South Central Ambulance Service
NHS Trust
Annual Quality Accounts
May 2010
Compiled by B. Playfoot 23/04/2010 Lead for Quality and Patient Safety
TABLE OF CONTENTS
QUALITY ACCOUNTS MANDATORY STATEMENT 30TH APRIL 2010 .............1
Part 1. Statement on Quality from the Chief Executive of the Provider .........1
Part 2. Priorities for Improvement and Statements of Assurance from the
Board................................................................................................................2
Priority 1 Patient Safety ..............................................................................2
Priority 2 Clinical Effectiveness .................................................................2
Priority 3 Patient Experience ......................................................................2
STATEMENTS OF ASSURANCE FROM THE BOARD ......................................3
Statement of Assurance from the Board following Board meeting on 6th
May 2010 ..........................................................................................................3
Part 3. Other Information....................................................................................8
Annex - statements from Primary Care Trusts, Local Involvement
Networks and Overview and Scrutiny Committees ..................................8
PUBLISHING A QUALITY ACCOUNT...............................................................10
Compiled by B. Playfoot 23/04/2010 Lead for Quality and Patient Safety
QUALITY ACCOUNTS MANDATORY STATEMENT 30TH APRIL 2010
The quality report must contain (in the following order):
Part 1. Statement on Quality from the Chief Executive of the Provider
o A statement signed by the Chief Executive summarising the providers’
view of the quality of the NHS services that it provided or sub-contracted
during 2009/10. The statement must outline that to the best of that
person’s knowledge the information in the document is accurate.
I acknowledge that it has been a difficult year; however, despite this, the Trust
has continued to provide outstanding care to patients across South Central,
whilst remaining financially sound. We have achieved this by providing high
quality, cost-effective care for our patients.
Clinical care and quality is a primary focus for the Trust, as we strive to
implement innovative initiatives that enhance the safety, experience and
outcomes for all our patients. In addition to embedding new quality initiatives
throughout the Trust, as an organisation we also seek to embed a culture of
continuous improvement.
We continue to work closely with the staff we directly employ as well as those
that provide subcontracted services to the population we provide services to.
The information contained within this report is, to the best of my knowledge, a
true and accurate reflection of the quality of services the Trust has provided
during 2009/10.
Signature
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Part 2. Priorities for Improvement and Statements of Assurance from the
Board
Priorities for Improvement
Following a Board consultation and also consultation with our Quality and Safety
Committee the following priorities have been approved and confirmed for the
year 2010/11. These are monitored by the Clinical Review Group which receives
formal reports bi-monthly, the Quality & Patient Safety Committee (Sub-group of
the Board) will in turn approve and ratify the results on a monthly basis, and this
in turn informs the Board report.
Priority 1 Patient Safety

We will deliver infection control training to 100% of all of our staff (clinical
and non-clinical to include community responders).

We will deliver a 50% improvement in our actual audit returns for the year
to provide assurance on our infection prevention and control practices.
Priority 2 Clinical Effectiveness

Demonstrating a 2% increase in quality performance above the average
for 2009/10 in relation to the following clinical performance indicators:
o Stroke, Heart Attack, Cardiac Arrest, Asthma and Hypoglycaemia.
Priority 3 Patient Experience

Demonstrate effective engagement with patient and stakeholder groups
through the use of quality surveys.

To ensure that there is a 50% improvement in the Falls Referral
Programme through the use of quality data capture and sharing of this
information with Falls Teams throughout the catchment area (in line with
the Chief Nurses ‘High Impact Changes’).
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STATEMENTS OF ASSURANCE FROM THE BOARD
Statement of Assurance from the Board following Board meeting on 6th
May 2010
The Board considered the Quality Accounts and the Quality Report presented to
them. The Board discussed the Priorities and the necessity for achievement of
these in the coming year. The Board reiterated its commitment to the Quality
Agenda and has requested six-monthly updates on the quality outcomes.
The Board is assured that the content of the Quality Accounts is an accurate
statement of how the Trust demonstrates quality both internally and to external
organisations.
Information on the review of services, in the following form of statement:
During 2009/10 the South Central Ambulance Service Trust provided and/or
sub-contracted 2 NHS services.
The South Central Ambulance Trust has reviewed all the data available to them
on the quality of care in all of these NHS services.
The income generated by the NHS services reviewed in 2009/10 represents
100% of the total income generated from the provision of NHS services by the
South Central Ambulance Trust for 2009/10.
The data reviewed should aim to cover the three dimensions of quality – patient
safety, clinical effectiveness and patient experience - and indicate where the
amount of data available for review has impeded this objective.
o Information on participation in clinical audits and national
confidential enquiries, in the following form of statement:
During 2009/10, 6 national clinical audits and 0 national confidential
enquiries covered NHS services that the South Central Ambulance
Trust provides.
During 2009/10 the South Central Ambulance Trust participated in
100% national clinical audits and 0% national confidential enquiries of
the national clinical audits and national confidential enquiries which it
was eligible to participate in.
The national clinical audits and national confidential enquiries that South
Central Ambulance Service NHS Trust was eligible to participate in
during 2009/10 are as follows:
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National Clinical Performance Indicator Asthma
National Clinical Performance Indicator Stroke
National Clinical Performance Indicator Cardiac Arrest
National Clinical Performance Indicator Hypoglycaemia
National Clinical Performance Indicator ST Elevation Myocardial
Infarction
Myocardial Infarction National Audit Project MINAP
The national clinical audits and national confidential enquiries that South
Central Ambulance Service NHS Trust participated in during 2009/10
are as follows:
National Clinical Performance Indicator Asthma
National Clinical Performance Indicator Stroke
National Clinical Performance Indicator Cardiac Arrest
National Clinical Performance Indicator Hypoglycaemia
National Clinical Performance Indicator ST Elevation Myocardial
Infarction
Myocardial Infarction National Audit Project MINAP
The national clinical audits and national confidential enquiries that South
Central Ambulance Service NHS Trust participated in, and for which
data collection was completed during 2009/1, are listed below alongside
the number of cases submitted to each audit or enquiry as a percentage
of the number of registered cases required by the terms of that audit or
enquiry.
National Clinical Performance Indicator Asthma
Number submitted 300 / 600 100% submitted to date rest due
submission May 2010
National Clinical Performance Indicator Stroke
Number submitted 574 / 600 95% of requirement 100% of cases
meeting the criteria
National Clinical Performance Indicator Cardiac Arrest
Number submitted 238 / 600 40% of requirement 100% of cases
meeting the criteria
National Clinical Performance Indicator Hypoglycaemia
Number submitted 590 / 600 98% of requirement 100% of cases
meeting the criteria
National Clinical Performance Indicator ST Elevation Myocardial
Infarction
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Number submitted 290 / 600 48% of requirement 100% of cases
meeting the criteria
Myocardial Infarction National Audit Project MINAP
Number submitted 218 cases entered in to the audit by acute Trusts
data quality checked by South Central Ambulance Service NHS Trust.
The reports of 6 national clinical audits were reviewed by the provider in
2009/10 and South Central Ambulance Service NHS Trust intends to
take the following actions to improve the quality of healthcare provided:
The actions for improvement over 2009/10 were formed into an action
plan attached. The summary of the actions is that the Trust Board will
monitor CPIs by reviewing 50 clinical records for each of the 5 CPIs
monthly. The submission of data will be signed off by a Director before
submission, staff awareness and reminder of responsibility and an
independent internal audit of CPI processes.
The reports of 1 local clinical audit were reviewed by the provider in
2009/10 and South Central Ambulance Service NHS Trust intends to
take the following actions to improve the quality of healthcare provided:
1.
Improve deployment model to ensure double crew vehicle back
up for chest pain patients.
2.
Improve the handover procedure between crews.
3.
Create good communication of good practice.
o Information on participation in clinical research, in the following form of
statement: The number of patients receiving NHS services provided or subcontracted by South Central Ambulance Service Trust that were recruited
during that period to participate in research approved by a research
ethics committee was 0.
o Information on the use of the CQUIN framework, in the following form of
statement: The South Central Ambulance Trust income in 2009/10 was not conditional
on achieving quality improvement and innovation goals through the
Commissioning for Quality and Innovation Payment Framework because
no CQUIN incentives were included in the contract last year.
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o Information relating to registration with the Care Quality Commission
(CQC) and periodic/special reviews, in the following form of statement: The South Central Ambulance Trust is required to register with the Care
Quality Commission and its current registration status is Registered without
conditions; however, South Central Ambulance Service NHS Trust was
subject to a periodic review by the Care Quality Commission covering the
Hygiene code requirements and the last review was on 5th and 6th August
2009. The CQC’s assessment of the South Central Ambulance Service
NHS Trust following that review achieved compliance with the Health Act
2006 as amended.
South Central Ambulance Service NHS Trust intends to take the following
actions to address the points made in the CQC’s assessment:
An action plan was completed following four recommendations from the
CQC which covered:
Clinical supervision and training
Audit of infection control processes
The storage of airway equipment
Aseptic techniques
South Central Ambulance Service NHS Trust has made the following
progress by 31 March 2010. In taking such action The action plan attached
as been completed and a follow up review by the CQC stated that they
were satisfied that the Trust had achieved them.
The South Central Ambulance Trust is required to register with the Care
Quality Commission and its current registration status is registered without
conditions to all of the 16 clinical governance relegations. However,
following a ‘risk summit’ on the Trust by the CQC on the 26th February
2010, the Trust has received notification from the CQC of improvements in
three areas centred on the three regulated activities.
‘Regulated activities’
These are Treatment for disease disorder or injury
Diagnostic and Screening Procedures
Transport services triage and medical advice provided remotely.
The Improvement letter centres on three regulations as detailed below:
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Regulation 9 outcome 4: care and welfare of service users
The Trust must provide evidence to the CQC of actions being taken to
mitigate the ongoing risk to service users in relation to the expected level
of service agreed within the contract with the commissioners. An
achievement date for this is 31st July 2010.
Regulation 23 outcome 14: supporting workers
The Trust must provide evidence to ensure that staff receive an annual
appraisal that supports their professional development and indentified
training needs are responded to appropriately. An achievement date for
this is 31st October 2010.
Regulation 24 outcome 6: cooperating with other providers
The Trust must provide evidence to ensure that there is ongoing work to
improve relationships and commission with commissioners and partner
providers. An achievement date for this is 31st July 2010.
The Trust has been requested to provide a detailed action plan to the CQC
by the 5th May 2010 to make the necessary improvements indentified by
the risk summit.
o Information on the quality of data, in the following form of statement: South Central Ambulance Service Trust did not submit records during
2009/10 to the Secondary Uses Service for inclusion in the Hospital Episode
Statistics which are included in the latest published data.
The South Central Ambulance Trust score for 2009/10 for Information
Quality and Records Management assessed using the Information
Governance Toolkit was 73%. A gain of 11% over the past 2 years and this
is seen as an ‘advancing Trust’ and equal to our benchmarked
organisations.
The South Central Ambulance Trust was not subject to the Payment by
Results clinical coding audit during the reporting period by the Audit
Commission; this is not a requirement for the Trust.
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Part 3. Other Information
o Other additional content relevant to the quality of NHS services.
Annex - statements from Primary Care Trusts, Local Involvement Networks and
Overview and Scrutiny Committees
o Providers must send copies of their Quality Reports to their relevant lead
commissioning Primary Care Trusts (PCTs), Local Involvement Networks
(LINks) and Overview and Scrutiny Committees (OSCs) for comment prior
to publication, and should include these comments in their published
Quality Reports.
Wokingham Borough Council Health Overview
Committee Response Received - 17 June 2010:
and
Scrutiny
The Committee appreciated being involved in the Quality Accounts and
Annual Quality Report process and felt it was encouraging to see this level
of consultation from the Trust.
The Committee discussed the Report and felt that considering what the
Trust has to achieve it was good to see how well it was doing. There was
some feeling that the Committee would like more contact with the Trust
and more explanation about this type of report in the future in terms of a
representative attending a meeting to talk through the content of the report,
including what data collection was required and how this was done.
It was suggested that the Trust be invited to a future meeting to talk about
the work it does in the Borough and that the idea of having a Borough
Member on the Trust’s Board in the future be explored, as this was felt a
good way for the Committee to be kept informed about developments at
the Trust.
o The lead commissioning PCTs will have a legal obligation to review and
comment, while LINks and OSCs will be offered the opportunity to
comment on a voluntary basis. There are specific timeframes for seeking
and receiving responses.
Commissioner comments in response to South Central Ambulance
Service Quality Accounts and Annual Report:
Further to receiving a copy of your draft Quality Accounts and Audit report,
I would like to respond, as Co-Coordinating Commissioner on behalf of the
eight mainland South Central Primary Care Trust (PCT) Commissioners.
Firstly thank you for sharing the document which I recognise to accurately
reflect the information contained within it.
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1. Statement by the Board:
The document endorses the commitment by the Board to ensure
South Central Ambulance Service (SCAS) move towards, and be
recognised as, a clinically led, patient centred, quality driven
organisation. This has been evidenced by the changes to the
Executive Team during Q3 2009 and the improvements seen since
the publication of the 2008/2009 annual Care Quality Commission
(CQC) report.
Additionally the root cause analysis training undertaken by Trust
staff, including the Trust Board members, supports the level of
challenge to learn from and reduce the number of serious untoward
incidents that occur.
2. Improvement:
Continuous improvement is now recognised by commissioners as
embedded within the organisation although timing has sometimes
been contentious (outstanding actions from the ATOS review).
The areas outlined by SCAS as priorities for quality improvement
are supported by Commissioners, particularly the improvement to
the Falls Referral Programme in line with the Chief Nurses High
Impact Changes.
Commissioners feel it is important there must be improvement in the
five national priorities areas and will be closely monitoring
performance particularly the numbers and quality of submissions for
Cardiac Arrest and Myocardial Infarction audits.
The engagement by SCAS in the development and transition /
implementation of Primary Percutaneous Coronary Intervention
(PPCI) has been appreciated by stakeholders and has again
evidenced the improvement in joint working between organisations.
Following the publication of the QCQ report and the subsequent
SCAS action plan to improve performance, Commissioners are
assured the actions already taken and ongoing are robust and will
deliver the improvements required. The Hygiene Code review is an
example of the swift actions taken by the Trust to improve and
achieve compliance of these standards.
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Improvements have been seen in a number of areas e.g.





Internal processes to manage staff clinical performance
Healthcare acquired Infections reductions / make ready
Drive to reduce hospital handover delays, led by SCAS
Engagement with stakeholders
The introduction of the Clinical Support Desk in the triaging of
calls has proved pivotal in improving the patient experience
and outcome
 Managing risk
3. Concerns:
Commissioners remain concerned about the ability of SCAS to
deliver the national response time standards and the impact on
patient outcomes for patients waiting longer than the prescribed
standard.
As stated above, I confirm the information contained within your document
does accurately reflect the services provided to the population of South
Central by your organisation.
Carole Le-Marechal
Head of Ambulance Commissioning (SCAS)
Lead Commissioner for Ambulance Emergency and Urgent Care Services
South Central Specialised Commissioning Group
22 June 2010
PUBLISHING A QUALITY ACCOUNT
The requirement to publish a Quality Account is met by uploading it to the NHS
Choices website.
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