The Care Certificate is aimed at Health Care Assistants, Assistant Practitioners, Care Support Workers, and those in a Band 1 to 4 post, giving support to clinical roles in the NHS where there is any direct contact with patients and is designed to be used at the start of your career in healthcare. The Care Certificate forms part of your induction and training at UHMBT and the e-learning will be added to your TMS (Training Management System) account.
Care Certificates are aimed at equipping you with the knowledge, skills, and confidence you need to feel safe and supported at work. Ultimately, it will enable you to provide safe and compassionate patient care.
To be awarded the Care Certificate you must meet all the outcomes and assessment requirements for all 15 standards. You will be assigned an assessor to support you whilst you’re working through it.
Once completed you will receive a certificate to add to your portfolio. The Care Certificate is a national standard and can be transferred with you between different healthcare settings once completed.
Clinical Governance is a framework through which NHS organisations are responsible for continually improving the quality of care and demonstrating this by setting and monitoring standards. Clinical audit is one method of monitoring and changing practice to improve quality.
Definition of Clinical Audit
Clinical audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality and taking action to bring practice in line with these standards to improve the quality of care and health outcomes (Source: New Principles of Best Practice in Clinical Audit, HQIP, Jan 2011).
Why is Clinical Audit Important
Clinical audit helps the Hospital to measure how good patient care is and see where we can improve care. We also use information from audits to plan new services for patients.
Clinical audit is one of the ways the Hospital checks that the care we provide to patients is of a good standard and looks to find areas where we can improve patient care. Clinical audit is done by measuring the care provided to patients against known standards of good care, using information from the Hospital’s healthcare records. The audit results tell us how good care is and if there are areas for improvement. Once steps are taken to improve care, another audit is done to be sure the care has improved.
Clinical Audit Cycle
Audit is often shown as a ‘cycle’. This cycle can have many stages and appear quite complex. A simplified version is shown here for information. Clinical Audit within UHMBT is expected to follow this model.
The audit process is divided into 4 official steps and the cycle is only considered complete if all steps are performed. The four steps are as follows:
- Step 1 - Preparation and Planning - Determine the criteria for the current best practice. Common standards include: NICE guidance, Royal College Guidance, & local policies etc.
- Step 2 - Measuring Performance - Identify what data needs to be collected, how, and who is going to collect it. Decide whether the data will be collected prospectively or retrospectively and what sample size is needed. Analyses the data collected.
- Step 3 - Implement Change -The results should be shared with the stakeholder group. Develop, agree and implement an action plan to bring actual practice closer to the standard.
- Step 4 - Sustaining Improvement - The audit cycle is not complete until evidence has been obtained to demonstrate that implementation of the action plan has resulted in an improvement in the quality of services.
How do I register my Clinical Audit?
- Clinical Audits that fall outside of the forward audit plan (national and locally mandated or repeated clinical audits) need to be approved by the specialty audit lead and then the Division will give final approval.
- Complete and send a Clinical Audit Proposal Form for Additional Audits via the Clinical Audit team (clinical.audit@mbht.nhs.uk)
- On approval the clinical audit will be registered in AMaT and assigned a unique identifiable number.
Services Provided by our Clinical Audit Team
- Guidance on how to complete the audit proposal form
- The approval process for additional audits
- Registering the audit
- Guidance on Identifying and setting standards.
- Identifying the patient sample by liaising with the Information Department
- Ordering case notes if required
- Devising a data collection tool
- Guidance on data analysis, presentation template and charts
- Support with completing the summary report sheet
- Support & guidance in developing a robust action plan
Meet the team
- Heather Pratt, Head of Clinical Audit & Effectiveness (heather.pratt@mbht.nhs.uk)
- Amber Sanderson, Clinical Audit Team Leader (amber.sanderson@mbht.nhs.uk
- Lynne Kaighan, Clinical Audit Facilitator (lynne.kiaghan@mbht.nhs.uk
- Zoe Fergusson-Batte, Clinical Audit Facilitator (zoe.fergusson-batte@mbht.nhs.uk)
- Lisa Magtoto, Clinical Audit Facilitator
- (list.magtoto@mbht.nhs.uk)
- Jasima Ali, Clinical Audit Facilitator
- (jasima.ali@mbht.nhs.uk)
- Rachel Martin, Clinical Audit Facilitator
- (rachel.martin@mbht.nhs.uk)
All staff can be contacted via Microsoft Teams or via generic email clinical.audit@mbht.nhs.uk
Visit the Clinical Audit Intranet Page where there are lots of support materials.
When a person with dementia finds that their mental abilities are declining, they often feel vulnerable and in need of reassurance and support. The people closest to them - including their carers, friends and family - need to do everything they can to help the person to retain their sense of identity and feelings of self-worth.
At UHMBT we aim to deliver care centred around the needs of the person with dementia. It’s important that we involve not only the person themselves, but their families and carers in the assessment, care planning and updates on the care we give.
Find out more about Dementia Care at UHMBT.
NICE balances the best care with value for money across the NHS and social care, to deliver for both individuals and society as a whole.
They do this by:
- providing rigorous, independent assessment of complex evidence to produce guidance and advice for health and social care practitioners.
- developing recommendations that drive innovation into the hands of health and care professionals.
- encouraging the uptake of best practice to improve outcomes for everyone.
NICE is an independent organisation which provides guidance, sets quality standards and manages a national database to improve people’s health and prevent and treat ill health. Its recommendations are based on evidence of both clinical and cost effectiveness.
NICE currently produces the following types of guidance/standards,
- Technology appraisals (TAs)
- Clinical guidelines (CG/NGs)
- Public Health Guidance (PHG)
- Interventional Procedures Guidance (IPGs)
- Quality Standards (QS)
- Medical Technologies Guidance (MTG)
- Diagnostics Guidance (DG)
- Staffing Guidance (CG)
- Health Technology Evaluation (THE)
Our Process
Newly published NICE guidance is added to the AMaT system. There are three key stages when managing NICE guidelines:
Dissemination and Assessment
- When the guideline is published it is sent, via AMaT (Trust monitoring system, available to all employees on main desktop) to the relevant Care Group(s)
- The Care Group NICE Lead identifies a NICE Guideline Lead who leads on the baseline review by working with experts and identifying evidence of compliance.
- If guidance is non/partially achieved improvement needed an action plan is developed and monitored at Care Group Quality Meetings.
- Progress against NICE guidance is monitored at the bi-monthly Clinical Audit and NICE Steering Group.
Contact details
- NICE inbox - nice@uhmbt.nhs.uk
- NICE admin - Teresa.Mcdowell@mbht.nhs.uk
- Nice manager - Madalina.bleau@mbht.nhs.uk
- Located in the Clinical Audit Office, FGH, Level 4.
More people than ever are living with and beyond cancer. Receiving care that is tailored to a person’s needs can have a significant impact on their experience and quality of life. If you are going to be dealing with cancer patients as part of your new role at UHMB, it is important that you understand the NHS personalised care agenda and expectations. If you are taking up a Cancer Clinical Nurse Specialist or Cancer Support Worker role, you should add the CNS and CSW Lesson Plan for Lorenzo to your TMS list to ensure you capture the personalised care activity.
The NHS Long Term Plan for Cancer states that where appropriate every person diagnosed with cancer will have access to personalised care, including holistic needs assessment (HNA), a personalised care and support plan (PCSP), health and wellbeing information and support, a treatment summary and after treatment, patients will move to a follow-up pathway that suits their needs and ensures they can get rapid access to clinical support.
What is a Holistic Needs Assessment and why is it so important?
A HNA ensures people’s physical, practical, emotional, social needs are met and that resources are targeted to those who need them most and allows for the development of a PCSP.
Holistic Needs Assessment (HNA) - Macmillan Cancer Support
What is a Treatment Summary?
A Treatment Summary provides both the person and their GP with valuable information, including a detailed summary of:-
- Treatment completed
- Potential side effects
- Lifestyle advice
- Signs and symptoms of recurrence
- Information to support Primary Care support
- Who to contact, when and how.
When you start your role at UHMBT, please speak to your Line Manager regarding the process within your Department to complete End of Treatment Summaries within Lorenzo and Somerset Cancer Registry (SCR).
National Reporting
HNA/PCSP and Treatment Summary activity data is submitted to the Cancer Outcomes and Services Dataset (COSD) and therefore must be recorded accurately on Somerset Cancer Registry.
Health and Wellbeing Information and Support is the provision of information about emotional support, coping with side effects, financial advice, getting back to work and making healthy lifestyle choices. This support will be available before, during and after cancer treatment from a variety of resources, including
- Clinical team
- Macmillan Cancer Information and Support Service
- Local charities
- Support groups
- Local events
We know people who receive the right information have a much better understanding of their cancer as well as the confidence to make informed choices about their treatment and health.
Prehabilitation helps people living with cancer prepare themselves for treatment. It can include areas like physical activity, healthy eating, mental health, reducing alcohol intake and stopping smoking. It can improve general health prior to treatment and increase the likelihood of recovering beyond baseline health following treatment.
Prehabilitation guidance for healthcare professionals - Macmillan Cancer Support
Rehabilitation promotes the benefit from increased physical activity and healthy lifestyle changes after treatment.
Cancer rehabilitation pathways guidance - Macmillan Cancer Support
Cancer Teams
A team of health professionals will work with patients to plan their Cancer treatment - Cancer services roles
What is Personalised Stratified Follow-up (PSFU)/Supported Self Management (SSM)?
Routine, clinical examination type appointments are replaced by a system where patients call us when they have a problem. SSM is about giving the patients control of their follow-up and includes:-
- Cancer Support Worker (CSW) will be the first point of contact.
- Personalised care and support planning is delivered
- Access to Education
- Rapid re-access to their cancer team
- Regular surveillance scans or tests which comply with follow up criteria in line with national guidelines
At UHMB we have introduced SSM for Breast, Colorectal, Prostate, Gynaecology and Skin cancer patients.
National Cancer Patient Experience Survey
The National Cancer Patient Experience survey allows cancer patients to give feedback on the care they have received.
- This feedback is used to understand where care is working well and how NHS cancer services across England can be improved.
- Results from the survey are used by providers to improve the experience of cancer patients at a national, regional, and local level.
- The survey is run by Picker on behalf of NHS England.
- Results can be looked at from national level through to Trust and tumour site specific results and help drive improvements.
Latest results - National Cancer Patient Experience Survey
The Cancer Quality of Life Survey
Macmillan Cancer Information and Support Service
The Macmillan Information and Support Service (MCISS), is a non-clinical service, working in partnership with the Hospital Cancer Teams, providing information and Support to people living in North Lancashire and South Cumbria.
They provide a wide range of literature including information in different formats, languages and ‘easy read’. They can signpost / refer to local and National services, including counselling and complementary therapies.
The MCISS Team can support with applications such as Attendance Allowance and Blue Badges, however, they are also linked with the local Citizen’s Advice Teams and can offer direct referrals to Citizens Advice for financial assessments, work, and employment concerns.
UHMB Cancer Website
The UHMBT cancer webpage contains information for staff and patients about all things cancer. There is a section for each team containing contact details, common leaflets and questions specific to each tumour group.
Working in Partnership
All staff caring for people with a cancer diagnosis have a responsibility to ensure peoples’ holistic needs are assessed.
For further help please contact.
Fiona Macdonald, Macmillan Lead Cancer Nurse, Corporate Nursing Team
E-mail: fiona.macdonald@mbht.nhs.uk
Teams: Call me on Teams
Mobile: 07765256674
The Risk Management team consists of our Risk Manager and Risk Advisor who work cross-bay but are most easily contacted via Teams. Our email addresses are below but we can also be contacted at: Risk.Register@mbht.nhs.uk. We are always happy to provide support to colleagues.
Risk Management is everyone’s responsibility. It is a fundamental part of good governance and helps the organisation make good decisions. As an organisation we are open and honest and we welcome discussions about risks so they can be understood and managed.
Risks are present in everything we do and it’s important that we manage those risks effectively to maintain good services and patient and colleague safety. Its everyone's responsibility to think about risks and raise concerns - risks are not something to hide, we welcome discussions about risks so they are understood and can be managed. So for example, if a service can't be delivered to the required standard for some reason, it’s important we understand what risk that creates for patients or the Trust as a whole.
Our definition is “Risk is about the uncertainty of achieving our objectives” so where there is a chance that something will prevent us or hinder us from achieving our objectives, we should describe this as a risk and enter it on to our Risk Register
The Risk Register is divided into several sections:
• Risks featured on the Board Assurance Framework which are the concern of the Trust Board.
• Risks on the Trust – Wide Risk Register, managed at the corporate level because they cannot be managed by a Division or Corporate Department or there is a significant external involvement or requirement.
• Risks managed by a Division or a Corporate Department
• Risks managed by a Speciality,
• Risks managed at Ward or Department level.
There is a process for creating and accepting a risk on to the register, for reviewing and for closing a risk and there are several Standard Operating Procedures to help you do this.
Training available
If you would like individual coaching on how to create, manage and keep a risk or action up to date, please contact us. There is a 2 x half day course for Leaders (Risk Management for Leaders - Level 2) which covers the why and how of risk management at UHMBT. We can run workshops for groups of colleagues e.g. by Division or specialty etc.
What is your role?
Anyone can identify a risk and should discuss with Managers to raise their concerns. If you are a Manager, it may be something you can resolve quickly (more likely to be an issue than a risk) or it may be something that needs to be recorded on the Risk Register with actions and timescales attached. If you are assigned ownership of a risk or an action within a risk, you must take appropriate action, keep your risk updated and escalate if you cannot achieve what is required.
Contacts
Your Line Manager
Governance Business Partners can advise on new risk creations and risk reviews etc
For the Corporate Division – please contact
Anna.smith@mbht.nhs.uk or jemma.preston@mbht.nhs.uk
The transfusion department offers a service covering the processing, testing and investigation of transfusion samples and supplies blood, blood components and blood products. The Transfusion Practitioner writes policies procedures and guidelines and provides training and guidance surrounding the transfusion process.
The laboratory is manned
- 24/7 at RLI (call extension 53761) and FGH (extension 51276)
- Monday to Friday 8am-5pm at WGH (extension 55284)
The Transfusion Practitioner, Jill Livingstone, is available Monday to Thursday.
The transfusion process is a paper-based system and consists of four competencies:
- Completion of the request form.
- Taking the transfusion sample.
- Collection of blood and blood components.
- Administration of blood and blood components.
To take part in the transfusion process you must complete the required competencies on your TMS account. TMS is our training system which your manager will help set you up with an account as part of your local workplace induction when you start. The training will be aimed at those involved in blood transfusion, most likely in clinical areas.
Your line manager and the Practice Educators, who support Wards/Units with their clinical training, will decide which training is appropriate for your job role.
Advice, help and guidance can be obtained from the transfusion practitioner jill.livingstone@mbht.nhs.uk or from the transfusion laboratory.