to

complete the review and introduce the new menus by December 2019.

2.2.9 Mealtime Matters Project

To work in collaboration with Nursing staff to roll out the Mealtime

Matters Project which will help to improve the nutritional care provided

to patients by ensuring Nursing engagement at ward level throughout

meal times.

3.0 DOMESTIC SERVICES (ENVIRONMENTAL CLEANLINESS CONTROLS

ASSURANCE)

There are circa 313 whole-time equivalent staff employed within Domestic

Services who carry out cleaning duties. Services are provided in Craigavon

Area Hospital, Bluestone Unit, Daisy Hill Hospital, Lurgan Hospital, South

Tyrone Hospital, St Luke’s and Tower Hill site and community facilities mainly

covering Health Centres. On Acute sites there are ward-based domestic staff

who not only provide a cleaning service ranging from bed-washing to

specialist cleaning but also duties associated with catering/ patient feeding.

During 2018/19, 45 Managerial Audits were carried out and the scores are

shown in the table at Appendix 1. The Managerial Audits are undertaken by a

Managerial Audit Team which provides a level of independence and the Team

includes representation from Support Services, Infection Prevention and

Control, and Estates Services. The Managerial Audits are in additional to

Domestic Cleaning Audits and Departmental Audits. The Departmental

Audits are carried out by the Domestic Supervisor and the Ward/Department

Managers.

During 2018/19, two unannounced infection prevention / hygiene inspections

were conducted by the Regulation and Quality Improvement Authority (RQIA)

and the scores are shown in the table at Appendix 2. The full audit reports

are available on the RQIA website.

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3.1 Key Issues/Achievements 2018/19

3.1.1 Estates Works at Craigavon and Daisy Hill Hospitals

During 2018/19 there were estates works carried out on both the

Craigavon Area and Daisy Hill Hospital sites. New services were

opened and there were significant moves. Cleaning was well managed

by Domestic Services to ensure that areas were cleaned in time for

opening and that cleanliness was maintained to a high standard during

these works.

At Craigavon Area Hospital, Domestic Services had to increase

cleaning while work was underway for the new Ambulatory Ward and

Aseptic Suite and also in the main foyer of the hospital. The

Boardroom was relocated to beside the Dining Room, the shop was

relocated, and a new waiting area and public toilets were created.

At Daisy Hill Hospital, Domestic Services had to increase cleaning

while work was underway for the opening of the Direct Assessment

Unit in February 2019 and also the relocation of Outpatients

Department and GP Out-of-Hours to Bernish House.

3.1.2 Pressures on Domestic Services

2018/19 was another busy year for Domestic Services. The usual

Winter Pressures, new services and the introduction of new inpatient

beds added to pressures for the Domestic Services Teams at both

Craigavon Area and Daisy Hill Hospitals.

During outbreaks additional cleaning is required and a full terminal

clean is needed before the next patient. The number of terminal cleans

carried out by Domestic Services was 11,146 in 2018/19. During

outbreak periods Domestic Services staff worked additional hours to

ensure service delivery requirements were met and beds were turned

around quickly.

At Craigavon Area Hospital, Domestic Services continue to deliver a

high quality service in Emergency Department without additional

funding following the reconfiguration of that area in 2017.

As a result of the new model of inpatient beds being introduced in the

Trust the bed cleaning sections of the Terminal and Discharge

Cleaning Standard Operating Procedures (SOPs) were updated and

the updated SOPs have been trained out to Domestic Services staff

from February 2019 as the new beds were installed.

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All ward based Domestic Services staff required this update training,

which was a considerable task for Domestic Services to deliver in a

tight timeframe but was critical to ensure the safety of patients and

staff.

3.1.3 Controls Assurance Standard

The Trust’s 2018/19 self-assessment score against the Environmental

Cleanliness Controls Assurance Standard was Compliant at 88%.

3.1.4 Micad Cleaning Monitoring System

Following the regional decision to use the Micad Cleaning Monitoring

System, during 2018/19 Domestic Services began trialling the new

system and have worked collaboratively with IT Department, engaging

with the suppliers and other Trusts to resolve technical difficulties

encountered during the trial.

3.1.5 IPC Strategy 2018-2021

In 2018 the Trust launched a new three year Infection Prevention

Control (IPC) Strategy to enable progress and sustained improvement

in infection prevention and control and Healthcare Acquired Infections

incidence across the Trust.

The Strategy includes a ten point plan to ensure success of the

Strategy, one of which is ‘Clean Place’ which links to environmental

cleanliness. An action plan was developed to meet the objectives of

the IPC Strategy and Domestic Services have started to address the

actions required which included a review of the Trust’s Environmental

Cleanliness Policy and progressing the implementation of the new

Micad cleaning monitoring system.


3.2.1 Micad Cleaning Monitoring System

Finalise the implementation plan for the rollout of the Micad cleaning

monitoring system to Domestic Services in all hospitals by October

2019.

3.2.2 Funding for Domestic Services

Submit bids for additional resources to meet the deficits in funding at


3.2.3 IPC Strategy 2018-2021

Progress the actions required in relation to environmental cleanliness

to meet the objectives of the IPC Strategy.

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4.0 PORTERING, SECURITY AND CAR PARKING SERVICES

There are circa. 80 whole-time equivalent Portering staff employed on the

hospital sites across the Trust. Portering staff are responsible for the

movement of patients within the hospitals.

In 2018/19 Porters undertook circa. 2,000 planned and unplanned patient

movements in a typical week compared to 1,500 in 2017/18. This includes

moving patients to and from Emergency Departments/ Wards to Theatres, X-

Ray and other therapies. Portering Services are also responsible for the

movement of laundry, linen and waste and deliveries of medical gases and

pharmacy supplies. They also receive, sort and deliver approx. 5,500 items of

mail each day.

Portering Services manage the day-to-day operation of the car parking

systems at Craigavon Area and Daisy Hill Hospitals. Car parking enforcement

is in place at Craigavon Area and Daisy Hill Hospital sites, which has

significantly improved traffic flow and reduced inappropriate parking. On the

4 February 2019 a new Pay and Display Car Park opened at the main

entrance at Daisy Hill Hospital for the convenience of patients attending

Outpatients Department following its relocation to Bernish House and parking

enforcement was extended to cover pay and display parking.

There are a minimum of three Porters with Security Duties on duty on each

shift at Craigavon Area and Daisy Hill Hospitals. As part of this security role

they respond to security incidents involving patients and visitors in Emergency

Department and on the Wards to support the Nursing and Medical staff. The

Security Porters provide an immediate response when the security bleep is

activated and their good response times are crucial for the protection of

patients and staff, and this has been acknowledged by staff and the PSNI.

The Trust, in line with the Department of Health’s commitment to protect staff to ensure that they can provide a quality service without fear of abuse, continues to deliver Management of Aggression or Potential Aggression (MAPA) training to front line staff on a risk and needs led basis. All Porters with Security Duties receive MAPA training and refresher MAPA training is delivered annually to Security Porters. This ensures that they have the knowledge and skills to deal with potentially aggressive situations.

The table below shows the total number of security incidents for the period

2018/19 compared to 2017/18. A breakdown is provided at Appendix 3.

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Column1

2018/19 2017/18 2018/19 %

Increase

No. of Verbal abuse incidents as

reported to the DoH

712 316

125%

No. of Physical abuse incidents as

reported to the DoH

1577 941

68%

Security incidents other than abuse

recorded on Datix

125 100 25%

Absconders / Missing Patients

recorded on Datix

513 475 8%

Total 2927 1832 60%

During 2018/19 the Trust used an external contractor (Noonan) to provide

security guarding services at Daisy Hill Emergency Department, Lurgan

Hospital and Dromalane site. The external security contract is due to expire

on 31 August 2019 and Support Services have been involved in the tender

process for the new contract.

The Trust has responsibility for the security of circa 227 blocks/buildings over

60 sites. The external contractor also provides locking / unlocking and key

holding / alarm response services at some sites based on the level of

occupancy and assessed need.

During 2018/19 the external security contractor responded to circa. 264

callouts across the Trust (compared to 277 in 2017/18) and these mainly

related to intruder alarm activations.



The Trust’s 2018/19 self-assessment score against the Security

Management Controls Assurance Standard was Compliant at 84%.

4.1.2 Access Control System Craigavon Area Hospital

During 2018/19, work has continued to extend the network’s access

control system at Craigavon Area Hospital as the hospital moves

towards a more integrated access control system.

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4.1.3 CCTV

During 2018/19, Support Services have been working closely with

Estates and IT Services in relation to the new CCTV infrastructure.

Capital funding of £100k was secured to upgrade the CCTV

infrastructure and replace faulty cameras at Craigavon Area and Daisy

Hill Hospitals, and also Carrickore Respite Unit.

4.1.4 Security Review Emergency Department & Acute Medical Unit

Following some significant security incidents in the Emergency

Department and Acute Medical Unit, Craigavon Area Hospital, and

subsequent concerns raised by staff work began to develop plans to

enhance security in these areas. This included a series of meetings

and the review of security incident statistics to inform a Discussion

Paper. To ensure the safety of staff additional security cover was

provided in these areas on an ad hoc basis but there is a need a more

cohesive plan going forward.

4.1.5 Acute Hospitals Lockdown Plans

During 2018/19 a group including Support Services, Estates and

Emergency Planning held meetings to finalise lockdown plans for


4.1.6 Review of Access Arrangements at Night Daisy Hill Hospital

At Daisy Hill Hospital access to the hospital at night was reviewed and

additional lockdown arrangements have been implemented to restrict

access to the main block at night.

4.1.7 Regional Zero Tolerance

A new Regional Zero Tolerance Group has been established to take

forward regional issues regarding zero tolerance and the management

of violence and aggression across all of the Trusts. The Southern

Trust is waiting on a regional policy document being completed and

when this is received Support Services will participate in this Trust

Group once convened.


4.2.1 External Security Contractor

Complete the tender process for the new external security contract and

have the new contract in place by 1 September 2019.

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4.2.2 Review of Access Control & CCTV Systems

The Trust plans to employ Consultants to undertake a review of access

control and CCTV across the Trust and their report is due by the 31

July 2019. Support Services will work in collaboration with Estates

Services to implement the recommendations form this review.

4.2.3 Security Review Emergency Department & Acute Medical Unit

To finalise plans for enhancing security arrangements in the

Emergency Department and Acute Medical Unit, Craigavon Area

Hospital. This will involve engagement with Estates Services and

Nursing to carry out a review of the physical layout of these areas to

identify any physical changes to the environment that may help to

improve the security of both patients and staff.

4.2.4 Acute Hospitals Lockdown Plans

To finalise and test lockdown plans for Craigavon Area and Daisy Hill

Hospitals in conjunction with Estates Services and Emergency

Planning.

To refine Standard Operating Procedures for Portering staff in the

event of hospital lockdown.

4.2.5 Security Audits Out-of-Hours

There are plans to introduce security audits in the out-of-hours period

at Craigavon Area Hospital from April 2019 and at a later date roll them

out at Daisy Hill Hospital. These audits will be carried out at Craigavon

Area Hospital by the Security Manager to provide assurance regarding

the security of the hospital at night.

5.0 DECONTAMINATION SERVICES (DECONTAMINATION OF REUSABLE

MEDICAL DEVICES CAS)

There are two Sterile Services Departments (SSDs) located at Craigavon

Area and Daisy Hill Hospitals employing approximately 42 whole time

equivalent staff. Reusable surgical instruments used in Craigavon, Daisy Hill

and South Tyrone Hospitals, as well as Community Dental Clinics and G.P.

surgeries throughout the Southern Trust are decontaminated within these

SSDs. During 2018/19 the SSDs decontaminated circa. 170,400 sets of

instruments compared to 170,000 in 2017/18.

Flexible endoscopes are decontaminated in Endoscope Washer Disinfectors

in four locations throughout the Trust, i.e. Day Surgery Units in Craigavon and

South Tyrone Hospitals, Theatres in Craigavon Area Hospital and the

Endoscope Decontamination Unit at Daisy Hill Hospital.

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During 2018/19 approximately 25,000 flexible endoscopes were

decontaminated in the four locations compared to 23,000 in 2017/18.

Bedpans are decontaminated in bedpan washer disinfectors at ward /

department level.




Decontamination of Reusable Medical Devices Controls Assurance

Standard was Compliant at 91%.

5.1.2 BS EN ISO 13485:2016 Quality Management Standard and the

Medical Devices Directive (MDD) 93/42/EEC

The Trust’s SSDs are externally audited annually by the British

Standards Institute (BSI) as part of their accreditation. Both SSDs

received a three day audit by BSI (22-24 January 2019) and they were

audited against the new BS EN ISO 13485:2016 Quality Management

Standard and the Medical Devices Directive (MDD) 93/42/EEC. There

were five minor non-compliances and an action plan was developed

and implemented to address these. The next audit is due in October

2019.

5.1.3 DoH Review of Specialised Probes

In accordance with Department of Health Decontamination policy best

practice guidance issued in 2017, all specialised probes (including

trans-vaginal, trans-rectal, trans-oesophageal (TOE)) should be

decontaminated through an automated / semi-automated process (ie a

manual process is no longer acceptable). Radiology, Thorndale Unit

and Integrated Maternity and Women’s Health Services are all using

the Trophon semi-automated system for the decontamination of

specialised probes in line with the Department of Health

Decontamination policy best practice guidance. The TOE probes used

in the Cardiac Cath Lab are not yet being processed through a semi-

automated decontamination process in an Endoscope Washer

Disinfector (EWD) as staff training has not yet taken place but this is

planned for the Autumn and this risk is logged on the Medicine and

Unscheduled Care Divisional Risk Register.

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5.1.4 Decontamination of Reusable Medical Devices - Strategic

Planning

The endoscope decontamination facilities in Daisy Hill and South

Tyrone Hospitals meet the requirements of the Department of Health

Decontamination Strategy but the two interim endoscope

decontamination facilities in Day Surgery Unit and Theatres, Craigavon

Area Hospital do not meet the requirements and this risk is logged on

the Acute Services Risk Register. The new endoscope

decontamination facilities will not be addressed until the redevelopment

of the Craigavon Area Hospital site.

The Endoscope Washer Disinfectors (EWDs) on the Craigavon Area

Hospital site have past their life expectancy and funding for

replacement EWDs has been included in the Trust’s Capital Priority List

and this risk is logged on the Acute Services Directorate Risk Register.


5.2.1 SSD Quality Management Accreditation

Maintain accreditation to the BS EN ISO 13485:2016 Quality

Management Standard. In October 2019 it is planned to extend the

accreditation to the decontamination of flexible endoscopes at

Craigavon Area Hospital Theatres.

5.2.2 DoH Review of Specialised Probes

Transfer the decontamination of trans-oesophageal (TOE) probes to an

Endoscope Washer Disinfector by November 2019.

6.0 LAUNDRY SERVICES

The Southern Trust Laundry Service is one of the largest laundry providers

within NI and is based on Craigavon Area Hospital site. The service currently

employs 51 staff (circa. 44.7 whole-time equivalents) and provides clean linen

to the hospitals and community facilities in the Southern Trust as well as

providing a service to the Belfast HSC Trust. A linen hire laundry service is

also provided to a number of private nursing homes and commercial

companies that generate income for the Trust. During 2018/19 the Laundry

Service handled circa. 5 million pieces of linen. The laundry has an important

role to play in the prevention of hospital acquired infection.

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6.1.1 ISO 9001:2015

Laundry Services were externally audited by National Quality

Assurance (NQA) in February 2019 and they were successfully re-

accredited to the ISO 9001:2015 Standard.

6.1.2 Modernisation and Reform

During 2018/19 the Laundry started a programme of modernisation and

reform. Capital investment of circa £330,000 was secured for the

replacement of a new calender (ironing line) and two replacement

washing machines, which were installed on the 1 April 2019. Some

refurbishment work also took place to improve the working environment

in the Laundry including new LED lighting and painting work on the

stairs, front entrance, and dining room and meeting room.

Equipment maintenance/breakdown problems are still a major issue for

the Laundry and this risk is logged within the broader Capital risks on

the Board Assurance Framework. This creates challenges for the

management and staff in maintaining productivity to meet the demands

on the service and further investment in new equipment is required.


6.2.1 ISO 9001:2015

Maintain accreditation to the ISO 9001:2015 Standard.


To secure additional capital funding for replacement equipment.

To introduce staff rotation in all areas within the Laundry, and this will

result in a more flexible workforce.

To employ dedicated staff within the Laundry to provide regular

cleaning of Laundry equipment to improve equipment efficiency and

reduce fire risks.

7.0 SWITCHBOARD SERVICES

The main Switchboards are located at Craigavon Area and Daisy Hill

Hospitals. Craigavon Area Hospital’s Switchboard provides a call answering

service for Craigavon, Lurgan, South Tyrone and the Armagh Hospitals and

handles approximately 19,000 calls per week. Daisy Hill Hospital’s

Switchboard deals with approximately 11,500 calls per week.

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There are approximately 17 whole time equivalent staff employed at both

Switchboards. Switchboard staff also provide a reception service to answer

visitor queries, deal with alarms including fire and emergency calls (Cardiac,

Stroke, Obstetrics, Paediatrics etc), manage staff bleeps/keys and deal with

car park queries.

Both Switchboards are an important support network for Medical and other

staff throughout the Hospitals.


7.1.1 iMessage Bleeping System

Switchboard worked collaboratively with Estates Services to introduce

the new iMessage bleeping system. The new system has now been

implemented at Craigavon Area, Daisy Hill, South Tyrone and Lurgan

Hospital sites. This has resulted in a faster bleeping service and staff

can now bleep staff across the different sites.


During 2018/19 capital funding of £50,000 was secured to purchase a

new Avaya Equinox switchboard system for both Craigavon Area and

Daisy Hill Hospitals. Switchboard staff worked collaboratively with

Estates Services to install and test the new equipment, and staff

training was completed before implementation of the new system in

April 2019. The new Equinox system will provide a more modernised

call answering system.


7.2.1 iMessage Bleeping System

Work collaboratively with Estates Services to develop the use of the

iMessage system as part of the Trust’s Major Incident Plan.


Continue to work collaboratively with Estates Services to implement

and embed the new switchboard system.

8.0 CHAPLAINCY SERVICES

Chaplaincy Services transferred to Functional Support Services in 2017. The

Chaplaincy Teams are from the main Christian traditions and they are

supported by Spiritual and Pastoral Care Volunteers and are available in

Daisy Hill, Craigavon Area, South Tyrone and Lurgan Hospitals and Bluestone

Unit. The service is available to everyone, irrespective of faith or background.

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Chaplains visit the wards regularly and are available to offer spiritual, religious

and pastoral care to all those who request support. They also provide the

opportunity for individual prayer and communion for patients on the ward.

The Chaplaincy Teams are available for emergency calls out of hours and

they can be contacted by asking a member of the ward staff.


8.1.1 Chaplaincy Team Meetings

During 2018/19, regular meetings of the Chaplaincy Teams at

Craigavon Area and Daisy Hill Hospitals were established, which has

improved information sharing and communications.

8.1.2 Review of Patient Information supplied to the Chaplains

A review of patient information supplied to the Chaplains was carried

out to ensure that it was in line with General Data Protection

Regulations (GDPR).


8.2.1 Major Incident Action Cards

Review Action Cards for Chaplaincy Services to record actions to be

taken in the event of a Major Incident.

8.2.2 Recruitment of Vacant Posts

Complete recruitment exercise to fill vacant posts and increase the

number of bank staff to help stabilise the Chaplaincy Teams.

8.2.3 Increase Awareness of Chaplaincy Services

To increase awareness and promote Chaplaincy Services, issue press

release and update information on the Trust website, also develop

information for the Trust’s Corporate Induction pack for new staff.

9.0 ADMIN & CLERICAL SERVICES

9.1 Health Records

There are Health Record Departments on six sites across the Trust –

Craigavon Area Hospital, Daisy Hill Hospital, Armagh Community Hospital,

Banbridge Polyclinic, South Tyrone Hospital and St Luke’s.

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Health Records are the custodian of the patient’s hospital chart, and are

responsible for the storage, issue, retrieval and management of the chart

during its lifetime. During 2018/19 Health Records staff pulled approximately

520,000 patient charts for outpatient appointments, admissions, ward

attenders and also charts required for Consultants for dealing with queries, for

complaints, subject access requests, medico legal requests etc. The hospital

charts are used across the sites, with Transport delivering approximately 80 -

100 boxes of charts per day to the various Acute sites. Although there are a

large number of charts required on a daily basis for the various clinics etc the

Chart Availability Key Performance Indicator is approximately 99.5% each

month. Health Records also provide copies of medical information for patients

requesting this through a Subject Access Request. In the past patients were

charged a fee of £50 for the provision of this information however since this

fee was waived there has been an increase in the number of requests with

263 requests being received in 2018/19 compared to 123 requests in 2017/18.

Health Records staff also work in Outpatient receptions, meeting and greeting

patients, making review appointments and updating information on the Patient

Administration System (PAS). Outpatient departments also offer the patients

the choice of checking in at the reception or via a self-service kiosk. The

kiosk also provides instructions in several languages, which some of our

patients whose first language is not English find useful. The self-service

check in allocates a number to each patient and it is this number that is used

to call the patient to the clinic rather than using their name.

9.1.1 Key Issues/Achievements 2018/19

The Ophthalmology Service was centralised to the Belfast HSC

Trust. This meant that all of the Southern Trust information had to

be pulled and photocopied and forwarded to the Belfast HSC Trust

for their records. This was a huge piece of work for Health

Records staff, which involved photocopying over 4,000 records.

A proposal was submitted and approved for iFIT technology for

locating patient charts and this is on the capital list for consideration

of funding. Implementation of iFIT will revolutionise the work of

Health Records on the wards.

9.1.2 Key Objectives 2019/20

Health Records are keen to progress the use of electronic records,

thus paving the way for encompass and the digital revolution

transforming care within HSCNI.

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Meetings will be held with Consultants in various Specialties to see if

some clinics can be run without a chart, and with just referring to the

Northern Ireland Electronic Care Record (NIECR).

Health Records will also progress the use of digital information by

working with Consultants to see if clinical documentation can be

accessed via NIECR rather than looking in the chart for the paper

copy of the clinic/discharge letter. This will not only reduce printing

and filing time, but it will also reduce storage requirements as less

information will be filed in the chart.

A new method of requesting charts from the Issue Desk in

Craigavon Area and Daisy Hill Hospitals will be implemented which

will improve efficiency for Health Records staff and also result in

charts being sent to the requester in a shorter turnaround time.

As a result of new regional guidance a revised method of dealing

with DNAs (patients who do not attend appointments) at Consultant

led clinics will be implemented in June 2019, with Health Records

staff sending letters to patients and GPs regarding the new

guidance.

9.2 Ward Clerks

There are Ward Clerks based on the wards at Craigavon Area and Daisy Hill

Hospitals. The Ward Clerk is responsible for ensuring the patient

documentation is available and up to date for the Medical and Nursing staff on

the ward. They also record the admissions, transfers and discharges of the

patients on the ward, and make any follow up appointments or onward

referrals for the patient following discharge. This information not only

provides necessary data for tracking the patient through their journey in the

Trust, but also is used to determine bed capacity, bed occupancy and can be

used in the planning of new services. During 2018/19 they processed

approximately 110,000 patients, including day cases and maternity patients

compared to 76,000 patients during 2017/18.


The processing of requests of blood via Ordercomms from the core

wards is now carried out by Ward Clerks on both the Craigavon Area

and Daisy Hill Hospital sites. This has freed up Junior Doctors’ time

to enable them to provide more face-to-face care for patients.

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The Ward Clerks have worked with the Medicine and Unscheduled

Care Division to set up the Direct Assessment Unit at Daisy Hill

Hospital. Patients are referred to the Unit either by their GP or by

Emergency Department. The Ward Clerk Service have been

trained on the new functionality for the recording of these patients,

and have developed Standard Operating Procedures for the admin

flow of patients through the Department, and for providing statistics

to assist with the evaluation of the Unit.

The Ward Clerks have been involved in implementing a new ward

attender process for Cardiology patients, which will ensure that all

patients seen by Cardiologists will be captured on PAS. Previously

Cardiologists would have been asked to see patients who may have

been on a Medical or Surgical ward but this activity was never

captured and so the Consultants were never credited with additional

work. By recording these consultations as a Ward Attender the

activity will be reflected in the overall Cardiology activity, thus giving

a more accurate reflection of the workload of the Specialty.

Regular refresher training on Patient Centre system has been

carried out at Craigavon Area and Daisy Hill Hospitals to help

improve the recording of information. These have proved very useful

with positive feedback being received from the Ward Clerks. The

Ward Clerks across both sites have received the same refresher

training and guidance with regard to the correct codes to use when

admitting patients, and making appointments which has led to

consistent recording across the sites and has also reduced the

validation of errors occurring on the wards.

The Ward Clerks assist with the timely recording of Delayed

Discharge information, which has improved during 2018/19. Ward

Clerks prepare a tracker form for each patient and if this is not

completed for a patient on discharge they will escalate to the Ward

Sister. The Ward Clerk Supervisor runs a weekly report highlighting

patients who have not been coded and the Ward Clerks use this

report to follow up with the Ward Sister. A report detailing the

outstanding coding is also provided each week to the Assistant

Directors, Heads of Service and Lead Nurses for discussion with

their teams.

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Work with the Specialties to ensure all patient activity is captured on

the Patient Administration System (PAS).

Develop a new Training Manual for each ward.

9.3 Emergency Department Admin

Admin staff are based in the two Emergency Departments at Craigavon Area

and Daisy Hill Hospitals and at the Minor Injuries Department, South Tyrone

Hospital. These staff are the first point of contact for patients attending

Emergency Departments and Minor Injuries Department and they are

responsible for registering patients on the electronic Emergency Medicine

System (eEMS), recording and arranging any follow up for the patient and for

coding the patients diagnosis. The Emergency Departments and Minor

Injuries Department saw and treated circa. 186,000 patients during 2018/19

compared to 180,818 patients during 2017/18.

The capture of patient activity is crucial to the business of the Trust. Data

Validation Admin staff play a large role in capturing the data and also in

validation of the same. A suite of reports are run on a weekly and monthly

basis with the Admin staff validating all of the information to ensure accuracy

and timeliness of information. This information forms the basis of the reports

that are provided for each Directorate, the Trust and also for the HSC

Board. In addition to validation reports several other reports are provided for

the Directorates which include patient activity such as the number of daily

number of discharges, number of Emergency Department attendances,

number of admissions via Emergency Department, number of patients coming

to hospital via ambulance, waiting times in Emergency Department, number of

complex discharges and reasons for delay in their discharge. This information

provides the Bed Management Team with data to help them with the planning

of patient activity. Delayed Discharge coding is regularly reviewed by the

HSC Board, with comparisons being made between Trusts on the number of

complex discharges and reasons for delay.


Scanning of Emergency Department documentation for under four

year old patients in Craigavon Area Hospital Emergency

Department has commenced.

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This means that if an under four year old patient re-attends

Craigavon Area Hospital their information will be immediately

available on Emergency Medicine System (eEMS) for the Medical

staff, so negating the need to retrieve previous manual notes.

When this has been implemented on all sites it will mean that

information will be easily available for the Medical staff irrespective

of the site that the patient attended. This will assist Medical staff in

the treatment of the patient as they will have access to the

complaint, diagnosis and treatment from a previous attendance

which may impact on the care provided to the patient.

Admin staff have been involved in setting up virtual wards at both

Craigavon Area and Daisy Hill Hospitals which means that patients

who are under the care of a Physician can be recorded on PAS and

appear on a Patient Flow Board. This enables the Medical Team to

produce an electronic discharge letter, and also creates an episode

on the Patient Administration System (PAS). This addresses a

patient safety risk by reducing the risk of the patient being lost to

follow up as there was no electronic or manual record of that

patient being under the care of a Physician.

Admin staff have been involved with the setting up of the

Pulmonary Embolism (PE) Service ensuring patient information is

recorded accurately to ensure retrieval of statistics.

A new system of registering patients for a Major Incident has been

implemented which means that all the paperwork for a major

incident is prepared in advance, each patient with a unique

number. Previously the numbers were allocated manually and

prefixed with the year which meant that the Major Incident packs

had to be updated every year. This new numbering system

negates this as the unique Emergency Department number is not

prefixed with a year.


Roll out scanning of Emergency Department patient attendance

records to Daisy Hill Hospital Emergency Department and South

Tyrone Hospital Minor Injuries Unit.

Work with the Head of Service and Lead Nurse on the lockdown

plan for Emergency Department from an admin perspective re

reception.

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Carry out a review of recording on eEMS to ensure consistency of

recording in both Craigavon Area and Daisy Hill Hospital

Emergency Departments and South Tyrone Hospital Minor Injuries

Department. On completion of this piece of work in the Southern

Trust the findings of the review will be tabled at the Regional

Emergency Medicine System (eEMS) Meeting to ensure

consistency with the South Eastern HSC Trust. This piece of work

will be useful in starting the journey of recording on encompass.

Carry out a review of the Emergency Department admin rota to

ensure adequate staffing levels at the appropriate times.

9.4 Referral and Booking Centre

The Referral and Booking Centre, based at Craigavon Area Hospital, operate

a centralised booking service for all GP referrals in the Southern Trust. The

opening hours are to 8pm in the evening and Saturday morning making the

service more accessible for patients. The Booking Centre ensures that clinics

are booked to capacity to meet regional targets, patients are offered choice

and waiting lists are maintained taking account of chronological

management. During 2018/19 the Booking Centre booked circa. 312,000

appointments during 2018/19 compared to 297,000 appointments in 2017/18.

9.4.1 Key Issues/Achievement 2018/19

The Referral and Booking Centre has supported the

implementation of the E-Referrals system within Northern Ireland

Electronic Care Record (NIECR) across the Trust with sixteen

Specialities now live across Acute Services. The implementation of

this solution enables electronic GP referrals to be triaged within a

rich clinical data set, which is easily accessible by the Clinician and

is fully auditable. It has supported processes which improve patient

safety by decreasing the triage time and in some Specialities

around 30% of GP electronic referrals completed on the same day

GP made referral. The e-referral system automatically carries out

the following key functions: register referral automatically on Patient

Administration System (PAS) adhering to registration protocols,

identifies open referrals to same Specialty enhancing Data Quality

and present referral to Specialty Consultants for Triage. This has

enabled efficient processes within the Booking Centre and on

completion of the triage process the Booking office can then add

the patient to waiting list and make the appointment.

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With all of the information now held within NIECR, this has also

enabled a paper-lite approach reducing the need for printing and filing

of referrals.

On the back of the Patient and Client Council Survey ‘Our lived

experience of waiting for healthcare’ (March 2018) the Referral and

Booking Centre has re-introduced the sending of acknowledgment

letters to patients advising them that their referral has been

received by the Southern Trust.


To continue to work with Information Team to complete the roll out

E-triage to Neurology, General Surgery, Breast, Vascular and

Colorectal Specialties by December 2019.

9.5 Medical Secretaries, Audio Typists & Clerical Officers

There are circa. 144 Medical Secretaries, Audio Typists and Clerical Officers,

providing a service on all hospital sites for inpatients, outpatients and

investigations. Secretaries and Audio Typists provide a very valuable service

to Clinicians and patients and are an integral part of the Clinical team. They

are often the first point of contact with patients regarding surgery, letters to

GPs and rotas etc. They schedule Theatre Lists and undertake the role of

contacting the patients, and when these lists are cancelled, patients have to

be contacted by telephone, and this is time consuming and particularly

challenging for staff.

The Admin Managers continuously work with their staff to cross train them to

cover in the most critical areas and provide a workforce that is flexible and re-

active to the needs of services. To achieve this regular Activity Reports are

run to ensure equity of support and that resources are re-directed as and

when required. The Admin Managers produce monthly backlog reports of the

position regarding the typing / dictation of clinical correspondence and

filing. This assists with planning audio typing support and alerts senior staff

of the status of clinical correspondence backlogs.

Staff also provide an admin service for RACP (Rapid Access Chest Pain),

cardiac investigations and respiratory investigations. These are all critical

areas providing a booking service and admin service. Staff record

appointments on the Tomcat and Paris systems.

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9.5.1 Key Issues/Achievement 2018/19

Admin staff have played an important key role in establishing the

new elective centres, in particular the Regional Cataract Service at

South Tyrone Hospital. This has involved the review and

identification of cataract patients from the General Ophthalmology

Waiting List for specific cataract procedures for transfer to the

Belfast HSC Trust, to ensure chronological management of the

regional waiting list. This also ensures the Patient Hospital Number

is linked to the Theatres Management System. This work involved

communications with the Belfast HSC Trust and the development

of detailed Standard Operating Procedures for admin staff.

Admin staff were involved in the transfer of the Ophthalmology

Service to Belfast HSC Trust. They had to check original referrals

and validation lists for all new patients and review patients that

transferred. This work was very challenging but good working

relationships with the Belfast HSC Trust ensured a seamless

transition.

Admin staff worked alongside Health Records as a joint project to

try and introduce ‘chartless’ clinics.

As a pilot, Voice Recognition has been rolled out successfully in

Geriatric Specialty. This helps the Clinicians write letters using

voice narration and without typing which speeds up the typing to

GPs. To promote an electronic environment it is hoped to roll

Voice Recognition out to the other Specialities.

The roll out of EDT (Electronic Document Transfer) was completed

during 2018/19 with the result that the Trust now sends letters

electronically to GPs. This has reduced patient safety risks as

letters are delivered to the right GP in a timely manner and it is a

more auditable process.

Data quality remains a challenge for Admin Managers who have

continued to work alongside the Patient Administration System

(PAS) / Information and Data Quality Teams to enhance the quality

of information throughout the Trust. Additional support was

secured to support this work which involved working on Standard

Operating Procedures and crib sheets for all Specialties.

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In the past virtual activity was uncaptured and during 2018/19

Admin Managers have worked with the Information and Data

Quality Teams in the recording of information for most of the

Specialities. Virtual activity means there is an electronic record of

all patients under the care of a Physician without a face to face

appointment. In order to meet data quality requirements a letter

needs to be completed which ensures Clinicians are given credit for

virtual activity.

Biologics therapies are increasingly being introduced as specialist

treatment for some patients within existing Specialties for example

Rheumatology/Dermatology. This has meant a change to admin

processes as the recording requirements are different for these

treatments so Admin Managers have developed Standard

Operating Procedures along with the Consultants/Specialist Nurses

and PAS Team to ensure that the data is captured accurately for

these patients.

For good information governance and in line with the focus on a

more digital and paper-lite environment, admin staff in Antenatal

Department have facilitated the roll out of electronic sign-off system

for results. This means results are signed electronically without the

need for printing / filing them. This has been extended to

Dermatology Speciality as a pilot and if this is successful with

Consultant buy-in there are plans to roll this out to other

Specialities. This reduces patient safety risks as results can never

be lost and it clearly demonstrates what results need signed off and

by whom etc.

A review of booking processes was completed for RACP (Rapid

Access Chest Pain) and procedures written up resulting in the

Admin staff now providing a more centralised booking system

which ensures equity for patients using this service.

Admin Managers in conjunction with the Information Team have

been involving in reviewing patients that have an Open Outpatient

Referral Registration on PAS, and this work has involved a lengthy

validation exercise to ensure data quality and patient safety.

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Continue working with the Information and Data Quality Teams to

ensure all virtual activity is recorded for the other Specialities.

Continue working alongside the Patient Administration System (PAS)

/ Information and Data Quality Teams to enhance the quality of

information throughout the Trust and ensure staff are adequately

trained to understand that good data quality means getting it right

first time.

Complete and evaluate the pilot of rolling out the electronic sign-off

of results in Dermatology and roll out to the other Specialities.

To roll out Voice Recognition to the other Specialties.

Continue with the refinement of Electronic Document Transfer.

Admin Managers will continue to monitor the use of Electronic

Document Transfer to optimise the use of the system.

Continue to work alongside Health Records for ‘chartless’ clinics.

Continue to refine Procedures and Standard Operating Procedures

while developing better reporting systems for fail safes and patient

safety.

Review administrative processes to reduce patient safety risks and

also improve efficiency amongst admin and clerical staff.

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APPENDICES

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Appendix 1

Environmental Cleanliness Managerial Audit Scores 2018/19

Ward / Dept / Facility

Overall CleaningNursing/

ManagerEstates

Acute Services

Craigavon Area Hospital - 3 South Back (Urology) 16-Apr-18 86 93 81 85

Craigavon Area Hospital - Intensive Care Unit 18-May-18 92 96 94 87

Craigavon Area Hospital - 4 North 23-May-18 91 92 90 92

South Tyrone Hospital - Theatres 06-Jul-18 98 100 98 97

Daisy Hill Hospital - Female Surgical 15-Aug-18 81 84 83 78

Daisy Hill Hospital - Male Surgical 19-Sep-18 90 92 88 91

Craigavon Area Hospital - Trauma 07-Nov-18 90 87 96 89

South Tyrone Hospital - Day Procedure Unit 24-Jan-19 95 98 91 94

Craigavon Area Hospital - Day Surgery Unit 20-Feb-19 87 91 92 78

Daisy Hill Hospital - High Dependency Unit 27-Feb-19 94 89 95 98

South Tyrone Hospital - B Floor Left Day

Procedure Admissions Ward

27-Feb-19 97 98 98 96

Craigavon Area Hospital - 1 East Gynae 24-Oct-18 86 85 89 83

Craigavon Area Hospital - 2 West 14-Nov-18 84 86 88 78

Daisy Hill Hospital - Maternity 06-Feb-19 95 92 98 97

Craigavon Area Hospital - Delivery Suite 06-Mar-19 87 90 91 80

Daisy Hill Hospital - Female Medical 16-May-18 89 90 92 85

Craigavon Area Hospital - 2 North Respiratory 08-Jun-18 93 93 93 92

Craigavon Area Hospital - 1 South 18-Jul-18 89 86 92 89

Craigavon Area Hospital - 1 North 18-Aug-18 86 88 88 82

Craigavon Area Hospital - 2 South Medical 03-Sep-18 92 92 94 90

Daisy Hill Hospital - Renal 17-Oct-18 94 95 97 89

Daisy Hill Hospital - Male Medical /

Coronary Care 21-Nov-18

93 90 91 97

Daisy Hill Hospital - Stroke Rehab 12-Dec-18 91 89 87 98

Craigavon Area Hospital - Elective Admissions 06-Feb-19 86 88 93 76

Craigavon Area Hospital - 3 North Winter Ward 20-Mar-19 90 88 94 88

Mental Health Services

Bluestone Unit - Cloughmore Ward 23-Apr-18 88 87 91 88

Bluestone Unit - Willows Ward 13-Jun-18 80 86 80 75

Bluestone Unit - Bronte Ward 19-Sep-18 83 87 85 77

Mullinure - Gillis Ward 20-Sep-18 96 97 98 94

Bluestone Unit - Silverwood Ward 24-Oct-18 83 83 85 82

Bluestone Unit - Dorsy Ward 07-Feb-19 90 81 96 93

Bluestone Unit - Rosebrook 28-Feb-19 85 79 87 89

Children & Young People's Services

Daisy Hill Hospital - SCBU 20-Jun-18 87 90 90 81

Craigavon Area Hospital - Neonatal 03-Aug-18 93 96 93 90

Craigavon Area Hospital - Delivery 06-Mar-19 87 90 91 80

Daisy Hill Hospital - Daisy Unit 20-Mar-19 88 92 79 92

Older People Services

South Tyrone Hospital - Ward 1 24-May-18 94 95 97 89

Crozier House 28-Jun-18 89 79 96 91

Lurgan - Ward 3 02-Aug-18 85 86 80 88

South Tyrone Hospital - Rehab 2 26-Jul-18 92 95 87 94

Slieve Roe House 23-Aug-18 80 66 86 87

Cloughreagh House 25-Oct-18 96 96 96 96

Lurgan Hospital - Ward 2 03-Dec-18 86 87 85 85

Roxborough House 30-Jan-19 93 91 95 92

Lurgan Hospital - Ward 1 07-Mar-19 85 91 88 75

Level of Compliance:-

Compliant - 90% or above

Partial Compliance - 76% to 89%

Minimal Compliance - 75% or below

Managerial

Audit Date

Managerial Audit Scores

TOTAL NUMBER OF AUDITS COMPLETED 45

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Appendix 2

RQIA Unannounced Hygiene Inspection Scores 2018/19

Areas inspected Daisy Hill Hospital Emergency Dept

23 Oct 2018

Craigavon Area Hospital Acute Medical Unit

4 Dec 2018

General Environment

88 80

Patient Linen 92 96

Waste 98 94

Sharps 89 88

Equipment 91 81

Hygiene Factors / Cleaning Practices

96 95

Hygiene Practices / Staff Questions

94 94

Average Score 93 90

RQIA Level of Compliance:-

Compliant - 85% or above

Partial Compliance - 76% to 84%

Minimal Compliance - 75% or below

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Appendix 3

Breakdown of Security Incidents 2018/19

Breakdown of Abuse Incidents reported to the DoH 1/4/18-31/3/19

A

cu

te

CY

P[1

]

MH

D[2

]

OP

PC

[1][

3]

To

tal

No. of Verbal abuse incidents 169 61 405 77 712

No. of Physical abuse

incidents

370 350 757 100 1577

Total 539 411 1162 177 2289

Breakdown of Security Incidents other than Abuse Recorded on Datix 1/4/18 -

31/3/19

Acu

te

CY

P

MH

D

OP

PC

To

tal

Security Incidents other than

Abuse 60 8 49 8 125

[1]

Children & Young People’s Services [2]

Mental Health & Disability [3]

Older People & Primary Care

of 38

Breakdown of Absconding / Missing Patients Recorded on Datix 1/4/18 -

31/3/19

Acute

CYP

MHD

OPPC Total

Absconding / Missing Patients

222 212 78 1 513

The figures in relation to absconding/ missing patients include patients who leave

Emergency Departments and Mental Health facilities before treatment and for

Children and Young People’s Services they include missing young persons from

Children’s Homes including those who are habitual absconders.

board report summary sheet€¦ · catering services (food hygiene & safety) the trust’s...

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