Quality Account 2009-10
June 2010
STATEMENT FROM MATHEW WINN, CHIEF EXECUTIVE, CCS NHS TRUST
Community based services are at the heart of a modern and flexible NHS. As the main
provider of such services to children and adults across Cambridgeshire, we are committed to
ensuring continuous improvements to the quality of services we provide.
Set out in this report are our priorities for improving patient safety, effectiveness and
experience in 2010/11. We have set ourselves high ambitions and have every expectation of
meeting these and building on them further in future years.
I have been impressed throughout the year by the commitment of staff to providing high
quality care to patients and service users on a daily basis and the pride they take in doing the
very best for each and every person they meet. This commitment will continue to be
fundamental to achieving the standards set out in this report.
In February 2010, a new system for registering health services was introduced. I am
delighted to report that that the Care Quality Commission registered all services provided by
Cambridgeshire Community Services NHS Trust without conditions. This validates the
standards of quality and safety provided throughout our services and is fantastic recognition
of the hard work and commitment of our staff.
We are of course not complacent and identified two areas to the CQC where we want to
make further improvements. These include arrangements for safeguarding adults and
recruitment plans for Health Visitors, District Nurses and hospital based children’s services.
Actions plans are already well underway in these areas and I am confident will be fully
implemented within the appropriate timescales.
You will also see later in this report a summary of our contractual targets and how we are
performing against each of these. Again, comprehensive action plans are in place to ensure
we achieve each of these targets by year end.
You will read later in this Quality Account of progress we have made against priorities
identified for 2009/10, as well as our priorities for improving quality in 2010/11.
In identifying these priorities, we have sought the views of NHS Cambridgeshire, our main
commissioner; our own internal Patient Focus Committee including patient representatives;
Cambridgeshire Local Involvement Network and Cambridgeshire Health and Adult Scrutiny
Committee. We have invited their voluntary comment on the content of this report. Where
these have been provided they are incorporated verbatim in this document.
I look forward to reporting in twelve months time on progress made with the standards set out
in this report.
I can confirm on behalf of the Trust’s Board that to the best of my knowledge and belief the
information contained in this Quality Account is accurate and represents our performance in
2009/10 and our priorities for continuously improving quality in 2010/11.
Matthew Winn
Chief Executive
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SECTION A : SUMMARY FROM 2009/10
Introduction:
Cambridgeshire Community Services NHS Trust (the Trust) has focused in 2009/10 in
developing systems to measure and analyse information relating to Quality activity. A regular
monthly Quality performance report has been presented to the Trust’s Board incorporating
amongst others, progress against areas of Infection control, safeguarding children and patient
experience.
Further performance data is presented monthly to the Board as part of the balanced
scorecard. See Appendix A for end of year summary of national indicators included on the
scorecard.
The Trust participated in the national pilot to develop appropriate community based Quality
Improvement Indicators. This gave us an opportunity to reflect on areas for improvements
locally and we have included several of these in our priorities for improvement in 2010/11.
A further substantial piece of work was undertaken to develop and pilot an internal
Governance and Quality information framework – a Business Unit Dashboard. This enables
Service Managers to consider many aspects of governance for their service in an integrated
way. Data includes information in the areas of quality and risk, finance, workforce alongside
locally agreed indicators and improvement projects. The performance data will be reviewed
at Divisional level and exceptions against plans reported to the Trust’s Board. It is anticipated
that this will extend to include specific clinical outcome based data as appropriate community
based clinical dashboards develop nationally.
The summary below reflects quality based improvement activity as outlined for 2009/10.
Review of Quality Indicators for 2009/10
1. PATIENT SAFETY
NHS East of England has pledged to make this Strategic Health Authority area the safest in
England (Pledge 6). The Trust contributed to this pledge in its priorities for Quality
Improvement in 2009/10 by focusing on the areas below:
We have successfully implemented a web based incident reporting management system
(Datix) which links to the National Reporting and Learning System. This has enabled us to
develop a comprehensive quarterly safety and risk report which outlines trends in aspects of
patient safety activity for example the number of patient/staff safety incidents. We continue to
be one of the top Trusts in the region for reporting incidents. We commend our staff for
ensuring that all accidents, incidents and near misses are appropriately reported so that we
can lean from such incidents and strive to improve our care in order to minimise patient safety
issues.
We have reduced the numbers of patients falling in our inpatient facilities – this has been
through an extensive programme of quality improvement activity relating to the DH
‘Productive Ward’ programme. We will continue this work and have selected this as an
improvement area for 2010/11 (see p12).
Please note: the final year end figures will be available prior to publication.
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1.1 Infection control
An extensive programme of clinical audits based on the Essential Steps and Clean Your
Hands campaigns have highlighted defined improvements in Infection Prevention and Control
resulting in the following:
MRSA
C Diff
target 0 cases
target no more than 6 cases
0 cases as of end Jan 2010
1 lab confirmed case by end Jan 2010
The Infection Prevention and Control Team has also been strengthened throughout 2009/10
with the successful recruitment to remaining vacancies. This has had a positive effect
throughout the organisation with improved access to specialist advice and training.
Reporting of progress against the Infection Prevention and Control action plan has occurred
regularly in the monthly Quality Performance Report to the Trust’s Board.
1.2 Safer employment standards
The Initial action plan from baseline assessment includes the following:
 Specific documents developed for recruitment process in line with major reviews i.e.
Laming report. Examples include CRB declaration forms, improved reference proforma etc
 Electronic recruitment management system - ERICA is due imminent upload of the above.
 CRB checks introduced nationally in 2002 – people employed before this date do not have
one – the Trust has started a rolling programme to check all existing staff – started with
Children’s services and although no legal requirement to check regularly – the Trust
decided to check certain staff groups every 3 yrs ie those working with vulnerable client
groups.
 Independent Safeguarding Authority with be legislative in Nov 2010 –This requires a large
piece of work to ensure that all staff will be registered as required. Action plan in place.
 Internal audit conducted a review against Safer Employment standards in summer 2009 –
actions included above.
1.3 Controlled drugs (CDs)
An Initial baseline assessment was undertaken across the Trust in 2009 and resulting action
plan developed. This audit enabled us to understand the following:





Which services hold CDs
What the administrative processes are for each area
Storage issues
Any learning relevant to CD incidents
Re audit planned for Spring 2010
A further study by Internal Audit gave a level of ‘Substantial Assurance’ for the Trust in the
safe management of CDs, offering a further level of assurance that our systems and
processes are robust and adhered to by staff.
The September 2009 Learning from Experience Group (formal quarterly session including
members of the Clinical & Practice Governance Committee) looked at learning from incidents
and issues around medications including CDs. Learning points from a root cause analysis
have been disseminated across the organisation, i.e. ordering, responsibilities for registered
nurses, layout of storage areas, etc.
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2. EFFECTIVENESS
2.1 NICE guidance
The system for dissemination of NICE guidance involving Medical Director overview, Clinical
& Practice Governance Team dissemination, gap analysis, etc. has been reviewed. Formal
reporting to Board to commence in 2010 re appropriate NICE guidance for the Trust’s
services. The NHS Litigation Authority risk management standards assessment in 2011 will
have a component based on the Trust’s response to selected NICE guidance. Work is
underway to ensure that we comply with all relevant guidance.
2.2 EoE Obesity strategy implementation
The Weight Measurement Team is in post and has commenced measurements in schools.
The target was met for 2008/09 and we are on course to meet the 09/10 target (based on
school year so July is final month).
2.3 Safeguarding adults: policy implementation
There has been an intense focus on Safeguarding Adults activity across the Trust’s services
throughout 2009/10. An audit tool is being developed by Cambridgeshire County Council –
work is underway to customise and condense this extensive document for the Trust. A full
audit is planned for 2010.
The Trust’s Adult Safeguarding Board has been initiated as a formal sub group to the Clinical
& Practice Governance Committee. This group also links with the County Council
Safeguarding Board. This group aims to provide strategic monitoring of all adult safeguarding
issues and includes representation from the Trust’s business divisions, corporate services
and the County Council.
3. PATIENT EXPERIENCE
3.1 Measuring & monitoring service users experience
Patient survey and Dr Foster hand held kits fully implemented across the Trust. Business
Managers are currently developing action plans in response to feedback.
3.2 Essence of Care post update
Dignity focus. Twelve month fixed term appointment to lead project. Post holder commenced
January 2010 and has collated examples of improvements in the areas of privacy and Dignity.
3.3 Trends from incidents
Divisional level reports developed and implemented. Reported fully to Patient Focus
Committee to enable Committee to identify proposals for learning and feedback into the
Trust’s clinical governance systems.
3.4 Patient Focus Committee to input to policy decisions
Lead Trust policy in terms of developing patient experience feedback mechanisms,
introduction of use of PALS service by ethnic communities (monitoring form), informed debate
on moving to Trust status, informed policy on reporting of risk (e.g. specific reports produced
for Patient Focus Committee on Serious Incidents, complaints, incidents, PALS etc.),
contributed patient perspective to awareness raising/targeting of smoking cessation services.
3.5 Single sex accommodation
The four community hospitals within the Trust’s remit are currently fully compliant with single
sex accommodation requirements.
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4. INVOLVEMENT IN NATIONAL CLINICAL AUDITS
4.1 National clinical audits
The Trust’s staff have been involved in the following national clinical audits:
 UK Cystic Fibrosis National Database (2007, 2008, 2009). Lead by Maternal & Child Health
Sciences
 University of Dundee. Rates the participants on outcomes, our Paediatric Dept is highly
rated.
 Paediatric Diabetic National Database. Lead by Diabetes UK.
 National continence care audit
 Glaucoma audit
 Diarrhoea & Vomiting in children under the age of 5 years.
We are currently working to identify clear outcomes from such audits that may be applicable
for the Trust’s services. We are developing our staff intranet to inform staff of such outcomes
alongside the results and outcomes from our internal clinical audit programme.
NB Alongside these national audits, we have developed a robust Trust Clinical Audit Plan for
2010/11 which has involved the input from many of our clinical leaders prior to its Board
approval.
Many of the prospective areas of Quality Improvement identified for implementation in
2010/11 are included in the plan for example, compliance with relevant NICE guidance, audit
of safeguarding adults standards and use of Controlled Drugs.
4.2 Research activity 2009/10
Below is a summary of research activity in the Trust for 2009/10:
 Research across the Trust has been stimulated by a Bright Ideas Workshop in April 2009.
We have established research active clinicians and are developing support systems for
them. Twenty attended. Four new projects have commenced since then.
 Active research for Patient Benefit applications. Links established to Deanery and Clinical
School, Cambridge University.
 We have appointed a Clinical Audit, Effectiveness and Research Manager within the
Clinical Governance team. Dr Paula Waddingham commenced in this role October 2009. A
research governance protocol is in development.
 Regular input from the Comprehensive Local Research Network.
 We have compiled list of research active professionals
 Several significant programmes are under development:
- Oliver Zangwill neurological rehabilitation at POW hospital.
- Physiotherapy Direct
- Diabetes in childhood study
- Support for 5 Masters course applicants: all financed via the Trust and Anglia Ruskin
University.
- We are developing our staff Intranet for research interested staff to post ideas, links to
published papers, completed audit projects etc
 We have secured funding for 1 day a week for 2 years research support from the Primary
Care Research Network and will be looking to establish their relevant national studies
within our services.
 Our new Medical Director post includes research support and stimulation as key role in job
description and will work with the Audit, Effectiveness and research Manager and
transformation team to stimulate research appropriate for the organisation objectives.
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SECTION B : REVIEW OF SERVICES
During 2009/10 the Trust provided the following services (note that clinical services within the
Trust are grouped together in three Divisions):
Care at Home Services
 Integrated health and social care services for adults and older people which includes
district nursing and social care management
 Assistive Technology and telehealthcare
 Specialist nursing services (respiratory, parkinsons, tissue viability, diabetes,
anticoagulation, continence, colorectal and stoma care, heart function and heart failure,
multiple sclerosis)
 Community matrons
 Community rehabilitation i.e. physiotherapy, occupational therapy and speech and
language therapy, day rehabilitation, falls prevention
 Discharge Planning
 Inpatient rehabilitation
 Specialist palliative care services (inpatient, day case, community based)
 Care services in extra care and sheltered housing/day centres
 Nutrition and dietetics
 Neuro-rehabilitation
Care in and around hospitals/clinic based care
 Radiography
 Outpatient clinics
 Minor injury units
 Community Dental Services and Dental Access Centres
 Musculo-skeletal services
 Podiatry
 Sexual health services including Chlamydia Screening
 Human Papilloma Virus vaccination programme
 Primary care for homeless people
Children’s Services
 Paediatric inpatient services , outpatient services and special care baby unit
 Paediatric community nursing including continuing care
 Paediatric occupational therapy, physiotherapy, speech and language therapy
 Paediatric vision screening
 Paediatric audiology
 Safeguarding children
 Consultant based community paediatric services
 Health Visitors
 School Nurses, including special school nurses
The Trust is developing systems to collate, monitor and review information on various aspects
of Quality information for all of the services it provides. We have considered all available
information in the analysis of appropriate Quality Improvement activity for this report.
Minor restructuring of component Business Units for each division is currently underway to
reflect appropriate patient pathways. This includes Care in and around Hospitals/Clinic based
division re-aligned as Ambulatory Care.
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SECTION C : TRUST WORKFORCE
Alongside the Quality elements of safety, effectiveness and patient experience, the Trust is
committed to ensuring that we monitor and improve experiences of our staff at work.
Having a workforce that is up to date and fit to practise is key to the delivery of safe, effective
and respectful care.
Clear leadership from the Senior Management Team has been an essential component of our
staff engagement activity throughout 2009/10.This has involved implementation of the
following areas:
1. Back to the Floor
The Trust runs a programme of Back to the Floor visits where Executive Directors shadow a
member of staff providing front line services within the Trust to experience, first hand, the day
to day challenges of providing front line care. These visits take place in parallel with the
Executive Director attending that service’s team meeting so that corporate messages can be
shared and discussed at a team level, and front line staff can share good news or challenges
within their service. Taken together, these two initiatives provide an additional and effective
mechanism for senior management to understand in detail and respond to quality issues
within the Trust. Over a 12 month period, each and every service within the Trust will have
been visited for a Back to the Floor and team meeting visit.
2. Health and wellbeing
The organisation is actively working to reduce sickness absence and, following on from the
no-smoking policy across the NHS, is embarking upon a project to promote the benefits of
healthy living and healthy lifestyles amongst its own staff.
3. Staff development and appraisal
The organisation is promoting the requirement for an appraisal and PDP for all staff and has a
target of 95%.
4. NHS Pensions Choice
The organisation has a nominated HR lead and staff side lead to oversee this work. All staff
have received the relevant Pensions Choice information.
5. Apprenticeships
The organisation has currently committed to achieve at least nine apprenticeships within its
business administration function for 09/10, however, health and social care apprenticeships
will be developed for 2010/2011.
6. Talent and leadership plans
Cambridgeshire Community Services submitted its top level talent plans to the SHA in 2009.
The organisation is promoting and developing its Chrysalis Leadership programme which
aims to develop the Organisational values, behaviours and skills necessary to deliver a
successful Quality, innovation, Productivity and Prevention agenda. This programme will
initiate our talent pipeline and populate our leadership plans at all levels of the organisation.
7. Workforce / healthcare career modernisation
Further work on role design around patient and service user pathways will continue
throughout 2010. The Trust intends to continue its work on further developing its workforce to
increase its profile of assistant practitioner and new clinical and practice roles. Partnership
working will continue with local HEIs so that education commissions meet the needs of the
organisation’s role redesign agenda. Delivering service developments will deliver further
Page 8 of 16
workforce productivity outcomes.
8. Workforce planning
The tools and data set disseminated by the County Workforce Group and SHA will be used to
structure the organisation’s workforce planning activity. The workforce profile report will be
used to underpin the skills and gap analysis.
9. Workforce strategy
The main elements of the Trust’s Workforce Strategy for 2010/11 are expected to be:
 Workforce Planning
 Recruitment and retention
 Talent management
The strategy will be reviewed in April 2010 following the approval of the Three Year Business
Plan. The immediate objectives for progressing the strategy have been identified as
leadership development and ensuring that basic workforce enabling processes are efficient
and effective. This will enable the organisation to focus on achieving the following workforce
objectives:
 Recruit talented people to deliver our service
 Manage a right sized, diverse and balanced workforce
 Measure workforce performance activity
 Deliver a better colleague employment experience
- Valuing and developing colleagues
- Staff involvement and engagement
- Segmenting the workforce needs and market
- Retaining valuable talent
- Support and manage inadequate performance
 Develop excellent leadership, people management and professional capability
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SECTION D: RESPONSES TO REGULATORS
1. Care Quality Commission
The Trust contributed to the NHS Cambridgeshire declaration against the Standards for
Better Health core standards for 2009/10.
A mid year declaration was made in November 2009 and the Trust declared non compliance
with two of the 24 core standards. These were:
 C2 Safeguarding Children – this related to a specific requirement that had not previously
been identified, to have central recording of level 3 safeguarding training in place. The
Trust achieved compliance for this at the end of December 2009.
 C20a Estates – this related to an earlier survey which had identified a number of urgent
health and safety property issues. A total of £1.2 million in tenders have been awarded in
2009/10 including work around fire safety, legionella survey remedial work, asbestos
removal, roof replacement and electrical remedial work. The Trust was compliant with this
standard by the end of march 2010.
 The Trust is required to register with CQC as a provider of Health care from 1 April. The
application process involved joint NHS Cambridgeshire/CCS NHS Trust registration prior to
1 April 2010. This application was accepted with no conditions applied. The application for
the organisation as an Independent NHS Trust was made as requested by CQC and final
Confirmation of no conditions is anticipated.
 We declared two areas of non compliance with the new ‘Essential Standards of quality and
safety’ namely:
 Safeguarding – this new section in the CQC assessment framework covers safeguarding
activity across all ages and we felt that although there are some very strong areas of
practice relating to safeguarding adults, we have work to do in order to implement robust
reporting and training systems for all staff. A comprehensive action plan has been
developed and agreed with CQC in which the actions will be undertaken by the end of
September 2010.
 Staffing – this again is a new section in the assessment framework and we have declared
non compliance relating to three areas of our services where there have been recruitment
difficulties. Action plans are in place for Health Visiting, District Nursing and Acute
Paediatrics. These areas are planning to become compliant by the end of March 2011.
2. NHS Litigation Authority (NHSLA)
A key function of the NHSLA is to assist NHS Trusts in reducing the number of negligent or
preventable incidents. It achieves this through an extensive risk management programme
which sets standards and assessments against which healthcare organisations are regularly
assessed. The NHSLA Standards are divided into three levels. NHS organisations that
achieve success at level one in the relevant standards receive a 10% discount on their
Clinical Negligence Claim for Trusts and the Risk Pooling Scheme For Trusts contributions,
with discounts of 20% and 30% available to those passing the higher levels.
The Trust underwent an assessment by the NHSLA in March 2009 which resulted in the
award of level one status. This involved the assessment of fifty policy documents relating to
areas such as governance, workforce, clinical care, safe environment and learning from
experience. An optimum score of 10 out of 10 was achieved in the Clinical Care category.
Work is underway to demonstrate compliance activity for level two during 2010/11 preparation
for reassessment potentially in early 2011
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3. Connecting for Health Information Governance Toolkit
All NHS organisations are required to self assess against a variety of standards relating to
information creation, storage, management, security and quality. The annual declaration for
2009/10 was completed by the Trust jointly with NHS Cambridgeshire and achieved a level
two compliance rating (72%).
Work has started to demonstrate compliance with level three.
Achievement of level 2 is very important for any NHS Trust as it ensures our continued use of
an N3 connection. This is access to our national clinical information systems and essential for
our services.
4. PEAT (Patient Environment Action Teams) Assessments 2009/10
All NHS Trusts are required to undertake self assessments against a suite of standards
relating to the patient environment for inpatient facilities. The Trust undertook the self
assessments throughout February and completed by 25 March. This was the deadline set by
the National Patient Safety Agency (NPSA). The information is then collated by the NPSA
and their results are expected mid May 2010. We will include this information in our final
Quality Account if it becomes available prior to the publication deadline for Quality Accounts.
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SECTION E : OUR SELECTED PRIORITIES AND PROPOSED INITIATIVES FOR 2010/11
A variety of initiatives have been identified and agreed by the Trust as priorities for
demonstration of quality improvement in the services provided. They fall under the headings
of improvements in:
 Patient Safety
 Clinical Effectiveness
 Experience
Where available, we will utilise researched and approved Community Trust Quality
Improvement Indicators and develop our recording systems accordingly.
The Trust’s Board will receive regular updates on the progress of the improvement areas
identified below.
1. Patient Safety
NHS East of England has pledged to make this strategic health authority area the safest in
England (Pledge 6). The Trust will contribute to this pledge by achieving the following:
1.1 We will strive to ensure that all Serious Incidents are reported and investigated
appropriately and that the learning is captured and applied to relevant services across the
organisation.
1.2 We will focus our efforts to ensure that all staff complete the appropriate level of
mandatory safeguarding children training relevant to their post.
1.3 We will monitor the number of patients falling in Community Hospitals and ensure that
relevant Quality Improvement projects are undertaken to ensure an annual reduction.
Of these 1.1 will be our top priority for safety activity in 2010/11.
Sponsor: Chief Nurse
 NB in addition to the three priorities identified above, the Trust will continue to strive for
excellence in Infection Prevention and Control in order to comply with our target of zero
cases of MRSA and two cases of C Difficile.
 We are also implementing the National Patient safety Agency’s ‘Patient Safety First
Campaign’ across the Trust and look to report our outcomes and improvements in next
year’s Quality Account.
2. Clinical effectiveness
2.1 We will continue to promote the uptake of the HPV vaccine by 12/13 year old girls mainly
in school settings. This indicator is reported annually at the end of the school year.
2.2 In order to build on the extensive actions underway within the Chlamydia Screening Team
for 2009/10, we will continue to identify mechanisms to improve uptake of this screening
teat amongst the targeted population of 15-24 year olds.
2.3 Trust staff across Cambridgeshire are responsible for the National Child Measurement
Programme. The indicator that we will monitor and strive to improve is based on the
percentage of year 6 school children measured as part of this national programme.
Of these 2.1 will be our top priority for Effectiveness activity in 2010/11
Sponsor: Chief Nurse
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3. Experience
3.1 The Trust will continue to seek patients’ views on the quality of our services and ensure
all services have an action plan in place to address identified issues, specifically:
How would you rate the service you received today relating to:
 confidence in the person treating the patient
 whether they were treated with dignity and respect
 whether they were involved as much as they wanted to be with their treatment/care
 Would they recommend our services to a friend or relative?
3.2 The number of complaints resolved locally within timescale agreed with complainant as a
percentage of the total complaints
3.3 The proportion of patients who are satisfied when their complaints have been resolved.
Of these 3.1 will be our top priority for Patient Experience activity in 2010/11.
Sponsor: Head of Communications and Patient & Public Involvement
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RESPONSE FROM CAMBRIDGESHIRE LOCAL INVOLVEMENT NETWORK
Thank you for giving Cambridgeshire LINk to opportunity to comment on your 2009/2010
Quality Accounts. The Cambridgeshire LINk CCS Group would like to make the following
comments:
Page 3 Introduction: Based on a LINk representative attending Trust meetings (including the
sessions or part of sessions where members of the public are not invited due to
confidentiality) we are pleased there is such an active response from NED’s (Non Executive
Directors) to any points raised, require clarity or question.
Page 4 paragraph 1.1 Infection Control: We are very pleased to see the encouraging results
as a result of the action taken in regards to infection control.
Page 5 paragraph 2.3 Safeguarding Adults: We feel that this is an area where it is critical to
be able to measure end points
Page 10 item 1 Care Quality Commission: It would seem to LINk that the adherence to these
24 core standards (now integrated into the Care Quality Commission registration process) is
of critical importance and whilst we can accept the reasons behind non compliance against
two of these standards we would hope that the NED’s will continually monitor these areas for
improvement over the next 12 months.
Page 12 Section E Selected priorities for 2010/11: Whilst it is impossible to disagree with the
selection of these priorities the measurement of outcomes will be critical. We would also like
to suggest that staff mandatory training should also be given a priority.
Page 13 Patient Experience: We would like to congratulate all the staff at the Trust and
Karen Mason in particular, for the very active way in which the views of patients and the
public have been sought.
Page 15 Quality Overview: Whilst the Trust should be congratulated on meeting and
overachieving most of their performance targets we are concerned that under the 18 week
maximum wait for direct access audiology treatment performance is only 52% against a target
of 95%.
RESPONSE FROM CAMBS OSC
Cambridgeshire County Council's Adults Wellbeing and Health Scrutiny Committee
congratulates Cambridgeshire Community Services on its achievements over the past year.
We particularly note the excellent results for infection prevention and control.
We are concerned at the underperformance against national targets in relation to waiting
times for direct access audiology and waiting times for diagnostic tests, and expect to see
improvement in both of these during 2010/11. We also wish to highlight the importance of
improving waiting times for OT services in all parts of the County for ensuring that the high
performance against the national targets relating to older people can be sustained.
We wish to emphasise the importance to both service users and carers of maintaining the
provision of carers services, including respite, particularly in the light of increasing demand.
The Committee thanks Cambridgeshire Community Services for the opportunity to comment
on its Quality Account.
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RESPONSE FROM NHS CAMBRIDGESHIRE
NHS Cambridgeshire commentary on Cambridgeshire Community Services NHS Trust’s
Quality Account 2009/10.
This quality account sets out the priorities for improving patient safety, effectiveness and
experience in 2010/11, for the services provided by Cambridgeshire Community Services
(CCS) NHS Trust.
The Trust continues to be one of the best Trusts in the region for reporting incidents and near
misses, so that they can learn from such incidents and strive to improve care in order to
minimise patient safety issues. Also there has been progress with quality improvement
relating to the Department of Health “Productive Ward” programme, and also action to reduce
falls. The Trust is also contributing significantly to the safeguarding adults agenda.
From the information presented the Trust will need to achieve the 18 weeks maximum wait for
direct access audiology treatment, and access to physiotherapy and speech and language
therapies. It is recognised that during 2009/10, the audiology target was not achieved
following a significant increase in referrals which exceeded the capacity commissioned which
has been addressed for 2010/11.
The biggest challenges for the trust will include contribution to the delayed discharges across
the NHSC healthcare system, through contribution to discharge planning, reducing length of
stay in rehabilitation and reducing time to assessment. Also increasing the number of
common assessment frameworks completed for vulnerable children and families as part of
the safeguarding children agenda, and recruitment to health visitor posts. Increasing
referrals into the smoking cessation services is identified as a key public health priority.
NHSC will work with the Trust to help achieve their quality aims. In particular the national
stroke strategy for England requires improvement of stroke services, while the national
dementia strategy requires improvements in health and social care for those with dementia.
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Appendix A: QUALITY OVERVIEW
The Trust’s performance in 2009/10 against national indicators and/or targets is set out below
(as per returns to Department of Health UINIFY where applicable)
National Target
Fully met all CQC Quality standards (Standards
for Better Health 09/10 and Essential Standards of
Quality and Safety for 2010/11)
C Difficile: reduce infection rates to no more than
6 cases
MRSA: reduce infection rates
18 week consultant led referral to treatment
completed pathways (non-admitted patients)
Total time in minor treatment centres: patients
seen within 2 hours or less
Number of inpatients waiting longer than 20 weeks
(percentage)
No of outpatients waiting longer than13 weeks
(percentage)
Percentage of patients waiting 6 weeks or more
for diagnostic tests
18 weeks maximum wait for direct access
audiology treatment
Prevalence of Chlamydia: achieve 15% screening
rate of 15-24 year olds
Access to GUM clinic: 100% referrals offered
appointment within 2 working days
Access to GUM clinic: 90% referrals to be seen
within 2 working days
Age 16+ smoking prevalence: number of four
week quitters declared - figure shown here reflects
data collection at 29/0410
Independence of older people maintained through
rehabilitation/intermediate care: percentage of
patients at home after 90 days following acute
hospital discharge
Percentage of new referrals for older people who
receive a social care needs assessment within 28
days
Percentage of new referrals for older people who
receive all services identified within their needs
assessment within 28 days of the assessment
being completed
Percentage of all clients with services in year,
receiving a carers service
2009/10 target
2009/10 actual
performance
Full compliance
2 areas of non
compliance C2
and C20A
6
1
0
0
95%
99%
95%
99%
0%
0%
0%
0%
0%
15%
95%
52%
22,000 screens
23,670 screens
100%
100%
90%
94%
3,214
3366
78%
84%
86%
95%
93%
94%
21%
19%
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