the berkshire independent hospital

Author: Jacqueline Capel Data Classification The Berkshire Independent Hospital Public Use Issued: May 2019 Version 1

The Berkshire Independent Hospital Quality Account 2018/19

Quality Accounts 2018/19 of 50


Contents

Introduction Page

Welcome to Ramsay Health Care UK 4

Introduction to our Quality Account 5

PART 1 – STATEMENT ON QUALITY

1.1 Statement from the Hospital Director 6

1.2 Hospital accountability statement 7

PART 2

2.1 Priorities for Improvement 11

2.1.1 Review of clinical priorities 2018/19 (looking back) 11

2.1.2 Clinical Priorities for 2019/20 (looking forward) 16

2.2 Mandatory statements relating to the quality of NHS services

provided 17

2.2.1 Review of Services 17

2.2.2 Participation in Clinical Audit 18

2.2.3 Participation in Research 20

2.2.4 Goals agreed with Commissioners 20

2.2.5 Statement from the Care Quality Commission 21

2.2.6 Statement on Data Quality 21

2.2.7 Stakeholders views on 2019/20 Quality Accounts 23

PART 3 – REVIEW OF QUALITY PERFORMANCE

3.1 The Core Quality Account indicators 26

3.2 Patient Safety 36

3.3 Clinical Effectiveness 41

3.4 Patient Experience 45

Appendix 1 – Services Covered by this Quality Account 47

Appendix 2 – Clinical Audits 48


Welcome to Ramsay Health Care UK

The Berkshire Independent Hospital is part of the Ramsay Health Care Group

The Ramsay Health Care Group was established in 1964 and has grown to become a global hospital group operating over 100 hospitals and day surgery facilities across Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health Care is one of the leading providers of independent hospital services in England, with a network of 31 acute hospitals. We are also the largest private provider of surgical and diagnostics services to the NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs, Clinical Commissioning Groups Statement from Dr Andrew Jones, Chief Executive Officer, Ramsay Health Care UK “The delivery of high quality patient care and outcomes remains the highest priority to Ramsay Health Care. Our clinical staff and consultants are critical in ensuring we achieve this across the whole organisation and we remain committed to delivering superior quality care throughout our hospitals, for every patient, every day. As a clinician I have always believed that our values and transparency are the most important elements to the delivery of safe, high quality, efficient and timely care. Ramsay Health Care’s slogan “People Caring for People” was developed over 25 years ago and has become synonymous with Ramsay Health Care and the way it operates its business. We recognise that we operate in an industry where “care” is not just a value statement, but a critical part of the way we must go about our daily operations in order to meet the expectations of our customers – our patients and our staff. Everyone across our organisation is responsible for the delivery of clinical excellence and our organisational culture ensures that the patient remains at the centre of everything we do. At Ramsay we recognise that our people, staff and doctors, are the key to our success and our teamwork is a critical part of meeting the expectations of our patients. Whilst we have an excellent record in delivering quality patient care and managing risks, the company continues to focus on global and UK improvements that will keep it at the forefront of health care delivery, such as our global work on speaking up for safety, research collaborations and outcome measurements. I am very proud of Ramsay Health Care’s reputation in the delivery of safe and quality care. It gives us pleasure to share our results with you.” Dr Andrew Jones Chief Executive Officer Ramsay Health Care UK


Introduction to our Quality Account

This Quality Account is The Berkshire Independent Hospital’s annual report to the public and other stakeholders about the quality of the services we provide. It presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience and demonstrates that our managers, clinicians and staff are all committed to providing continuous, evidence based, quality care to those people we treat. It will also show that we regularly scrutinise every service we provide with a view to improving it and ensuring that our patient’s treatment outcomes are the best they can be. It will give a balanced view of what we are good at and what we need to improve on. Our first Quality Account in 2010 was developed by our Corporate Office and summarised and reviewed quality activities across every hospital and treatment centre within the Ramsay Health Care UK. It was recognised that this didn’t provide enough in depth information for the public and commissioners about the quality of services within each individual hospital and how this relates to the local community it serves. Therefore, each site within the Ramsay Group now develops its own Quality Account, which includes some Group wide initiatives, but also describes the many excellent local achievements and quality plans that we would like to share.


Part 1

1.1 Statement on quality from the Hospital Director

Elaine Long, Hospital Director

The Berkshire Independent Hospital

Welcome to The Berkshire Independent Hospital’s Quality Account which has been produced to provide accurate information about how we monitor and evaluate the quality of the services that we deliver and our continued commitment to measuring and acting on feedback from all our patients about their experience, with the intention to continually learn and improve on all aspects of the services we provide. We are aware that patients can be anxious about coming into hospital and understand that providing reassurance is very important to you, the patient, and your family. To this end we continually monitor the clinical care that we provide, outcomes and feedback, via audit and observation and through regular open, analytical review which helps promote a healthy learning culture. The Berkshire Independent Hospital is committed to ensuring that patients are kept fully informed about their treatment, which is also a significant factor associated with improving treatment outcomes. We involve our patients in treatment decisions at the earliest stage so that the options and benefits are fully discussed before patients consent to treatment. Our medical and clinical teams recognise the importance of devoting time preparing patients for surgery, which not only reduces risk but also improves patient understanding and confidence, reduces anxiety, improves rates of recovery and shortens lengths of hospital stay. Our care extends to the post discharge period, where we offer post discharge support and guidance 24 hours a day to provide you with ongoing reassurance. The hospital remains committed to maintaining an organisational culture that puts the patient at the centre of everything we do through innovation; evidence based clinical practice and exemplary customer service.


1.2 Hospital Accountability Statement

To the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate. Elaine Long

Hospital Director The Berkshire Independent Hospital Ramsay Health Care UK This report has been reviewed and approved by:

Chris Brown Rajee Vijayanand Medical Advisory Committee Chair Clinical Governance Committee Chair

Signed Signed

Date 21 June 2019 Date 21 June 2019

Ms Debbie Simmons Nurse Director, Berkshire West CCG

Signed Date 21/06/19


Welcome to the Berkshire Independent Hospital

The Berkshire Independent Hospital was opened in 1993 and is a private hospital with a reputation for delivering high quality healthcare treatments and services. The hospital, built in 1993 is registered for 43 beds, with 32 individual patient rooms; four of which are double rooms; all with en-suite facilities which accommodate inpatients and day cases. The hospital has one Extended Recovery Bed for patients requiring 1-1 nursing. There are three fully equipped Theatres, one fully integrated theatre 2 Ultra Clean Ventilation (UCV), with a six-bedded Recovery; a dedicated Day Surgery wing and an Endoscopy unit. The Outpatient Department on the ground floor of the hospital has 12 consulting rooms with associated examination and treatment facilities, a Gynaecology and Minor Operating Theatre. Outpatient facilities include a large Physiotherapy department with a Gymnasium, X-ray, Ultrasound, DEXA and MRI scanning which are situated in the Mansion adjacent to the hospital. We provide fast, convenient, effective and high quality treatment for patients above the age of 18, whether medically insured, self-pay, or NHS.


The hospital offers a wide range of Specialties including:

Orthopaedics

Spinal

Rheumatology

Urology

General Surgery

Gastroenterology

Dermatology

Elderly care

Gynaecology

Ophthalmology

Plastic Surgery

Respiratory Medicine

Pain management

Vascular Surgery

Endoscopy

The total number of patients treated between the 1st April 2018 and 31st March 2019 was 3711, 65.9% of

these being NHS patients.

We provide direct referral services for Physiotherapy, MRI, Bone Density Scans and Ultrasound Scans.

Miss Julie Deadfield, our GP Liaison Officer works closely with both Practice Managers and GPs at our

local practices and maintains ongoing contact with surgeries located in the surrounding areas. She

regularly organizes ‘Continuous Professional Development’ (CPD) lunches taking consultants into GP

practices to offer training and latest development awareness, as well as running Healthcare Professional

Training Seminars. We value our contact with GP’s as customers and strive to ensure we actively work

to enhance patient care.

We are committed to working closely with our local NHS Foundation Trust to actively assist and reduce

waiting times for patients suitable for treatment at our hospital.

As a hospital we support both national and local charities and currently support Macmillan Cancer

Research.

We provide outreach clinics in Wokingham, Nettlebed and at Kendrick Road, Reading.

Past patients are involved in our ‘Patient Led Assessment of the Care Environment ‘PLACE’ Audit, for

which we received favorable outcomes and excellent feedback from both patient and staff assessors.

Consultants with Practicing Privileges = 100

We have 24 hour Resident Medical Officer cover

We employ 119 Staff which equates to104.5 Full Time Equivalent


Our staff mix as of April 2019

Number WTE

Trained Nurses 26 23.93

Operating Department Practitioners

6 5.6

Healthcare Assistants 11 8.87

Administrators 40 45.76

Support Services 20 16.42

Radiographers 5 4.47

Physiotherapists 4 3.53

Others 7 6.4


Part 2

2.1 Quality priorities for 2018/2019

Plan for 2018/19

On an annual cycle, The Berkshire Independent Hospital; develops an operational plan to set objectives for the year ahead. We have a clear commitment to our patients as well as working in partnership with our local CCGs ensuring that the services that we are commissioned to provide safe, evidence based treatments for all NHS patients whilst they are in our care. We constantly strive to improve clinical safety and standards by a systematic process of governance including audit and feedback from all those experiencing our services. To meet these aims, we have various initiatives on going at any one time. The priorities are determined by the hospitals Senior Leadership Team taking into account patient feedback, audit results, national guidance, and the recommendations from the various hospital committees which represent all professional and management levels. Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital.

Priorities for improvement

2.1.1 A review of clinical priorities 2018/19 (looking back)

Patient Safety

Appropriate staffing levels:

The Berkshire Independent Hospital’s Clinical Staffing Strategy is to ensure that the hospital is staffed with the appropriate number and skill mix of clinical practitioners in order to deliver quality care and to keep patients safe from avoidable harm. The Berkshire Independent Hospital has a Governance Strategy for skill mix and staffing levels with a focus on patient care and patient safety. Measures are in place to monitor, review and react ensuring that skill mix and staffing level requirements are met at all times. Staffing levels and skill mix were reviewed twice daily taking into account patient activity and acuity, with a staffing ratio not exceeding 5 patients to 1 nurse on the ward. Our Outpatient Department staffing levels met clinic requirements with a Registered Nurse on duty when the department was open. Theatre staffing was reviewed against theatre sessions and the requirements of individual theatre lists The Berkshire Independent Hospital carried out a daily huddle meeting attended by representatives from each department and reviewed staffing across the entire hospital.


The Berkshire Independent Hospital focused on safe staffing levels in 2018/19 by updating the Workforce Strategy and Quality Report in 2018 to meet the requirements of CQC Regulation 18 – Staffing. This is linked to the domains of Safe, Effective and Well-led. This was monitored by our Electronic Rostering System (Healthroster) and by our daily review of man hours per patient day. Safeguarding:

The Berkshire Independent Hospital has continued to take very seriously our responsibility for the safeguarding of vulnerable members of society. In accordance with regulatory requirements we continued to ensure that all staff working within the hospital hold the level of DBS check appropriate to their role. We continued to provide our staff with safeguarding training, updating the content of this training in accordance with national guidance and ensured that staff had access to the necessary resources available to manage any concerns appropriately and in a timely manner. The Head of Clinical Services (Matron) is the Safeguarding and Prevent Lead for The Berkshire Independent Hospital The Head of Clinical Services (Matron) participated in local safeguarding meetings to ensure we were able to offer the best service to our Patients. Effective from April 2019 the Berkshire Independent Hospital achieved 96% compliance with Safeguarding Adults Training, exceeding the threshold of 95%. The Head of Clinical Services attended Prevent Train the Trainer training and implemented a rolling PREVENT/WRAP Training programme in-house; 81.6% of staff trained in PREVENT/WRAP. The Berkshire Independent Hospital continued to submit the Safeguarding Annual Audit to the CCG and the Quarterly Prevent Return Audits. This is linked to CQC domains Safe, Caring and Well led Speak up for Safety:

The Berkshire Independent Hospital implemented the ‘Speaking Up for Safety’ (SUFS) Programme. The Head of Clinical Services (Matron) was accredited as a trainer to deliver a one hour Speak Up for Safety Seminar to all staff.

The Speaking Up for Safety programme will help us:

achieve culture change by increasing the ease and motivation for all staff to feel safe to ‘speak up for safety’

develop insights and skills to respectfully raise issues with colleagues when concerned about a patient’s safety

The Berkshire Independent Hospital launched Speak Up for Safety on July 2018.

Speak up for safety training was presented to the Clinical Governance and Medical Advisory Committees; effective from May 2019, 98% of staff employed by The Berkshire independent Hospital have attended Speaking Up for Safety Training. This is linked to the CQC domains Safe, Caring, Responsive, Effective and Well-led.


Clinical Effectiveness

Pre-Operative Assessment:

The Berkshire Independent Hospital focused on the Pre-Operative Assessment service in 2018/19; the service was further developed to ensure that Patients fitness for surgery was assessed in advance of their admission to reduce the chance of their operation being cancelled on the day of the procedure. We reviewed staff skill mix, availability of clinics and pre-operative information given to Patients. We successfully recruited an Outpatient Manager to lead the team and further Registered Nurses for the Pre-operative Assessment Clinic; the pre-operative assessment team underwent further training to improve their knowledge and skills. Our employed Anaesthetist, who is available to review all patients where concerns are raised by our pre-assessment nurses, continued to work closely with the pre-assessment team and the Consultants, further streamlining our processes to improve patient outcomes. Our Pre-operative assessment lead has been working with the Berkshire Partnership of Anaesthesia with the aim of implementing a weekly Anaesthetist led Pre-operative Assessment Clinic. This is linked to CQC domains Safe, Effective and Well-led

Patient Cancellations:

Cancellations are a missed opportunity; they have both an operational, financial and reputational impact to the business and impact on the patient journey and outcomes. The Berkshire Independent Hospital identified a need to focus on this key strategy to reduce the number of cancellations which could be avoided. The aim was to identify key points of the patient journey where due to failure in processes, staff training/education and lack of clear systems cancellations occur. The Berkshire Independent instigated a full review of cancellations and the reasons contributing to them. In order to measure the success of the review the objective was to reduce the number of avoidable cancellations by 25% using the number of cancellations from April 1st 2017 to March 31st 2018 as a baseline. The following actions were implemented to achieve this outcome:

Raising Staff Awareness

Staff Training/Education

Accurate recording of cancellations

Use of a cancellation tracker and the Ramsay Risk Management System

Establish monthly MDT Cancellations Committee to review cancellations

Weekly Activity Meetings

The Berkshire Independent Hospital monitored cancellations monthly and a report was written and circulated to the Senior Leadership Team and Heads of Department to communicate to staff in order to continue to raise awareness.


The report was discussed at the Clinical Governance Committee and Medical Advisory Committee to ensure that awareness was raised to the Consultants. An annual report has been written which evidences actions taken and outcomes achieved. All cancellations have been monitored through the use of ‘Riskman’, our risk information management system. The monthly Cancellations Meeting has reviewed all cancellations, identified trends and any variances that can be influenced have been actioned through this meeting. The objective that the number of cancelled procedures will be reduced significantly across the targeted areas has not been achieved; this is due to the increase in reporting of cancellations on ‘Riskman’ therefore the data from 2017/18 is not a qualitative benchmark. The data from 2018/19 will be used as a benchmark and the review of cancellations will be carried forward to 2019/20. As a result the number of cancellations recorded increased providing more qualitative data during 2018/19 The 2.7% cancellation rate will be the benchmark for 2019/20. This is linked to CQC domains Safe, Effective, Responsive and Well led.

Patient Experience

Patient Satisfaction survey:

Patient feedback is taken seriously by The Berkshire Independent Hospital and is used in the continuous improvement of our services in order to ensure positive patient outcomes.

We have continued to review all feedback from our Patients and implement any changes necessary to ensure they have the best patient experience and that we meet their expectations. To this end we have introduced a Patient Experience Committee with representatives from each department and patient participants. We have continued to review our Friends and Family Test responses and have received positive feedback with a recommends percentage from 95 – 100%. The Patient Experience Committee reviews the feedback from the Ramsay patient survey, ‘We value your opinion’, compliments and any complaints received in order that recommendations from department representatives are taken into account where any changes to processes and procedures are required to improve patient experience. Feedback is communicated to staff via compliments have been reviewed and through the patient experience champions and the Heads of Department and monthly Department Meetings. This is linked the CQC domains Responsive, Caring and Well led


2.1.2 Clinical Priorities for 2019/20 (looking forward)

Patient Safety Falls Prevention

This quality initiative is linked to NHS Outcomes Framework domain 5 “Treating and caring for people in a safe environment and protecting them from avoidable harm”. Falls prevention has been agreed as one of The Berkshire Independent’s CQUINs for 2019/20; a falls strategy will be created by the Head of Clinical Services and the Clinical Heads of Department; the aim of which is to reduce avoidable falls in hospital. The strategy will involve building a team of champions/leads collated to identify concerns and to create additional risk reduction objectives. An action plan will be developed to structure training for staff in relation to the strategy, to address concerns identified and to identify how the actions will be monitored and measured. Each quarter we will have a falls focus week with additional emphasis on staff and patient education. A specific audit tool will be developed and implemented and results will be reported to the CCG quarterly. Results will be reported at Clinical Heads of Department Meetings and Departmental Team Meetings where the action plan will be reviewed on a monthly rolling programme. This is linked to the CQC domain Safety and to the principle of The Ramsay Way ‘positive outcomes.’

Clinical Effectiveness Patient Cancellations:

Patient cancellations will continue to be a focus for 2019/20; the aim was to identify key points of the patient journey where due to failure in processes, staff training/education and lack of clear systems cancellations occur. As stated in the 2.1.1 reducing the number of cancellations on the day has not progressed as quickly as would have liked. Qualitative data has been collected to benchmark the percentage of cancellations and actions have been implemented to identify the root causes for these cancellations and allow the hospital team to put in place measures which ensure that the number of avoidable cancellations is reduced. The Berkshire Independent Hospital will carry the review of cancellations forward into 2019/20; cancellation committee meetings will be held quarterly to review the cancellation rate and the reason for this. The committee will review cancellations and establish actions to address the reasons for cancellations with the objective of reducing the cancellation rate. The strategy will involve building on the reporting of cancellations at the point of care to ensure accurate and timely reporting. An action plan will be developed to structure training for staff in relation to the strategy, to address concerns identified and to identify how the actions will be monitored and measured. The action plan will be reviewed and the outcomes will be reported and analysed at the quarterly cancellation committee which will report in to the quarterly Clinical Governance Committee. Results will be reported at


Clinical Heads of Department Meetings and Departmental Team Meetings where the action plan will be reviewed on a monthly rolling programme. Progress will be monitored at the quarterly cancellation committee meetings and an annual report will be written to report the outcomes. This is linked to CQC domains Safe, Effective, Responsive and Well led and to the principles of The Ramsay Way ‘positive outcomes and sustainability.’

Patient Experience

Throughout the Healthcare sector there is a national objective to improve the health and wellbeing of all employees; The Berkshire Independent Hospital is committed to embracing this vision. The Berkshire Independent Hospital recognises the link between staff health and wellbeing and patient safety, patient experience and the effectiveness of patient care. The Berkshire Independent Hospital is committed to the introduction of health and wellbeing initiatives covering physical activity, mental health and improving access to physiotherapy for people with MSK issues. This will be a focus for 2019/20 and has been agreed as one of the CQUINs for The Berkshire Independent Hospital. The Berkshire Independent Hospital has developed an action plan to meet the three main requirements of this initiative:

a) Introducing a range of physical activity schemes for staff. Providers would be expected to offer physical activity schemes with an emphasis on promoting active travel, building physical activity into working hours and reducing sedentary behaviour. They could also introduce physical activity sessions for staff which could include a range of physical activities such as, team sports, fitness classes, running clubs and team challenges.

b) Improving access to physiotherapy services for staff. A fast track physiotherapy service for staff suffering from musculoskeletal (MSK) issues to ensure staff who are referred via GP’s or Occupational Health are able to access physiotherapy in a timely manner without delay.

c) Introducing a range of mental health initiatives for staff. Providers would be expected to offer support to staff such as, but not restricted to; stress management courses, line management training, mindfulness courses, counselling services including sleep counselling and mental health first aid training.

A strategy and action plan will be developed and implemented to embed the Health & Wellbeing Initiative into the hospital’s culture. Progress towards achieving the priority will be monitored by review of the action plan and a quarterly update and report to the Senior Leadership Team and Heads of Department. The Berkshire Independent Hospital will submit a report to West Berkshire Clinical Commissioning Group in line with the requirements of the CQUIN.


2.2 Mandatory Statements The following section contains the mandatory statements common to all Quality Accounts as required by the regulations set out by the Department of Health.

2.2.1 Review of Services

During 2018/19 the Berkshire Independent Hospital provided and/or subcontracted Outpatient Consultations, Diagnostics and Elective Surgery in 19 NHS services. Gynaecology, Orthopaedics - Knee and Hip, Podiatric Surgery, Hand and Wrist - Carpal Tunnel Syndrome, Cataracts, Colorectal Surgery, DEXA Bone Density Scan, Foot and Ankle Surgery, Shoulder and Elbow Surgery, Hernia Surgery, Upper GI, Endoscopy, MSK Physiotherapy, Gall stone, Gall Bladder and Cholecystectomy, Spinal Surgery, Neck and Back Pain, Urology. The Berkshire Independent Hospital has reviewed all the data available to them on the quality of care in 19 of these NHS services. The income generated by the NHS services reviewed in 1 April 2018 to 31st March 19 represents 60.8% per cent of the total income generated from the provision of NHS services by The Berkshire Independent Hospital for 1 April 2018 to 31st March 19. Ramsay uses a balanced scorecard approach to give an overview of audit results across the critical areas of patient care. The indicators on the Ramsay scorecard are reviewed each year. The scorecard is reviewed each quarter by the hospitals senior managers together with Regional and Corporate Senior Managers and Directors. The balanced scorecard approach has been an extremely successful tool in helping us benchmark against other hospitals and identifying key areas for improvement.

In the period for 2018/19, the indicators on the scorecard which affect patient safety and quality were:

Human Resources

Staff Costs as a % Net Revenue 34.11%

HCA Hours as a % of Total Nursing 31.36%

Agency Cost as a % of Total Staff Cost 5.14%

Ward Hours Per Patient Day 4.2

Staff Turnover 23.6%

Sickness 3.7%

Lost Time 18.95%

Appraisal 82%

Mandatory Training 94%


Number of Significant Staff Injuries 0

Patient

Formal Complaints per 1000 HPD's 0.945%

Patient Satisfaction Score 95 – 100%

Significant Clinical Events per 1000 Admissions 0.25%

Readmission per 1000 Admissions 0.33%

Quality

Workplace Health & Safety Score 97%

Infection Control Audit Score 99 – 100%

Consultant Satisfaction Score – No survey performed in the period

2.2.2 Participation in clinical audit

During 1 April 2018 to 31st March 2019 The Berkshire Independent Hospital participated in 100% of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that The Berkshire Independent Hospital participated in, and for which data collection was completed during 1 April 2018 to 31st March 2019, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

Name of audit / Clinical Outcome Review Programme

% cases

submitted

National Joint Registry (NJR) 99.28%

Elective surgery (National PROMs Programme) 100%

The reports of two national clinical audits from 1 April 2018 to 31st March 2019 were reviewed by the Clinical Governance Committee and The Berkshire Independent Hospital intends to take the following actions to improve the quality of healthcare provided.


National Joint Registry (NJR)

Recommendation Actions required (specify “None”, if none required)

Action by date

Continue to ensure robust

systems are in place to

guarantee that a MDS form

is generated for all eligible

NJR procedures

Currently this is the

responsibility of one ODP in

Theatre – A second member

of the team to be trained to

input data

July 2019

Continue to reinforce to all

Consultants the importance

of completing a MDS form

for all eligible NJR

procedures,

Discuss at Medical Advisory

Committee and cascade to

Consultants

July 2019

Include NJR audit in the

hospital annual audit plan

Discuss at SMT & HODs

Review with POAC and

Theatres

July 2019

PROMS

The Berkshire Independent Hospital participates in Patient Reported Outcomes Measures Survey for patients undergoing Groin Hernia Procedures, Hip Replacement Surgery and Knee Replacement Surgery pre-operatively and post-operatively.

Surgical Site Infection

Surgical Site Infection following hip and knee arthroplasty: PHE Surgical Site Infection Surveillance Scheme (SSISS) and reporting of infections on internal Risk Management incident reporting system. The Berkshire Independent Hospital participates in the Surgical Site Infection Surveillance Scheme (SSISS). This is a national scheme which is mandatory for hip and knee arthroplasty. PHE mandates that all hospitals must undertake at least one full quarters’ surveillance in these categories. The Ramsay Surveillance Policy implemented in 2015 stipulates that hospitals undertake continuous surveillance during all 4 quarters. This is to minimise statistical variation in sites that undertake lower numbers of operations. Local Audits

The reports of The Berkshire Independent Hospital Ramsay mandatory clinical audits and local clinical audits from 1 April 2018 to 31st March 2019 were reviewed by the Clinical Governance Committee and The Berkshire Independent Hospital intends to take the following actions to improve the quality of healthcare provided. The clinical audit schedule can be found in Appendix 2. The Berkshire Independent Hospital participates in the Ramsay Corporate Clinical Audit Programme which between 1 April 2018 and March 2019 comprised 70 separate audits (which includes infection prevention and control, transfusion, physiotherapy and radiology local clinical audits). The results were reviewed by the Clinical


Governance Committee and The Berkshire Independent Hospital intends to monitor audit and to improve the quality of healthcare provided. The clinical audit schedule can be found in Appendix 2. All audit results showed an excellent degree of compliance – our main priorities for 2019/2020 will be ensuring standards are met, and where we identify room for improvement, we have documented action plans with evidence of changes implemented. To facilitate improvement and staff participation in audit ongoing audit training will continue to be a focus for 2019/20. The Head of Clinical Services, the Ward Manager and the Infections Prevention Control Link Nurse have attended a Clinical Audit Programme Training Day and will cascade the learning from this to the Clinical Heads of Department to increase knowledge and optimize audit performance.

2.2.3 Participation in Research

The number of patients receiving NHS services provided or sub-contracted by The Berkshire Independent Hospital in 2018/19 that were recruited during that period to participate in research approved by a research ethics committee was Zero. There were no patients recruited during 2018/19 to participate in research approved by a research ethics committee.

2.2.4 Goals agreed with our Commissioners using the CQUIN

(Commissioning for Quality and Innovation) Framework

A proportion of The Berkshire Independent Hospital’s income in from 1 April 2018 to 31st March 2019 was conditional on achieving quality improvement and innovation goals agreed by The Berkshire Independent Hospital and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. The CQUIN themes participated in for 2018/19 were:

Reporting of Patient Safety Incidents – No harm/low harm

Preventing Ill Health by Risky Behaviour - Alcohol and Tobacco

The Berkshire Independent Hospital successfully achieved 100% CQUIN compliance.

2.2.5 Statements from the Care Quality Commission (CQC)

The Berkshire Independent Hospital is required to register with the Care Quality Commission and its current registration status on 31st March is registered without conditions. The Berkshire Independent Hospital has not participated in any special reviews or investigations by the CQC during the reporting period.

The CQC carried out an unannounced inspection at The Berkshire Independent Hospital on 19th March 2019to follow up on some information of concerns that they had received about the Surgery service; the draft CQC report has rated The Berkshire Independent Hospital Good over all domains.


2.2.6 Data Quality Statement on relevance of Data Quality and your actions to improve your Data Quality

The Berkshire Independent Hospital will be taking the following actions to improve data quality.

NHS Number and General Medical Practice Code Validity

The Ramsay Group submitted records during 2018/19 to the Secondary Users Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data included:

The patient’s valid NHS number:

100% for admitted patient care;

100% for outpatient care; and

Accident and emergency care N/A (as not undertaken at Ramsay hospitals).

The General Medical Practice Code:

100% for admitted patient care;

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


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

Ramsay Group DSP Assessment Report overall for 2018/9 was 83% and was graded as ‘Standards Met’. A score is no longer assigned.

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

Clinical coding error rate

Hospital Site Next Audit Date

Primary Diagnosis

Secondary Diagnosis

Primary Procedure

Secondary Procedure

Berkshire Independent

21st May 2019

100% 91.3% 100% 93.6%

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


2.2.7 Stakeholders views on 2018/19 Quality Account

Berkshire West Clinical Commissioning Group (CCG) has reviewed The Berkshire Independent Hospital (BIH) Ramsay Healthcare Quality Account and is providing this response on behalf of Berkshire West CCG and associate CCGs across the Thames Valley. The Quality Account 2018/19 provides information for a wide range of quality measures giving a comprehensive review of quality of care and details upcoming priorities to be undertaken by the provider during 2019/20. There is evidence that BIH has relied on internal governance structures to maintain oversight and external assurance mechanisms to triangulate the available data to maintain and improve safety, quality and effectiveness of the patient population. The CCG is satisfied with the accuracy of the data and information contained in the Account. The CCG supported the key priorities in 2018/19, identified within the domains of patient safety, clinical effectiveness and patient experience. Care Quality Commission (CQC) Inspection – March 2019

The CQC recently carried out an unannounced inspection at BIH on 19th March 2019 and rated the provider ‘Good’ across all domains in Medical Care, Outpatients and Diagnostic Imaging and Surgery. We are delighted BIH have maintained their rating of ‘Good’ and continue to support the provider to deliver a high quality service to patients. Patient Safety Improvement Priorities

BIH identified three priorities for 2018/19 under patient safety, and discussed below: We are pleased the Hospitals Clinical Staffing Strategy has been key to maintain the quality of care whilst ensuring the appropriate number of skill mix. It is evident that a significant amount of work undertaken to ensure appropriate staffing levels are maintained to deliver its services. It is positive to note that the priority relating to Safeguarding training compliance achieved 96% in 2018/19. BIH successfully implemented the ‘Speaking up for Safety’ programme during 2018/19, with 98% of its staff attending training delivered by the Matron using a ‘train the trainer’ approach. We are pleased that the programme has supported staff to develop insight and confidence to raise concerns for the safety of its patients. Clinical Effectiveness Improvement Priorities

Two Clinical Effectiveness priorities were defined for 2018/19; this includes Pre-Operative Assessment and Patient Cancellations. There has been significant work to develop the pre-operative service to ensure patient fitness for surgery assessments are carried out in advance of admission, with staff training and closer working relationships between pre assessment teams / consultants. A reduction in patient cancellations within 2018/19 has not been achieved. However, the CCG are satisfied that a significant amount of work has been undertaken with the processes and staff training/education. The CCG are pleased this remains a quality priority for 2019/20 and the provider target has been revised with an action plan to improve this outcome.


Patient Experience Improvement Priorities

The CCG are delighted patient satisfaction continues to prevail at the hospital. The Patient Experience Committee has proven to be a valuable addition in listening to the patient voice. Clinical Priorities 2019/20

Fall prevention

The CCG welcomes this priority as a quality priority for 2019/20 and recognises this initiative as part of the National CQUIN. The CCG are appraised of the on-going work to reduce avoidable hospital falls and fully support of the additional emphasis on staff and patient education. Patient cancellations

Over the last year patient cancellations continue to increase and this will be the focus for 2019/20. BIH have acknowledged the issues around processes / staff training and developed an action plan to address. Staff health and well being

The CCG fully support the inclusion of staff health and wellbeing initiatives by providing access to physiotherapy services, introducing mental health initiatives and physical activity schemes for staff. Overall, there have been many positive highlights for the provider and the CCG has gained assurance via a number of forums and by undertaking quality assurance visits. The CCG are pleased that BIH has chosen to continue their focus on priorities within the domains of patient safety, clinical effectiveness and patient experience. It is recognised that a significant amount of combined effort has been undertaken over the past year. We support the provider in its continuing focus on the results from 2019/20 priorities and the on-going requirements to further those improvement and strengthen priorities over the coming financial year through the integrated care system.

Debbie Simmons Nurse Director - Berkshire West Clinical Commission Group June 2019


Part 3: Review of quality performance 2018/2019

Statements of quality delivery

Head of Clinical Services (Matron), Jacqueline Capel

Review of quality performance 1st April 2018 - 31st March 2019

Introduction

“This publication marks the ninth successive year since the first edition of Ramsay Quality Accounts. Through

each year, month on month, we analyse our performance on many levels, we reflect on the valuable feedback

we receive from our patients about the outcomes of their treatment and also reflect on professional assessments

and opinions received from our doctors, our clinical staff, regulators and commissioners. We listen where

concerns or suggestions have been raised and, in this account, we have set out our track record as well as our

plan for more improvements in the coming year. This is a discipline we vigorously support, always driving this

cycle of continuous improvement in our hospitals and addressing public concern about standards in healthcare,

be these about our commitments to providing compassionate patient care, assurance about patient privacy and

dignity, hospital safety and good outcomes of treatment. We believe in being open, transparent and honest

where outcomes and experience fail to meet patient expectation so we take action, learn, improve and

implement the change and deliver great care and optimum experience for our patients.”

Vivienne Heckford Director of Clinical Services Ramsay Health Care UK

Ramsay Clinical Governance Framework 2019

The aim of clinical governance is to ensure that Ramsay develop ways of working which assure that the quality of patient care is central to the business of the organisation. The emphasis is on providing an environment and culture to support continuous clinical quality improvement so that patients receive safe and effective care, clinicians are enabled to provide that care and the organisation can satisfy itself that we are doing the right things in the right way. It is important that Clinical Governance is integrated into other governance systems in the organisation and should not be seen as a “stand-alone” activity. All management systems, clinical, financial, estates etc. are inter-dependent with actions in one area impacting on others.


Several models have been devised to include all the elements of Clinical Governance to provide a framework for ensuring that it is embedded, implemented and can be monitored in an organisation. In developing this framework for Ramsay Health Care UK we have gone back to the original Scally and Donaldson paper (1998) as we believe that it is a model that allows coverage and inclusion of all the necessary strategies, policies, systems and processes for effective Clinical Governance. The domains of this model are:

• Infrastructure • Culture • Quality methods • Poor performance • Risk avoidance • Coherence

Ramsay Health Care Clinical Governance Framework

National Guidance

Ramsay also complies with the recommendations contained in technology appraisals issued by the National Institute for Health and Clinical Excellence (NICE) and Safety Alerts as issued by the NHS Commissioning Board Special Health Authority. Ramsay has systems in place for scrutinising all national clinical guidance and selecting those that are applicable to our business and thereafter monitoring their implementation.


3.1 The Core Quality Account indicators

All acute hospitals are required to report against these indicators using a standardised statement set out below. The Berkshire Independent Hospital is only required to include indicators in our Quality Accounts relevant to the services the hospital provides. Data sets are routinely submitted to NHS and Non-NHS bodies by NHS Digital, a comparison of the numbers, percentages, values, scores or rates of the NHS Trust and non-NHS bodies (as applicable) are included for each of those listed in the tables below: Mortality

The table below shows the Mortality data, the latest data release from the Health & Social Care Information Centre (HSCIC), the mortality data is a Summary hospital-level Mortality Indicator (SHMI). The figures below have been extracted from the most recent data sets available. The data submission is to prevent people from dying prematurely and enhancing quality of life for people with long-term conditions as part of the NHS outcomes framework.

Mortality: Period Best Worst Average

Period Berkshire

Apr 16 - Mar

17 RKE

0.7075 RLQ

1.2123 Average 1 2017/18 NVC0

2 0.0000

Apr 17 - Mar

18 RJ1 0.6994 RE9 1.2321 Average 1 2018/19

NVC02

0.0000

Prescribed Information Related NHS Outcomes Framework Domain

The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to— (a) the value and banding of the summary hospital-level mortality indicator (“SHMI”) for the trust for the reporting period; and (b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period. *The palliative care indicator is a contextual indicator.

1: Preventing People from dying prematurely 2: Enhancing quality of life for people with long-term conditions

The Berkshire Independent Hospital considers that this data is as described for the following reasons:

The hospital provides services for elective care

The hospital has an acceptance criteria the objective of which is to maintain patient safety


Patient Reported Outcome Measures (PROM’s)

PROM’s are a series of questions that patients are asked in order to gauge their views on their own health. The purpose of PROMs is to ascertain patients’ own assessment of their health and health-related quality of life – PROMs questionnaires do not ask about patients’ satisfaction with or experience of health care services, or seek their opinions about how successful their treatment was. Annual datasets are typically finalised fifteen months after the end of the reporting period that they cover. The Oxford Scores focus on joint function and pain and include questions about patients’ mobility and factors such as ability to navigate stairs and use transport specifically affected by the hip or knee. The EQ-5DTM score is a standardised instrument for use as a measure of health outcome and has a broader base than the Oxford Scores. Its questions relate to mobility, self-care, usual life activities, pain/discomfort and anxiety/depression.

The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the trust’s patient reported outcome measures scores for— (i) groin hernia surgery, (ii(ii) hip replacement surgery, and

(iii) knee replacement surgery, during the reporting period.

3: Helping people to recover from episodes of ill health or following injury

0

1

16/17 17/18 18/19

Unexpected Deaths

Berkshire Independent Hospital


Hernia

PROMS: Period Best Worst Average

Period Berkshire

Hernia Apr16 - Mar 17 RJR 0.1618 RNA 0.016 Eng 0.089

Apr16 - Mar 17 NVC02 0.0820

Apr17 - Mar 18 RQM 0.136 RXK 0.029 Eng 0.089

Apr17 - Mar 18 NVC02 no data


The number of hernia procedures is small The Berkshire Independent Hospital intends to take the following actions to improve this rate and so the quality of its services, by:

Monitoring the amount of hernia procedures and increasing submission if the numbers become sufficient.

Hips


Period Berkshire

Hips Apr16 - Mar 17 NTPH1 25.2044 RFS 17.838 Eng 22.019 Apr16 - Mar 17 NVC02 *

Apr17 - Mar 18 NTPH1 26.299 RBK 18.87 Eng 22.679 Apr17 - Mar 18 NVC02 20.600


We have good systems for ensuring pre-op questionnaires are returned and patients understand the importance of returning their post op questionnaire.

The Berkshire Independent Hospital intends to take the following actions to improve this rate and so the quality of its services, by:

Continue and further improve return rates;

Ensure patients have realistic expectations and appropriate rehabilitation

Knees


Period Berkshire

Knees Apr16 - Mar 17 NTPH1 21.3485 RK5 12.647 Eng 16.877 Apr16 - Mar 17 NVC02 16.160

Apr17 - Mar 18 NT235 20.635 RAN 13.156 Eng 17.258 Apr17 - Mar 18 NVC02 15.275


We have good systems for ensuring pre-op questionnaires are returned and patients understand the importance of returning their post op questionnaire;

Patients report good outcomes when returning for follow up.


The Berkshire Independent Hospital intends to take the following actions to improve this rate and so the

quality of its services, by

Continue and further improve return rates;

Ensure patients have realistic expectations and appropriate rehabilitation.

Hospital Re-admissions

Monitoring rates of readmission to hospital is another valuable measure of clinical effectiveness and outcomes. Any emerging trend identified with a specific surgical operation or surgical team may identify contributory factors to be addressed. The table below shows the data set reviewing patients aged 18 or over, who were readmitted to hospital within 28 days of being discharged. The latest data sets available from SUS have been reported on for this Quality Account, this data is not updated until August 2018.

The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the percentage of patients aged— 18 or over, Readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period.

3: Helping people to recover from episodes of ill health or following injury

Readmissions: Period Best Worst Average

Period Berkshire

2010/11 Multiple 0.0 5P5 22.76 Eng 11.43 2017/18 NVC02 0.00

2011/12 Multiple 0.0 5NL 41.65 Eng 11.45 2018/19 NVC02 0.00


There is a safe discharge policy in place and patients are given good aftercare instructions, including a 24 hour follow up call after discharge.

We have robust clinical pathways which include discharge criteria The Berkshire Independent Hospital intends to take the following actions to improve this rate, and so the quality of its services, by:

Maintaining a system of comprehensive patient assessment and information.

Improving our awareness of readmissions to other hospitals


Transfer to External Hospital Transfer can be defined as the purposeful planned movement of patients from one health service to another. The main reason that a patient would transfer from The Berkshire Independent Hospital to an acute hospital would be the requirement for advanced clinical support. It can be seen that very few transfers take place per 100 discharges. The number has gradually reduced over the last year as we have an effective pre-operative assessment team supported by two experienced Anaesthetist. We also have robust tools used to identify deteriorating patients, reducing the amount of emergency transfers. There is acknowledgement that some transfers cannot be prevented, such as those requiring specialist treatment centres.

0

2

4

6

8

10

12

14

16

18

16/17 17/18 18/19

Readmissions


0.00%

0.05%

0.10%

0.15%

0.20%

0.25%

0.30%

0.35%

16/17 17/18 18/19

Transfers



Responsiveness to personal needs

Patients and the public justifiably expect public services which are responsive to their needs and driven by them. Monitoring Patient experience and improving patient satisfaction leads to positive service improvements. This composite measure is made up of the following five survey questions:

Were you involved as much as you wanted to be in decisions about your care and treatment?

Did you find someone on the hospital staff to talk to about your worries and fears?

Were you given enough privacy when discussing your condition or treatment?

Did a member of staff tell you about medication side effects to watch for when you went home?

Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?

The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the trust’s responsiveness to the personal needs of its patients during the reporting period.

4: Ensuring that people have a positive experience of care

Responsiveness: Period Best Worst Average

Period Berkshire

to personal 2012/13 RPC 88.2 RJ6 68.0 Eng 76.5 2013/14 NVC02 92.8

needs 2013/14 RPY 87.0 RJ6 67.1 Eng 76.9 2014/15 NVC02 93.6


We provide excellent customer service as demonstrated by patient surveys.

Each patients care is planned on an individual basis

The Berkshire Independent Hospital intends to take the following actions to improve this rate and so the quality of its services, by:

Continuing to ensure patients remain the focus of everything we do.


Venous Thromboembolism (VTE)

From 1 June 2010, the Department of Health (DH) required that VTE risk assessments take place for every patient, and that results are closely monitored in order to reduce the 25,000 preventable deaths that occur in UK hospitals every year. The trigger for the VTE prevention pathway is the assessment of risk so that appropriate preventative treatment can be given in line with national clinical guidance and outcomes can be improved. This is the focal objective of the National VTE Prevention Programme and its delivery is supported by a number of measures that have been introduced over the last number of years. The VTE assessment domain reviews data to see if patients are being treated and cared for in a safe environment and are being protected from avoidable harm. The data looks at all patients who have had an adequate risk assessment prior to admission in relation to the prevention of post-operative VTE events.

VTE Assessment: Period Best Worst Average

Period Berkshire

17/18 Q4 Several 100% NT490 0.0% Eng 95.2% 17/18 Q4 NVC02 96.7%

18/19 Q3 Several 100% NVC0M 14.7% Eng 95.7% 18/19 Q3 NVC02 98.8%

The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.

5: Treating and caring for people in a safe environment and protecting them from avoidable harm


Our Clinical Pathway documents direct staff to undertake VTE Risk Assessment;

Staff understand the importance of VTE Risk Assessment.

VTE Assessment rates are reviewed through audits and monthly reports

96.5 96.5

0

20

40

60

80

100

2017 2018

Sati

sfac

tio

n S

core

s


Satisfaction Scores NHS/Private Patients


The Berkshire Independent Hospital intends to take the following actions to improve this rate, and so the quality of its services, by:

Continuing to undertake local audit and ensure risk assessments are completed

Working with our Consultants via our Medical Advisory Committee to ensure their understanding of the importance of VTE Risk Assessment

Clostridium-Difficile infection

Clostridium difficile infection (CDI) remains an unpleasant, and potentially severe or fatal infection that occurs mainly in elderly and other vulnerable patient groups especially those who have been exposed to antibiotic treatment

C. Diff rate: Period Best Worst Average

Period Berkshire

per 100,000 2016/17 Several 0 Q71 82.6 Eng 13.2 2017/18 NVC02 0.0

bed days 2017/18 Several 0 Q71 91.0 Eng 13.7 2018/19 NVC02 0.0

The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the rate per 100,000 bed days of cases of C difficile infection reported within the trust amongst patients aged 2 or over during the reporting period.


0.8

0.82

0.84

0.86

0.88

0.9

0.92

0.94

0.96

0.98

1

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

100%


Excellent

Fail

Actual

Target



The Local IPC Committee is chaired by our Infection Prevention and Control lead and consists of representatives from all key areas of the hospital and includes a Consultant Microbiologist. The committee meets quarterly to oversee implementation of corporate policies and National guidance and review clinical audit and practice.

All staff undertake mandatory infection prevention and control (IPC) training annually

Completion of corporate clinical audits, incident reporting, identifying trends and identification of further training requirements

Bare Below the Elbows is a focus of our clinical strategy

Information sharing at Clinical Governance level locally, corporately and with our commissioners. Also through local Medical Advisory Committee and Senior Leadership Team meetings.

The Berkshire Independent Hospital has an Anti-Microbial Policy in place which prohibits the use of restricted antibiotics.

The Berkshire Independent Hospital intends to take the following actions to maintain this rate and so the quality of its services, by:

Continuing to provide all stakeholders with education and information about infection prevention and control practice.

Patient Safety Incidents The Francis Report (2013) emphasised the need to put patients first at all times, and that they must be protected from avoidable harm. In addition, the Berwick report (2013) recommended 4 guiding principles for improving patient safety, including: placing the quality and safety of patient care above all other aims for the NHS, engaging, empowering, and hearing patients and carers throughout the entire system, and at all times. Incident reporting supports clinicians to learn about why patient safety incidents happen within their own service and organisation, and what they can do to keep their patients safe from avoidable harm.

SUIs: Period Best Worst Average

Period Berkshire

(Severity 1 only) Apr17 - Sep17 Several 0 RJW 0.64 Eng 0.15 2017/18 NVC02 0.00

Oct17 - Mar18 Several 0 RWD 0.55 Eng 0.15 2018/19 NVC02 0.00

The data made available to the National Health Service trust or NHS foundation trust by NHS Digital with regard to the number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death


The Berkshire Independent Hospital considers that this data is as described for the following reasons.

We risk assess all patients and provide them with an appropriate environment which enables risks to be reduced.

We have a rolling training programme in place relating to the reporting of incidents on the Ramsay Risk Management System ‘Riskman’


We review all reported incidents at Clinical Heads of Department meetings monthly and Clinical Governance Committee quarterly

We have embedded ‘Speaking up for Safety’ into our culture

We have a rolling training programme in place relating to Sepsis The Berkshire Independent Hospital intends to take the following actions to improve this proportion, and so the quality of its services, by:

Continuing to schedule a mandatory rolling training programme for update relating to ‘Riskman’ annually

Continuing to schedule a rolling training programme relating to Sepsis

Engaging all Clinical Heads of Department and Clinical Leads to attend Root Cause Analysis Training

Ensuring our environment is well maintained and risk assessments are in place.

There have been no Severity 1 SUIs

Friends and Family Test The NHS Friends and Family Test (FFT) is an opportunity for patients to provide feedback on the hospitals services. It was introduced in 2013 and asks people if they would recommend the services they have used and offers a range of responses. When combined with supplementary follow-up questions, the FFT provides a mechanism to highlight both good and poor patient experience. This gives the hospital a better understanding of the needs of their patients and enabling improvements.

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

4: Ensuring that people have a positive experience of care

0

2

4

6

8

10

12

14

16/17 17/18 18/19

SUIs (Severity 1 or 2)




We actively encourage patients to complete the Friends and Family Test Survey

We have Friends and Family Test Champions in each department

We analyse data received from the survey on monthly and communicate the results to our staff

We write to individual members of staff who have been named commending them for positive feedback

We take both positive and negative feedback seriously and use this to continually improve our services The Berkshire Independent Hospital intends to take the following actions to improve this score, and so the quality of its services, by:

Continuing to raise staff awareness of the importance of patient feedback by highlighting results through Clinical Governance meetings, Patient Experience Committee, Department meetings and Customer Care Excellence training.

Continuing to raise patient awareness of the importance of patient feedback by displaying results in patient facing areas of the hospital.

F&F Test: Oct Best Worst Average

Period Berkshire

Jan-19 Several 100% RJR 71.0% Eng 96.0% Jan-19 NVC02 *

Feb-19 Several 100% NVC12 70.0% Eng 96.0% Feb-19 NVC02 100.0%

3.2 Patient safety We are a progressive hospital and focussed on stretching our performance every year and in all performance respects, and certainly in regards to our track record for patient safety. Risks to patient safety come to light through a number of routes including routine audit, complaints, litigation, adverse incident reporting and raising concerns but more routinely from tracking trends in performance indicators. Our focus on patient safety has resulted in a marked improvement in a number of key indicators as illustrated in the graphs below.

3.2.1 Infection prevention and control

The Berkshire Independent Hospital has a very low rate of hospital acquired infection and has had no

reported MRSA Bacteraemia in the past 3 years.

We comply with mandatory reporting of all Alert organisms including MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents year on year. Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic joint surgery and these are also monitored. Infection Prevention and Control management is very active within our hospital. An annual strategy is developed by a corporate level Infection Prevention and Control (IPC) Committee and group policy is revised and re-


deployed every two years. Our IPC programmes are designed to bring about improvements in performance and in practice year on year. A network of specialist nurses and infection control link nurses operate across the Ramsay organisation to support good networking and clinical practice. Programmes and activities within our hospital include:

The Berkshire Independent Hospital understands that Infection Control is a core part of an effective risk management programme, aiming to improve the quality of patient care and the occupational health of staff, in addition to the clinical need to prevent Healthcare Associated Infections (HCAI), and protect patients from harm.

• Our Infection and Prevention Control Link Nurse is one of the Senior Registered Nurses on the ward. • The Infection and Prevention Control Link Nurse coordinates audits relating to Infection Prevention

Control throughout the hospital. • The Infection Prevention Control Link Nurse and the Head of Clinical Services perform mandatory

IPC Training for all staff in the hospital. • IPC Training is offered to external medical secretaries and the Berkshire Partnership of Anaesthesia

administrative staff who attend the hospital. • In addition Clinical staff undertake further training and assessment of competencies in Aseptic No

Touch Techniques (ANTT). • All staff receives education and training in Infection and Prevention Control and Hand Washing. • Monthly Infection and Prevention Control audits are performed. • Annual skin surveillance assessments are completed for all relevant staff. • Annual Hand washing assessments are completed for all relevant staff. • The cleanliness of the hospital is audited regularly as part of the Ramsay corporate clinical audit

programme as well as regular monitoring by The Head of Clinical Services (Matron) and the Operations Manager.

• There is a focus on wearing the correct uniform and personal protective equipment. • There is a focus on Bare below the Elbows and there are posters displaying this strategy featuring

members of The Berkshire Independent Hospital’s staff. • We have introduced individual hand hygiene wipes which are provided on all meal trays in order that

patients can ensure good hand hygiene prior to eating their meals


The Berkshire Independent Hospital closely monitors all infections. As can be seen in the above graph our infection rate has decreased over the last year. This is due to our rolling Infection Prevention Control Training, our reporting structure and audit processes. The Infection Prevention Control Link Nurse works closely with The Head of Clinical Services (Matron) reviewing all infection related incidents to identify areas for improvement and lessons learned are shared with the relevant teams.

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

2016/17 2017/18 2018/19

Infe

ctio

n R

ates

(p

erce

nta

ge o

f A

dm

issi

osn

s)

Berkshire

Infection Rates

0

2

4

6

8

10

12

16/17 17/18 18/19

Hospital Acquired Infections



3.2.2 Cleanliness and hospital hygiene

Assessments of safe healthcare environments also include Patient-Led Assessments of the Care Environment (PLACE) PLACE assessments occur annually at The Berkshire Independent Hospital, providing us with a patient’s eye view of the buildings, facilities and food we offer, giving us a clear picture of how the people who use our hospital see it and how it can be improved. The main purpose of a PLACE assessment is to get the patient view.

3.2.3 Safety in the workplace

Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to incidents around sharps and needles. As a result, ensuring our staff have high awareness of safety has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety. Our record in workplace safety as illustrated by Accidents per 1000 Admissions demonstrates the results of safety training and local safety initiatives. Effective and ongoing communication of key safety messages is important in healthcare. Multiple updates relating to drugs and equipment are received every month and these are sent in a timely way via an electronic system called the Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and new and


revised policies are cascaded in this way to our Hospital Director which ensures we keep up to date with all safety issues. Falls

There was an increase in patient falls without harm during 2018/19, although the number was low; The

Berkshire Independent Hospital made this a focus in order to optimise patient safety.

All patients undergo a falls risk assessment on admission and when their condition requires further assessment

Falls posters have been introduced in all bedrooms and bathrooms advising patients ‘To call before you fall’

All patients are sent a falls leaflet in their admission pack which advises on falls prevention

All patients are assessed in relation to mobilising and supervised until able to mobilised independently

During 2018/20 all clinical staff will undertake falls E-learning training

Prevention of falls will be a CQUIN for The Berkshire Independent Hospital for the coming year.

The Berkshire Independent Hospital has a designated Occupational Health Link Nurse who is linked to the wellbeing programme. This ensures the needs of staff are met locally and facilitates close monitoring and robust reporting. All staff members complete a health surveillance programme on appointment of position. Any occupational health issues during employment are tracked through the ‘Riskman’ reporting system. All staff at The Berkshire Independent Hospital attend annual mandatory training which includes:

Fire, Health and Safety

Manual Handling

0

1

2

3

4

5

6

7

8

16/17 17/18 18/19

Falls



3.3 Clinical effectiveness

The Berkshire Independent Hospital has a Clinical Governance team and committee that meet regularly through the year to monitor quality and effectiveness of care. Clinical incidents, patient and staff feedback are systematically reviewed to determine any trend that requires further analysis or investigation. More importantly, recommendations for action and improvement are presented to hospital management and medical advisory committees to ensure results are visible and tied into actions required by the organisation as a whole.

3.3.1 Return to theatre

Ramsay is treating significantly higher numbers of patients every year as our services grow. The majority of our patients undergo planned surgical procedures and so monitoring numbers of patients that require a return to theatre for supplementary treatment is an important measure. Every surgical intervention carries a risk of complication so some incidence of returns to theatre is normal. The value of the measurement is to detect trends that emerge in relation to a specific operation or specific surgical team. Ramsay’s rate of return is very low consistent with our track record of successful clinical outcomes.

As can be seen in the above graph our return to theatre rate has increased over the last year, although it remains low. This is due to our ongoing focus on reporting and a result of our focus on recognition of a deteriorating patient in which staff have received increased training.

Every surgical intervention carries a risk of complication so some incidence of returns to theatre is normal. The value of the measurement is to detect trends that emerge in relation to a specific operation or specific surgical team. Ramsay’s rate of return is very low consistent with our track record of successful clinical outcomes.

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0.18

2016/17 2017/18 2018/19

Ret

rnn

to

Th

eatr

e

(Per

cen

tage

of

Ad

mis

sio

sns)

Berkshire

Return to Theatre Score


3.3.2 Learning from Deaths

Following events in Mid Staffordshire, a review of 14 hospitals with the highest mortality noted that the focus on aggregate mortality rates was distracting Trust boards “from the very practical steps that can be taken to reduce genuinely avoidable deaths in our hospitals”. This was reinforced by the recent findings of the Care Quality Commission (CQC) report Learning, candour and accountability: A review of the way NHS trusts review and investigate the deaths of patients in England. It found that learning from deaths was not being given sufficient priority in some organisations and consequently valuable opportunities for improvements were being missed. The report also pointed out that there is more we can do to engage families and carers and to recognise their insights as a vital source of learning. For this reason the team at The Berkshire Independent Hospital review all patient deaths which take place to identify if there is any learning. During the last 12 month period there was one unexpected death following discharge, post-operatively; the coroner’s inquest identified that this was not due to problems in the care provided to the patient. In December 2018 HM Coroner issued a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, in relation to a patient death that occurred as a result of a post-operative complication and failure to expedite the transfer of deteriorating patient in August 2017. The report highlighted 3 specific concerns in relation to preventing future deaths. A comprehensive review was undertaken to ensure that lessons, following this event, have been learned and that significant changes have been made to prevent such an incident happening again. As a result of the investigation that was undertaken following this death the following actions were implemented:

A review of all low volume procedures is undertaken on a quarterly basis and acted on to stop individual Consultants and the hospital performing procedures where the required skills are not available on site.

Implementation of a Resuscitation Huddle. This is a twice daily meeting the hospital’s emergency team to discuss the role of each member and ensure they are familiar with protocols and policy; it also discusses every patient, their NEWS2 score, any escalation required, any emergency consultant visit and any diagnosis from that, any concerns of staff or the RMO. This is recorded in writing and available for staff to review.

0

1

2

3

4

5

6

7

16/17 17/18 18/19

Reoperations



The on call Senior Leadership Team Member calls into the hospital each night to obtain an update from the Resuscitation Huddle.

Staff have been trained in both NEWS 2 and sepsis recognition management including Sepsis 6 pathways

We have reviewed our NEWS Policy and the escalation points

In July 2018 we introduced a programme called ‘Speaking Up for Safety’. This programme that encourages all staff to ‘Speak Up’ if they believe that there is a risk to patient safety, using a prescriptive tool and offering ‘psychological safety’ in speaking up The response to the Coroner’s report and the action plan were reviewed during the unannounced CQC inspection that took place on 19th March 2019 and all elements of the action plan were noted to have been implemented

Following a Ramsay VTE review a lessons learned report was reviewed by the Berkshire Independent Hospital actions were taken against the lessons learnt:

Registered Nurses assess Medical Questionnaires at pre-operative assessment

Patient medication and use of hormone therapy is reviewed

Mobility is assessed

Significant comorbidities are reviewed

All patients undergo a VTE assessment pre-operatively

All patients undergo a hydration assessment pre-operatively

Written information relating to VTE management is documented in the patients’ medical records

0

1

16/17 17/18 18/19

Unexpected Deaths



3.3.3 Staff Who Speak up new for 2018/19

In 2018, Ramsay UK launched ‘Speak Up for Safety’, leading the way as the first healthcare provider in the UK to implement an initiative of this type and scale. The programme, which is being delivered in partnership with the Cognitive Institute, reinforces Ramsay’s commitment to providing outstanding healthcare to our patients and safeguarding our staff against unsafe practice. The ‘Safety C.O.D.E.’ enables staff to break out of traditional models of healthcare hierarchy in the workplace, to challenge senior colleagues if they feel practice or behaviour is unsafe or inappropriate. This has already resulted in an environment of heightened team working, accountability and communication to produce high quality care centred on the best interests of the patient. Ramsay UK has an exceptionally robust integrated governance approach to clinical care and safety, and continually measures performance and outcomes against internal and external benchmarks. However, following a CQC report in 2016 with an ‘inadequate’ rating, coupled with whistle-blower reports and internal provider reviews, evidence indicated that some staff may not be happy speaking up and identifying risk and potentially poor practice in colleagues. Ramsay reviewed this and it appeared there was a potential issue in healthcare globally, in response to this Ramsay introduced ‘Speaking Up for Safety’. The Safety C.O.D.E. (which stands for Check, Option, Demand, Elevate) is a toolkit which consists of these four escalation steps for an employee to take if they feel something is unsafe. Sponsored by the Executive Board, the hospital Senior Leadership Team oversee the roll out and integration of the programme and training at The Berkshire Independent Hospital and across Ramsay. The programme is employee led, with staff delivering the training to their colleagues, supporting the process for adoption of the Safety C.O.D.E through peer to peer communication. Training compliance for staff and consultants is monitored corporately; the company benchmark is 85%. Since the programme was introduced serious incidents, transfers out and near misses related to patient safety have fallen; and lessons learnt are discussed more freely and shared across the organisation weekly. The programme is part of an ongoing transformational process to be embedded into our workplace and reinforces a culture of safety and transparency for our teams to operate within, and our patients to feel confident in. The tools the Safety C.O.D.E. used, not only provide a framework for process, but they open a space of psychological safety where employees feel confident to speak up to more senior colleagues without fear of retribution. Ramsay UK is currently embedding the second phase of the programme which focuses on Promoting Professional Accountability, specifically targeted for peer to peer engagement for our Consultant users who work at The Berkshire Independent Hospital and within Ramsay Health Care.

3.3.4 Priority Clinical Standards for Seven Day Hospital

Services

The provision of ‘Seven Day Services’ is a requirement of the NHS Standard Contract and in essence requires providers of acute care to deliver high quality care and improve outcomes on a seven day basis for patients admitted to hospital in an emergency. There are ten separate Standards that providers must aim to achieve, with four of those being designated as being priority areas. Ramsay Health Care has very few emergency admissions due to the nature of services provided to NHS patients (which is generally elective planned care in nature, rather than being emergency). As such many of the requirements of the Seven Day Services Programme are not applicable to Ramsay Health Care. Nonetheless Ramsay has been working to comply with the Standards and in line with national guidance a self-assessment process is being undertaken during spring/summer 2019


3.4 Patient experience

All feedback from patients regarding their experiences with Ramsay Health Care are welcomed and inform service development in various ways dependent on the type of experience (both positive and negative) and action required to address them. All positive feedback is relayed to the relevant staff to reinforce good practice and behaviour – letters and cards are displayed for staff to see in staff rooms and notice boards. Managers ensure that positive feedback from patients is recognised and any individuals mentioned are praised accordingly. All negative feedback or suggestions for improvement are also feedback to the relevant staff using direct feedback. All staff are aware of our complaints procedures should our patients be unhappy with any aspect of their care. Patient experiences are feedback via the various methods below, and are regular agenda items on Local Governance Committees for discussion, trend analysis and further action where necessary. Escalation and further reporting to Ramsay Corporate and DH bodies occurs as required and according to Ramsay and DH policy. Feedback regarding the patient’s experience is encouraged in various ways via:

Continuous patient satisfaction feedback via a web based invitation

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

Yearly CQC patient surveys

Friends and family questions asked on patient discharge

‘We value your opinion’ leaflet

Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers whilst visiting patients and Provider/CQC visit feedback.

Written feedback via letters/emails

Patient Experience Committee

PROMs surveys

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

4.1 Patient Satisfaction Surveys

Our patient satisfaction surveys are managed by a third party company called ‘Qa Research’. This is to ensure our results are managed completely independently of the hospital so we receive a true reflection of our patient’s views. Every patient is asked their consent to receive an electronic survey or phone call following their discharge from the hospital. The results from the questions asked are used to influence the way the hospital seeks to improve its services. Any text comments made by patients on their survey are sent as ‘hot alerts’ to the Hospital Manager within 48hrs of receiving them so that a response can be made to the patient as soon as possible.


As can be seen in the above graph our Patient Satisfaction rate has remained stable over the last year.

96.5 96.5

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Satisfaction Scores NHS/Private Patients


Appendix 1

Services covered by this quality account

Regulated Activities – Berkshire Independent Hospital

Services Provided Peoples Needs Met for:

Treatment of Disease, Disorder Or injury

Allergy Testing, Cosmetics, Dermatology, Dietetics, ENT, Gastroenterology, Geriatric Medicine, General Surgery, Medico Legal, Neurology, Orthopaedics, Psychology, Psychiatry, Physiotherapy, Rheumatology, Sports Medicine, Urology, Women’s Health Outreach Wokingham Medical Centre Private GP service

All adults over 18 years. Outreach clinic consultation only

Surgical Procedures

Bariatric Surgery, Colorectal,

Cosmetics, Dermatological,

Endoscopy, Ear Nose and

Throat, (ENT), General

Surgery, Gynaecological,

Maxillofacial / Oral Surgery,

Ophthalmic, Orthopaedic,

Plastic Surgery, Pain

Management, Spinal Surgery,

Upper GI Surgery, Urology,

Ambulatory, Day and Inpatient

Surgery

All adults excluding the following:

Patients with blood disorders (haemophilia, sickle cell, thalassaemia)

Patients on renal dialysis

Patients with history of malignant hyperpyrexia

Planned surgery patients with positive MRSA screen are deferred until negative

Patients who are likely to need ventilator support post operatively

Patients who are above a stable ASA 3.

Any patient who will require planned admission to ITU post-surgery

Dyspnoea grade 3/4 (marked dyspnoea on mild exertion e.g. from kitchen to bathroom or dyspnoea at rest)

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

MI in last 6 months

Angina classification 3/4 (limitations on normal activity e.g. 1 flight of stairs or angina at rest)

CVA in last 6 months However, all patients will be individually assessed and we will only exclude patients if we are unable to provide an appropriate and safe clinical environment.

Diagnostic and screening

Clinical Chemistry, Cytology

and Histopathology, Diagnostic

Radiology, GI Physiology,

Haematology, Microbiology,

MRI, Phlebotomy, Transfusion,

Ultrasound, Urinary Screening

and Specimen collection,

Urological Screening

All adults 18 years and over.

Family Planning Services

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

All adults 18 years and over as clinically indicated


Appendix 2

Clinical Audit Programme 2019/20. Findings from the baseline audits will determine the hospital

local audit programme to be developed for the remainder of the year.


The Berkshire Independent Hospital

Ramsay Health Care UK

We would welcome any comments on the format, content or purpose of this Quality Account.

If you would like to comment or make any suggestions for the content of future

reports, please telephone or write to the Hospital Director using the contact details below.

For further information please contact:

Elaine Long, Hospital Director

Hospital phone number

0118 902 8000

Hospital website

www.berkshireindependenthospital.co.uk

http://www.berkshireindependenthospital.co.uk/

the berkshire independent hospital

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