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Project Leads Lyn McIntyre – Assistant Chief Nurse Nicola Woodruff – Clinical Governance & Audit Coordinator

INTRODUCTION Equality and Diversity (E&D) can be traced back to legislations in the 1970’s, such as the Race Relations Act 1976 and the Sex Discrimination Act 1975. Over the years however, Equality and Diversity has gained a renewed emphasis through a series of more recent legislations, such as the Race Relations (Amendment) Act 2000 and the Disability Discrimination Act 1995, the Human Rights Act 1988 and the EU Employment Equality Regulation 2003 (Sexual Orientation and Religion or Belief). These legislations outlaw discrimination on the ground of sexual orientation, religion or belief, disability and age. Following this, Equality and Diversity is now central to the UK Government’s NHS Modernisation Agenda. The NHS Plan (DoH, 2000) states that; ‘The NHS of the 21st Century must be responsive to the needs of different groups and individuals within society, and challenge discrimination on the grounds of age, gender, ethnicity, religion, disability and sexuality.’ In addition to these legislations there are a range of national and local drives that underpin Equality and Diversity work. The Trust serves a diverse community within Cambridge and its surrounding areas. Cambridge City’s total population, according to the National Statistics Online Census 2001, is 101,863 which is more or less equally distributed between males and females. The proportion of ethnic population in the city has doubled over the last decade to 10.6% compared to the national average of 9.1%. In 2004 alone, the Trust received 369,491 patients in clinics and admitted 55,168 of these. The 2001 National Census also shows that while the city in general enjoys a good health record (70.35% of the population consider their health is good) relative to the rest of England and Wales (68.55% of the population consider their health is good), there are still challenges that have to be met to serve its diverse community. Consequently, for the Trust ‘Equality and Diversity’ is not just a legislative requirement, but also pivotal to improving the quality of services that the Trust provides to its community. The Essence of Care – patient focused benchmarking for healthcare practitioners (DoH 2001) identified eight aspects of fundamental care that were recognised as high priority for improvement. These were updated in 2003 to nine areas: • Communication • Self-Care • Hygiene • Continence • Nutrition • Pressure Ulcers • Privacy & Dignity • Record Keeping • Safety In 2005, Addenbrooke’s introduced its own tenth area, Enabling & supporting patients with individual needs. The audits were instigated as part of the Addenbrooke’s Essence of Care Project to assess whether the Trust is meeting the requirements set out in the Essence of Care: Patient focused benchmarks for clinical governance. A number of Essence of Care working groups reviewed the benchmarks and set standards for best practice that they felt were most important to Addenbrooke’s. These standards are known as the Addenbrooke’s Essence of Care Standards. As part of the NHS Plan, the Trust is required to take part in mandatory annual national patient and staff surveys run by the Healthcare Commission. The Inpatient survey results


for 2005 have recently been published and some of the questions focus on communication and involvement in care (Please see Appendix 1).

AUDIT BACKGROUND In late 2004, a number of working groups were set up with the primary aim to develop Trust Essence of Care Standards. The working groups met and developed standards for each of the Essence of Care benchmarks and these standards were endorsed by the Essence of Care Steering Group. The groups went on to develop a range of patient and staff questionnaires and audit of documentation tools to be used to audit the standards. In order to identify the areas for further review and development, the data relating to the Equality and Diversity agenda has been collated in this first report. This report focuses on the Essence of Care benchmarks for communication, self-care, hygiene and continence. AUDITING


OBJECTIVES To ensure inpatient wards at Addenbrookes are meeting the requirements set out in the Addenbrooke’s Essence of Care Standards. To identify those areas which require further review and development in relation to the Equality and Diversity Agenda. EXCLUSIONS Paediatric wards, ITU areas and Outpatient clinics. METHOD The patient & staff questionnaires were sent to the Local Research & Ethics Committee for ethical approval prior to distribution. For each audit, an audit pack containing the standards, audit tools and a guidance letter were delivered to Inpatient wards across the Trust. Wards were asked to complete the audit packs and return them to the audit department within a 2 week time frame.


CONCLUSIONS COMMUNICATION CONCLUSIONS All healthcare professionals demonstrate effective interpersonal skills when communicating with patients and/or carers (Standard 1) • The number of respondents that had watched the staff training videos relating to communication in the past year were Putting People First (73%), Dignity at Work (71%) and Role to Play (79%). Most of the staff had watched the Fire Safety Video. The number of respondents that had attended mandatory training relating to communication was only around a quarter for each session. Nursing staff gave feedback on many mediums through which the ward receive feedback from patients, carers or relatives regarding issues with communication, these included letters, discharge feedback cards, informal complaints and one respondent said they used comments cards. 86% of the respondents knew of support for staff whose first language was not English with the majority saying English language courses were available. 76% knew of a policy for obtaining interpreters for British Sign Language and 89% for Foreign Language. However, a quarter of the respondents said they experienced specific problems with obtaining interpreters, these problems mainly related to availability on a emergency basis or time constraints when arranging interpreters for certain languages. None of the respondents said staff received training for working with interpreters, but it was suggested that training wasn’t necessary and it would not eliminate the main problem being the lack of timely interpreters to suit the fast paced ward routines. 66% of staff said there is no routine practice for checking whether hearing aids are functioning properly, but wards appeared to work well with the Audiology department when problems arose. On the whole, patients said that staff gave timely responses to their requests for help to repair or replace batteries.


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All patients and/or carers communication needs are assessed on initial contact and are regularly reassessed. Additional communication support is negotiated and provided when a need is identified (Standard 2). • Nurses gave feedback on many types of resources/aids available to assist patients with communication, these included picture/sign boards, paper & pencils, hearing loops and light writers. 23% said staff were not trained to use any of these resources/aids. Very few respondents said they had information available in braille, audiotape or large print text and lot of people were unsure where to get information in these formats from.


Appropriate, consistent and effective methods of communication are used before, during and after ward rounds to promote shared plans of care (Standard 3). Shared plans of care are disseminated to all members of the multi-disciplinary team, patients and/or carers and widely promoted across all communities (Standard 4). • 60% of respondents said patients are allocated a designated nurse and most of these said this person would be their first point of contact if they had any questions regarding their care. In areas where they didn’t have designated nurses, patients were usually told to contact team or shift leaders.



To share information between different members of the multi-disciplinary team on the ward a lot of respondents said they used ward rounds, handover or general verbal communication. People also mentioned care plans or discharge planning documentation. It was expressed by some that there is room for improvement and that there needs to be more consistency in the notes from patient to patient. On discharge the main procedure for sharing patient information with external agencies is by phone referral or fax. Further comments about the way patient information is shared between healthcare professionals included the need for patients and relatives to take some responsibility for seeking out information (Communication is a two way process).

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SELF-CARE CONCLUSIONS Conclusions – Ward Manager Questionnaire Did patients receive information on and access to the resources available and the hospital environment that will enable them to meet their individual self-care needs? (Self-Care Standard 1) 84% of ward managers stated that they do not give patients written information about the Trust, this could explain the small number of patients who were aware of PALS. Only 39% of staff said they give patients written local information about the ward e.g. orientation, routines etc, which again could account for the low numbers of patients saying they received information on the availability of snacks & regular drinks, trolley rounds, how to use Patientline, visiting arrangements, mealtimes etc. 39% of wards said they do not display the names of the staff on duty in an area visible to patients and carers and 85% of wards did not have information displayed about voluntary services (defined as ‘volunteers that are available to help with self care’). 76% of ward managers stated that patients are not given information on the different religious denominations available at Addenbrooke’s. Many stated that this information is available on request, but it is not routinely given to patients. Just over half of the ward managers reported that their ward does not have adequate resources to meet the needs of the heavy and heavier patient. Comments included difficulty obtaining suitable equipment promptly e.g. wheelchairs for inter-department transfers and armchairs. Wards normally have to hire specialist equipment, which can be expensive and access to larger gowns/nightwear is an issue. 80% claimed this puts pressure on their budget. This is currently being addressed by the Trust Bariatric Group. Ward managers reported that 62% of patients are not discharged at a time of day in relation to their specific individual needs and preferences. Reasons included: delays in TTO’s, hospital transport and pressure on beds at the time. In the National Inpatient Survey, 48% of patients said they experienced discharge delays and of these 65% said the main reason was a wait for medicines. Do wards seek and use the information provided by patients, to develop or improve patient self care support? (Self-Care Standard 4) Wards use a variety of mediums to disseminate feedback to the ward team, these include communication books, verbal discussions, team and ward meetings, emails, handovers, and thank you cards.


21% of ward managers said they utilise Patientline to provide information for patients and very few use it to receive feedback from patients. Are patient’s self-care abilities and the risk factors affecting these continuously assessed and does this inform care management? (Self-Care Standard 2) 59% of wards do not carry out self-care risk assessments when patients are admitted to the ward. On a lot of wards, a patient’s ability to self-care is assessed and reassessed, but it is not done on a risk assessment, instead it is done informally as part of the general ward assessment and actions are documented on care plans. One area said they have integrated care pathways for each condition. Are appropriate referrals made to agencies to support self-care? (Self-Care Standard 3) 81% of ward managers said staff receive training on the role of Specialist Nurses in supporting patients to self care and 88% said staff are given information on how to refer patients to Specialist Nurses. Half of the wards do not refer people to local community groups, which may be available to support self-care activities.

PERSONAL & ORAL HYGIENE CONCLUSIONS Provision of toiletries (Personal Hygiene Standard 5) and access to the facilities to meet personal and oral hygiene needs (Personal & Oral Hygiene Standard 4) With regards to nail cutting, across the Trust there is some confusion over who is able to cut nails, in particular for diabetic patients. 64% of staff thought there was a nail cutting policy and people stressed the need for proper guidance regarding nail cutting. The questionnaire has highlighted that some areas have specific problems to do with their washroom facilities, such as leaking baths and showers that will need addressing. There are also a number of negative comments regarding staff shortages, and the impact this has when people are trying to uphold theory and practice. Some of the issues highlighted in the hygiene audit have been addressed by an action group that was set up by the Assistant Chief Nurse. As a result of this group, the following actions have taken place: • • The decision has been made to replace all ward stock ordering for toiletries to single sachet/supplies so that patients can be given emergency supplies as needed. Assistant Chief Nurse is liaising with the MRVS to see if they can stock supplies on their daily newspaper trolley. This will ensure patients have the opportunity to buy toiletries.

CONTINENCE CONCLUSIONS Access to information regarding continence and the promotion of bladder and bowel care (Standard 1) Perhaps surprisingly, 25% (16/64) of the staff that completed the questionnaire said they didn’t know of any bladder/bowel care information on their ward and feedback suggests that there is no continence information for different user groups i.e. Braille or in large print in use across the Trust. It was identified that the ward continence resource folders need to be updated, with some areas stating that they did not have one.


Continence Care Training (Standard 4) Nursing staff gave feedback on many types of training with several attending sessions provided by the continence representatives, often about their products. The Trust has had some training provided by the PCT but this does not appear widespread. Current continence related policies have also recently been reviewed to ensure that they comply with best practice guidelines. The Trust is due to advertise for a Continence Advisor in 2006 and the audit will provide the baseline analysis for the new post holder. The post holder will be responsible for a review of the current procurement process and stock availability, in order to streamline the process offering best value with best quality.


RECOMMENDATIONS • Assistant Chief Nurse to feedback findings and recommendations to the SCN Forum, the Nursing & Midwifery Strategic Advisory Committee, the Nursing & Midwifery Forum and the Operations Board. Feedback the audit results to the learning centre in order to influence the Customer Care training. Review the training delivered as part of the Trust’s mandatory training group and feed into the Trust review of mandatory training. To disseminate findings to the Patient Information Team. To ensure staff are aware of how to access patient information in Braille, audiotape and large print text. To feedback results to the Equality and Diversity Patient and Carer Group in order to improve the patient experience. To utilise the findings in the review of the Trust Interpreting Policy. To disseminate findings to the Audiology Department as part of the review of Communication (Hearing loops and Hearing aids). To ensure that patients and carers are orientated to wards upon admission and made aware of who to contact on the ward on a regular basis. To feed this information into the Elective Admission Assessment process currently being developed. To link findings into the current review of Trust Handover Practices. To disseminate findings to the Trust Discharge Planning Group as a means of improving patient and carer involvement in the discharge process. To ensure that the new Trust Uniform posters, identifying ‘who is who’ in the team are displayed in all clinical areas to help patients and carers identify the key staff roles and therefore improve communication. To feedback to Rev. Derek Fraser to raise awareness of the current religious and cultural services available in the Trust and how staff, patients and carers can access them. To disseminate findings to PALS and Patientline as a means of strengthening the Ward Managers feedback regarding the patient and carer experiences. To raise awareness of the availability of Self Help Groups for patients and carers by developing a ‘Care of the disabled’ handbook for staff in the clinical area. To collate findings from the Essence of Care audits of standards for food & nutrition, privacy & dignity, safety and record keeping into the 2nd report. To utilise the findings to develop the Essence of Care Outpatients Audits and standards and audit tools for the Essence of Care Enabling and Supporting Adults with Individual Needs (vulnerable adults, learning disabilities, mental health, older people, and patients who are confused).

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REFERENCES Department of Health (2005) Self care – A real choice: Self care support – A practical option. London: Department of Health. Modernisation Agency (2003) Essence of Care. Patient – Focused Benchmarks for Clinical Governance. London: Department of Health Department of Health, National (www.npsa.nhs.uk/pleaseask) Patient Safety Agency (2005) Please Ask.

Addenbrooke’s Hospital Practice Development Team (2005) Patient Stories: Self Care. Health Care Commission (2005) National Patient Surveys Nursing Times Vol 102 No 6 (2006) The Rise of the Expert Patient. Department of Health (2004) NHS Improvement Plan. London: Department of Health. Department of Health (2005) Supporting Self Care – A Practical Option. London: Policy and Strategy Directorate, Department of Health.




Race Relations Act 1976 Sex Discrimination Act 1975 Race Relations (Amendments) Act 2000 Disability Discrimination Act 1995 Human Rights Act 1998 EU Employment Equality Regulation 2003



19/10 /06




Context • Mandatory annual national surveys (patient & staff) • Run by the Healthcare Commission • Focus on issues that patients say are important to them. • Survey responses provide more detailed information on how patients feel about the service they receive and they form part of the assessment of trusts against the Healthcare standards. • Healthcare Commission publish comparative data for each Trust to inform the public and guide funding Results • Response Rate 62% (515 respondents) • Comparison with 9400+ acute patients Performance Issues There were performance differences between hospitals caused by: • • Differences in practice and quality – but also: Differences in social composition • Ethnicity: EM patients less positive than white patients Age: Young patients 20-30% less satisfied than middle aged – older patients 55-74 are the most satisfied. Emergency Admission: less positive on information etc, than elective admission Gender: Women always more critical than men

So, the kinds of patients in your sample are crucial.

Patient details • Women = 57% (All Trusts = 54%) • Men = 43% (All Trusts = 46%) • Emergency = 51% (All Trusts = 56%) • White British = 94% (All Trusts = 90%) • Ethnic Minority = 2% (All Trusts = 5%) • 16-34 year olds = 10% (All Trusts = 12%) • 65 year olds & over = 40% (All Trusts = 45%) • Health in the past 4 week – poor / very poor = 13% (All Trusts = 15%) • Long standing problem or disability = 48% (All Trusts = 50%) • 16 or under when left F/T education = 62% (All Trusts = 69%) Some of the Inpatient Survey questions providing feedback relating to the essence of care and Equality & Diversity are outlined below: The Doctors • Always got understandable answers = 66% (All Trusts = 66%) • Always had confidence and trust = 82% (All Trusts = 80%) • Doctors never talked as if patient wasn’t there = 72% (All Trusts = 72%) The Nurses • Always got understandable answers = 55% (All Trusts = 64%) • Always had confidence and trust = 68% (All Trusts = 73%) • Nurses never talked as if patient wasn’t there = 78% (All Trusts = 78%) • Always had enough nurses to care for patients = 52% (All Trusts = 55%)


Care and treatment • Often/sometimes got conflicting information = 42% (All Trusts = 37%) • Definitely involved in decisions about care = 55% (All Trusts = 52%) • Not given enough information = 17% (All Trusts = 21%) • Family definitely could talk to doctor = 43% (All Trusts = 43%) • Could talk to someone about worries/fears = 37% (All Trusts = 41%) • 2 mins or less wait after using call button = 47% (All Trusts = 58%) Leaving Hospital • Purpose of medication explained completely = 80% (All Trusts = 80%) • Told about side effects to watch out for = 41% (All Trusts = 40%) • Given clear written information about medication = 61% (All Trusts = 61%) • Family given all information needed to help patient recover = 44% (All Trusts = 43%) Overall • Always treated with respect and dignity = 77% (All Trusts = 78%) • Rating of how doctors and nurses worked together – excellent / v good = 74% (All Trusts = 76%)



Audit Effectiveness Trail Form (Action Plan)
Recommendations made from the audit:
(Please ensure that recommendations and actions are as specific and detailed as possible)
Recommendation Action required • To utilise findings in the review of the Trust Interpreting Policy. • • To raise awareness of the availability of Self Help Groups for patients and carers by developing a ‘Care of the Disabled’ Handbook for staff in the clinical area. • • • To disseminate the policy in draft format to appropriate personnel and groups for comment. To launch the approved policy and develop guidelines for staff. Project group to develop a draft To be reviewed by the Equality and Diversity Patient and Carer Group Funding to be agreed Handbook to be disseminated to practice areas and other agreed locations in the Trust Report to be disseminated Actions to be agreed at the Equality and Diversity Patient and Carer Group By whom? Assistant Chief Nurse By when? October 2006 Percentage achieved?** General comments including any potential problems, who they have been referred to and actions to be taken

Equality & Diversity Patient and Carer Group

January 2007

To disseminate Audit findings to the Audiology Department as part of the review of Communication (Hearing Loops and Hearing Aids)

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Assistant Chief Nurse and Equality & Diversity Patient and Carer Group

November 2006


To ensure that the new Trust Uniform posters, identifying ‘Who is Who’ in the team are displayed in all clinical areas to help patients and carers identify the key staff roles and thereby improve communication. To utilise findings to develop the Essence of Care Outpatient and Essence of Care Enabling and Supporting Adults with Individual Needs (vulnerable adult) audit tools


Posters to be disseminated

Office of the Chief Nurse

October 2006

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Audit tools developed Outpatient audit to take place in September 2006 Vulnerable Adult audit with ward staff to take place in September 2006 Findings to be feedback to the Equality and Diversity Patient and Carer and Staff Groups in order to identify further project work

Assistant Chief Nurse And Clinical Audit

January 2007

* All audit projects must be subject to a re-audit at least once to check compliance has been sustained ** If the achievement is minimal and does not reach expectations, the reasons why should be noted in the comment column

Please continue on a duplicate sheet if required (blank copies are available on the Clinical Governance & Audit Intranet site http://bluepages/audit/). If you would like any assistance completing this form please call ext 2022. Once completed please return to the Clinical Governance & Audit Department, Box 147.


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