1

Nova Healthcare Quality Account

April 2016 – March 2017

3

ContentsWelcome to Aspen Healthcare 4

Statement on Quality from Aspen Healthcare’s Chief Executive 7

Introduction to Nova Healthcare 9

Statement on Quality 10

Quality Priorities for 2017-18 11 Patient Safety Clinical Effectiveness Patient Experience

Statements of Assurance 14 Review of NHS Services Provided 2016-17 Participation in Clinical Audit Participation in Research Goals Agreed with Commissioners Statement from the Care Quality Commission

Review of Quality Performance for 2016-17 20 Patient Safety Clinical Effectiveness Patient Experience

External Perspectives on Quality of Services 23

With many thanks for all your kindness.

We are so grateful. Mrs PA, York. March 2017

5

Welcome to Aspen Healthcare Nova Healthcare is managed by the Aspen Healthcare Group.

Aspen Healthcare was established in 1998 and is a UK-based private healthcare provider with extensive knowledge of the healthcare market. The Group’s core business is the management and operation of private hospitals and other medical facilities, such as day surgery clinics, many of which are in joint partnership with our Consultants.

Aspen Healthcare is the proud operator of four acute hospitals, two specialist cancer centres, and three day-surgery hospitals in the UK. Aspen Healthcare’s current facilities are: • Cancer Centre London

Wimbledon, SW London• The Chelmsford Private Day Surgery

Hospital, Chelmsford, Essex• TheClaremontHospital,Sheffield• The Edinburgh Clinic, Edinburgh• Highgate Private Hospital

Highgate, N London• The Holly Private Hospital

Buckhurst Hill, NE London• Midland Eye, Solihull• Nova Healthcare, Leeds• Parkside Hospital

Wimbledon, SW LondonAspen Healthcare’s facilities cover a wide range of specialties and treatments providing consulting, diagnostic and surgical services, as well as state of the art oncological services. Within these nine facilities, comprising over 250 beds and 19 theatres, in 2016 alone Aspen has delivered care to: • over 45,000 patients who were admitted into

our facilities for surgery• 300,000 patients who attended our

outpatient and diagnostic departments.

We have delivered this care always with Aspen Healthcare’s mission statement underpinning the delivery of all our care and services.Aspen is now one of the main providers of independent hospital services in the UK and through a variety of local contracts we provided nearly 20,000 NHS patient episodes of care last year, comprising nearly 45% of our patient numbers. We work very closely with other healthcare providers in each locality including GPs, Clinical Commissioning Groups and NHS Acute Trusts to deliver the highest standard of services to all our patients.It is our aim to serve the local community and excel in the provision of quality acute private healthcare services in the UK and we are pleased to report that in 2016 our patient satisfaction ratings continued to be high with 99% of our inpatients rating their overall quality of their care as ‘excellent’, ‘very good’ or ‘good’, and 97% responding that they were ‘extremely likely’ or ‘likely’ to recommend the Aspen hospital they visited.Across Aspen we strive to go ‘beyond compliance’ in meeting required national standards and excel in all that we endeavour to do. Although every year we are happy tolookbackandreflectonwhatwehaveachieved, more importantly we look forward and set our quality goals even higher to constantly improve upon how we deliver our care and services.

Aspen Healthcare Hospitals and Clinics locations:

Cancer Centre London

The Chelmsford

Claremont Hospital

The Edinburgh Clinic

Highgate Private Hospital

The Holly Private Hospital

Midland Eye

Nova Healthcare

Parkside Hospital

Specialists in complete eye careMidlandEye

Our aim is to provide first-class independent healthcare for the local community in a safe, comfortable and welcoming environment; one in which we would be happy to treat our own families.

7

Statement on Quality from Aspen Healthcare’s Chief Executive

Welcome to the 2016-17 Quality Account, which describes how we did this year against our quality and safety standards.On behalf of Aspen Healthcare I am pleased to provide the annual Quality Account for Nova Healthcare. This report focuses on the quality of services we provided over the last year (April 2016 to March 2017) and importantly, looks forward and sets out our plans for further quality improvements in the forthcoming year.At Aspen Healthcare we aim to excel in the provision of the highest quality healthcare services and work in partnership with the NHS to ensure that the services delivered result in safe, effective and personalised care for all our patients. Each year we review the quality priorities we agreed in the previous year’s Quality Account. Our quality priorities form part of Aspen’s overall quality framework which centres on nine drivers of quality and safety, helping to ensure that quality is incorporated into every one of our hospitals/clinics and that safety, quality and excellence remain the focus of all we do, whilst delivering the highest standards of patient care. This is underpinned by Aspen’s Quality Strategy, which focuses on the three dimensions of quality: patient safety, clinical effectiveness and patient experience.The past year has seen nearly all our hospitals/clinics externally inspected by the Care Quality Commission (CQC), England’s health and social care regulator. These comprehensive inspections have provided external validation of the quality and safety of care we deliver and I am pleased to report that all our hospitals/clinics to date have been rated as ‘Good’, with our staff commended for their kind and compassionate care.

This Quality Account presents our achievements in terms of clinical effectiveness, safety and patient experience, and demonstrates that our managers, clinicians and staff at Nova Healthcare are all committed to providing the highest standards of quality care to those patients we treat. The Account aims to provide a balanced view of what we are good at and where additional improvements can still be made. In addition, our quality priorities for the coming year (2017-18), as agreed with the Aspen Senior Management Team, are outlined within this report. In 2016-17 we saw further improvements made to our patient safety and experience, with patients consistently telling us the experience they have at our hospital/clinics is of the highest standard. We will remain committed to monitoring all aspects of our patients’ experience within Nova Healthcare, ensuring this feedback is effectively utilised to continue to drive quality improvements.I would like to thank all the staff who everyday show commitment to our high standards and contribute to the continuous improvements we make to our patients’ care and experience. The majority of information provided in this report is for all the patients we have cared for during 2016-17 – both NHS and private.

Des ShielsChief Executive, Aspen Healthcare

9

Introduction to Nova HealthcareNova Healthcare is a specialist provider of medical and clinical oncology, haematology, stereotactic radiosurgery and specialist prostate surgery. The unit opened in 2009, and is located within the Bexley Wing of the Leeds Cancer Centre, part of the Leeds Teaching Hospitals NHS Trust.

The unit offers facilities for outpatient consultations, day-case and ambulatory care treatments. Nova Healthcare works in partnership with Leeds Teaching Hospitals NHS Trust to provide a range of services and facilities. External beam radiotherapy and brachytherapy are provided through comprehensive service level agreements. This ensures our patients have access to one of the leading NHS radiotherapy providers in the UK, set within an academic framework, with the highest quality assurance standards and technically advanced delivery.

All services at Nova Healthcare are Consultant-led and, in addition to being granted practising privileges at Nova Healthcare, all Consultants hold an employment contract or honorary contract at Leeds Teaching Hospital NHS Trust.Nova Healthcare is accredited with all major insurers.Nova Healthcare offers the following facilities:

• Gamma Knife® Treatment Unit• 3 consulting rooms, with associated

examination rooms• Outpatient waiting area with free

refreshments• 1 special procedures room

• 3 day-case / ambulatory patient rooms• 4 ambulatory patient treatment bays• Stereotactic radiosurgery suite• Free on-site parking

To a fantastic team. Y ou are amazing people.

Ms JJ, York March 2017

11

Quality Priorities for 2017-18National Quality Account guidelines require us to identify at least three priorities for improvement. Aspen’s Quality Strategy outlines how we will progress a number of quality and safety initiatives for the forthcoming years and the following information provided focuses on our main priorities for 2017-18. These priorities were agreed with our senior management team and are informed by feedback from our patients and staff, audit results, national guidance and recommendations from the various hospital/clinic teams across Aspen Healthcare. Our quality priorities are regularly reviewed by our Aspen Quality Governance Committee which meets quarterly to monitor, manage and improve the processes designed to ensure safe and effective service delivery. Nova Healthcare is committed to delivering services that are safe, of a high quality & clinically effective and we constantly strive to improve our clinical safety and standards. The prioritieswehaveidentifiedwill,webelieve,drive the three domains of quality: patient safety, clinical effectiveness and patient experience.

1. Patient SafetyImproving and increasing the safety of our care and services provided.2. Clinical EffectivenessImproving the outcome of any assessment, treatment and care our patients receive to optimise patients’ health and well-being.3. Patient ExperienceAspiring to ensure we exceed the expectations of all our patients.

The key quality priorities identified for 2017-18 are as follows:

Patient Safety

Involving patients in monitoring hand hygieneThe hands of healthcare workers and other staff working in clinical areas can become contaminated with micro-organisms during the course of their duties. Hand hygiene by healthcare workers (HCW’s) is the leading measure in preventing the transmission of healthcare acquired infections. Inviting patients to report on staff hand hygiene will be a useful intervention in assuring compliance. A proforma will be developed for patients to complete to record staff compliance with hand hygiene practice and the results fed back to staff. This initiative will complement our existing hospital-based hand programme and develop further our patient-centred safety initiatives.

Statement on Quality Nova Healthcare is delighted to present this second Quality Account which we believe will further demonstrate our commitment to quality and safety for all our patients. The report will seek to measure progress made in an objective manner, identifying those areas we wish to seek improvement in during 2017-18 and focuses on the areas of patient safety, clinical effectiveness and patient experience.This Quality Account is actively owned by the Nova Healthcare team and staff who work with us as part of our wider team. We share a real desire to progress our quality initiatives over the coming year, modelled on the Aspen Healthcare Quality Governance Framework and Quality Strategy. Our Quality Account

will also allow us to openly report on what we do and where we believe improvements can be made. Our local Quality Governance Committee meets quarterly and provides data on outcomes and quality throughout the patient journey, including feedback from our patients. This committee feeds into the HTI St James’s Ltd Board, the Medical Advisory Committee and the Group Quality Governance Committee which is chaired by Aspen Healthcare’s CEO. This committee provides assurance to the Aspen Healthcare Executive Team and Board that we are responsive to any changes in values, expectations and perceptions and ensure that our services provided to patients are based on best practice.

1.2 Accountability Statement

Directors of organisations providing hospital services have an obligation under the Health and Social Care Act 2008, National Health Service (Quality Accounts) Regulations 2010 and the National Health Service (Quality Accounts) Amendment Regulation 2011 to prepare a Quality Account for each NHS financialyear.

This report has been prepared based on guidance issued by the Department of Health setting out these legal requirements.To the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate.Date: 16th May 2017

Dawn Abbott, Clinic Manager

This report has been reviewed and approved by:Mr Roger Cannon, Chair, Medical Advisory Committee, Nova Healthcare Dr Adrian Crellin, Medical Director, Nova Healthcare Mr Ron Gilden, Chairman, Nova Healthcare Board MrDesShiels,ChiefExecutiveOfficer,AspenHealthcareMrs Judi Ingram, Clinical Director, Aspen HealthcareMrs Rachel Bradbury, Director of Clinics, Aspen HealthcareMrs Moira Betteridge, Quality Lead, NHS England.

13Quality Priorities for 2017-18

Clinical Effectiveness

Improve Practical Training ComplianceEnsuring our staff have undertaken training to support them in their roles is a priority. In order to ensure that the care delivered is at its most efficientandeffective,weaimtoincreaseourfocus on training compliance of face-to-face practical training sessions for all our staff, to complement our comprehensive eLearning suite of training programmes. Each hospital/clinic is to develop an annual practical training programme and report regularly back on this to its senior management team and governance committee.Compliance with Cancer Standards – Multidisciplinary Team DiscussionsMultidisciplinary care is the hallmark of high-quality cancer management. Multidisciplinary team discussions prospectively review individual cancer patients and make recommendations on the best management of a patient’s cancer pathway, informing treatment options and decisions. We will ensure that records of multidisciplinary team discussions are recorded and accessible to inform patient care and treatment at our hospital/clinic.

Patient Experience

Implement Online Patient Survey Data CollectionPatient satisfaction is at the heart of our business, with patient feedback being very important to us in informing how we are doing and highlighting areas that require further focus to enhance our patients’ experience. In 2017 we will move to complement our paper surveys with online electronic surveys that will permit timely capture of this information, permitting real time monitoring and the ability to respond to patient feedback more promptly. While targeting the areas above, we will also continue to:• Strive to further improve upon all our quality

and safety measures • Continue with our programme of

development relating to other quality initiatives

• Continue to develop our workforce to ensure they have the skills to deliver high quality care in the most appropriate and effective way

• Embed our 2017-18 Commissioning for Quality and Innovation (CQUIN) initiatives so they become ‘business as usual’, and work to implement any locally agreed CQUINs with our commissioners

• Meet and exceed the Quality Schedule of our NHS Contracts.

... would like to say a very big ‘Thank You’ for all the help he received. Words can’t express the gratitude we feel, when we

think about what you all did. Again, ‘Thank You’.

MS, Patient Feedback Survey, January 2017

15

Statements of Assurance Review of NHS Services Provided 2016-17

During April 2016 to March 2017, Nova Healthcare provided 1,576 episodes of NHS services.Nova Healthcare has reviewed all the data available on the quality of care for these NHS services.The income generated by the NHS services reviewed in 2016-17 represents 100% per cent of the total income generated from the provision of NHS services by Nova Healthcare for 1 April 2016 to 31 March 2017.

Participation in Clinical Audit

National clinical audits are a set of national projects that provide a common format by which to collect audit data. National confidentialenquiriesaimtodetectareasofdeficienciesinclinicalpracticeanddeviserecommendations to resolve them. There were no patients cared for during the reporting period where participation in a nationalclinicalauditoranationalconfidentialenquiry was appropriate to the services and care provided by Nova Healthcare.Local Audits The reports of our local clinical audits were reviewed by the provider from 1 April 2016 to 31 March 2017 and these included:• Medicine Security• Consent• Safeguarding• Privacy and Dignity.Nova Healthcare intends to take the following actions to improve the quality of healthcare provided:• Ensure all patients receive a copy of their

consent form• ‘Closing the loop’ – ensure that audit actions

arereviewedtoconfirmchangesinpracticehave become embedded.

Participation in Research

There were no NHS patients recruited during the reporting period for this Quality Account to participate in research approved by a research ethics committee.

Goals Agreed with Commissioners

A proportion of Nova Healthcare’s income from 1 April 2016 to 31 March 2017 was conditional on achieving quality improvement and innovation goals agreed between Nova Healthcare and its NHS Commissioners, through the Commissioning for Quality and Innovation payment framework.

Statement from the Care Quality Commission

Nova Healthcare is required to register with the Care Quality Commission (CQC) and its current registration status is for the provision of:• Diagnostic and screening procedures• Treatment of disease, disorder or injury• Surgical procedures. Nova Healthcare does not have any conditions on registration. The Care Quality Commission has not taken enforcement action against Nova Healthcare during April 2016 to March 2017 and Nova Healthcare has not participated in any special reviews or investigations by the CQC during the reporting period.Nova Healthcare was last inspected by the CQC in August 2016 and was awarded an overall rating of ‘Good’.We were rated as ‘Good’ in the safe, caring, responsive and well-led domains. The ‘effective’ domain was not rated as the CQC werenotconfidentthattheywerecollectingsufficientevidencetorateeffectivenessforoutpatients & diagnostic imaging. Of note, the CQC commented that Nova Healthcare was a very well-led service with a clear vision that was known to all staff and patients. The culture of the organisation was open and collaborative with strong internal and external

relationships. All the feedback received from patients and staff was extremely positive. The response to individual needs and preferences was exceptional in that it provided care that met individuals’ needs and preferences.Areasidentified,bytheCQC,ofoutstandingpractice included:• Seamless working with NHS professionals

at the local NHS Trust for the best outcomes for patients.

• Feedback from patients and their relatives was overwhelmingly positive, describing theircareintermsof‘fantastic’and‘firstclass’.

• Staffprovidedaflexibleandresponsiveservice. Patients could access services in a way that suited them, providing choice and continuity of care. The service had minimal waiting lists or none at all.

TheCQCalsoidentifiedafewareasforimprovement and these were:• Review systems so doctors with practising

privileges, who access mandatory training through the local NHS Trust, are included inNovaHealthcaretrainingfigurestoensure oversight.

• Ensure that actions from the biennial safeguarding assessment are undertaken and documented.

Statement on Data Quality

Good quality information underpins the effective delivery of patient care and is essential if improvements in quality of care are to be made. Improving data quality, which includes the quality of ethnicity and other equality data, will improve patient care and improve value for money. On induction our

staff are trained on how to obtain and input data correctly onto the electronic system and alsoonhowtohandleconfidentialdata.Nova Healthcare will be taking the following actions to further improve their data quality:• Ensure that all staff complete the

Information Governance training via eLearning

• Ensure that patient details on registration forms are reviewed at each appointment.

Information Governance Toolkit attainment levels: The Information Governance Toolkit is a performance assessment tool, produced by the Department of Health, and is a set of standards the organisations providing NHS care must complete and submit annually by 31 March each year. The toolkit enables organisations to measure their compliance with a range of information handling requirements, thus ensuring that confidentialityandsecurityofpersonalinformation is managed safely and effectively.Aspen Healthcare’s Information Governance Assessment Report overall score for 2016 2017 was 76% and was graded satisfactory, meeting national level 2 requirements.Secondary Uses System (SUS)Nova Healthcare did not submit records during April 2016 to March 2017 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published data.Clinical Coding Error RateNova Healthcare was not subject to the Payment by Results clinical coding audit during April 2016 to March 2017 by the Audit Commission.

17

Quality Indicators

In January 2013, the Department of Health advised amendments had been made to the National Health Service (Quality Accounts) Regulations 2010. A core set of quality indicatorswereidentifiedforinclusioninthequality account.Not all indicator measures that are routinely collated in the NHS are currently available in the independent sector and work will continue during 2017-18 on improving the consistency and standard of quality indicators reported across Aspen Healthcare. A number of metrics have been chosen to summarise our performance against key quality indicators of effectiveness, safety and patient experience.Nova Healthcare considers that this data is as described in this section as it is collated on a continuous basis and does not rely on retrospective analysis.

Nova Healthcare has taken the following actions to improve its data collection submissions, and the quality of its services, by working with the Private Healthcare Information Network (PHIN) which was launched in April 2013. Data is collected and published about private and independent healthcare, which includes quality indicators. Nova Healthcare does not currently submit data to PHIN. Aspen Healthcare is an active member of PHIN and is working with other member organisations to further develop the information available to the public. See: www.phin.org.uk. When anomalies arise, each one of the indicators is reviewed with a view to learning why an event or incident occurred so that steps can be taken to reduce the risk of it happening again.

Statements of Assurance

Number of Patient Safety Incidents, including Never EventsSource: From Aspen Healthcare’s incident reporting system:

2015-2016 % of patient contacts 2016-2017% of patient

contactsSerious Incidents 1 0.06 Serious Incidents 0 0Serious Incidents resulting in harm or death

0 0 Serious Incidents resulting in harm or death

0 0

Never Events 0 0 Never Events 0 0Total 1 0.06 Total 0 0

Indicator Source 2015 - 20162016 - 2017 Actions to improve quality

Number of people aged 15 years and over readmitted within 28 days of discharge

CQC performance indicator Clinical audit report

0 2 Ongoing monitoring and review

Number of Clostridium difficileinfectionsreported

From national Public Health England/Scotland returns

0 0 Ongoing monitoring

Number of patient safety incidents which resulted in severe harm or death

From hospital incident reports

0 0 Ongoing monitoring

Responsiveness to personal needs of patients

Patient satisfaction survey data – for overall level of care

100% 100%

Friends and Family Test - patients

Patient satisfaction survey – rated extremely likely/likely

100% 100%

Friends and Family Test - staff

Staff satisfaction survey

83.3% N/A Survey staff once every two years and review response

As Nova Healthcare did not have any serious incidents, key learning from other reported incidents were: • Review of pathology labelling and the

migration to the ICE system to reduce risk of human error during labelling within Nova Healthcare and the Pathology department

• Review of the storage of prescription pads.Hospital Level Mortality Indicator and Percentage of Patient Deaths with Palliative Care CodeThis indicator measures whether the number of people who die in hospital is higher or lower than would be expected. This data

is not currently routinely collected in the independent sector.Patient Reported Outcome Measures (PROMs)Patient Reported Outcome Measures (PROMs) assess general health improvement from the patient perspective and calculate the health gains after surgical treatment using pre and post operative surveys. Nova Healthcare does not treat any patients that are eligible for any of the Aspen PROMs related procedures.

Other Mandatory IndicatorsAll performance indicators are monitored on a monthly basis at key meetings and then reviewed quarterly by both local and corporate level Quality Governance

Committees.Anysignificantanomalyiscarefully investigated and any changes that arerequiredareactionedwithinidentifiedtime frames. Learning is disseminated through various quality forums in order to prevent similar situations occurring again.

19

Areasofimprovementidentifiedinthereporting period were:• Improved compliance with the audit

calendar• Implementation of quarterly hand hygiene

training sessions, using UV gel and UV light source

• Decluttering of all clinical areas• Weekly hygiene code checklist audits are

now embedded• Implementation of daily fridge temperature

checks in the patient servery.

AUDIT SCHEDULE SUMMARY 2017

AUDIT Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Infection Prevention and Control

Hygiene code weekly checklist

x x x x x x x x x x x x

PLACE x

IPC Environmental & Clinical Practice

x x x x

High Impact Intervention Hand Hygiene

x x x x

Corporate Audit on Infection Prevention and Control practices

x

Hand Hygiene Observational Audit

x x x x x x x x x x x x

Outpatient Services Patient Turnover

x x x x

Antimicrobial Stewardship x x x x

Infection Prevention and ControlNova Healthcare has an Infection Prevention and Control Link Practitioner who monitors the effectiveness of hand hygiene and environmental cleanliness through regular audits, and training sessions.An audit calendar is in place as shown below

and action plans are formulated for any areas identifiedasrequiringimprovement.Allauditsand associated action plans are reviewed through the local Quality Governance committee, and action plans are regularly reviewed to ensure that any changes in practice have become embedded.

Infection 2015-2016 2016-2017MRSA positive blood culture 0 0MSSA positive blood culture 0 0E. Coli positive blood culture 0 0Clostridiumdifficilehospitalacquired infections 0 0

ComplaintsAll complaints are led and coordinated by the Clinic Manager who acknowledges receipt of the complaint letter. All complainants are offered, where appropriate, a face-to-face meeting with the Clinic Manager at the acknowledgement stage, to help ensure a good understanding of the concerns raised.The complaint is risk assessed to ensure any actions/concerns are immediately addressed. The complaint is entered on to the complaints register. Any complaints that are particularly complex or sensitive may require a more comprehensive investigation similar to a root cause analysis investigation. This would normally be led by the Clinic Manager, supported by the relevant manager. A responsewouldthenbedraftedandthefinalresponsewouldbeverifiedandsenttothecomplainant by the Clinic Manager within 20 working days.If any complaints are received via NHS Commissioners, a lead investigator would be agreed and the unit would liaise with

stakeholders to ensure a comprehensive single response was provided.Although no complaints were received in 2016-17, complaints would be reviewed and discussed between the senior managers as they occur to identify the issues raised and learning to be shared. If any complaints were risk assessed as high, or particularly sensitive or complex, these would be discussed with Aspen’s Group Clinical Director. Complaints involving a Consultant or relating to their practice would be discussed with the individual Consultant and, if necessary, with the Medical Advisory Committee Chair and/or Nova Healthcare Medical Director. If the complaint involved any aspect relating to the doctor’s fitnesstopractice,thenthecomplaintwouldalsobediscussedwithAspen’sResponsibleOfficerand guidance sought.Sharing of learning from complaint investigations are discussed at Quarterly Governance meetings as a standard agenda item and at the Medical Advisory Committee meetings.

Indicator 2015-2016 2016-2017Number of complaints 1 0% per 100 patient contacts 0.16 0

In 2016-17 changes were made to:• Review how Gamma Knife treatments are

planned, ensuring that approval to proceed with treatment has been received from the relevant multi-disciplinary team, prior to advising the patient of their treatment date

For 2017-18, other improvement initiatives include:• Systematic review of the quarterly patient

satisfaction reports to prioritise areas for improvement in services

• Ensure patient satisfaction reports are shared with all staff members

• A ‘suggestion’ box – allowing patients to provide ‘live’ anonymous feedback

• Introduce staff training to ensure point of service/informal complaints (e.g. verbal) areidentifiedandmanagedappropriately

• Enhance the local complaints register to aid trend analysis

• Turn learning from complaints into measurable change and close the loop

• Establish a clear process for managing email interactions with complainants

• Complete training of all staff on the WorldHost® Programme.

Statements of Assurance

21

Review of Quality Performance 2016-17This section reviews our progress with the key quality priorities we identified in last year’s Quality Account.

Patient Safety

STEP-up to Safety Programme Aspen’s aim is for all our hospital and clinics to be recognised as having an outstanding standard of patient safety and in 2016 we implemented a new training programme for all staff called ‘STEP-up to Safety’. This innovative programme explores safety behaviours and engages staff in helping them understand their own role in our safety culture.Progress:Our staff attended a Safety Culture training session centred on ‘human factors’ led by the Group Medical Director and Group Clinical Director. Heads of Department, Team Leaders and clinical staff also attended further training to support our aim that, by working together to establish a robust safety culture, we can come closer to our goal of eliminating all avoidable harm. Two Nova staff members have been nominated as STEP-up Ambassadors to support safety improvement initiatives locally.

Using our Patients’ Experience to Improve SafetyThis involved working in partnership with our patients to improve their safety. An improved understanding of our patients’ perceptions of safety would help to inform any improvements required & support co-production of changes to service delivery and our safety. Progress:Apatientinformationleaflet‘Makingyourstaywith us safe: simple steps to keep yourself safe’ has been developed, outlining some steps that patients can take to help contribute toassuringtheirownsafetywithus.Theleafletincludes information on aspects of care such ascorrectidentification;preventinginfections;medicines safety and discharge advice. The leafletwaslaunchedinearly2017andwillbefollowed up with a patient survey exploring their perceptions of safety.

Clinical Effectiveness

Develop an Audit Tool to Review Cardiac Arrests/CallsAlthough there are a very low number of cardiac arrests in our hospitals and clinics we wished to collect audit data to permit us to identify and promote improvements in the prevention, care delivery and outcomes from cardiac arrest.Progress:We have developed and implemented a new audit tool to ensure we utilise every opportunity to review and analyse any cardiac arrests and cardiac arrest calls to inform and further improve practice and policy. We have also added a bi-annual audit of cardiac arrests to our audit programme.There have not been any cardiac arrest calls at Nova Healthcare during this reporting period, however we have used the audit tool during our resuscitation training scenarios, to improve how we would manage an arrest situation.

Review and Improve Patients’ Fluid and Hydration PathwayIn ensuring the provision of optimum hydration to our patients, we aimed to review ourpoliciestoensurethesereflectedbestpractice guidance.Progress:We have reviewed and updated how we assess and record the hydration status of our patients. We have also updated our intravenous(IV)fluidtherapypracticeandfasting guidance, including the provision of information for patients on IV therapy and whentofast.Ourfluidmanagementrecordinghas been enhanced by the implementation ofreviseddocumentationofallfluidintakeand output for all patients. We now regularly audit the outcome of these changes via our integrated audit programme.

Myself and my two daughters would like to thank you for your care and kindness you and your staff showed to my wife during her recent

illness. Sadly my wife passed away on the 11th Feb 2017 so she never got a chance to thank you herself. I’m sorry we didn’t get to meet under better circumstances. You’re a lovely person doing a great job.

Mr KS, Northern Ireland March 2017

23

Patient ExperienceImplement a Dementia Awareness StrategyWith an ageing population, the number of people in the UK living with, or at risk of, dementia is continuing to rise and we wished to review our practice to ensure this supported the quality, safety and experience of our care to patients and families/carers who are affected by dementia.Progress:We have developed and implemented a Dementia Strategy across all our hospitals and clinics and worked to raise staff awareness to ensure they have an improved perception and understanding of dementia, to enhance the care they provide. This has included the introduction of Dementia Champions in each hospital/clinic, staff training, awareness informationleaflets,dementiaresourcefolders, overview at staff induction, and the implementation of a Dementia Care pathway. We have also registered with the Alzheimer’s Society’s Dementia Friends programme and asked as many of our staff as possible to learn a little bit about what it’s like to live with dementia and turn that understanding into making a difference to people living with the condition by watching a range of videos. By the end of 2016, 50% of our permanent staff had already watched these videos.We have developed a ‘Dementia’ resource fileontheunit,andonememberofstaffhas undergone further training to become a Dementia Champion.Develop Ways to Improve Meaningful Patient Involvement and Engagement Patients are at the centre of the services we provide and we wished to explore how we could improve their involvement and have meaningful engagement with our patients. Progress:We have developed a Patient Involvement and Engagement Strategy to support our hospitals and clinics in developing meaningful initiatives. This is in a ‘toolkit’ format and provides a route map of engagement ideas, as applicable to the services we provide, aiming to promote the involvement of our patients in the planning and improvement of our services. This has included making it easier for our patients to feedback on their

experience with the development of on-line surveys that will be launched in 2017. The majority of focus has been on establishing and including patients in new Patient Forums, improving their inclusion in any complaints & incident investigations, and inviting them to participate in the design, planning and delivery of any new services. This will be an ongoing process of ensuring a truly patient–focused approach and a culture of engagement and involvement.Develop, Review and Implement Revised Patient Feedback SurveysAspen Healthcare is genuinely committed to delivering and excelling at providing excellent care to all our patients & being responsive toourpatients’needs.Wewishedtorefinethe survey tools used, to obtain improved information on the views and perceptions of our patients on the care they received at our clinic, so we can use this information to inform the continued development and improvement of our services. Progress:Our patient survey was revised in 2016. This now includes the Friends and Family test question on how likely a patient is to recommend our clinic to their friends and family, if they needed similar care or treatment and is providing us with valuable insights that will help us further enhance the care and services we provide.This revised patient feedback survey was introduced at Nova Healthcare in April 2016, and completed forms were sent to the external survey provider to enable an independent report to be compiled. We have received four quarterly reports to date, and these have enabled us to prioritise our focus on areas that our patients feel require improvement. We review the patient feedback reports at our local Quality Governance meetings, and identify how we can improve the overall experience of our patients. The reports have a section where all comments made by patients are recorded and this enables staff to see how they have personally impacted on the patients’ experience, as staff are often named very positively within this section.

External Perspective On Quality Of Services

What others say about our services.Nova Healthcare requested the Team Leader at Healthwatch Leeds and the Chair of Health, Wellbeing and Adults at Leeds City Council to comment on this Quality Account. Prior to publication no comments had been received.

Review of Quality Performance 2016-17

Thank you for taking the time to read our Quality Account. Your comments are always welcome and we would be pleased to hear from you if you have any questions or wish to provide feedback.

Please contact us via our websites:

www.aspen-healthcare.co.uk www.novahealthcare.co.uk Or call us on:

02079776080 HeadOffice,AspenHealthcare 0113 206 7830 Nova Healthcare, Leeds

Write to us at:

Nova HealthcareLevel 4, Bexley WingSt James’s HospitalBeckett StreetLeeds LS9 7TF

Aspen Healthcare Limited Centurion House (3rd Floor) 37 Jewry Street London EC3N 2ER