Air Liquide (Homecare) Ltd Quality Account 2015/16/17

Air Liquide (Homecare) Ltd Quality Account 2015/16/17

Contents Part 1 Welcome and Introduction to the Quality Account 3-5 Statement of Quality from the Managing Director 6-7 Statement of Quality from the Business Relationship and Contracts Manager 8 Statement of Quality and Safety from the Health and Safety Manager 8 HOSAR Mission, Aims and Objectives 9 Part 2 (a) Looking ahead Our quality priorities for Improvement in 2016-17 10 Full list of Quality priorities for 2017-18 11 Details of Quality Priorities 12-22 Part 2 (b) Looking back Review of Quality Priorities in 2015-16-17 23 Patient Safety23 Patient Experience 24 Clinical Effectiveness 24 Part 2(c) Review of Services 25 Clinical Audit 25-26 Goal agreed with Commissioners 27-28 Statements from the CQC 29 Data Quality 29 Page 1 of 43

Part 3 Other information 30 Staff Training 30 Staff Survey 31 Complaints 32 Patient Satisfaction 32-37 Page 2 of 43

Part 1 WELCOME AND INTRODUCTION OUR QUALITY ACCOUNT FOR 2016-17. The Air Liquide Group is a global business that supplies medical gases and related services to hospitals, clinics, ambulances and patients in the home. As a world leader in gases, technologies and services for Industry and Health, Air Liquide is present in 80 countries with more than 50,000 employees and serves more than 2 million customers and patients. AIR LIQUIDE IN THE UK: AIR LIQUIDE HEALTHCARE strives to provide the highest levels of service and quality to our customers. Our customers include NHS Hospitals & Ambulance services, Private Healthcare organisations, and Emergency Service organisations such as Fire & Rescue, GP's, Dental Practices and Veterinary Surgeries. AIR LIQUIDE (HOMECARE) LTD (ALHC) is a provider of healthcare to patients with long term conditions such as COPD (Chronic Obstructive Pulmonary Disease). Our range of homecare services includes Home Oxygen Therapy (HOS) and Home Oxygen Assessment and Review Service (HOSAR). We strive to deliver a high quality service to patients and Health Care Professionals HCP's which is cost effective for the NHS. We deliver home oxygen to over 39,000 patients in London, North West England, the East Midlands and South-West of England enabling them to remain active, independent and improve their overall quality of life and support over 4,000 patients through our Home Oxygen Assessment and Review Service (HOSAR). Our staff of over 300 makes sure that patient care and safety is at the centre of all that we do. Page 3 of 43

Air Liquide (Homecare) Ltd (ALHC) provides a HOSAR service in the North East of England and also in Trafford, Greater Manchester. Working closely with the NHS Commissioners our teams of Specialist Oxygen Nurses assess patients according to the national guidelines ensuring each patient receives the appropriate oxygen therapy according to their clinical need and the locally agreed pathways, ensuring value for money to the NHS through cost effective prescribing. Patients are regularly reviewed in line with national clinical guidelines and best practice to make sure that their home oxygen therapy continues to meet their current needs. The assessments can take place either in the patient s own home or at a clinic close to their location NHS TRAFFORD CCG OVER 250 OXYGEN USERS Page 4 of 43

NORTH EAST CCGS NHS DARLINGTON CCG, NHS DURHAM DALES, EASINGTON AND SEDGEFIELD CCG, NHS GATESHEAD CCG, NHS NORTH DURHAM CCG, NHS SOUTH TEES CCG, NHS SOUTH TYNESIDE CCG, NHS SUNDERLAND CCG OVER 4000 OXYGEN USERS QUALITY ACCOUNT All NHS healthcare providers are required to produce an annual Quality Account, to provide information on the quality of services they deliver. ALHC welcomes the opportunity to outline how well we have performed over the course of 2015/16/17, taking into account the views of service users, carers, staff and the public. This Quality Account outlines the good work that has been undertaken; the progress made in improving the quality of our services and identifies areas for improvement. Page 5 of 43

STATEMENT OF QUALITY FROM THE MANAGING DIRECTOR JOHN WEBBER Thank you for taking the time to read our 2015/16/17 quality account, we welcome this opportunity to take a look at how well we have performed over the previous year, to outline the quality improvement priorities we aim to make in the next year and how we will go about achieving them. As Managing Director of Air Liquide (Homecare) Limited, it is my responsibility to ensure that our core objectives are implemented and that Quality is at the core of everything that we do. To that end, Quality simply put means:- a systematic approach to ensure a continuously high level of performance in all things we do and staff are empowered/ motivated to continuously improve both themselves and the service they provide on behalf of Air Liquide (Homecare) Limited ensuring a high quality service for all our patients, stakeholders and commissioners Air Liquide (Homecare) Ltd is committed to the provision of the highest quality service and working in partnership with the NHS to ensure that the services delivered result in safe, effective care and that their patients needs and priorities are met. We do this by working collaboratively and by always putting the patient at the centre of everything we do, ensuring that we deliver a safe, equitable, consistent and reliable service to all our patients. The report is designed to assure our patients and our commissioners that we provide high quality clinical care. Throughout 2015/16/17 I have overseen continued improvement in the way that we deliver on quality and safety, and a strengthened assurance and reporting structure with the introduction of a Quality Assurance Manager and a reconfigured Quality, Governance, Performance, Safety and Risk Committee. Page 6 of 43

We saw a steady increase in the number of patients over 2015/16/17 and continued to perform extremely well with regard to patient satisfaction. Patient safety is an overriding priority and our aim in 2015/16/17 has been to minimise patient harm, recognising that when an incident does occur we act and learn accordingly. We did not receive an unannounced inspection from the CQC and we look forward to their inspection. This year we have continued to endeavour to ensure that our services meet the highest standards, underpinned by our principle of delivering safe, high quality services by the right people in the right place at the right time. I believe the evidence provided in this quality report demonstrates our commitment to providing the highest quality clinical care. I am very proud of our staff, our achievements and of the services we provide. Equally, I know that we have more to do to ensure that we consistently provide services that are safe, effective, responsive, well led and that every service user and family feels that we are providing the best care. I hope you will find the information in the document useful. To the best of my knowledge the information contained in this document is accurate. JOHN WEBBER MANAGING DIRECTOR Page 7 of 43

STATEMENT FROM THE BUSINESS RELATIONSHIP AND CONTRACTS MANAGER Quality is a core component in the clinical services we deliver. It is the driver for consistent, auditable, deliverable effective services for our patients and it is a measurable assessment used in our Patient and Staff experience audits. JUDE LIVINGSTON BUSINESS RELATIONSHIP AND CONTRACTS MANAGER STATEMENT FROM QUALITY, HEATH AND SAFETY MANAGER Quality and safety are at the forefront of everything we do in our business. Do it once, do it right; think safety, act safely. Quality and safety first time equals efficiency every time. DAVE WILSON NATIONAL SAFETY, HEALTH, ENVIRONMENT & QUALITY MANAGER Page 8 of 43

MISSION, AIMS AND OBJECTIVES ALHC HOSAR AIM AT ALL TIMES TO WORK IN ACCORDANCE WITH OUR MISSION, AIMS AND OBJECTIVES. Our Mission To provide excellence in patient centred specialist care, by providing a high quality, safe and caring service that promotes independence We take great pride in ensuring that our patients are treated as individuals and that they receive the best treatment to ensure the best possible health outcomes for them We strive to deliver a personalised, responsive, high quality service in a manner that demonstrates respect and dignity and is sensitive to their ever changing needs Essential standards of quality and safety are central to our work Our Aims To deliver a comprehensive HOS-AR for the management of patients requiring or potentially requiring the provision of home based oxygen To identify accurately those who will clinically benefit from oxygen therapy and review existing patients prescribed oxygen therapy but will not clinically benefit Adherence to evidence based recommendation and guidelines To provide a comprehensive service using diagnostic equipment. Timely assessments undertaken by qualified clinicians with relevant expertise Safety education and compliance checks at each interaction To deliver a service that is appropriate, equitable, effective and efficient To reduce inequalities in health, promoting well being and independence for patients Our Objectives To improve the quality of life for people requiring oxygen therapy To educate patients and their carers on the effective use and management of oxygen therapy To work collaboratively with primary care, community and secondary care respiratory services To ensure that users of the service have a positive experience of care Page 9 of 43

Part 2 (a) Looking ahead Our quality priorities for Improvement in 2017-18 This section of the quality report outlines the key quality priorities identified by ALHC to improve the quality of our service in 2017-18. We have developed our priorities focusing upon three key themes: Patient Safety Patient Experience Clinical Effectiveness Lord Darzi defined quality for the NHS as comprising three dimensions: Safety ( avoiding harm from the care that is intended to help) Effectiveness (aligning care with science and ensuring efficiency) Patient Experience (including patient centeredness, timeliness and equity) All these dimensions count, but one among them safety emerges repeatedly as the most expected; patients, families and the public expect that the people and organisation that exist to help them will not hurt them. First do no harm is not just a slogan in health care it is a central aim. Page 10 of 43

Quality of care and patient safety are core themes underpinning our organisations values and objectives. Our focus must be on how we can create a culture across the organisation where every member of staff provides the best care for every patient every time and delivers services we would be happy to receive ourselves or for our family and friends. Our continued commitment to improving the quality of our care and service quality for our patients remains our number one priority. OUR QUALITY PRIORITIES FOR 2017/2018: Priority One: Patient Safety Embed Risk Assessment Sign up to safety campaign Embed Incident Management Introduce a shared lessons learned document Priority Two: Patient Experience Introduce Care Plans and documentation Introduce Patient Survey FFT Priority Three: Clinical Effectiveness Embed audit Programme Embed QA Manager Role The detail of the work linked to each priority is described below: Page 11 of 43

PRIORITY ONE: PATIENT SAFETY WHY WE CHOSE THIS PRIORITY: Following the publication and recommendations from The Francis Report The Mid Staffordshire NHS Foundation Trust Public Inquiry 2013 and The Berwick report A promise to learn and commitment to act: Improving the safety of patients in England August 2013 Air Liquide Homecare has committed to providing safe services to patients and is aligned to NHS England commitment to improve patient safety. Patient safety should be the ever present concern of every person working in or affecting the NHS-funded care. The quality of patient care should become before all other considerations in the leadership and conduct of the NHS care, and patient safety is the keystone dimension of quality. (National Advisory Group 2013). Air Liquide Homecare follows the recommendations from the Berwick report Placing the quality of patient care, especially patient safety, above all other aims. Engaging, empowering, and hearing patients and carers throughout the entire system and at all times. Fostering whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work. Embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge. Our staff: Participate actively in the improvement of systems of care. Acquire the skills to do so. Speak up when things go wrong. Involve patients as active partners in their own care. Page 12 of 43

GOAL 1: TO EMBED RISK ASSESSMENT Air Liquide Homecare are aware that every person working in NHS funded care has a duty to identify and help to reduce risks to the safety of patients and to acquire the skills necessary to do so in relation to their own job. Oxygen therapy as with many treatments carries its own risks if not managed and used safely and correctly. The BTS Guidelines for Home Oxygen Use in Adults (2015) advise that a risk assessment may be conducted by the home oxygen assessment service and the fire and rescue service according to local protocols therefore providing a balanced decision between the individuals needs and their safety. The risk assessment process is about identifying and taking sensible and proportionate measures to control the risks. Although we already take steps to control the risks, the use of these tools will help us to decide the safest course of action. HOW WE WILL DO THIS? Air Liquide Homecare has developed risk assessment tools to ensure and support the safe prescribing of oxygen therapy and will in the next year embed these tools into everyday practice therefore enhancing patient safety. Every new patient that we assess will have a general pre installation risk assessment completed to assess safety and suitability of an oxygen prescription and a post installation risk assessment to ensure appropriate interventions are put in place to minimise all potential risks. The risks of prescribing oxygen to active smokers will be on a case-by-case basis and will include a home visit to assess the patient s home situation, attitude toward risks and smoking behaviour, a further smoking risk assessment will be completed and appropriate actions taken. Air Liquide Homecare home oxygen assessment service may decide not to prescribe home oxygen to smokers if the risks are in their judgement too high. Page 13 of 43

HOW WILL WE KNOW HOW WE HAVE DONE? All patients who are commenced on domiciliary oxygen by ALHC oxygen assessment service will have a current risk assessment document completed and attached to their account. Any potential risk will have been highlighted and mitigation will have been put into place. WHO WILL THIS BE REPORTED TO? Governance Committee The risk assessment process and safety issues that are highlighted will be discussed with the patient and carers. GOAL 2 SIGN UP TO SAFETY ALHC holds Health & Safety as a top priority within the business. We are committed to prevent injury and ill health and to a continual improvement in Health & Safety Management and Performance. We have an annual safety plan which sets out our objectives and we will hold regular reviews and updates against the plan. Our policy is communicated on induction and in direct briefings with our staff. The Managing Director has overall responsibility for all matters involving Safety. To enhance our current focus on safety we will sign up to the NHS England campaign Sign up to Safety Sign up to Safety is a national initiative to help NHS organisations and their staff achieve their patient safety aspirations and care for their patients in the safest possible way. Healthcare is high risk and mistakes can happen. Only safe healthcare services are truly efficient, effective and able to offer the best experience - patient safety is the organising principle of the high quality healthcare we all want to provide. Sign up to Safety is helping to make improvements and create a supportive, open and transparent environment for patients and staff. Page 14 of 43

HOW WE WILL DO THIS? We will sign up to the campaign by describing the actions we will take in response to the five Sign up to Safety pledges: The five Sign up to Safety Pledges 1. Putting safety first. Commit to reduce avoidable harm in the NHS by half and make public our locally developed goals and plans 2. Continually learn. Make our organisation more resilient to risks, by acting on the feedback from patients and staff and by constantly measuring and monitoring how safe our services are 3. Being honest. Be transparent with people about our progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong 4. Collaborating. Take a lead role in supporting local collaborative learning, so that improvements are made across all of the local services that patients use 5. Being supportive. Help people understand why things go wrong and how to put them right. Give staff the time and support to improve and celebrate progress. HOW WILL WE KNOW HOW WE HAVE DONE? We will publish our Sign up to Safety pledges on our website and regularly monitor our compliance and progress. WHO WILL THIS BE REPORTED TO? Our sign up to safety pledges will be reported on our website Governance Committee Commissioning CCG s Page 15 of 43

GOAL 3 EMBED INCIDENT MANAGEMENT ALHC is committed to providing a safe environment for its staff, service users and visitors as well as delivering high standards of care. It acknowledges that sometimes, in the course of providing healthcare, incidents can occur, some of which may have serious consequences for service users, their carers, families, staff and the public. In cases, even where human error is involved, incident investigation may reveal other related organisational failings which need to be addressed. It is important that patient safety incidents that could have or did harm a patient receiving NHS funded care are reported so they can be learnt from and any necessary action can be taken to prevent similar incidents from occurring in the future. Action may need to be taken both locally and on a national level, so we encourage open and honest reporting of risks, hazards and incidents via our incident reporting systems. HOW WE WILL DO THIS? We have developed a web /Google based incident reporting process which automatically populates a shared spreadsheet which allows us to monitor and review any near miss or incidents that are identified by the clinical team. HOW WILL WE KNOW HOW WE HAVE DONE? This new tool will allow us to provide reports, updates and themes that our clinical services report. This will allow us to develop action plans and lessons learned throughout the organisation. WHO WILL THIS BE REPORTED TO? Reported incidents will be periodically analysed and results will be shared at team meetings, governance committee and with CCG s and stakeholders where appropriate, enabling the organisation to learn lessons and support implementation of action to prevent incidents reoccurring. Page 16 of 43

GOAL 4 INTRODUCE A SHARED LESSONS LEARNED DOCUMENT Reporting when things go wrong is essential in healthcare but it is only part of the process of improving patient safety. Incidents may occur because of any one of multiple reasons. When a patient safety incident occurs the crucial issue is not who is to blame for the incident? but how and why did it occur? One of the most important things to ask is what is this telling us and how can we learn from it? Lessons learned logs are designed to be updated immediately or as soon as possible after an issue or positive outcome has occurred and frequently to ensure all team members are aware of actions taken forward and progress made. It is recommended that lessons learned logs form part of a regular team meeting agenda, to reinforce the importance of capturing and acting on learning. The lessons learned log should be contributed to by all team members. We have developed our own lessons learned log to use HOW WE WILL DO THIS? We have developed Google based document that will be shared throughout the organisation to allow different departments to share relevant lessons learned with their teams. The document will be updated frequently to ensure all team members are aware of actions and progress made in different areas. HOW WILL WE KNOW HOW WE HAVE DONE? The lessons learned document will form part of team meetings and reinforce the importance of capturing and acting on learning, it will be updated frequently as actions occur and progress made. All members of the shared group can contribute their own specific outcomes and actions to the shared lessons learned log. WHO WILL THIS BE REPORTED TO? Governance committee and team meetings Page 17 of 43

PRIORITY TWO: PATIENT EXPERIENCE Why we chose this priority: Over the past few years several documents and initiatives have highlighted the importance of the patients experience and the need to focus on improving these experiences where possible: Lord Darzi s report High Quality Care for All (2008) highlighted the importance of the entire patient experience within the NHS, ensuring people are treated with compassion, dignity and respect within a clean, safe and well managed environment. High quality care should be clinically effective, safe ad be provided in a way that ensures the patient has the best possible experience of care. Patient experience means putting the patient and their experience at the heart of quality improvement; by introducing patient held care plans and supportive documentation we opt to enhance patients experience of our service. In order for us to measure patient experience we currently use a patient satisfaction survey, although this format gives us valuable feedback we have decided to amend the survey and introduce NHS Friends and Family test (FFT) to our questionnaire GOAL 1 PATIENT HELD CARE PLANS AND SUPPORTIVE DOCUMENTATION HOW WE WILL DO THIS? Each time we assess a new patient for domiciliary oxygen therapy and commence an oxygen prescription the nurse discusses and shares lots of information with the patient and their relatives/carers, this information sharing will now be supported by a patient held care plan with individualised supportive documentation. Previously patients have given feedback stating that we share lots of important information and in conjunction with starting a new prescribed medication it is often daunting, therefore the patient held care plan and Page 18 of 43

supportive documentation will allow the patients to have written information about the topics discussed. The care plans will also be used for communication between other HCP involved in the patients care. HOW WILL WE KNOW HOW WE HAVE DONE? We will actively seek verbal and written patient feedback and will act upon the findings. WHO WILL THIS BE REPORTED TO? Governance Committee Team meetings GOAL 2 FRIENDS AND FAMILY TEST (FFT) The Friends and Family Test (FFT) is an important feedback tool that supports the fundamental principle that people who use NHS services should have the opportunity to provide feedback on their experience. It asks people if they would recommend the services they have used and offers a range of responses. The FFT provides a mechanism to highlight both good and poor patient experience. This kind of feedback is vital in transforming NHS services and supporting patient choice. HOW WE WILL DO THIS? We have adapted our current patient feedback questionnaire to include the friends and family test. The questionnaire will be sent out with the initial assessment letter and again handed out by the nurse at the 12 month review. HOW WILL WE KNOW HOW WE HAVE DONE? Responses will be collated and where patients comments identify areas where improvements can be made, action plans will be developed and put into action. Page 19 of 43

WHO WILL THIS BE REPORTED TO? Patients and public via website Governance committee Commissioning CCGs Team meetings PRIORITY THREE: CLINICAL EFFECTIVENESS Clinical effectiveness is an essential component of the Clinical Governance agenda to improve and assure quality. As with all aspects of Clinical Governance, clinical effectiveness is about improving patients total experience of their healthcare and involves a framework of informing, changing and monitoring practice. Clinical effectiveness is about doing the right thing at the right time for the right patient and is concerned with demonstrating improvements in quality and performance: - the right thing (evidence based practice requires that decisions about health care are based on the best available, current, valid and reliable evidence) in the right way (developing a workforce that is skilled and competent to deliver the care required) at the right time (accessible services providing treatment at the point of need) in the right place (location of treatment / services) with the right outcome (clinical effectiveness / maximising health gain) Clinical effectiveness is thinking critically about what you do, questioning whether it is having the desired result and making a change to practice if required. It is based on evidence of what is effective in order to improve patient care and experience Page 20 of 43

GOAL 1 EMBED CLINICAL AUDIT PROGRAMME Clinical audit is a way to find out if healthcare is being provided in line with standards and lets us and patients know if our service is doing well, and where there could be improvements. Clinical Audit is a quality Improvement process that measures current patient care and outcomes against agreed standards of best practice. In order to inform, change and monitor our service we have developed a comprehensive clinical audit programme. HOW WE WILL DO THIS? The audit programme has been shared with our governance committee and the clinical team, several audits are ongoing and we are introducing new audits and re audits at regular intervals HOW WILL WE KNOW HOW WE HAVE DONE? Quarterly updates on audits progress, changes to practice following audit outcomes WHO WILL THIS BE REPORTED TO? Governance committee Commissioning CCGs Team meetings GOAL 2 EMBED THE QUALITY ASSURANCE MANAGER ROLE In 2015/16 we enhanced our clinical and managerial team with the introduction of a new role, Quality Assurance Manager. The creation of this post confirms the importance that we place on the governance agenda within the organisation. The main areas of responsibility will be the co-ordination of the organisations compliance with key areas of Clinical Governance, such as clinical audit, patient and carer experience. Page 21 of 43

HOW WE WILL DO THIS? The post holder will work with the lead nurses and clinical services manager to, establish, coordinate and implement key processes to demonstrate assurance and monitoring of quality standards. HOW WILL WE KNOW HOW WE HAVE DONE? Evidence and production of audit programme report and updates, review of concordance, introduction of tools to enhance the patient experience, evidence of compliance with agreed standards. Evidence that we meet local, national and regulation standards. WHO WILL THIS BE REPORTED TO? Governance committee Commissioning CCGs Team meetings. Page 22 of 43

Part 2(b) Looking back review of Quality goals and priorities in 2015-16-17 As this is ALHC s first quality account we are unable to give updates on specific goals and priorities that were set last year although we can give an update on the excellent work we have undertaken over the past year to improve patient safety and the quality of the service we provide. PATIENT SAFETY LIFE SAVING RULES, 10 MINUTE TOPICS AND SAFETY FORUM. June 2015 saw the launch of Air Liquide Homecare enhanced safety programme; "Life Saving Rules" are twelve rules designed to drive our safety compliance and safety culture. We have now completed team briefings for each one. Ten minute topics are a monthly paper/information resource shared throughout the organisation raising awareness of such topics as smoking. In 2015 we also introduced the National Safety Forum which is a bottom up committee with representatives from all areas of our business bringing ideas to the table for change and involvement of our teams. We have also started the National Safety Committee in addition to local safety committees. This is a policy and process driving committee. This comprehensive safety campaign raises awareness amongst the clinical staff when attending patients homes and enhances the safety focus of oxygen provision and prescribing. Among the ten minute topics we have covered areas such as infection prevention and control and safeguarding. Page 23 of 43

PATIENT EXPERIENCE PATIENT EXPERIENCE SURVEY Previously ALHC distributed feedback surveys to all patients at every assessment. However verbal feedback from service users highlighted that patients were often receiving feedback surveys every three months, this process has been amended. We now have a rolling programme patient survey where customer services and the HOSAR nurses hand out patient feedback surveys at each initial and annual assessment. The feedback is discussed and shared at team, governance and service review meetings, action plans and lessons learned are developed, shared and reviewed accordingly. CLINICAL EFFECTIVENESS REVIEW OF GUIDELINES In June 2015 The British Thoracic Society (BTS) published updated guidance on home oxygen management; this guidance provides detailed evidence-based guidance for the use of home oxygen for patients out of hospital. It explores the evidence base for the use of different modalities of oxygen therapy and patient related outcomes such as mortality, symptoms and quality of life. The guideline also makes recommendations for assessment and follow-up protocols, and risk assessments, particularly in the clinically challenging area of home oxygen users who smoke. The home oxygen guideline provides expert consensus opinion in areas where clinical evidence is lacking, and seeks to deliver improved prescribing practice, leading to improved compliance and improved patient outcomes, with consequent increased value to the health service. We reviewed the new guidance, recommendation and good practice points, to ensure our service is still aligned and shared new recommendations with the CCG s and our governance committee. Page 24 of 43

Part 2 (c) REVIEW OF SERVICES During 2015/2016/17ALHC provided HOSAR services for over 4000 patients covering 8 CCGs 7 North East CCGs (Darlington, Durham Dales, Easington and Sedgefield, Gateshead, North Durham, South Tees, South Tyneside, Sunderland) and 1 North West CCG (Trafford). In total 8153 assessments were completed during this period. CLINICAL AUDIT Although we did not participate in any national audits in 2015/16/17we are committed to delivering an effective and coordinated clinical audit programme covering all of the clinical services we provide, our programme is regularly reviewed to ensure it reflects the needs of our clinical services. Clinical audit is a key quality improvement tool within ALHC to continually monitor and improve the quality of care provided to patients. We know that high quality clinical audit enhances the care and safety and provides assurance of continuous quality improvement. It also contributes towards the wider quality, safety, assurance and governance frameworks that are in place across the organisation. Page 25 of 43

Title of Clinical Audit BTS Guidelines NICE Quality Standard COPD HAND HYGIENE CLEANLINESS CQUIN Aims and Objectives To gain assurance that the HOSAR are providing a service in line with BTS Guidelines To gain assurance that the HOSAR are compliant with Quality Standards set for COPD To identify effective hand preparation and hand decontamination of all staff within HOSAR to minimise the risk of transmission of infection. To ensure the HOSAR provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention and control of infections To evidence compliance and achievement of CQUIN targets Clinic To gain assurance that clinical areas comply with Health and Safety Uniform Letter Audit KLOE To ensure that HOSAR staff comply with the uniform policy, and adhere to infection control and health and safety requirements. To provide assurance that the HOSAR correspondence is accurate and clinical decision making is appropriate. To gain assurance that the HOSAR is complaint with CQC standards Zero concordance Over and Under use Near Miss To review the concordance of oxygen users and gain assurance that prescribing is appropriate To review the concordance of oxygen users and gain assurance that prescribing is appropriate To audit near miss reports, identifying and analyzing trends Inhaler Technique To review inhaler technique, and reassess following intervention Adhoc Visits Hygiene Code Safeguarding Procedure To review the visit regime and gain assurance that patient safety is maintained To determine how the HOSAR comply with the infection prevention requirements, set out in the Health and Social Care Act 2008 To determine how the HOSAR is compliant against Safeguarding Policy HOSAR Activity To review activity and gain assurance that service is efficient and effective SBOT To review SBOT and rationalise prescriptions Record Keeping To review nursing notes on accounts Page 26 of 43

GOAL AGREED WITH COMMISSIONERS USE OF THE COMMISSIONING FOR QUALITY & INNOVATION (CQUIN) FRAMEWORK The CQUIN framework aims to embed quality improvement and innovation at the heart of service provision by linking a proportion of providers income to the achievement of local quality improvement goals. A proportion of ALHCs income for 15/16 was conditional on achieving quality improvement and innovation goals agreed between ALHC and Clinical Commissioning Groups through this framework. Details of the CQUIN Goals: TRAFFORD: Reducing admissions in COPD patients COPD checks and signposting Producing quarterly quality account In addition to the existing assessment, the HOSAR Team will include additional checks for all COPD patients to reflect admission avoidance planning and anticipatory care planning/ coordination. Disease Awareness Check Rescue Pack Check Medication Check Inhaler Technique Check Nebuliser Check Self Management Plan Flu Vaccination check Changes in MRC score This information was captured against each patient to allow for individual patient reporting A quarterly quality account was produced using Trafford CCG template evidencing a safe and effective service. NORTH EAST: Improving Inhaler Technique. Where a patient is identified as using inhalers, ALHC will assess their inhaler technique and provide the appropriate level of training for their particular device. Training will be provided to the patient and/or carer where required. Where it is felt that the device prescribed is Page 27 of 43

not suitable for the patient or where additional consumables, i.e. spacers, are required, ALHC will make recommendations to the patients managing HCP. This CQUIN will help to support more cost effective drug usage, improve patient outcomes and help to manage the inappropriate usage of oxygen to manage their breathlessness. Managing Patients who require but continue to smoke All home oxygen patients are provided with stop smoking advice, receive full safety training and are given safe smoking advice. This is also provided to carers and family members where appropriate. Where this advice is not followed patients put both themselves and others at risk. The ongoing management of oxygen in this patient group needs to be considered and managed to limit and where possible mitigate the risks. This may lead to the withdrawal of oxygen. To be successful in managing these patients a multi disciplinary approach is required. This needs to be specific to the local organisation. ALHC will provide patients who smoke and receive oxygen with a formalised bundle including: Offer stop smoking referral Completion of home safety and safety compliance Provision of written information Fire Service Liaison In addition to this ALHC will work with the individual CCGs to develop specific escalation protocols to manage high risk patients where there are concerns regarding smoking and oxygen. All CQUIN were achieved for 2015/2016/17. Page 28 of 43

STATEMENTS FROM THE CQC ALHC is required to register with the Care Quality Commission and our current registration is: COMMUNITY HEALTHCARE SERVICES Our regulated activities are; 5 - TREATMENT OF DISEASE, DISORDER AND INJURY 8 DIAGNOSTIC AND SCREENING PROCEDURES ALHC have not been inspected by the CQC. MONITOR ALHC is also required to register with Monitor, our Monitor License number is: Licence Number: 200056 Issued 01/04/2014 DATA QUALITY INFORMATION GOVERNANCE (IG) TOOLKIT ATTAINMENT LEVELS Information governance means keeping information safe, this relies on good systems, processes and monitoring. Every year ALHC is assessed by NHS Digital and the Department of Health Information Governance Toolkit, we audit the quality of specific aspects of information governance through this toolkit. The Assessment Report overall score for 2015/16 was 100% and was graded green (satisfactory) as level 3 had been achieved for all relevant requirements (27 out of the maximum 29). The Information Governance annual training was also completed with all staff in conjunction with this toolkit. Page 29 of 43

Part 3 OTHER INFORMATION REVIEW OF QUALITY PERFORMANCE In this section we will report on the quality of the services we provide, by reviewing progress against indicators for quality improvement, and feedback from sources such as service user and staff surveys. STATUTORY AND MANDATORY TRAINING It is important that our staff receive the training they need in order to carry out their roles safely. All our clinical staff attended mandatory training, in addition to training appropriate to their role and responsibilities, in the form of study days, informal in house training, conferences, E-Learning packages, university courses. supervised visits. All staff take part in shadowing and To maintain their registration NMC registered practitioners need to be prepared for revalidation, all nursing staff attended a study session to prepare them for this new process. A training programme is to be developed to ensure each member of staff achieves an agreed standard. Page 30 of 43

STAFF SURVEY 2015 We surveyed all the clinical staff in 2015, 14 team members were in post at the time of the survey, the feedback and overall responses were very positive. The outcome of the survey was presented at the team meeting and also the governance meeting. A number of points were identified, actions were developed and shared. DO YOU FEEL VALUED BY AIR LIQUIDE? RECOMMEND ROLE TO A FRIEND? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Yes 2015 No 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Yes 2015 No 7 Q2 2015 East Midlands SRG Air Liquide, world leader in gases for industry, health and the environment 26 Q2 2015 East Midlands SRG AirLiquide, world leader in gases for industry, health and the environment HOW MUCH DO YOU AGREE OR DISAGREE? RECOMMEND AIR LIQUIDE AS AN EMPLOYER? 16 2015 100% 2015 14 90% 12 80% 10 70% 8 60% 6 50% 4 40% 2 0 L&D needs Opportunity to develop Mandatory training Career progression 30% 20% 10% 12 Q2 2015 East Midlands SRG Air Liquide, worldleader in gases for industry, healthandthe environment 0% Yes No 28 Q2 2015 East Midlands SRG AirLiquide, world leader ingases for industry, health and the environment HOW MUCH DO YOU AGREE OR DISAGREE 2015 14 12 10 8 6 4 2 0 Opinions, ideas & views Transparent & open culture listened to 15 Q2 2015 East Midlands SRG Air Liquide, world leader in gases for industry, health and the environment KEY MESSAGES: ACTIONS: Positive changes to ways of working, support and management increased moral and feeling like a team Source different mandatory training provider Look at alternatives to the i-pad To adopt NHS survey patient safety culture/staff questionnaire In 2016 we adopted the NHS staff survey which gave an overall positive message Page 31 of 43

COMPLAINTS ALHC works hard to provide high standards of clinical care delivered with dignity and compassion, we welcome the valuable information gathered through our complaints process, it helps us to understand what we do well and what we can improve on and is used to direct our service improvements and ensure we provide the best possible care to our patients and carers. In 2015/16/17 we received three complaints; the theme of the complaints was communication. All complaints were responded to and closed within appropriate timescales. All lessons learned from complaints are taken back to the clinical team and shared with the governance committee. PATIENT SATISFACTION SURVEY Listening to our patients is one of the most effective ways of driving improvement in our services. By asking for their thoughts and feedback demonstrates that we are keen to make improvements and make service users feel more involved. ALHC patient satisfaction survey is a continuous programme, each patient receives a survey with the initial appointment letter and again at their annual assessment. At the end of the assessment the nurse completes section one of the survey, returns it to the patient and explains the process of completion and return. As the survey is anonymous the patient also receives a SAE to return the survey. The majority of the responses are very positive, when we do receive comments or issues about the service or staff, action plans are developed to raise awareness and to reduce the likelihood of similar issues occurring, lessons learned are shared with the team, governance committee and commissioners. Positive comments are also shared with the team, governance committee and commissioners. Page 6 of 43

We collate the number of returns we receive and develop action plans and lessons learned from any negative comments that are received. The majority of our assessments are home visits, and this is reflected in the number of clinic returns in comparison to home assessment returns. NUMBER OF RETURNS BY LOCATION BY MONTH 2015-16 100 80 60 40 20 0 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Clinic Home Total number of surveys 1134 returned 2015-17 Home assessment 1025 Clinic Assessment 109 NUMBER OF RETURNS BY LOCATION BY MONTH 2016-17 60 50 40 30 20 10 0 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Clinic Home Page 33 of 43

Our patient satisfaction survey asks a number of questions about the patient experience of our service, the assessment process and staff. Below are some of the questions and responses. TAKING EVERYTHING INTO CONSIDERATION, ARE YOU HAPPY WITH THE SERVICE YOU RECEIVE? 2015-16 100% 80% 60% 40% 20% 0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 No Yes TAKING EVERYTHING INTO CONSIDERATION, ARE YOU HAPPY WITH THE SERVICE YOU RECEIVED? 2016-17 Are you happy with the 1065 service received? Yes 1063 No 2 100% 80% 60% 40% 20% 0% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 No Yes Page 34 of 43

DID THE NURSE DISCUSS THE REASON AND PURPOSE OF THE ASSESSMENT 2015-16 100% 80% 60% 40% 20% 0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 No Yes Discuss the reason and 1129 purpose of the assessment Yes 1125 No 4 DID THE NURSE DISCUSS THE REASON AND PURPOSE OF THE ASSESSMENT 2016-17 100% 80% 60% 40% 20% 0% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 No Yes Page 35 of 43

DID THE NURSE TREAT YOU IN A COURTEOUS AND RESPECTFUL MANNER 2015-16 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 No Yes DID THE NURSE TREAT YOU IN A COURTEOUS AND RESPECTFUL MANNER 2016-17 Treat you in a courteous 1136 and respectful manner Yes 1136 No 100% 80% 60% 40% 20% 0% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 No Yes Page 36 of 43

THE HELPFULNESS OF CUSTOMER SERVICES 2015-16 100% 80% 60% 40% 20% 0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 1 2 3 4 5 THE HELPFULNESS OF CUSTOMER SERVICES 2016-17 The helpfulness of staff 1 0 2 1 3 4 4 47 5 941 100% 80% 60% 5 Excellent-----1 Very Poor 40% 20% 0% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 1 2 3 4 5 Page 37 of 43

THE ACTION TAKEN IN RESPONSE TO YOUR CALL TO CUSTOMER SERVICES 2015-16 100% 80% 60% 40% 29 27 43 66 40 30 49 48 38 36 40 58 20% 0% Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 100% 80% 60% 40% 20% 0% 1 2 3 4 5 THE ACTION TAKEN IN REPONSE TO YOUR CALL Apr-16 May-16 Jun-16 TO CUSTOMER SERVICES 2016-17 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 The action taken in response to your call 1 0 2 0 3 6 4 47 5 789 5 Excellent-----1 Very Poor 1 2 3 4 5 Page 38 of 43

HOW LONG DID IT TAKE TO TRAVEL TO CLINIC 2015-16 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Less than 30 mins 30 mins to 1 hour Longer than 1 hour HOW LONG DID IT TAKE TO TRAVEL TO CLINIC 2016-17 How long did it take to travel to clinic less than 30 minutes 63 30 minutes to 1 hour 38 Longer than 1 hour 2 100% 80% 60% 40% 20% 0% Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Less than 30 mins 30 mins to 1 hour Longer than 1 hour Page 39 of 43

WERE YOU SEEN LATER THAN YOUR APPOINTMENT? 2015-16 14 12 10 8 6 4 2 0 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 No Yes Were you seen later than your appointment No 91 Yes 7 WERE YOU SEEN LATER THAN YOUR APPOINTMENT? 2016-17 5 4 3 2 1 0 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 No Yes Page 40 of 43

Some of the comments from our patient surveys: We review the outcome and findings of the surveys and although we receive predominantly positive comments on a couple of occasion s patients have not been totally happy with our service which is reflected in a few of the tables. Although the format of our current questionnaire asks patients to give details about their responses; very little qualitative feedback is received, we have therefore amended our questionnaire to encourage patients to elaborate on their responses and added in the NHS Friends and Family test which is one of our quality priorities for 2017/18. Page 41 of 43

Thank you for taking the time to read our Quality Account for 2015/16/17 We welcome your feedback on this Quality Account and any suggestions you may have for future reports. Please contact us as indicated below Air Liquide Homecare Ltd Alpha House Wassage Way Hampton Lovett Droitwich WR9 0NX Tel: 08000223445 Page 42 of 43