CircleBath
Quality Account
2015-16
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Contents
Part One
About the Quality Account
Statement from the General Manager and Clinical Chairman
The Circle Ethos
About CircleBath
Mandatory Statements
The CQC
Part Two
Review of Quality Improvement Objectives for
2015/16
Quality Improvement objectives for the year ahead - 2016/17
Part Three
Review of Services 2015/16
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Clinical Audit
Clinical Outcomes
Patient Safety
Infection Control
Pressure Ulcers
Venous Thrombo Embolism (VTE)
Safety Thermometer
Returns to Theatre
Patient Experience
Staff Engagement
Our Vision and Strategy
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Part One
Patient Comment……
‘Very kind and patient staff. Everyone was
helpful, polite and attentive.
Very positive environment.’
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About the Quality Account
What are the required elements of the Quality Account?
The Health Act 2009 requires all providers of healthcare services to NHS patients to
publish an annual report about the quality of their services; this report is called a
Quality Account. Amendments were made in 2012, such as the inclusion of quality
indicators according to the Health and Social Care Act 2012.The primary purpose of a
Quality Account is to enhance organisational accountability to the public, to engage
Boards and leaders of organisations in fully understanding the importance of quality
across all of the healthcare services they provide, and to promote continuous
improvements on behalf of their patients. The quality of the services is measured by
looking at patient safety, the effectiveness of treatments that patients receive and
patient feedback about the care provided.
What are the key requirements?
1. a statement summarising the Registered Manager’s view of the quality of
services provided to NHS patients;
2. a review of the quality of services provided over the previous financial year
(2015/16); and
3. the quality priorities for the forthcoming financial year (2016/17)
How did we produce our Quality Account?
We have used the Department of Health’s Quality Accounts Toolkit as a guide for our
Quality Account.
To supplement all the mandatory elements of the account, we have also worked
closely with our patients, consultants and other partners to ensure this account truly
reflects the quality measures in place and provides readers with an accurate and
comprehensive insight into the organisation.
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Statement from the General Manager and Clinical
Chairman
It is with great pleasure that we welcome you to the 2015/16 Quality Account produced by
CircleBath which has been written in accordance with the Department of Health’s policy
document ‘High Quality Care for All’. We are pleased to report on the quality of our services,
patient experience and assurance procedures. We hope you find our reflections on 2015 of
interest, and are clear on our plans for the coming year.
During 2015 CircleBath has taken every step to ensure the quality of the patient experience is
at its very best. This encompasses the medical treatment received, the quality of
accommodation and facilities, food and hospitality, which are all centered around the
individuals’ personal needs. We pay meticulous attention to the whole patient pathway, from
making an enquiry, booking an appointment, the treatment, and after care.
We have developed a number of methods of measuring and benchmarking the quality of our
services and pride ourselves on our focus to continuously improve. Our Quality Account
explains our approach to continuous quality improvement.
CircleBath is committed to providing the very highest quality services for patients and
working environment for our clinicians and partners. We strive to provide choice and
innovative, safe and personalised care for our patients and feedback is welcomed. All our
staff are partners in CircleBath, everyone has a voice on how to ensure and improve the
quality of our services and we promote a culture that advocates ‘we are the agents of our
patients’ in line with our credo. We are proud of all our achievements to date.
The Quality Account for 2015/16 details our successes and the areas that have been our focus
over the last twelve months. We remain committed to working with our commissioners,
patients, GPs, staff and other stakeholders and to continuing our quality improvement
journey. The Quality Account explains our main priorities for the coming year.
We confirm that the Quality Account reflects a balanced view of the quality of our services
and we believe, to the best of our knowledge that the information contained in this document
is accurate and informative.
Lisa Carroll
Interim General Manager
Andrew Chambler
Clinical Chairman
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The Circle Ethos
Our Principles
Agents of our patients
Everybody matters
Good enough never is
Our Values
PASSION
We are driven by the needs of our patients. We believe in our Credo and the
importance of our mission. Each of us has a significant contribution to make.
DISRUPTION
We are not afraid to challenge the norm or the vested interest. We encourage
creativity when balanced with discipline and methodology. We have the courage to
call it as it is.
HUMANITY
We value care, compassion and empathy. We engage our partners to be their best. We
are straightforward, listen to and respect each other.
RESILIENCE
We learn from setbacks and come back stronger. We are tenacious and see
obstacles as challenges. Our belief in ourselves underpins our resolve.
AGILITY
We are always open to new ideas and ways of doing things. We believe that „good
enough‟ never is. We keep it simple and make things happen.
PARTNERSHIP
We have a sense of ownership for what we do. We feel valued and able to make a
difference. We hold each other to account for what we believe in.
Our Purpose
A great company dedicated to our patients.
Our Parameters
Passionate
Best
Sustainable
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CircleBath
Circle was founded on the belief that hospitals should be dedicated to patients.
st
CircleBath has been designed to offer 21 century medical technology with an
unequivocal focus on quality of care and customer service. Each of our hospitals is coformed, co-owned and co-run by clinicians. We are the largest partnership of
healthcare professionals in Europe.
CircleBath is wholly committed to delivering clinical excellence and the highest level of
customer service, every step of the way. We embrace innovation and look for ways to
improve what we do every single day. We believe that makes us different to other
hospitals.
Our Facilities
Circle Hospital Bath facilities are state-of-the-art and include:
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Four operating theatres and recovery unit
Pre-assessment Unit
One endoscopy suite
22 day case beds and 5 ambulatory pods
30 in-patient beds
9 consultation rooms
4 treatment rooms
Physiotherapy suite including hydrotherapy off site
Full diagnostic service -MRI, Mammography Screening, X-ray, ultrasound,
CT, pathology and cardiac testing
Satellite first Consultation only clinics at a selection of local GP surgeries
Aims and Objectives
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The hospital operates 7 days a week on a 24 hour basis.
We aim to deliver a patient experience characterised by comfort and
respect for the patient’s individual needs and views.
We aim to provide speedy access to out-patient, in-patient and day
case surgery treatments in a first-class facility.
We aim to deliver high quality evidence based clinical care that
provides patients with the best outcomes.
Based on:
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Operational Efficiency
Clinical Excellence
Collaborative Approach
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Mandatory Statements
Duty of Candour
Circle implements the statutory Duty of Candour Regulation of the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2014 which came into legal force in
2015 and builds on the requirements set out in the Being Open Framework 2009 ‘Being
open – saying sorry when things go wrong’ National Patient Safety Agency (NPSA), and
Safety Alert 2009.
Circle has a Duty of Candour policy that applies to all facilities within CircleHealth; this
policy was issued in April 2015. The aim of the policy is to help all health professionals
to apply Duty of Candour principles within their daily work. All incidents which involve
Duty of Candour are discussed within the CGRMC meetings on a monthly basis, which are
then taken to the Executive Board
Revalidation
CircleBath has embraced the process of revalidation for medical staff in 2015. This is
fully implemented, and compliance is monitored quarterly by CircleHealth’s Integrated
Governance Committee.
Safeguarding
The Executive Board is accountable for and committed to ensuring the safeguarding of
children and all vulnerable adults in their care. CircleBath also has a responsibility to
liaise with other agencies and provide information to them where necessary, to ensure
the on-going safety of children and vulnerable adults once they leave our care.
CircleBath’s safeguarding team are comprised of an executive lead, a named nurse and a
named doctor who attend the Operational
Management Board, a sub-committee of the Local Safeguarding Children’s Board, and
the Safeguarding Partnership meetings.
CircleHealth has a safeguarding policy that applies to all its facilities, including
CircleBath which was re-reviewed in March 2016. CircleBath adheres to the Local
Authority safeguarding procedures.
CircleBath provides all staff with Level 2 training in safeguarding and provides an update
every two years. An annual staff leaflet is circulated which provides the contact details
of the safeguarding leads and other useful telephone numbers. In addition safeguarding
issues are reported to the Clinical Governance and Risk Management Committee (subcommittee of the Executive Board) which meets monthly.
The Executive Board takes the issue of safeguarding extremely seriously, and receives an
annual report on safeguarding.
Staff Survey
All staff were asked to complete a ‘Working at Circle’ staff survey between February
and April 2016. Data from this is currently being analysed and will be reviewed by the
Executive Board and an action plan developed during 2016 to address any areas of
improvement.
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The CQC
CircleBath has not been inspected by the Care Quality Commission (CQC) during the
reporting period. The Care Quality Commission has not taken enforcement action
against CircleBath during the reporting period 2015/16
CircleBath was last inspected by the CQC in January 2014.
CircleBath is registered with the Care Quality Commission and has no conditions on
registration.
CircleBath has not participated in any special reviews or investigations by the CQC
during the reporting period.
A Quality Improvement plan is in place to support our hospital teams in ensuring we
are delivering care to the highest standard within the CQC domains of safe, effective,
caring, responsive and well-led. Work continues to enable us to reach a standard of
good across the domains when we are inspected. We anticipate an inspection will
occur during 2016.
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Part Two
Patient Comment……
‘Similar to flying business class on a world class
airline – it was a great 5 star experience.’
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Reviewing Quality Improvement Objectives
from our last Quality Account:
Our priorities for improvement in 2015 were based on the value equation:
Our priorities for last year were:
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Patient Connect
Quality Improvement Programme
The details of progress made on our key priorities from last year are outlined within
this Quality Account.
The outcomes of further planned initiatives will be reviewed and analysed over the
coming year. Our successes will be clearly demonstrable and areas for improvement
identified.
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REVIEW OF LAST YEARS OBJECTIVES
1.
Patient Connect
‘Every Patient, Every Day’
What have we achieved?
We piloted a new initiative in 2015 called Patient Connect.
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A team of Patient Connect Partners were selected and they underwent specific
training to enable them to fulfil their role.
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A member of the Patient Connect Team now undertakes a visit to every Inpatient
on every day of the working week (Monday to Friday).
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This is an effective way to allow patients to pass on their feedback and patient
stories regarding their experience with us.
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We now resolve any issues at the point of discussion to allow the best possible
patients experience e.g. a patient recently asked for a chair to be added to the
shower room as they were feeling nervous. This action was implemented with
immediate effect.
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The Patient Connect Team meet on a regular basis to reflect on the patient
feedback provided and thus improvements are made to the services we offer in a
timely manner.
The learning from the pilot has now been reviewed and Patient Connect was fully
implemented in quarter 4, 2015/16.
New partners have joined the team from many hospital departments, and additional
training has been instituted. Our aim remains, to visit every patient every day. Engaging
in this way with patients’ is proving effective in addressing concerns. Following on from
the initial trial, the patient connect group has designed a new format to document
responses, in order to provide a record of actions taken. A code system has been
developed to capture information and to identify areas of concern. This also provides
evidence of excellent practice. The patient connect team meet regularly and are
currently developing a pathway to ensure that issues that cannot be addressed by the
patient connect partner, are escalated appropriately. In the future it is anticipated that
by coding responses, trends can be identified and if required addressed.
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2. Quality Improvement Programme
We have developed a programme of quality improvements to ensure that we at
CircleBath achieve:
• Sustainable change
• Communication of good practice
• An open-door policy for feedback on new ideas and improvement opportunities
• The embedding of new processes into our culture
• Staff partner involvement in providing the highest possible care for our patients
• The highest quality working environment for our staff partners
• Maximum utilisation of the Circle Operating System (COS) to implement change(s)
The steps involved focused around the following Stages:
Stage 1 – the review stage
Stage 2 – celebrating our successes and identify actions which can improve quality
further
Stage 3 – implementing the change(s) required
Stage 4 – auditing change(s) to ensure assurance, compliance and ensure that the
changes have been fully embedded.
During Stage 1:
We reviewed our existing: processes; patient feedback and experience; partner
feedback; incidents; complaints and claims; policies and SOP’s; patient pathways;
contracts; audits; ‘Walk-Arounds’, training levels and competencies.
During Stage 2:
A project plan was implemented with the role of the Steering Committee Group
(involving staff partners from all departmental areas) having been established. We have
undertaken regular weekly meetings, provided updates to the Executive Board and
departmental leads, communicated with all staff partners on plans and new initiatives
established and further embedded the utilisation of the Circle Operating System (COS).
During Stages 3 and 4:
We will continue to ensure that all staff partners take responsibility and ownership for
implementing change(s) and this should form part of their everyday practice, to ensure
that we remain sustainable.
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New Objectives for 2016
Our priorities for improvement in 2016/17 are as follows:
Quality Domain
Best clinical outcomes
Patient and Public
Engagement
Best patient experience
Quality Measures
Further develop and embed learning
from incidents and complaints,
through training and competencies
Further develop our patient and public
engagement initiatives.
Implement PLACE audits
Further develop the patient lunches
and patient forums
Build on our engagement with
Healthwatch and Commissioners
Review our approach to 7 day
working.
Review and develop an environment
conducive to the needs of patients
with learning disabilities, dementia
and sensory impairment.
Review compliance with Accessible
Information standards
Monitoring
CGRMC
CGRMC
CGRMC
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Part Three
Patient Comment……
‘The staff were all consistently excellent and I received
VIP treatment’
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Review of Services
During 2015/16 CircleBath provided E-Referrals (previously Choose and Book) and
transferred activity from NHS Services.
CircleBath has reviewed all the data available to them on the quality of care in 100%
of these NHS Services.
The income generated by the NHS services reviewed in 2015 represents 100% of the
total income generated from the provision of NHS services by CircleBath for 2015.
Review of Last Year’s Quality Indicators
Clinical Audit
Clinical Audit is a way to find out if healthcare is being provided in line with standards
and enables care providers and patients to know where their service is doing well, and
where improvements could be made. The aim is to allow quality improvement to take
place where it will be most helpful and will improve outcomes for patients. CircleBath
takes part in both national and local audit programs. The audits measure our healthcare
practice against national or locally agreed standards.
The table below provides a summary of the National Audits that were applicable to and
undertaken at CircleBath:
Name of National Clinical Audit
CircleBath
CircleBath
eligible to
participation
participate in
Falls and fragility fractures (includes the Hip
Yes
Comments
Yes / No
No
Fracture Database)
Circle Bath did consider participation in Falls and fragility fractures
audit, but the numbers of falls were too low for inclusion.
Heart: Cardiac arrhythmia (or ablation)
Yes
No
Circle Bath chose not take part in these audits.
Heart: Congenital heart disease
Yes
No
Circle Bath chose not take part in these audits.
Heart: Coronary angioplasty (PCI)
Yes
No
Circle Bath chose not take part in these audits.
Heart: Heart failure
Yes
No
Circle Bath chose not take part in these audits.
Heart: Myocardial ischaemia national audit project
Yes
No
Circle Bath chose not take part in these audits.
Joint replacement surgery: the National Joint
Yes
Yes
Circle Bath has taken part in this audit
Ophthalmology
Yes
No
Circle Bath choose not take part in these audits
Vascular: National Vascular Registry
Yes
No
Circle Bath choose not take part in these audits
Registry
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National Confidential Enquiries
During 2015/16 there were no applicable national confidential enquiries for which
Circle Bath was eligible to take part.
Blood Transfusion
A Service Level Agreement is in place with the Royal United Hospital (RUH) Bath to
provide blood and blood components and specialist advice.
Return Compliance
The Blood Safety and Quality Regulations (BSQR) 2005 require Trusts to ensure all blood
components are traceable from donor to recipient in 100% transfusions of blood and
plasma components. The MHRA (Medicines and Healthcare products Regulatory Agency)
are the inspection body enforcing this law.
The law requires evidence of fate of unit in 100% transfusions. It is the responsibility of
Circle staff to return the tags to the providing Blood Bank. The RUH will, as part of the
Service Level Agreement with Circle, contact the relevant area if tags are not
returned. The RUH will also, as part of the SLA, provide training support to staff.
Circle Bath Hospital Results
% traceability:
100%
Summary of Blood Usage March 15 - March 16
O negative
Blood Units issued
Units used
62
0
Units wasted
8
power & temp failure
failure
Patient specific
94
35
0
Blood Safety Audits
The following Blood Safety Audits are undertaken at CircleBath:
1. Monthly blood register audit – to ensure the register is always completed correctly,
all daily checks are carried out and the blood fridge disc has been changed every
week.
2. 10% of all (transfused) patients’ notes will be audited every three months – to
ensure they have had a blood transfusion, to check all paperwork was completed
correctly and within relevant time scales.
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Plans for 2016
1. Continue to develop our Transfusion meetings and align with governance
meeting structure
2. Continue with regular monthly and three monthly audits.
External Audits
Within the central audit tool, a number of audits are designated to be completed by
external advisors (corporate employees, with no affiliations to a specific Circle
Hospital).
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ISO 27001
QAAT (Quality Audit and Assessment Team)
Centralised audits
Internally collected by designated staff over the course of a year. All data is inputted
into a central audit tool, in line with all other Circle Sites. The data is then collated
centrally and reviewed by the Corporate Integrated Governance Committee, to which
all sites provide a representative. The following audits are undertaken:
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Hand Hygiene
Health and Safety
Environmental Cleaning
Clinical Records
Privacy and Dignity
Information Security
Security
Sharps
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Medical Gas
Controlled Drugs
Waste
Fire Warden
Internal Audit Programme
A further series of audits are completed internally in CircleBath, to enhance clinical
safety, patient care and quality of services specifically for our Hospital.
All internal audit findings are presented and discussed at the Clinical Governance & Risk
Management Committee (CGRMC). CGRMC is responsible for assigning and monitoring
any actions as and when needed. The below table provides a brief summary and
frequency of our internal audit programme:
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Audit Title
Purpose of the Audit
Frequency
Prevention of VTE (Venous thromboembolism)
To assess compliance to NICE guidance and best practice
for assessment of risk and the provision of prophylaxis
Pain and Nausea audit
To assess effectiveness of pain management protocols
WHO surgical site safety checklist audit
To assess compliance to W HO surgical site safety checklist
Monthly
Blood transfusion audit
Compliance with blood safety and national transfusion guidance
Monthly
CAS and NICE guidance audit
To ensure that all alerts (CAS & MHRA) are reviewed,
documented and circulated accordingly
Monthly
Emergency Scenario audit
To ensure that all staff are aware of their responsibilities in the
case of an emergency
Annual
Controlled drugs
To ensure best practice is followed at all times
Monthly
NEWS
Usage of NEW S audit to identify early signs of the deterioration of
a patient’s condition
Monthly
Nutrition and Hydration Audit
To ensure that patients who are identified at risk for
malnutrition are treated accordingly
Monthly
Pressure sore prevention Audit
To ensure patient who are at risk of developing pressure
sores are identified and treated
Clinical documentation
To supports best practice in patient documentation
Monthly
Consent form Audit
To supports best practice in patient documentation
Monthly
Monthly
Quarterly
Quarterly
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Clinical Outcomes
The vision
The Clinical Governance and Risk Management Committee oversee the collection and
reporting of clinical outcomes and patient satisfaction that will raise the benchmark of
excellence in clinical care delivery in the independent healthcare sector. We aim to
be:
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•
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•
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Best at collecting clinical outcomes and patient satisfaction
Best achievement in clinical outcomes and patient satisfaction
Open and consistent publication of unfiltered patient feedback
Best at translating what we learn to create positive impact on patient care
Become a Centre of excellence and a beacon for other organisations for clinical
outcomes
Patient Reported Outcome Measures (PROMS)
CircleBath collects PROMS for all NHS patients (four key procedures) as well as inhouse PROMS for most of our private patients (e.g. excluding diagnostic procedures,
paediatrics, ophthalmology etc.). Quarterly reports are generated and distributed to
the General Managers and Clinical Chairs of each Circle site for review and action. We
access and download our patient level data from Health and Social Care Information
Centre (HSCIC).
PROMs measures health gain in patients undergoing hip replacement, knee
replacement, varicose vein and groin hernia surgery in England, based on responses to
questionnaires before and after surgery. They measure a patient's health status or
health-related quality of life at a single point in time, and are collected through
short, self- completed questionnaires. This health status information is collected
before and after a procedure and provides an indication of the outcomes or quality of
care delivered to NHS patients and has been collected by all providers of NHS-funded
care since April 2009. CircleBath has been collecting and analysing PROMS data since
October 2010.
CircleBath monitors its PROMs data on a monthly basis. CircleBath PROMs data is
shared with all Clinical Units, including Clinical Governance and Risk Management
Committee. The following data shows our Quarter 4 compliance.
Oxford Hip PROMS – CircleBath Hospital Q4:
Current UK ranking
Average Patient Gain
Target
Oxford Hip Score
41 (211 hospitals)
22.597
24.433
Average Patient health gain Circle Bath
22.597
UK best
UK average
UK worst
Target
24.413
21.540
16.188
23.433
EQ5D Score
105 (207)
0.438
0.486
EQ5D-VAS
6 (206)
15.846
15.081
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Target
UK best
UK average
Circle Bath
20
21
22
23
24
25
Oxford Knee PROMS – Circle Bath Hospital Q4:
Current UK ranking
Average Patient Gain
Target
Oxford Knee Score
27 (217)
17.757
18.553
Average Patient health gain Circle Bath
17.757
UK best
UK average
UK worst
Target
19.436
16.194
10.870
18.553
EQ5D Score
61 (213)
0.332
0.376
EQ5D-VAS
23 (207)
8.331
9.396
Series1,
Target, 18.553
Series1, UK
average,
16.194
Series1, Uk
best , 19.436
Series1, Circle
Bath , 17.757
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Patient Safety
Device Alerts
A number of safety measures are in place at CircleBath, to ensure the highest
standards are adhered to. The following medical safety checks are made:
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MHRA Medical Device alerts – recorded electronically
MHRA Field Safety alerts – recorded electronically
NICE guidance
CAS Alert system – recorded electronically
MHRA Drug Alerts – Audited by our Pharmacy partners and in house pharmacist
Company field safety alerts (received directly from source)
All alerts are registered and cascaded to staff by the Governance Team. Results are
reported on a monthly basis to the Clinical Governance and Risk Management
Committee. Information is also reported to the Executive Board through Assurance
Reports.
Equipment
All equipment is thoroughly checked, logged and maintained either by our facilities
team or on site EBME engineer.
Incident Reporting
Incidents are reported electronically using the DATIX system. Full details of the
incidents are recorded with unit leads assigned the role of ‘investigator’. All details of
the review are then recorded on the electronic record, with clear lessons learnt and
actions taken logged. The Lead Nurse, who is also head of governance for the
hospital, is able to review all records, as can the Corporate Head of Risk and
Assurance.
Additional resources or procedures stated in the action plans can also be loaded into
the electronic record as evidence.
The incident records and any actions logged as a result of an actual incident, near
miss or accident are presented to the Clinical Governance and Risk Management
Committee and the Integrated Governance Committee corporately.
Accidents are reported to RIDDOR when appropriate. An incident form is also logged
for each accident. There were no RIDDOR reportable incidents in 2015.
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Summary Overview
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Accidents
1
2
5
5
2
5
3
6
3
2
1
3
38
Medication
2
3
6
7
9
8
9
7
1
5
11
12
80
Admin
9
5
5
7
4
4
3
7
10
9
4
16
83
Clinical
0
0
2
1
2
1
5
2
3
1
7
4
28
12
10
18
20
17
18
20
22
17
17
23
35
TOTAL
Apr
229
Examples of actions taken following incidents / near misses reported:
Outline of incident
There has been an increase in the number of medication errors and near misses reported. It is widely
recognised that an organization with a high reporting rate of no harm and near miss incidents is a safe
organisation. The increase in incident reporting at CircleBath is as a result of additional training in
incident management and an overall improvement in reporting rates.
The following actions have been taken in response to an increase in medication incident reporting to
ensure the required processes are in place to reduce the likelihood of an incident occurring and ensure
we are learning from any incidents that have occurred:
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Medicines management competencies have been reviewed and updated
Pharmacy team has delivered training sessions to all clinical staff and continues to provide
ongoing support to all clinical areas
All clinical staff have had their competencies reassessed
Combined Nurse in charge and Resident Medical Officer (RMO) daily ward rounds introduced
Medication errors anonymised and discussed during daily shift hand over / team meetings
Reporting continues to be encouraged
Patient Falls
All patient falls are logged through our incident management system and reported to
the Clinical Governance and Risk Management Committee. In 2015/16 6 falls were
reported.
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
1
2
2
0
1
2
0
1
1
1
0
0
TOTAL
Apr
Patient Falls
11
Actions taken
CircleBath has developed an internal Falls Standard Operating Procedure (SOP) that is
available to all staff. When a fall occurs there is an in house rapid response team SWARM
(meeting). The SWARM is attended by Lead/Deputy Lead Nurse, Governance Lead, Unit Lead
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(where fall occurred), RMO and any witnesses to the fall. The main aim of this meeting is to
establish whether the fall could have been prevented and to put immediate steps in place to
avoid further patient falls in the future.
Infection Prevention and Control
CircleBath hospital has a zero tolerance to avoidable infections and as such has a ward to
board approach to infection prevention and control and the potential for harm to occur as a
result of clinical practice. The Lead Nurse provides information and assurance to the
Hospital Board on the activities and results of infection prevention and control practice so
that they can discharge their duties with regard to this area of patient safety and quality of
care in line with Regulation 12 of the Health & Social Care Act 2008 (Regulated Activities)
2010.
Infection Prevention & Control Team Structure
The hospital lead for infection prevention and control is the Lead Nurse, who reports to the
hospital Board, General Manager and the corporate Director of Infection Prevention and
Control on all issues relating to IPC.
The Lead Nurse is supported by a team of trained infection prevention and control link
workers who work in each functional department of the hospital.
The link workers are responsible for:
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The provision of hand hygiene training within their departments
The completion of audits relating to infection prevention and control practice
Representing their departments at the hospital infection prevention and control
committee, so having a direct responsibility for the implementation and management
of IPC practice within the hospital
The provision of IPC knowledge to staff within their teams.
The Lead Nurse is supported in this role by the Corporate Director of Infection Prevention
and Control and by a Microbiologist who is employed on ‘an as required’ basis through a
local Service Level Agreement.
Hospital Infection Prevention & Control Management
The Hospital Board has overall responsibility for the management of infection prevention
and control practice, and has placed a signed statement to this effect on the hospital
website.
The Board delegates the responsibility for the day to day management of infection
prevention and control practice through the Clinical Governance and Risk Management
Committee (CGRMC). The CGRMC has established an infection prevention and control
committee which is led by the Lead Nurse. This committee meets every month in order to
review hospital practice and make recommendations for action and report these to the
CGRMC and onward to the Board.
Any shared learning from investigations, audit results and external inspections are
disseminated from the Infection Prevention and Control Committee via the link workers for
discussion and action within departmental meetings.
Surveillance of Infections
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The hospital has undertaken the surveillance of infections through participation in the
Surgical Site Infection Surveillance Scheme for Hip & Knee cases during the whole of the
reporting period.
For 2015-16 the following SSSI information was collated:
Total number
procedures undertaken
Q1
Hips
Knees
Q2
Hips
Knees
Q3
Hips
Knees
Q4
Hips
Knees
Number of infections
Total % Infection rate
per quarter
95
123
1
1
0.91
125
123
0
2
0.80
113
171
0
3
1.05
51
118
0
1
0.59
Annual infection rate – All cases (%)
Annual hip infection rate (%)
Annual knee infection rate (%)
0.87
0.26
1.3
Summary of Infections
There have been total of 8 reports of infections during the year,
The reported rate of infection during the year has been:
1.6 per 1000 bed days.
There were a total of 5007 bed days in 2015-16.
The hospital has participated in the monthly surveillance of MRSA, E.Coli and MSSA
bacteremia’s, submitting data to Public Health England. There has been one reported case
of MRSA during the reporting period. A Root Cause Analysis was undertaken in accordance
with hospital policy.
As with all hospitals in the country the numbers of C.Diff cases have been required to be
reported to Public Health England within 48hrs of them occurring. CircleBath has reported
zero cases during 2015.
Decontamination
The hospital has maintained a Service Level Agreement for the decontamination of reusable
surgical equipment with Nuffield Healthcare.
- 40 -
There have been 4 incidents reported relating to failures to decontaminate this equipment
to an acceptable standard which represents 0.023% of all instrument sets that were
decontaminated in 2015/16. All incidents are monitored through the contract management
arrangements with the provider.
This has occurred 4 times during the reporting period with the following corrective actions
being taken:


New staff training issue was addressed by HSSU.
We continually raise non-conformances if there are any incidents of re-occurrence to
ensure that issues are reported to HSSU and addressed.
The endoscopy unit undertakes decontamination in house in a dedicated decontamination
unit with 2 washer disinfector units with 2 washer disinfector units. The rinse water checks
have been undertaken on a weekly basis and action has been taken to correct any results
which fall out of the expected national guidance parameters.
During the 2015/16 reporting period there have been 16 incidents where the results of the
checking process have identified water levels outside of acceptable parameters. The
following corrective actions were taken:
















Quarterly service & machine calibration continues
Decontamination carried out on 15/04 using sodium hypochlorite &
resampled by Cantel
Quarterly validation carried out
Bottle cap CPC replaced
Activator tubing snapped, replaced tubing and checked all dosing
HPPI pump overheated. Bearings worn replaced motor & pump
Replaced motor & pump
Annual Service & included changing water filters
HPP2 motor & pump replaced.
Quarterly service & filters changed 12/11, sample is from 10th
Replaced index valve & SU15D valve
Polishing filters replaced
Replace exhaust valve on index valve
RO balanced & single polishing filter changed
Replaced RO membrane
Replaced solenoid valve
Audits of Infection Prevention & Control Practice
During the course of the year monthly hand hygiene audits have been carried out; the
results of which are reviewed by the Lead Nurse and the unit leads and action plans are
drawn up as required. The resulting actions have been disseminated through the infection
prevention and control committee.
- 40 -
Hand Hygiene Audit Results 2015-16 (by department):
Series1, Day
Series1,
Surgery
Theatre,
Series1,100
Radiology,
Series1, Recovery,
Series1, Outpatients,
Series1, Hospital
Series1, Physio, 99.5
Series1, Inpatients,
, 99.8
99.6
99.6
100
average, 99
Series1, Endoscopy ,
98.4
Series1, Hospitality ,
97.6
97
Light Box Audits
Additional audits are also carried out by link workers using the hospital light box.
Policies
The policies for infection prevention and control are produced corporately and as required
have had local Standard Operating Procedures introduced to ensure they are appropriately
implemented and monitored for compliance.
As with all corporate policies they have been available for staff to access through the
CALMS (Hospital policy management system) programme accessible on all of the hospital
computers.
Compliance is monitored automatically via CALMS. The Governance Team/Unit Leads ensure
that new starters have access to CALMS and read all corporate/local policies applicable to
their areas as part of their induction.
Outbreaks of Infection
The hospital has had during the year an outbreak management policy and the ability to call
an outbreak management committee. However, during the reporting period there were no
reported outbreaks of infection amongst patients and as such the committee was not
required to function.
There has been monitoring of diarrhea and vomiting amongst both patients and staff during
the year. There have been no episodes of transmission between individuals within the
hospital.
Education
There has been a programme of Infection Prevention and Control Training for all grades of
staff during the reporting period. This has involved mandatory annual updates, induction
training and hand hygiene training with light boxes in departments delivered by link
workers.
- 40 -
The IPC link workers are all trained to Level 3 and are responsible for training their area,
the unit leads monitor mandatory training compliance.
Any ‘mop up’ sessions will be undertaken by the Link workers or clinical trainer on
Mandatory training days as allocated.
Training compliance reports
There has been a concerted effort to continue to improve the level of IPC training
compliance during 2015-16. The overall compliance rate for 2015-16 is 77%.
Training compliance reports
Monthly training compliance
% by month
Series1,Series1,
April , 84
Series1,Series1,
October,
November,
84
84
May, 82
Series1,
Series1,
December,
February,
March,
77 77
Series1, June, 76.3 Series1, September, Series1,
Series1,Series1,
July, 71.2
August, 74
71
Series1, January, 64
The annual plan has been agreed by the Infection Prevention and Control Committee. This
plan is designed to ensure the continued compliance of the Hospital with the Code of
Practice for Infection Control as required under Regulation 12 of the Health & Social Act
2008 (Regulated Activities) 2014.
There is a requirement for improved management of antibiotic prescribing and
antimicrobial stewardship in 2016/17. CircleBath is committed to their role in reducing
antibiotic prescribing and the role this plays in resistance and educating our patients in
antibiotic usage.
- 40 -
Pressure Ulcers
Between April 2015 and March 2016 we have had 3 reported incidents of a patient acquiring
a grade 1 pressure ulcer during our care. In each of these cases skin became reddened but
with appropriate nursing intervention resolved swiftly with no harm to the patients.
There were no hospital acquired pressure ulcers of grade 2,3 or 4 in the reporting year.
VTE Risk Assessments
Venous thromboembolism (VTE) is a major potentially life threatening complication
associated with surgery. It is particularly associated with orthopaedic surgery, with hip and
knee replacements being the highest risk. In 2010, NICE produced guidance on the
prevention of VTE in patients who are admitted to hospital (CG92). CircleBath assesses all
patients admitted to the hospital for their risk of VTE and takes the required measures to
mitigate the risk of them developing.
In 2015/16 there were no avoidable VTEs.
In the event of an avoidable VTE occurring a Root Cause Analysis would be undertaken.
The VTE screening tool is integrated part of patients’ pathways (booklets), and as such it
is audited as part of general notes audit, rather than as a separate audit. All our surgical
patients receive a form of preventative VTE treatment, which may include; anti-embolism
stockings, Flowtron therapy, or dalteparin injections.
The most recent VTE audit was conducted within Q4 and the findings are summarised below
1
2
3
4
5
6
7
Criteria
Score
Outcome
Was the risk of VTE assessed
within 24 hrs of admission?
Was the risk of VTE Re
assessed after 24 hrs?
Numerator = 30
Denominator = 30
Numerator = 3
Denominator = 30
100% Patients were risk assessed within 24 hrs of admission.
If assessed to be at risk of
VTE,
was
prophylaxis
prescribed as per national
standard NICE guidance 92
If
pharmacological
intervention prescribed was
it
administered
as
prescribed?
Were there any reports of a
postoperative VTE during
the audit period
If VTE +, appropriate
treatment prescribed?
If VTE +, appropriate
treatment administered?
Numerator = 27
Denominator = 30
90% Patients had the appropriate prophylaxis prescribed.
10% did not have the standard prophylaxis prescribed.
Numerator = 28
Denominator = 28
100% Patients had their anticoagulant given as prescribed.
Safe
Good practice.
Numerator=30 (No)
Denominator =30
0% Patients developed VTE.
N/A
N/A
N/A
N/A
10% Patients were reassessed after 24 hrs
Requires improvement
- 28 -
Safety Thermometer
CircleBath began participating in the safety thermometer scheme in September 2012.
Every month data is formally submitted.
Results for 2015/16
Month
Number of Harms
Recorded
0
0
0
0
0
0
0
0
0
0
0
0
April
May
June
July
August
September
October
November
December
January
February
March
Returns to Theatre
During 2015-16, 9 patients returned to theatre following their procedure, from 6408
anaesthetic episodes. Patient transfer therefore represents 0.1% of total patients having
a surgical procedure.
Unplanned returns to the operating theatre within the same admission is one of the key
standard clinical performance indicators that CircleBath measures. Unplanned returns
to theatre are frequently due to complications, for example to treat bleeding or other
problems occurring early after the operation. Some complications following complex
surgery are to be expected due to patients’ pre-existing medical problems and the nature
of the disease being treated. A high rate can however indicate that the care being provided
could be improved.
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
1
516
0
471
2
549
0
610
0
489
1
564
0
450
1
608
0
408
2
576
1
599
1
568
TOTAL
Apr
Returns to Theatre
Anaesthetic
episodes
9
6408
Patient Re-Admissions
During 2015/16, 14 patients were re-admitted to the hospital within 28 days of their
procedure, from 6408 anaesthetic episodes. Patient re-admissions therefore represent
- 29 -
0.2 % of total patients seen.
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
0
1
3
2
2
2
1
2
0
0
1
0
TOTAL
Apr
Patient ReAdmissions
Anaesthetic
episodes
516
471
549
610
489
564
450
608
408
576
599
568
14
6408
Patient Transfers
During 2015/16, 16 patients were transferred out of the hospital, from 6408 anaesthetic
episodes. Patient transfers therefore represent 0.2% of total patients seen.
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
1
3
2
1
1
2
1
2
1
1
1
0
TOTAL
Apr
Patient Transfers
Anaesthetic
episodes
516
471
549
610
489
564
450
608
408
576
599
568
16
6408
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Patient Experience
CircleBath is committed to improving patient experience, using complaints
and other forms of feedback to better understand the areas of good and
outstanding performance and areas for improvement.
At CircleBath we seek patient feedback in a variety of ways. These are detailed
below:

Each patient is offered a Friends and Family Test (FFT) feedback card
following an episode of care to tell us about their experiences.

Patient connect where every inpatient is seen regularly to tell us about their
experiences.

Bi monthly patient lunches held by the general manager and lead nurse to
find out about the experiences of patients who have recently used the
service.

An annual inpatient survey is also undertaken.

Unit leads and their respective teams also speak with patients on a regular
basis to find out about their experiences.

CircleBath have a complaints policy and information available for patients
should they wish to make a complaint.

We receive a number of letters and informal feedback which is shared with
the relevant teams and departments
Patient lunches
In Q4, the first patient lunch was held. At this lunch, the feedback was
overwhelmingly positive. Patients were written to and invited to join us and were
selected at random who had received care or treatment at CircleBath within the
last 3 months. A selection of inpatient, outpatients and day procedures were
chosen.
Feedback Cards
Patient would
recommend %
Apr
May
Jun
Jul
99%
99%
99%
99%
Aug
99%
Sep
Oct
Nov
Dec
Jan
Feb
Mar
100%
97%
99%
99%
99%
99%
99%
NHS Choices users' overall rating (based on 135 reviews) for Circle Bath -
Extremely likely to recommend the hospital to friends and family if they
needed similar care or treatment. No patients gave CircleBath a 1 star rating
(extremely unlikely recommend the hospital to friends and family if they needed
similar care or treatment).

Average
% for year
All patients are asked to complete a feedback card regarding their experiences at
the hospital. Our patient recommends percentage for 2015/16 can be seen below:
98.9%
Complaints and Concerns
A complaint is defined as a written communication detailing dissatisfaction with any
aspect of the patient’s treatment pre, during and after their procedure and includes
all aspects of their experience. These, for example, may include catering,
ambience, nursing care and environment. Concerns, whether verbal or written, are
also addressed, recorded and reported in the same manner as complaints in this
report although clearly defined.
Apr15
May15
Complaint
1
1
Concern
1
Complaint
1
1
2
1
Concern
Jun15
0
Complaint
1
1
Concern
Jul-15
Aug15
1
Complaint
1
3
Concern
1
Complaint
1
Concern
Sep15
1
Nov15
Dec15
Jan-16
Feb16
1
1
1
4
1
1
3
2
2
1
2
1
Concern
2
1
2
Complaint
1
1
1
Concern
2
1
1
Complaint
1
1
5
1
6
3
1
1
2
2
4
1
4
Concern
5
1
3
Complaint
2
1
2
5
Concern
1
1
Complaint
1
Concern
Mar16
2
5
1
Complaint
Complaint
1
1
Concern
Oct15
Total
Test Results
Personal
Records
Patient
Property
Patient Privacy
/ Dignity
Other
Hospital
Acquired
Infection
Complaint
Handling
Competence
Communication
(written)
Communication
(oral)
Clinical
treatment
Attitude and
behaviour
Appointment
Apr 2015 – Dec
2015 (Q1-Q3)
Admission /
attendance
In 2015/16 we received the following formal complaints and concerns
1
Complaint
1
1
12
1
2
1
2
1
Concern
Total for 2015/16
1
2
1
4
2
3
19
15
2
16
8
4
1
1
1
1
1
1
1
1
74
Complaints upheld/not upheld (please see summary below)
Total for 2015/16
Not upheld
7
Partially upheld
12
Upheld
15
Formal Complaints
100% were acknowledged within 3 working
days 100% were investigated within 30 working
days
Parliamentary and Health Services Ombudsman (PHSO)
The PHSO make final decisions on complaints that have not been resolved by the NHS in
England and UK government departments and other UK public organisations. Within this
reporting timeframe, no complaints have been escalated to the PHSO for CircleBath.
Complaints Survey 2015/16
Circle Bath conducts a yearly survey in order to review effectiveness of its Complaints process.
The last survey was undertaken in January 2016 as it is in line with our policy. 36 patients were
sent letters explaining the survey and included the questionnaire. Thirty four percent of
patients responded and the following results were achieved:

100% of patients received Acknowledgment Letter

75% of patients were re-assured their complaints was investigated thoroughly (25% were
not)

63% of patients confirmed that the written response to their complaint reassured them
that corrective action would be taken to prevent future occurrences (12% were not sure and
25% were not re-assured)
Since the survey Circle has updated its Complaints policy to ensure it reflects national best
practice.
Inpatient Survey
The 2015 inpatient satisfaction surveys were distributed to all inpatients in November 2015.
During this period we aimed to distribute 100 surveys however we received 118 completed
surveys as additional patients requested to complete it. On the basis of these responses the
following results have been produced:
- 61 -
- 62 -
- 63 -
Partner Recognition Awards
We have recently re-launched our partner recognition award scheme, which invites
members of staff to nominate a member of staff or team who has ‘gone the extra mile’.
The Senior Management Team (SMT) will review all nominations and announce the winners
on a monthly basis. First and second prizes are then presented every month.
Circle Of Care Week:
The week of 23rd March 2015 saw our Circle of Care week. Staff were invited to attend
partnership sessions and make contributions to our future vision and strategy.
Over the reporting period we have continued to implement
the outputs of the week.
Outcomes of the Circle of Care Week:
 Implementation of a ‘Birthday Voucher‘ for staff
entitling them to a free drink and slice of cake
from the Deli Bar.
 Develop a social committee 

 General Manager and Clinical Chainman walk around
 A monthly newsletter circulated to all staff.
 A new staff room has been built to encourage the interaction between departments
and allow downtime during breaks.
 Communication boards in all departments, updated regularly.
- 64 -
Staff Continued Professional Development
Our staff are our greatest asset and we believe in investing in them.
A suite of mandatory training courses are attended by all staff; compliance being monitored
by unit leads and our Governance Team. Training days are provided throughout the year,
provided by both internal and external trainers.
Clinical Training
Examples include:








The deteriorating patient – for adults and paediatrics
Paediatric ILS and Paediatric Recovery
Surgical Site Surveillance
Male Catheterisation
Dignity and Privacy
Maintaining Records
Consent and the Mental Capacity Act
Normal Pressure Hydrocephalous
A variety of resuscitation training is provided by a Clinical Skills Nurse
Adult Basic Life Support
1. Recognition of cardiac arrest in the adult.
2. Adult Basic Life Support as per Resuscitation Council UK Guidelines 2010.
3. Recognition and emergency treatment of the choking adult as per Resuscitation
Council UK Guidelines 2010.
4. Safe positioning of the adult into the recovery position.
Paediatric Basic Life Support
1. Recognition of cardiac arrest in the child.
2. Paediatric Basic Life Support as per Resuscitation Council UK Guidelines 2010.
3. Recognition and emergency treatment of the choking child as per Resuscitation
Council UK Guidelines 2010.
4. Safe positioning of the child into the recovery position.
5. Familiarisation and contents of the Broselow system.
Immediate Life Support (ILS)
1.
2.
3.
4.
5.
6.
7.
Causes and prevention of cardiac arrest lecture.
ABCDE Approach to assessing a patient lecture.
Resuscitation Council UK ALS Algorithm lecture.
Initial resuscitation and defibrillation demonstration and practical.
Emergency treatment of Airway and Breathing problems demonstration and practical.
Scenario based practical.
Candidates are continually assessed throughout the course.
- 65 -
Recognition and Treatment of the Deteriorating Adult (RaToDa)
1. Identify a variety of likely conditions which cause deterioration in an adult
patient at Circle Bath. Revise and understand the emergency treatment of these
conditions. Lecture and group discussion.
2. Demonstrate and understand a systematic A-E assessment of an adult
patient. Demonstration, lectures and practical.
3. Discuss when and how to call for help at CircleBath.
Recognition and Treatment of the Deteriorating Child (RaToDchi)
1. Pre-Course quiz of basic paediatric emergency knowledge.
2. Understand basic anatomical differences of a child. Lecture and discussion.
3. Identify a variety of likely conditions which cause deterioration in a
paediatric patient at CircleBath. Revise and understand the emergency
treatment of these conditions. Lecture and group discussion.
4. Demonstrate and understand a systematic A-E assessment of a paediatric
patient. Demonstration, lectures and practical.
5. Discuss when and how to call for help at CircleBath.
Anaphylaxis
1.
2.
3.
4.
Signs and symptoms of anaphylaxis. Lecture and discussion.
Basic aetiology of anaphylaxis. Lecture and discussion.
Revision of Resuscitation Council UK Anaphylaxis algorithm. Lecture and Discussion.
Practical scenario of anaphylactic emergency.
ALS algorithm and defibrillator update
Revision sessions on the use of RCUK ALS algorithms - Lecture and discussion.
1. Tachycardia
2. Bradycardia
Practical use of the Phillips MRX defibrillator for cardioversion and pacing. Scenario based
practical.
- 66 -
All Staff E learning courses
We have also provided our staff with online training courses for 2015/16, to further develop
their knowledge and talents and allow them to train at a time and in a place convenient to
them.
Courses available for all staff
 NSPCC Child Protection Awareness in Health
 NSPCC Child Neglect
 Safeguarding Vulnerable Adults
 Mental Capacity Act and Deprivation of Liberty
 An introduction to Equality and Diversity
 Health and Safety
 Personal Safety
 An Introduction to Effective Team Work
 Food Hygiene
 Leadership development
 Introduction to Data protection 
Face to Face training:










Manual handling for non-clinical staff
Manual handling for clinical staff
Infection prevention and control
Conflict resolution
Fire safety
Incident reporting and Datix
CALMS – company policies
Circle Operating System
Dementia
PREVENT

- 67 -
Patient Comment……
‘From pre-med to going home every care and attention I
received by all staff was wonderful’
- 68 -
Our Vision and Strategy
Our strategy
To focus on becoming a centre of excellence, starting with musculoskeletal services.
Our purpose
To do our best for every patient, every day.
We will deliver this vision through our 8 point plan.
8 Point Plan
Compassionate care
We want everyone that experiences CircleBath hospitality to recommend us as their first
choice. We will continue to keep patients at the centre of all we do. We will listen to what
they have to say about the care that they have received and act upon comments and feedback
to always provide the best service. We will continue to prioritise patient engagement and
satisfaction as the main driver for change in the hospital. We will utilise the expertise within
Circle to create a patient connect, patient first hospitality service that is owned and
delivered in the hospital. This will ensure a seamless patient journey, from the first point of
contact to discharge, through to appropriate aftercare.
Great communication
We understand that when patients are involved in their own care, they recover faster. We will
continue to be open and maintain up-to the-minute communication with patients at all times
throughout their experience with us. We will ensure that those in our care are seen by the
right person, in the right place, at the right time.
Patient safety
Patient safety is at the forefront of all we do, and best care comes through the commitment
of all partners to continually maintain and improve our quality standards. Stop the Line is core
to our commitment to safety for patients, and we will continue to empower all partners and
teams to Stop the Line and ensure a responsible culture of safety. We will deliver a rapid
improvement cycle through our Circle Operating System (COS) methodology if safety is
compromised, to ensure that we are always delivering the best and safest quality of care. We
will share our learning locally and within our partnership.
Great outcome measures
We will ensure that we have relevant performance indicators to measure our patients’ clinical
outcomes, and we will monitor this through our Quality Quartet and audit processes. We will
continue to ask our patients to give us their feedback, and ask our clinicians to share their
outcome data with our teams to allow continuous learning and improvement. We will be open
and transparent and publish our clinical outcomes on our website for the public and patients
to view.
- 69 -
Efficient infrastructure
We recognise the growing needs of our healthcare population and, at CircleBath, we want to
provide sufficient and appropriate space for all our clinical activities. We will continue to
work towards a better, reliable and fit-for-purpose infrastructure. We will examine our
support services and remove waste and enhance services. We will improve services by
optimising the use of technology. We will objectively analyse our cost base and reduce waste
and any unnecessary spend. We will enrich working relationships with suppliers,
commissioners and partner organisations to get the best value and quality, and look for
opportunities to share resources and expertise across Circle hospitals.
Great leadership
Leadership is key to organisational success. We acknowledge the importance of a visible and
embedded leadership framework in CircleBath. We will develop authentic, focused and
accountable leaders, and ensure that our leadership team is a strong decision-making body,
made up of the best clinicians and managers.
Connected workforce
Having truly engaged partners is part of our DNA, and this makes us unique and successful. We
will connect across pathways and disciplines, and with our clinicians, managers and specialist
and functional partners, ensure that we deliver the best for every patient, every day. We will
continue to build effective external relationships to extend our scope and provide the best
and most innovative care.
Great workforce
We will create a workplace where every partner is supported to perform to their very best.
We will ensure that we live the credo, role-model COS values and behaviours, and have the
right skills and attitude to put our patients at the centre of all that we do. We will do this by
providing induction and training, supporting continuing professional development, recognising
partners for going the extra mile, rewarding loyalty and length of service, providing
incremental annual leave, and rewarding partners within our share scheme. We will improve
communication to deliver superior partner engagement and understanding, giving partners a
voice, listening and learning through established forums and partnership sessions,
newsletters, and ‘You said, we did’ bulletins.
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Thank you
Thank you for taking the time to read our Quality Account, we hope you found it interesting
and useful in understanding our commitment to quality for our patients and partners.
Should you have any further questions, we would be pleased to hear from you.
Please contact our Interim General Manager, Lisa Carroll on 01761 422 222 or email
[email protected]
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