Quality
Account
2010/2011
Looking after you locally
2
Norfolk Community Health and Care NHS Trust
Our
Health Visitors
see more than
1,000
new families
every month
We deliver
health services
to over
400
schools and
colleges
Our Community
Nursing teams
have around
108,000
face­to­face contacts
with patients
every month
We have
3,000
We have
around
300
members of dedicated
NHS staff across
the county
patient beds
in Norfolk
NCH&C receives
Our School
Nurses hold
16,500
1,300
referrals from GPs and
other healthcare
professionals
every month
More than
3,000
patients per year
are admitted to
our community
hospitals
face­to­face
appointments
with children
each year
We deliver
more than
70
different services
in and around
Norfolk
Quality Account Norfolk Community Health and Care NHS Trust
3
Contents
Part 1
Part 3
1.1
Statement on Quality
4
1.2
Our vision for the future
6
3.1
Review of Quality Achievements
in 2010/2011
22
3.1.1 Valuing Our Staff
22
3.1.2 Clinical Leadership
23
8
3.1.3 Quality, Innovation, Productivity
and Prevention (QIPP)
25
2.1.1 Quality Goals for 2011/2012
8
3.1.4 Performance Highlights
26
2.1.2 Commissioning for Quality and
Innovation (CQuIN)
3.1.5 Patient Safety
30
12
3.1.6 Effectiveness of Care
34
2.1.3 Quality, Innovation, Productivity,
Prevention (QIPP)
13
3.1.7 Patient Experience
39
2.1.4 Performance Monitoring
13
3.1.8 Commissioning for Quality
and Innovation (CQuIN) 2010/2011
45
Part 2
2.1
2.2
Priorities for quality improvement
(2011/2012)
Statements of assurance from the Board 14
2.2.1 Review of services
14
2.2.2 Participation in clinical audits
15
2.2.3 Participation in clinical research
18
2.2.4 Goals agreed with commissioners
19
2.2.5 Statement from the
Care Quality Commission
19
2.2.6 Statement on relevance of
data quality and actions to improve
20
2.2.7 Information Governance
Toolkit attainment levels
21
2.2.8 Clinical coding error rate
21
3.2
NCH&C Quality Account 2010/2011:
Involvement and Engagement
3.2.1 Third Party Statements
46
46
The content of this Quality Account has been
endorsed by the Trust Board and has taken into
account feedback from our lead commissioners,
and our local population via the representative
organisations, LINks and the Health Overview and
Scrutiny Committee. We trust that you will find our
Quality Account informative and helpful in reviewing
our progress against our key priorities for the
forthcoming year.
If you would like this publication in large print,
Braille, alternative format or in a different
language, please contact us on 01603 697300
and we will do our best to help.
design: woolfdesigns.co.uk
4
Quality Account Norfolk Community Health and Care NHS Trust
Statement on Quality
Norfolk Community Health and Care NHS Trust
(NCH&C) is a provider of generalist and
specialist community health services. We have
expert staff across a broad range of professional
disciplines: district nursing, physiotherapy,
occupational therapy, health visiting, medicine,
dietetics, psychology, dentistry, speech and language
therapy, school nursing, radiography, nursery
nursing, specialist services for diabetes, palliative
care, stroke, neuro­rehabilitation, respiratory care.
We have reorganised our service delivery structure
to focus on the delivery of pathway based on quality
outcomes. It is the outstanding personal motivation
of our staff, their expertise, their experience and
their local knowledge, that is at the heart of our
Community Foundation Trust application.
We cover all of Norfolk, in a wide range of community
settings, from over 200 locations. Our 3,000 staff cover
a broad range of professional disciplines and have many
years experience of working in our communities. We
are therefore supremely well placed for supporting the
care closer to home agenda, delivering service quality
and productivity, in every setting. Our breadth of
general community service provision, our experience of
specialist service provision and care for vulnerable
people, our track record of sustainable delivery and
innovation, gives us a strong base for developing new
services and in new geographies.
2010/11 has been another outstanding year for NCH&C,
with excellent progress in improving quality outcomes,
our Community Foundation Trust (CFT) application,
significant developments in our service portfolio and
organisational structure, and continued improvements in
our financial and operational performance. The quality
of services we offer our patients, as measured by the
Ipsos MORI survey, continues to be of the very highest
standard and has improved further, with 91% of
patients rating our services as good/very good and over
two­thirds of them giving us the highest score possible.
This improvement in patient experience has been built
upon increased involvement of patients in service
delivery and redesign, strengthened clinical leadership
and engagement, and robust quality and governance
processes, as evidenced by our achieving NHS Litigation
Authority level 1 compliance in March 2010. During
2010 the Trust was registered without conditions with
the Care Quality Commission under NHS Norfolk, and
received its own registration as an independent NHS
Trust on 1 April 2011 (with one condition).
Our commitment to clinical leadership is evidenced by
our Executive Team having over 100 years’ of NHS
clinical experience between them. We have
strengthened this through the appointment of a Medical
Director, who is a practicing GP and is the former Chair
of NHS Norfolk’s Clinical Executive. Our management
restructure included the identification of 12 key
leadership posts and the formation of a Clinical
Reference Group has strengthened clinical involvement
in key decision­making, starting with the development
of our Integrated Business Plan (IBP). We have embraced
the Transforming Community Services pathway
approach and are working on several pathways with
other providers from the local health economy.
The establishment of case managers to provide
proactive management of the frail and elderly is a
central pillar of both the local system Quality Innovation
Productivity & Prevention (QIPP) plan and of our IBP. By
combining quality, innovation, productivity and
prevention as corner stones for the delivery of excellent
quality services, we can ensure modern affordable
healthcare for all our patients and service users. After
successful pilots in North and Central Norfolk, we have
Part 1 1.1 Statement on Quality
secured funding for over 30 case managers across
Norfolk and are close to reaching agreement with the
remaining GP practices to complete the roll­out.
These roles are critical for helping to reduce local acute
activity and have been supported by the re­designation
of 11 ‘step­up’ beds in North Norfolk.
Other key service developments this year include:
1. Integrated Care Networks (ICN): We are participating
in the largest ICN pilot in the country, involving 30 GP
practices and a third of our Community Nursing &
Therapy staff. The approach has been embraced by our
staff and early indications are that the ICNs have
reduced local acute admissions by up to 15% as the
process becomes embedded.
2. Stroke Rehabilitation Service: The specialist stroke unit at
Norwich Community Hospital was opened in early 2010,
together with the establishment of an Early Supported
Discharge team based within the local community. In its
first year, this service has treated over 230 patients, with
significant improvements in patients’ quality of life (a 25%,
or 11 point, improvement in the Barthel score from
admission to discharge) and in the proportion of patients
who can continue to live at home. Acute length of stay has
also reduced from 14 to eight days.
3. Tilney Ward: NCH&C worked in partnership with the
Queen Elizabeth Hospital King’s Lynn NHS Foundation
Trust to establish a temporary ward to reduce acute
hospital admissions over winter 2010/11. At the
insistence of local GPs, the ward was co­staffed but was
managed by NCH&C in recognition of our expertise in
discharge co­ordination. In the first two months of
operation over 250 patients were seen, with the
average length of stay at 2.2 days.
5
Store items within seven days at 97.5%. There continue
to be pressures around access to Wheelchair Services
and Podiatric Surgery. We are working with NHS
Norfolk to redesign these services and to address the
system­wide issues that underlie underperformance.
Improved access to diagnostics has been instrumental in
reducing breaches significantly in Podiatric Surgery.
Stretched public health targets, notably in Chlamydia
Screening and Smoking Cessation have not been met,
however, we will end the year with a slight increase in
smoking quits, in the context of a significant reduction
in expenditure on public health awareness. Continued
improvement in those services that underperform
against access or public health targets is a key element
of our 2011/12 Annual Plan.
We are proud to have achieved independent NHS Trust
status on 1 November 2010. We are one of eight
community services providers who are in the first
wave of aspirant Community Foundation Trusts (CFTs).
Our CFT programme has continued to maintain good
progress against the timetable required for our Trust’s
authorisation as a CFT within 2012.
We also aim to improve the value given to the taxpayer
and, to date, our financial performance has been
robust, with a year end surplus £528,000. This has
been as a result of tight financial management and
controls. In addition to the achievement of mandatory
and contractually agreed commissioning targets for
access, patient safety and quality, we have taken
significant steps in transforming our services.
The information supporting the content of this Quality
Account is, to my knowledge, accurate and was
published by the Board on 30 June 2011.
4. Prisons: From October 2010, NCH&C has acted as the
prime sub­contractor to Serco in the delivery of
healthcare in three Norfolk prisons.
We know we have further improvements to make.
Access to our services continues to improve with
delivery of 18 weeks Referral to Treatment at 98.3%
year to date, and the delivery of Community Equipment
Sheila Adams­O’Shea
Chief Executive
6
Quality Account Norfolk Community Health and Care NHS Trust
Our vision for the future
We are part of Norfolk, and we know our community is changing.
Our population is getting older and living longer. We want to
continue to help keep local people healthy and living independent lives.
To do this, we have identified four key strategic priorities
for Norfolk Community Health and Care NHS Trust.
More joined up personalised care
We want to deliver services which are more joined up
for all of our patients across Norfolk. Our personalised
care approach will help to ensure that our patients and
clients receive the care that is right for them, and that
we help them to move seamlessly between our services,
and other health and social care organisations.
The right care close to home
More and more people in Norfolk are living with long­
term conditions, like diabetes and heart disease. Our
population of frail and elderly people is also growing.
We want to help keep our patients well ­ providing care
as early as possible, to help people avoid having to stay
in an acute hospital and we will support people to
return home as quickly and safely as possible.
We know that for many people with long­term conditions,
keeping well can be hard ­ having to attend regular
appointments at hospitals many miles from home or
travelling to receive the kind of rehabilitation needed.
We believe that patients are better served within the
community – having check­ups at clinics run at local
GP surgeries or receiving physiotherapy at home.
New services for our
changing population
As our population ages and more people are affected
by illnesses caused by lifestyle choices (like obesity,
smoking, alcohol or drug problems), the types of
services needed by our community will change.
We will develop new services, often in partnership with
others, to meet these changing needs, from tackling
childhood obesity to improving care for older people
with dementia.
Taking down borders
We will continue to offer excellent services to our
patients right across Norfolk, but we will also enable
more people from outside of Norfolk to benefit from
our expert community health and care.
We will continue to build services in the towns and
villages on the Norfolk border, so patients from
neighbouring counties can choose to use our services.
Part 1 1.2 Our vision for the future
KEY
Community
Team
7
Community Hospital
(includes rehabilitation,
step up beds and outpatients)
Specialist
Rehabilitation &
Specialist Palliative Care
Wells-next-the-sea
Sheringham
Hunstanton
Children’s Short
Breaks and Child
Development Units
Sure Start and
Children’s Centres
Hard to Reach
Prison
Health
Centres
Cromer
High Kelling
North Walsham
Aylsham
Fakenham
HMP Bure
King’s Lynn
Dereham
Norwich
Brundall
Swaffham
Acle
Great Yarmouth
Watton
Downham Market
Loddon
Wymondham
HMP Wayland
Long Stratton
Attleborough
Thetford
Diss
We shall deliver our strategies through:
1 Delivering quality: effective clinical outcomes,
providing the highest patient satisfaction in the
region and delivering high standards of safety
2 Having the voice of patients, the public and staff
at the centre of our organisation
3 Building our reputation: building membership,
building GP satisfaction
4 Building sustainability: strengthening financial
performance, delivering cost improvements,
developing our estates and Information
Management and Technology strategies
5 Building our organisation: strengthening clinical
leadership and engagement, developing a more
flexible workforce, building on our experience of
a variety of partnership arrangements.
We believe Community Foundation Trust status to be
the optimum organisational form for delivering our
strategy. Patient experience and outcomes will be
improved through: the membership model ‘hard­wiring’
the voice of patients and staff; reinvesting surplus in
service redesign; and being able to engage in a wider
range of partnership models. A strong and independent
community services provider is a catalyst for systemic
change within the health economy.
8
Quality Account Norfolk Community Health and Care NHS Trust
Priorities for quality
improvement (2011/2012)
At the heart of our
first service development
theme ­ ‘Strengthening the core’ ­
is the continual improvement
of the quality of our
services for patients.
Improving quality is at the heart of our strategy and we
are committed to sustaining what is already excellent,
and making improvements to achieve consistently and
sustainably high levels of quality across all areas of our
service provision, with regard to patient safety,
effectiveness of care and patient and carer experience.
Quality Goals for 2011/2012
NCH&C’s Quality Improvement Strategy sets out how
we will deliver continuous quality improvement and
identifies key quality goals in conjunction with our
Annual Plan 2011. In addition, we have negotiated a set
of Commissioning for Quality and Innovation (CQuIN)
Initiatives for 2011 and all of these improvements are
identified under the following quality headings:
Patient Safety – protecting people from harm
Effectiveness of care – looking at variations in
standards of care
Patient experience – listening to what our service
users think
(Extract from Annual Plan 2011)
Part 2 2.1 Priorities for quality improvement (2011/2012)
2.1.1 Quality Goals for 2011/2012
9
Patient safety &
quality improvement
Achieve Care Quality Commission (CQC)
Registration without conditions
Undertake rolling programme of CQC self­assessments
at each location throughout 2011
Produce action plans for any non­compliant
areas (monthly)
Produce dashboard of results (monthly)
Report results to Quality and Risk Assurance
Committee (QRAC) (quarterly)
Achieve Information Governance (IG) Toolkit level 2
IG Toolkit submission 31/3/11 action plans in place for
all requirements which do not meet level 2 standard
To reduce levels of pressure ulcers
Ref: High Impact Actions (HIAC) 'your skin matters'
Achieve 95% compliance for IG e­learning by 31/6/11
Develop policy for the prevention and treatment of
pressure ulcers
Progress towards level 2 NHS Litigation Authority
(NHSLA) (by March 2012)
Evaluation and decision on current assessment risk tools
for pressure ulcer prevention
Set up NHSLA Steering Group (reporting to
QRAC quarterly)
Implementation of the 'Safety Express' initiative in
partnership with acute trusts ­ reviewing the patient
pathway and tissue viability and sharing information
Review of level 1 requirements
Implementation of level 2 standards
(monitored by NHSLA Steering Group)
To reduce levels of falls resulting in serious harm
Q1 – Collect baseline data (2010/11 and Q1 2011/12)
and develop action plan
Q2 – Implementation of an action plan identified from
the Patient Safety First guidance due in Q2 and
continue to monitor falls data
Q3 – Implement actions due in Q3 and continue to
monitor falls data. Revise action plan in November,
adding additional actions where necessary
Q4 ­ Implement actions due in Q4 and produce
report showing comparison of falls data by
quarters during 2011/12
10
Quality Account Norfolk Community Health and Care NHS Trust
To reduce levels of attributable Clostridium
Difficile (C.diff)
To reduce levels of medication errors
(CQuIN indicator 4)
Implement the key recommendation of the NHS
Norfolk working group, to change the timeframe
of specimen testing
Development and implementation of a plan to put in
place the actions described in National Patient Safety
Agency (NPSA) RRR 009 and reduce harm from omitted
and delayed medicines in hospital
Staff training is being reviewed and updated in light of
the above recommendation
More timely specimen testing of newly admitted
patients (within 48 hours)
To reduce levels of MRSA bacteraemia
Implementation of a decolonisation team
Proactive treatment of high risk patients within our
community caseloads
IT alerts placed on any new MRSA isolates (PAS, ICNet)
including those in primary care
SystmOne local marker for MRSA to be developed
Q1 ­ Analysis of Q4 2010/11 incidents relating to
missed, omitted, or duplicated medicines or issues in
obtaining or supplying medicines in community
hospitals to determine the baseline numbers and trends
of root causes for previous incidents.
Point prevalence audit of the charts in community
hospitals to highlight the current issues. Each unit to
have all charts present at the time of the audit,
assessed using the audit tool. All units to be audited
once during the defined week within the quarter.
Development of an action plan to put measures in place
to reduce the risks due to omitted and delayed medicines
Q2 ­ Development of a list of critical medicines, specific
to our Trust. Review systems for supplying critical
medicines and procedures and guidance for staff who
are prescribing, ordering or administering medicines
Q3 – Instruct staff on above procedures and systems for
supplying critical medicines, including standardisation of
prescription charts and other related medicines
management paperwork
Q4 ­ Review of incident reports in January and February
2012 and re­point prevalence audit of practice
Part 2 2.1 Priorities for quality improvement (2011/2012)
2.1.1 Quality Goals for 2011/2012
Patient and carer experience
and effectiveness
Establishment of a monthly
Patient Experience Tracker (PET)
Including delivery of CQuIN indicator 5 Patient Experience
Procurement of PET tools
Staff training and communication
Implementation of PET tools
Monthly reporting internally
Quarterly reporting to NHS Norfolk for CQuIN
Implementation of action plans by service leads
Delivery of CQuIN indicator 7
Carer satisfaction
Implementation of Health Feedback questionnaires
Quarterly reporting to NHS Norfolk for CQuIN
Implementation of action plans by service leads
Patient Experience ­ improve four
Ipsos MORI areas < 50%
Action plans to be completed by each service pathway
Implementation of action plans by service leads
11
12
Quality Account Norfolk Community Health and Care NHS Trust
Commissioning for Quality and Innovation (CQuIN)
CQuIN requires primary care trusts to improve quality
and innovation by discussing, agreeing and monitoring
quality indicators with its providers. A CQuIN scheme is
the locally agreed package of quality improvement
goals and indicators which, if achieved in their totality,
enables the provider to earn its full CQuIN payment ­ a
quality based payment.
A CQuIN scheme should address the three pillars of
quality: safety, effectiveness and patient experience;
while also reflecting innovation. Indicators need to be
realistic to ensure that a provider can reasonably set out
to earn the allocated money.
The monies to meet the cost of this payment will come
from incentivising a proportion of annual contract
values (1.5% for 2010/2011 and 1.5% for 2011/2012).
The indicators set out in the table below have been
agreed and set within the contract as part of the
established quality schedule and monitored through the
CQuIN Steering Group.
Patient
CQuIN indicator description
Increase number of patients provided with assistive technology (Telehealth)
in the community and audit outcomes
To improve the care and access to palliative care services within our
community hospitals through improved awareness and adherence to
Gold Standard Framework
To analyse the rationale for admitting patients to the local acute trust
(Norfolk and Norwich Hospitals NHS Foundation Trust and Queen Elizabeth
Hospital King’s Lynn NHS Foundation Trust) who then die within four days
Implementation of a medicines management action plan to reduce harm
from omitted and delayed medicines in community hospitals
To improve Patient Experience in Adult Services by focusing on orthopaedic
triage, musculoskeletal physiotherapy, podiatry and biomechanics
To improve Patient Experience in Children’s Services by focusing on outpatient
appointments held at Upton Road Children’s Centre
Improve outcomes for patients in inpatient units by the reduction of falls, to
meet or be below the National Patient Safety Agency level of 8.4 falls per 1,000
occupied bed days (OBD)
Improve Carer Experience within community Adult Services by interaction
of Case Managers
Improve Carer Experience within the Children’s Short Breaks service
(residential units ­ Squirrels and Little Acorns)
Achieve UNICEF accreditation stage 1 and commence stage 2
Experience
Patient
Safety
Effectiveness
Part 2 2.1 Priorities for quality improvement (2011/2012)
2.1.2 Commissioning for Quality and Innovation (CQuIN)
2.1.3 Quality, Innovation, Productivity, Prevention (QIPP)
2.1.4 Performance Monitoring
Quality, Innovation,
Productivity, Prevention
(QIPP)
NHS Norfolk has recently established three system­wide
QIPP work streams. The intention is that NCH&C’s QIPP
Steering Group members will be invited to attend and
contribute to workshops over the coming months. As
this work progresses we will share the key outputs and
any actions we need to develop.
Frail Elderly Focus –
central and west Norfolk
• Single Point of Access – Online vision of all available
services, telephone triage offering clinical and
pathway advice, clinical responsibility handover,
directory of services
13
Performance Monitoring
During 2011/12, we will bring together data on several
areas of organisational performance to create one
integrated performance report. Not only will it include
information on waiting times and service productivity, it
will also incorporate a range of quality and safety
indicators in a dashboard format, supported by a
commentary and what actions will be required to
address adverse performance. The dashboard will
include data against three key quality domains: patient
safety, clinical effectiveness and patient experience. The
indicators reported on will include:
• Complaints, and how quickly we respond to them
• Adverse incidents, such as medication errors and
pressure ulcers
• Serious Incidents Requiring Investigation (SIRIs), and
how quickly we investigate and report on them
• Reshaping Out of Hospital Care – Management of the
frail elderly, assistive technology and diagnostics, end
of life care, access to beds, integrated support teams,
acute outreach. Dementia care, case management
and long term conditions management
• Health Care Associated Infection rates
• Discharge – Early planning, primary care/integrated
team as holder of case, staff rotation, timeliness
We will report on this data monthly, to ensure we
identify trends over time and take any action necessary
to address adverse performance.
• Use of technology to help manage patients’ conditions
within their own home, improving rehabilitation, and
empowering patients
Whole Norfolk system –
Referral Management and
Pathway Development
• Referral management and pathway development –
developing objective criteria planned for referrals, use
of email/Telemed, delivering consistency in quality and
reducing unnecessary appointments
• Integrated diagnostics; 24/7 electrocardiogram (ECG)
• Thresholds – consistent thresholds, de­commissioning
• Patient satisfaction levels
• Number of ‘never events’ – incidents that can cause
significant harm, including death of patient
14
Quality Account Norfolk Community Health and Care NHS Trust
Statements of assurance
from the Board
Review of services
During April 2010 ­ March 2011 NCH&C provided
and/or sub­contracted 74 services of which around
95% are commissioned by our three main
commissioners, NHS Norfolk, NHS Great Yarmouth &
Waveney and NHS Suffolk. These include; Learning
Disabilities; Prison Healthcare and the Stroke
Rehabilitation Service. The income generated by NHS
services reviewed during April 2010 ­ March 2011
represents 95% of the total income generated from the
provision of NHS services by NCH&C for 2010­2011.
NCH&C undertakes an extremely rigorous review of the
data available on the quality of care in our NHS services
via the monthly contract and clinical quality review
meetings with our commissioners.
We have also developed a ‘balance scorecard’ through
which we can give assurance to the Trust Board, our
regulators and commissioners, patients and the public,
that we are on track for realising our vision. Our
scorecard includes short term targets for years one and
two of our five­year plan, and stretching targets for year
five. It reflects the following elements:
1 Compliance
2 Quality for patients
(safety, effectiveness, experience)
3 Staff
4 GP commissioning
5 Finance
In addition to the review of data by the Trust Board,
each Non­Executive Director (NED) has been allocated a
‘locality’ area ­ north, south, west, Norwich and central
Norfolk ­ which provides an opportunity for them to
talk to frontline staff, patients and relatives and gain
further insight into the quality of our services.
Kelling
Hospital
North Walsham
Community Hospital
St Michael’s Hospital
Aylsham
St James Clinic
Kings Lynn
Swaffham
Community
Hospital
Dereham
Hospital
Norwich
Community
Hospital
Ogden Court
Community Hospital
Wymondham
Key
Central
North
South
West
Various leadership roles have been identified for
each of the NEDs, such as safeguarding adults
and children; infection control, patient­related issues,
and serious incidents. These provide an opportunity
for our NEDs to gain experience of our operational
services, across the county.
Part 2 2.2 Statements of assurance from the Board
2.2.1 Review of services
2.2.2 Participation in clinical audits
15
Participation in clinical audits
During April 2010 ­ March 2011, five national clinical
audits and one confidential enquiry covered NHS
services that NCH&C provides.
During that period NCH&C participated in 60% of
national clinical audits and 50% 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 NCH&C was eligible to participate in
during April 2010 – March 2011 are as follows:
National Clinical Audits
Audit
Lead organisation
Participation
from NCH&C
National Childhood Epilepsy Audit
Royal College of Paediatricians
and Child Health (RCPH)
Yes
Diabetes
(National Adult Diabetes Audit)
National Clinical Audit
Support Programme
No
Parkinson’s Disease
(National Parkinson’s Audit)
Parkinson’s UK
No
Falls and non­hip fractures
(Falls and Bone Health Audit)
Royal College of Physicians
Yes
Depression and anxiety
(National Audit of Psychological Therapies)
Royal College of Psychiatrists
Yes
16
Quality Account Norfolk Community Health and Care NHS Trust
National Confidential Enquiries
Title
Applicable to NCH&C
Participation
from NCH&C
National Confidential Enquiry into
Patient Outcome and Death (NCEPOD)
Yes
Yes
Confidential Enquiry into Maternal and Child Health (CMACH)
Yes (in part)
No
National Confidential Inquiry (NCI) into Suicide and
Homicide by people with mental illness
No
No
National Clinical Audits
The national clinical audits and national confidential enquiries that NCH&C participated in, and for which data
collection was completed during April 2010 – March 2011, 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.
Name
Lead organisation
Percentage
National Childhood Epilepsy Audit
Royal College of Paediatricians
and Child Health (RCPH)
Data collection ongoing
(January 2011 – May 2011)
Falls and non­hip fractures
(Falls and Bone Health Audit)
Royal College of Physicians
Organisational Audit – 100%
Patient Sample Audit – 95%
Overall average – 98%
Depression and anxiety
(National Audit of
Psychological Therapies)
Royal College of Psychiatrists
‘Service Context’
(Questionnaire 1) – 100%
‘Therapist’
(Questionnaire 2) – 100%
‘Retrospective patient audit’
(Questionnaire 3) – 100%
‘Service Users Survey
(Questionnaire 4) – 2%
Overall average – 76%
National Confidential Enquiry into
Patient Outcome and Death (NCEPOD)
Cardiac Arrest Procedures
NCEPOD
No cases occurred during audit
two­week period – therefore
no data to submit
Part 2 2.2 Statements of assurance from the Board
2.2.2 Participation in clinical audits
17
The report of one national clinical audit (Falls and
Bone Health Audit) was reviewed by the provider
during April 2010 – March 2011 and NCH&C intends
to take the following actions to improve the quality of
healthcare provided:
• All NCH&C Community Falls Teams will provide
relevant exercise programmes to patients within their
own home
• Identify ‘non­conveyed’ fallers with the development
of the Ambulance Service pathway which will link into
the community teams
• NCH&C is to develop a Falls Accident and Emergency
Pathway for the Queen Elizabeth Hospital King’s Lynn
NHS Foundation Trust. This model is to be
standardised with the Norfolk and Norwich University
Hospitals NHS Foundation Trust to ensure appropriate
referral into NCH&C teams
• Use of screening tool, standardised across the
county, to define patients at high risk of falling
to ensure these patients are referred to the correct
clinician or agency
• Introduction of a standard assessment tool which is
tailored to the individual
• Ensure that all patients seen by the NCH&C Falls
Prevention Service receive written copies of their
agreed action plans to help prevent falls
• All NCH&C Community Falls Teams will carry out
fracture screening using an agreed tool and process,
and will implement health education and lifestyle advice
for the patient with onward referral as appropriate
• Ensure public representation on the Falls Steering
Group. Falls documentation is to include patient
satisfaction surveys to evaluate the service
• The National Patient Safety Alerts (NPSA) ‘Slips, trips
and falls’ documentation will be used as a reference
tool to achieve a clear screening and care plan for our
community hospitals. Standardised tools (including
bone health screening) will be used within all of our
community hospitals
• Community services will work closely with primary
and secondary prevention strategies for falls and bone
health, in order to provide a continuous provision of
service for patients
• All high fracture risk patients will be referred to
their GP for either primary or secondary
osteoporosis treatment
• All NCH&C Community Falls Teams will continue to
visit patients in care homes
Local clinical audits
The reports of 11 local clinical audits were reviewed
by NCH&C during April 2010 ­ March 2011 and the
Trust intends to take the following actions to improve
the quality of healthcare provided:
• Training on record keeping to be provided to staff
• A review of the Prison Healthcare Discharge Policy to
be undertaken and a discharge checklist to be created
• Documenting outcome measures within Specialist
Rehabilitation and taking part in the UK Rehabilitation
Outcomes collaborative data collection which will help
us to see the cost benefits of rehabilitation
• To ensure our medical and nursing staff are
fully aware of, and engaged with, medicines
reconciliation process
• To explore options for greater pharmacy support
18
Quality Account Norfolk Community Health and Care NHS Trust
Participation in
clinical research
The number of patients receiving NHS services provided
or sub­contracted by Norfolk Community Health and
Care NHS Trust (NCH&C) in 2010/11 that were recruited
during that period to participate in research approved
by a research ethics committee, was 289.
Participation in clinical research demonstrates NCH&C’s
commitment to improving the quality of care we offer
and to making our contribution to wider health
improvement. Our clinical staff stay abreast of the latest
possible treatment possibilities and active participation
in research leads to successful patient outcomes.
We were involved in conducting 48 research studies
during 2010/11, of which 22 were new projects which
were given permission to start in 2009/10. The National
Institute for Health Research (NIHR) supported 59% of
these studies through its research networks, the majority
of non­supported studies being student research, which
is not eligible for adoption onto the national portfolio. In
conjunction with the Comprehensive Local Research
Network (CLRN) and Primary Care Research Network
(PCRN) we have developed a research support scheme
known as the Research Site Initiative Scheme to
encourage hosting of research in specified clinical areas.
This scheme aims to increase the capacity of our staff to
host portfolio studies alongside delivery of care, in order
to improve the health of our patients through the
delivery of innovative, high quality care.
There were 18 clinical staff participating in research (as
participants) approved by a research ethics committee
at NCH&C during 2010/11.
Over the 2010/11 period NCH&C conducted clinical
research studies within a number of different healthcare
specialties. However, none of these studies map to medical
specialties where mortality rate data is available and
therefore it is not possible to show any differences in the
healthcare/mortality rate from causes preventable in the
specialty compared with the 2009/10 reporting period.
Within the last year we have been successful
collaborators in three NIHR funded projects,
including one Health Technology Assessment (HTA)
and two ‘Research for Patient Benefit’ (RfPB) projects.
We have been awarded five research bursaries
through NHS Norfolk to enable our staff to develop
their research ideas, with academic partners, into
successful funding applications.
During 2010/11 NCH&C has not recorded any
publications that have arisen as a result of our
involvement in NIHR research. We plan to continue to
collect such information from the current financial year
and onwards and will be able to report on this activity
for 2011/12.
Part 2 2.2 Statements of assurance from the Board
2.2.3 Participation in clinical research
2.2.4 Goals agreed with commissioners
2.2.5 Statement from Care Quality Commission (CQC)
Goals agreed with
commissioners
Statement from the
Care Quality Commission
Use of the Commissioning for Quality and
Innovation (CQuIN) payment framework
NCH&C is required to register with the Care Quality
Commission (CQC) and its current registration status is
registered with a condition. NCH&C has the following
condition on registration:
A proportion of NCH&C’s income during April 2010 ­
March 2011 was conditional on achieving quality
improvement and innovation goals agreed between
NCH&C and any person or body they entered into a
contract, agreement or arrangement for the provision of
NHS services, through the CQuIN payment framework.
Further details of the agreed goals for April 2010 ­
March 2011 are set out in Part 3 of the Quality
Account and for the following 12­month period can
be found in Part 2.1.
19
The Registered Provider must ensure that the
regulated activity of “Accommodation for people
who require nursing or personal care” is managed
by an individual who is registered as a manager in
respect of the activities at or from all locations.
This condition has been imposed as the CQC see this
regulated activity as having a social care aspect and
therefore requires a Registered Manager situated at
each of our three Children’s Short Break locations.
NCH&C is currently working towards having this
condition removed.
The CQC did not take enforcement action against
NCH&C during April 2010 ­ March 2011.
The CQC conducted an unannounced inspection
on 27 July 2010 to assess whether NCH&C is
adequately protecting patients, workers and others
from Healthcare Associated Infections (HCAI). The
overall judgement of inspection stated; ‘We found no
cause for concern regarding the provider's compliance
with the regulation on cleanliness and infection
control’. This response supports the ongoing work that
is being undertaken with all levels of staff. There were
no actions required to be taken.
20
Quality Account Norfolk Community Health and Care NHS Trust
Statement on relevance
of data quality and
actions to improve
NCH&C will be taking the following actions to improve
data quality:
It has established a Data Quality Forum chaired by the
Assistant Director of Performance. The purpose of this
forum, which meets bi­monthly, is:
• To assist NCH&C to work to a common set of
principles around data quality issues
• To share experience, ideas and examples of good
practice in business units and corporate functions in
taking forward the data quality agenda
• To assist NCH&C in the delivery of the data quality
agenda in support of key national initiatives, eg.
Transforming Community Services Quality Indicators,
Patient Safety, QIPP, and the NHS Outcomes Framework
• To action collectively­agreed data quality initiatives
• To assist business units and corporate functions in
raising the profile of data quality at a local level and
making the links with the wider agenda outlined above
• To provide a forum for coordination of user issues,
support arrangements and developments for data
quality reporting
• To review, where available, local and national
benchmarking resources to identify any issues of data
quality, and consider any necessary actions
• To review the Data Quality Dashboard against local
benchmarks and targets as defined in the Data Quality
Improvement Plan, and to monitor trends over time in
order to assess progress in improving data quality
The Forum is action­oriented in order to effect
improvements in data quality. This ensures that when
decisions are made, it is clear what tasks are required by
Forum members or other staff.
This ensures responsibility is appropriately assigned and
that achievements can be followed up and monitored
to improve data quality.
Data quality reports have been designed to monitor a
range of key performance indicators on a monthly basis,
and the Secondary Uses Service (SUS) dashboards are
reviewed regularly in relation to key national indicators.
NHS Number and General Medical
Practice Code Validity
NCH&C submitted records during April ­ October 2010
to the SUS for inclusion in the Hospital Episode Statistics
which are included in the latest published data under
organisation code 5PQ. The percentage of records in
the published data which:
• Included the patient’s valid NHS number was:
100% for admitted patient care
100% for outpatient care
• Included the patient’s valid General Medical Practice
code was:
100% for admitted patient care
100% for outpatient care
Following separation from NHS Norfolk and our
establishment as an independent NHS Trust, NCH&C
submitted records during November 2010 ­ March 2011
to the SUS for inclusion in the Hospital Episode Statistics
which are included in the latest published data under
organisation code RY3. The percentage of records in
the published data which:
• Included the patient’s valid NHS number was:
100% for admitted patient care
100% for outpatient care
• Included the patient’s valid General Medical
Practice code was:
100% for admitted patient care
100% for outpatient care
Part 2 2.2 Statements of assurance from the Board
2.2.6 Data quality
2.2.7 Information Governance Toolkit attainment levels
2.2.8 Clinical coding error rate
21
Information Governance
Toolkit attainment levels
There are robust action plans in place which aim to
achieve level 2 compliance of all criteria by the end of
June 2011.
The Trust declared compliance at level 2 against each of
the 21 key requirements, although the 95% training
target was not achieved at the time of submission of
information to this Quality Account. However, an action
plan to achieve compliance by June 2011 was in place
to ensure compliance could be declared.
Using the NHS Connecting for Health submission
scoring, this represented an overall score for April 2010
­ March 2011 of 63% out of a possible 66% against
level 2 requirements.
Of the remaining 20 standards, 15 were declared at
level 2, with four declared at level 1. Prior to
submission, discussion with the support team enabled
an exemption to be applied to one of the standards.
The four criteria declared at level 1 were:
1 8­309 Business Continuity planning
2 8­324 Pseudonymisation of data
3 8­406 Monitoring the availability and tracing of
paper records
4 8­501 National data definitions incorporated into
key systems
For further information, the Information Governance
Toolkit is available on the Connecting for Health
website: www.igt.connectingforhealth.nhs.uk
Clinical coding error rate
NCH&C was not subject to the Payment by
Results clinical coding audit during 2010/11 by the
Audit Commission.
22
Quality Account Norfolk Community Health and Care NHS Trust
Review of Quality Achievements
in 2010/2011
It is important to recognise the role that every member of staff plays
in order for us to succeed in continuing to provide care high­quality
care to our patients. The hard work of our colleagues means we are
able to build upon previous successes and offer local people further
improved health and care services.
Valuing Our Staff
NCH&C’s Chief Executive, Sheila Adams­O’Shea recently
thanked staff for their ongoing commitment to the
development of our Trust and for continuing to deliver
excellent services to the people of Norfolk.
She said: “I am confident that our Trust will further
develop over the coming year and continue to offer
patients excellent services, particularly as we have such
an array of people with talent, skill and commitment to
patient care at all levels of NCH&C.
This was especially evident at the recent REACH for the
Stars staff awards, which recognised staff members
who have especially improved patient care, delivered
the highest standards and inspired colleagues.
“It was a wonderful event at which I was proud to share
in the comments made by patients about the care they
have received, as well as colleagues who witnessed the
excellent work being delivered by people across our Trust.”
Part 3 3.1 Review of Quality Achievements in 2010/2011
3.1.1 Valuing Our Staff
3.1.2 Clinical Leadership
23
Clinical Leadership
NCH&C’s clinical leadership was promoted in a national
journal ­ The Nursing Standard in December 2010. The
Trust’s development towards CFT status has been used
as an example of both good progress and robust clinical
leadership. Mrs Adams­O’Shea said: “Clinicians are
at the heart of what our Trust does... when we are
developing strategies or considering business
opportunities, our clinical leaders work with senior
managers to drive it forward.”
NCH&C’s Clinical Strategy provides our clinical staff with
a clear picture as to how they can ensure continuous
quality improvement and innovation in clinical care for
our patients and their carers.
This can be evidenced by a number of key initiatives
and projects which have been undertaken during
2010­11, such as:
Norfolk’s Key Worker service for children with
disabilities and their families celebrated its first
anniversary in September 2010.
The Family Nurse Partnership (FNP) scheme which
offers support to young, first­time mothers and
their babies. The project received praise from the
Department of Health (DoH) following its first
successful year.
Providing support to soon­to­be mums, under the age
of 18, from early pregnancy all the way through until
their child is two years old, the project aims to improve
the health and wellbeing of both parents and babies.
Launched in January 2010, the team has already helped
over 100 families, reduced the rates of smoking during
pregnancy and increased breastfeeding rates.
The scheme aims to help and support parents and
carers, who often find it overwhelming, confusing or
frustrating to deal with the many agencies and
individuals necessary to their child’s care and
development.
“Often the family of a disabled child will deal with a
whole range of professionals,” explains Clare Draper,
NCH&C’s Key Worker Coordinator. “But they may not
be getting all the assistance that’s available, or there
may be lots of duplication in terms of filling in forms,
arranging appointments or attending meetings.
Key Workers help to reduce the number of times
families have to ‘tell their story’ to different
organisations and provide a link to a whole range of
services, making sure they get all the help they need.”
24
Quality Account Norfolk Community Health and Care NHS Trust
A ‘trip’ aboard the NCH&C Health Bus
In February 2011 NCH&C invited people to hop aboard
the big, red double­decker bus to meet healthcare
professionals and receive a wealth of advice to improve
their quality of life.
Aboard the bus people were able to get advice on cervical
cancer (HPV) immunisations from an NCH&C school nurse,
or to pick up a discreet Chlamydia Screening test pack.
People were also able to undertake a simple lung health
check with the How Big Are Your Breaths Roadshow
Team from NCH&C’s Respiratory Triage Service. The
team aims to identify people who are at risk of
developing Chronic Obstructive Pulmonary Disease
(COPD), a condition commonly associated with
smoking, the progression of which can be slowed down
by early diagnosis.
The NCH&C Smokefree Norfolk team was also on board.
The team helped around 2,287 local people quit smoking
last year.
Department of Health selected our Health Visitors
to lead rollout of new­look service
NCH&C’s Health Visitor Service was granted ‘Early
Implementer’ status by the Department of Health to
begin rolling out a redesigned service to Norfolk
families. The decision means our health visitors will be
one of just 20 services nationally ­ and one of only two
in the East of England ­ to start delivering a new­look
health visitor service before March 2012. As an Early
Implementer, NCH&C’s Health Visitor Service will begin
delivering a newly designed service this year – while
the national roll out will run until 2015. The new
programme will ensure that all families are offered a
programme of health and care services to help meet
the needs of both the parents/foster parents and their
children, with additional care and support for those
who especially need it. Families and children will
benefit from health visitors providing joined up care
in partnership with their colleagues in Sure Start
Children’s Centres and GP practices to offer an even
more personalised service. There will also be a
significant recruitment drive to further increase the
number of NCH&C health visitors. In Norfolk, it is
expected that over 50 additional health visitors could
be recruited by 2015 – an increase of around 50% on
existing team numbers.
Part 3 3.1 Review of Quality Achievements in 2010/2011
3.1.2 Clinical Leadership
3.1.3 Quality, Innovation, Productivity, Prevention (QIPP)
Quality, Innovation,
Productivity and
Prevention (QIPP)
NCH&C are delivering across the Quality, Innovation,
Productivity and Prevention agenda (QIPP). Among our
our recent operational and service achievements are:
Quality
Tree Tops Day Nursery – Our nursery in Thetford
received an ‘outstanding’ report from Ofsted inspectors
in September 2010, placing it within the top four per
cent of educational settings in the UK. Our staff took
over its management just two years before, and raised
the quality of provision from ‘satisfactory’ to
‘outstanding’ in a short space of time.
End of Life Care – We have become a member of the
national Dying Matters Coalition, which aims to make
‘dying well’ a natural part of a good life. One of the
primary providers of integrated specialist palliative care
services in the country, we also provide a quality service
to the prison population through our innovative prison
palliative care service.
Innovation
Integrated Care Organisation pilots – This project is
a joint initiative between NCH&C, Norfolk County
Council Adult Social Services Department, 30 GP
practices and NHS Norfolk to develop more integrated
services for the community. It is the largest pilot in
England. Our objective has been to establish a series of
fully integrated, joined up care pathways, through
GP­based health and social care teams across Norfolk.
The teams comprise GPs, community health staff and
adult social care staff and provide cohesive, proactive
and personalised care for older and vulnerable people,
transcending the traditional boundaries between the
organisations involved.
25
Specialist Stroke Rehabilitation Unit –
NHS Norfolk commissioned an £8m purpose­built
specialist stroke rehabilitation unit, at Norwich
Community Hospital. Services are provided via a
partnership project between NCH&C and the
Norfolk and Norwich University Hospitals NHS
Foundation Trust (NNUH). NNUH subcontracts our
Trust to provide services within this new unit.
This represents significant partnership working
with an acute trust for the benefit of local people.
Productivity
Releasing Time to Care – Our Productive Community
Ward project has improved relationships between staff
and patients, and has improved patient experience. A
patient at our specialist palliative care rehabilitation centre
commented: “You are given respect and dignity, and you
are involved in all of the choices around your care.”
Better care for patients over winter – Thanks to
more joined up working between health and care
services, hundreds of patients avoided unnecessary
delays over the winter of 2009­10. This improved
patient experience, relieved pressure on acute services
and reduced costs and waste across the system. There
was a 75% reduction in the number of patients
experiencing delays in discharge over winter 2009­10.
Prevention
Kicking the habit – Our Smokefree Norfolk team
continues to lead thousands of local people to kick the
habit. Team Leader, Katie McGoldrick was recently
crowned ‘Stop Smoking Advisor of the Decade’ at the
East of England’s 10th anniversary Stop Smoking Awards.
Helping more than 1,200 smokers kick the habit, 85%
of the people she sees quit the habit for good.
Reducing cancer – Our children’s immunisation
team surpassed national averages for delivering human
papillomavirus (HPV) vaccinations among school girls
and young women in 2010. This will protect thousands
of women from developing cervical cancer later in life.
26
Quality Account Norfolk Community Health and Care NHS Trust
Performance Highlights
Infection Prevention and Control
Infection control rates remain good with no reported
cases of C.diff during March 2011, nor have there been
any reported cases of MRSA bacteraemias since June
2010. We had nine reported cases of C.diff during 2010­
11 against a contractually agreed ceiling of 10 cases.
Compared to previous years’ infection control rates,
2010­11 saw the lowest level of C.diff and MRSA
occurrences within our patients ­ a testament to the hard
work of staff in adhering to strict infection control
measures. The ceilings for C.diff and MRSA bacteraemias
for 2011­12 is nine cases and one case, respectively.
Community Equipment Store (CES)
The response times for the delivery of equipment by
the Community Equipment Store (CES) continues
to exceed the NHS East of England (EoE) target of 95%.
Throughout 2010/11, the CES delivered 21,490 items to
patients needing equipment, with just 2.3% being
delivered seven days after the referral was received.
This ensured that the vast majority of our patients were
not kept waiting unnecessarily.
18 weeks Referral­to­Treatment (RTT)
Most services provided by NCH&C are now compliant
with, or close to achieving a maximum wait of
18­weeks from referral­to­treatment (RTT). We have
seen particular improvements within our Adult Speech
and Language Therapy service, musculoskeletal
physiotherapy and Continence Management.
All services within our Children’s Services have achieved
18­week wait compliance and of the services which
are subject to an 18­week wait pathway, they treated
or assessed nearly 5,300 patients. Of these patients,
just 22 patients had to wait in excess of 18 weeks,
excluding those breached due to patient choice and
clinical reasons to delay treatment.
Part 3 3.1 Review of Quality Achievements in 2010/2011
3.1.4 Performance Highlights
Performance tables
The following tables show a number of indicators
common to community organisations, which are
monitored by NCH&C and NHS East of England.
These form part of the Provider Management Regime
(PMR) to which NCH&C is subject, and a number of these
indicators are closely monitored by NHS Norfolk as part of
the community services contract. These have been split
into separate tables to indicate where NCH&C is achieving
its targets, where it is approaching its ceiling/at risk of
missing a target, and where we are missing targets.
27
Several indicators reported to NHS East of England have
been performing consistently above the required level of
performance, and have therefore been removed to make
way for three further indicators from Children’s Services,
highlighted as ‘New’ in the performance tables ­
breastfeeding, smoking cessation in pregnancy and
new birth visits. All three areas are performing above
expected levels, which demonstrates the high quality of
service that expectant and new mothers in Norfolk are
receiving from our staff.
Title
Indicator
Target or upper ceiling
March
performance
Recent
trend
Year to date
performance
C.diff
No more than 10 cases during 2010/11
0 cases
9 cases
year­to­date
MRSA bacteraemia
No more than one case during 2010/11
0 cases
1 case
year­to­date
MRSA Screening
­ elective patients
100% of all patients having planned
surgery to be screened
100%
100%
Delayed transfers of care No more than 6% of beds occupied by
patients whose discharge is delayed
for non­medical reasons
4.3%
3.6%
Community Equipment
Store (CES) response
within seven days
95% delivered within seven days
of receipt of a referral
99.7%
97.7%
Breastfeeding
success rates NEW
Minimum of 21% of new mothers to
be fully breastfeeding at six weeks
32.40%
32.96%
Health Visiting NEW
95% or more of mothers receiving a
New Birth Visit within 28 days
of delivering
98.45%
97.74%
Smoking cessation
in pregnancy NEW
23% or more of women who gave up
smoking during pregnancy
35.71%
25.62%
28
Quality Account Norfolk Community Health and Care NHS Trust
At risk of breaching target – to end March 2011
Indicator
Target or upper ceiling
March
performance
18­week wait
referral to treatment
100% patients receiving definitive
treatment within 18 weeks of referral *
97.2%
Recent
trend
Year to date
performance
96.7%
* 18­week wait key: Green: 100%, Amber: 95­99.9%, Red: Below 95%
Target Breach Assurance
Below is a list of services which were breaching the 18­week wait target at end of March 2011,
with action plans for improvement. For comparison purposes, performance rates from the previous month
(February 2011) are also listed in brackets:
from 98.0%)
Biomechanics – 96.2% (
During 2010/2011, the average 18­week compliance for this service was around 97%. Plans were drawn up to
ensure there were no breaches at the end of March, but due to staff sickness these plans could not be fully
implemented. Consequently, new steps, such as recruiting more technicians and introducing patient tracking, have
now been brought in.
from 97.9%)
Podiatric Surgery – 69% (
Following significant improvements over the last few months which have seen an improvement in compliance,
waiting times are currently increasing due to a backlog of outpatient work which has impacted on waits for first
appointments. However, actions are in place to reduce backlog, including recruitment to a vacant post.
Wheelchairs – 92% (
from 97.6%)
A slight fall in compliance which is partly due to problems with suppliers delivering necessary items. Overall, the
service continues to show improvements in compliance compared to previous months.
Pulmonary Rehabilitation – 81.5% (
from 86.4%)
Changes to the way patients are managed are to be implemented in coming weeks. The service delivery model has
previously meant that patients had to wait over eight weeks for the next group if there was more demand than
capacity. However, the new model will see a rolling programme brought in with increased capacity, which should
enable a reduction in backlog.
Continence Management – 99.2% (
from 99.9%)
Musculoskeletal Physiotherapy – 99.7% (
from 99.9%)
Part 3 3.1 Review of Quality Achievements in 2010/2011
3.1.4 Performance Highlights
29
Missing target – to end March 2011
Indicator
Target or upper ceiling
March
performance
Recent
trend
Year to date
performance
Successful four­week
smoking quitters
Performance against the contractual
trajectory of 2,610 successful quits
during 2010/11*
211
2287
Chlamydia Screening
Performance against the contractual
trajectory of 1,500 successful screens
during 2010/11**
51
581
*NCH&C agreed a ‘stretch’ target of 3,557 quits for 2010­11 as part of a Norfolk­wide quit target
**We agreed a stretch target of 3,000 in 2010­11 for Chlamydia Screening
Target Breach Assurance
Smoking ­ Despite strong performance for much of the year, and a new management structure being put in place,
the Smokefree Norfolk team was below its contractual trajectory agreed with NHS Norfolk to the end of March
2011. Despite this, the service has raised its profile through various local events and was able to generate an
increased number of referrals from our own services, helping 2,287 people give up smoking by end of March. The
service is expecting more successful quits to be recorded (June 2011 data release) for the 2010­11 contractual year,
following national No Smoking Day events, which traditionally increases quit rates.
Chlamydia ­ NCH&C performed 51 successful chlamydia screens in March for young people aged 16­24 years of
age. For the whole year the Trust has achieved nearly 600 screens, more than double the number of screens
undertaken last year. This is a clear reflection of all the hard work by the Chlamydia Screening Project Team and our
staff in getting young people to accept the offer of a screening kit.
Quality Account Norfolk Community Health and Care NHS Trust
Patient Safety
2010-11 NCH&C cumulative community hospitals
MRSA bacteraemia cases against cumulative trajectory
Infection Control – Healthcare
Associated Infections
8
Care Quality Commission (CQC) inspection success
6
Number of Cases
5
4
3
2
1
Clostridium Difficile (C. diff) and MRSA bacteraemia
b11
ar
-1
1
M
Fe
0
11
n-
Ja
0
D
ec
-1
0
-1
-1
ct
ov
O
N
Se
p-
0
10
0
-1
ug
l-1
A
Ju
0
10
n-
Ju
-1
2010-11 2010-11 Cumulative actual
(Please note that the attribution criteria changed
between the periods 2009­10 to 2010­11)
2010-11 NCH&C cumulative community hospitals
C.diff cases against cumulative trajectory
20
18
16
14
12
10
8
6
4
2
0
pr
-1
M 0
ay
-1
Ju 0
n10
Ju
l-1
0
A
ug
-1
Se 0
p1
O 0
ct
-1
N 0
ov
-1
D 0
ec
-1
Ja 0
n1
Fe 1
b1
M 1
ar
-1
1
The IPC team has worked closely with NHS Norfolk,
acute hospitals, microbiologists, the Health Protection
Unit and the antibiotic pharmacists to identify trends
across Norfolk in relation to C. diff infections. A printed
information booklet was produced, mainly for primary
care, but it has also been shared with NCH&C, to
ensure collaborative working in reducing C. diff
infection rates across the health economy. This work
has also informed education and practice within
NCH&C; issues such as reviewing the timeframe in
which a specimen should be sent have been significant
in our management of C. diff.
2009-10 Pre 48 Cumulative actual
Number of Cases
Root cause analysis is undertaken on all cases and
examined within the Infection Prevention and
Control (IPC) team, and Trust colleagues, to inform
learning which is shared across the Trust. This has
culminated in the IPC team providing specific education
sessions for NCH&C staff.
2010-11 Cumulative trajectory
A
NHS Norfolk set local ceilings for NCH&C inpatient
beds during 2010/2011 against C. diff and MRSA
bacteraemia. Both graphs show that NCH&C finished
the year either on or below trajectory.
ay
pr
-1
0
0
A
CQC conducted an unannounced inspection on
27 July 2010 to assess whether NCH&C is adequately
protecting patients, workers and others from healthcare
associated infections (HCAI). The overall judgement of
inspection stated: ‘We found no cause for concern
regarding the provider's compliance with the regulation
on cleanliness and infection control.’ This response
supports the ongoing work that is being undertaken
with all levels of staff.
7
M
30
2010-11 Cumulative trajectory
2009-10 Pre 48 Cumulative actual
2010-11 2010-11 Cumulative actual
Part 3 3.1 Review of Quality Achievements in 2010/2011
3.1.5 Patient Safety
Adverse Incidents
All high level incidents reported in NCH&C were
analysed and three key areas have been identified for
action from the drilled down data:
1) Pressure Ulcers
A review of all reported grade 3 and grade 4 pressure
ulcers show the following contributory factors which
are in line with known risk factors. These include:
poor mobility, frail elderly and vulnerable patients,
incontinence, excoriated skin and poor nutrition.
Following this an internal audit tool was developed to
assess the prevalence of pressure ulcers and identify
where they were acquired. An audit was undertaken
in July 2010 looking at the high risk areas of Inpatient
units and Community Nursing & Therapy (CN&T) to
identify whether pressure ulcers occurred under the
care of NCH&C or prior to admission.
31
Actions are being taken at a local level to prevent ulcers
occurring and deteriorating. All inpatients have a tissue
viability and Malnutrition Universal Screening Tool
(MUST) or specialist palliative care assessment as part
of their admission procedure. All high risk patients in
the community are identified and assessed and
competencies have been devised for staff working in
the wider community.
Latest incidence data demonstrates that there has been
an overall reduction of pressure ulcers acquired while
under the care of NCH&C services. Work continues to
further reduce the prevalence of pressure ulcers and a
pan­Norfolk Pressure Ulcer Steering Group has been
established to set a consistent approach across the
county. Reporting requirements have recently been
updated, in line with the requirements of the National
Patient Safety Agency (NPSA) and CQC.
32
Quality Account Norfolk Community Health and Care NHS Trust
2) Falls
As a consequence of their rehabilitation some patients
experience a slip trip or fall. An action plan has been
agreed to reduce the incidence of falls. Data from
incidents will be used to measure the number of falls
across locations and identify trends. NCH&C recognises
that it is vitally important to be able to measure whether
interventions to reduce the risk of falls to patients,
visitors and the public are effective in keeping people
safe while on Trust premises or within our care.
The key measures used to assess the frequency and
severity of falls are:
• All falls reported using the incident reporting system
• The number of inpatient falls per 1,000
occupied bed days
• The degree of assessed harm
For 60% of reported falls, minimal harm occurred.
However, for the person who has fallen, even though
physical harm may not be apparent, it may cause delays
in recovery or loss of confidence and will have an effect
on their perception of the care received. Work is being
carried out both at ward level and in the community to
identify patients at risk of falling and to introduce
improvements through a number of initiatives, such as
use of risk assessment documentation within care plans
and use and monitoring of the post­fall protocol,
a National Patient Safety Agency (NPSA) requirement to
be implemented by July 2011.
In the nine months from April ­ December 2010 our
incident data shows that there was a reduction in falls
compared with the same period in 2009. There was an
average of 8.9 falls per 1,000 occupied bed days set
against a national average of 8.4 (NPSA 2007).
Assistive technology is in use in our Specialist
Neurological Rehabilitation ward to alert staff when
patients are out of bed and are at risk of falling.
However, such technology is only appropriate in
single room settings and for specific client groups.
NCH&C Falls Prevention Service will benefit
hundreds more Norfolk patients
Hundreds more patients across the county will benefit from
the expert support of the NCH&C Falls Prevention Service
after it won its bid to deliver services throughout the
remainder of Norfolk. The expanding service will also
develop new pathways of care in partnership with other
providers, aimed at reducing the number of admissions
to the acute hospitals resulting from falls.
Part 3 3.1 Review of Quality Achievements in 2010/2011
3.1.5 Patient Safety
33
3) Medication incidents
Numbers of incidents
Medication is the third most frequently reported
category of incident nationally (ref NPSA Safety in
Doses). It is therefore important that medication
incidents are reviewed and trends identified at both the
local ward/unit level and across the organisation. Trends
and common themes can then be discussed and actions
taken to address the factors contributing to incidents.
The reporting of medication incidents within NCH&C
appears to be in line with comparable NHS trusts.
The organisational medicines management structure
has recently been improved by the appointment of
a pharmacist to lead this area of work, and the
membership and terms of reference of the
Medicines Management Group has been updated.
The aim is also to ensure that the high level of reporting
across our Trust continues to improve, and that the
trend shows an increasing number of low risk incidents
compared with moderate/high risk incidents.
Overall, there has been a reduction in incidents
involving medication with 149 incidents being reported
during September ­ December 2010 compared to 163
during the previous quarter. However, this will continue
to be monitored to ensure that safe systems of working
are reducing the number of incidents.
There is evidence of a good reporting culture which
will ultimately lead to sharing of learning and overall
reduction in risk to patients.
34
Quality Account Norfolk Community Health and Care NHS Trust
Effectiveness of Care
Productive Community Series is
enabling more time for patients
The Community Nursing & Therapy Teams have been
able to re­invest more than 1,000 hours back into
patient care by using a new efficiency model.
The Productive Community Series provides a system to
identify and remove inefficient activities and reinvest
that saved time into making care more interactive,
stimulating, reliable and safe. The first stage of this
model is ‘Well Organised Working Environment’
(WOWE). This has been already implemented across six
integrated teams since May 2010 and has saved 1,113
hours which were reinvested into patient care.
The WOWE module helps team to transform their
working environment, using no cost/low cost
techniques, so that they contribute to, and do not
hinder, the efficient delivery of care.
Examples of time saving activities include: organising
office space and stock cupboards; implementing stock
control procedures; developing grab­and­go bags for
procedures; and relocating commonly used items so
they are easily accessible.
This approach involves teams designing the way they
plan, organise and deliver care. There are multiple other
important benefits including improved standards of
care, safety, dignity and job satisfaction.
Part 3 3.1 Review of Quality Achievements in 2010/2011
3.1.6 Effectiveness of Care
35
Clinical Audit 2010
Clinical Audit is defined as: “A quality improvement
process that seeks to improve patient care and outcomes
through a systematic review of care against explicit
criteria and the implantation of change. Aspects of the
structure, processes and outcomes of care are selected
and systematically evaluated against specific criteria.
Where indicated, changes are implemented at an
individual, team or service level and further monitoring is
used to confirm improvement in healthcare delivery.”
(Ref: National Institute for Clinical Excellence (NICE)
Principles for Best Practice in Clinical Audit 2002.)
Annual Clinical Audit Programme
All trusts are required to consider the following areas
for inclusion in the Annual Clinical Audit Programme:
• National Audits, eg. National Clinical Audit and
Patient Outcome Programme (NCAPOP), currently
managed by the Health Quality Improvement
Partnership (HQIP)
• NICE Guidance Technology Appraisals
The following are also integral to our clinical
audit programme:
• Nationally agreed guidance
• Commissioning for Quality and Innovation (CQuIN)
• National Service Frameworks (NSF)
• Audits initiated by other key national bodies, such as
the NHS Litigation Authority, Department of Health,
National Patient Safety Agency
• NCH&C Policies and Procedures
• Serious Incidents Requiring Investigation (SIRIs) trends
• Risk Assessments
• Root Cause Analysis (RCA)
• NICE Clinical Guidelines, Interventional Procedures,
Public Health Guidance
The NCH&C Clinical Audit Programme will be
developed by the Clinical Audit and Effectiveness
Team (CAET) one year in advance. The programme
will be shared with the Clinical Audit and Effectiveness
Committee (CAEC) and the Assistant Directors of
the operational business units for comment and
local agreement. The final version of the Clinical
Audit Programme will be ratified by the Quality & Risk
Assurance Committee and submitted to commissioners.
36
Quality Account Norfolk Community Health and Care NHS Trust
Medicines Reconciliation
A new clinical audit tool was devised by the Modern
Matron for Development (Community Rehabilitation),
and an audit was run in December 2010. In total 196
patient records were reviewed within Community
Rehabilitation teams across our Trust. This audit
demonstrated an overall achievement target of 74%,
which was set by the commissioners.
Osteoporosis
Staff in the Community Rehabilitation business unit
have run a local audit based on the NICE technology
appraisal ­ TA160 (osteoporosis).
Childrens’ Services Care Plan Audit
Local Clinical Audits completed during 2010
Record Keeping – mandatory trust­wide
Annual Clinical Audit
The Trust­wide Record Keeping Clinical Audit received
483 returns during November­ December 2010.
Both paper and electronic records were audited.
Trends found within the audit included:
• Clinical teams were generally highly successful with
effectively capturing patient identifiable information
in the health records, as well as documenting clear
accounts of their interaction with the patient without
involving personal judgement
• Religion was not effectively captured within the
patient notes: within SystmOne records there is no
place to record this
• Inconsistent methods for ensuring that when
abbreviations or acronyms are used, the first
entry in the record is in full with the corresponding
abbreviation or acronym in brackets to follow,
allowing the shortened form of the term to be
used consequently
• The audit tool will be revised in summer 2011 to take
into account the organisation’s transition from paper
to electronically held patient records
This audit was developed, taking into account the NICE
guidance TA79 (Epilepsy in Children – Newer Drugs)
which was released in 2004. Clinicians within Children’s
Services carried out the data collection for this audit
between February and September 2010, and have
asked the Clinical Audit and Effectiveness Team (CAET)
to collate, analyse and report on the result, making any
necessary recommendations.
Part 3 3.1 Review of Quality Achievements in 2010/2011
3.1.6 Effectiveness of Care
Participation in National Clinical Audits
National Service Framework (Diabetes)
The Diabetes Specialist Nurse, who is part of our
Community Nursing & Therapy team, based in west
Norfolk, has confirmed that their team is taking part in
this year’s National Service Framework audit which is
looking specifically at the treatment of diabetes.
Royal College of Physicians Falls and
Bone Health Audit
Data collection has been completed and all stages of this
national audit are now completed in terms of input from
NCH&C. The community input has been returned to the
two acute trusts ­ Norfolk and Norwich University Hospitals
NHS Foundation Trust and the Queen Elizabeth Hospital
King’s Lynn NHS Foundation Trust. Final results are expected
in 2011.
National Access to Psychological Therapies (NAPT),
Anxiety and Depression
Three of the four stages of this national audit have now
been completed for NCH&C.
The final outstanding section is the fourth questionnaire
the ‘Service Users’ Surveys’ which have been sent
directly to patient’s home addresses with a pre­paid, self
addressed return envelope directly back to the NAPT
team. The deadline for completion and return of these
surveys was the end of February 2011. Results are
expected to be published in mid 2011.
Health Quality Improvement Partnership (HQIP)
Children’s/Young People's Epilepsy Audit ‘Epilepsy
12’ (Royal College of Paediatric and Child Health)
The CAET received confirmation that one of our
Children’s Service leads is currently taking part in this
three­year national audit. 2011/12 is due to be the last
data collection year for this audit and results are
anticipated as being available early in 2012.
37
Implementation of National Institute for Health
and Clinical Excellence (NICE) Guidance
NICE is the independent organisation responsible for
providing guidance for the promotion of good health
and the prevention and treatment of ill health. NICE
guidance aims to ensure that the promotion of good
health and patient care within the NHS are in line with
best available evidence and practice of clinical
effectiveness and is cost effective.
NCH&C has developed a Clinical Quality & Effectiveness
Group which reviews all published NICE guidance for
relevance to our services prior to it being distributed to
the clinical teams for implementation.
For clinical interest / service development reasons,
clinical teams are enthusiastic in running clinical audits
on the following topics with the intention of linking
these to applicable NICE guidance.
Children’s Services: Clinical Guideline 99 ­
Constipation in children and young people
The CAET are in the process of working with key
clinicians to develop a suitable audit tool, using this
NICE guidance to supply areas of the criterion.
Community Nursing & Therapy (CN&T):
Clinical Guideline 20 ­ Epilepsy in Adults and Children
The CAET is setting up a clinical group to discuss the
development of an audit tool for CN&T based on
the guidelines and measurable patient outcomes.
Prisons and CN&T Clinical Guideline 109 ­ Transient
loss of consciousness in adults and young people
This guidance was shown to be relevant by both
of these teams. CN&T’s action plan was received
in October 2010, and found that there needed to
be a trigger question in the multi­disciplinary team falls
assessment, indicated when a more detailed history is
required with onward referral. The aim is to have all
documents amended and available on SystmOne.
A clinical audit followed on from this and a report was
delivered in Q4 of 2010­11.
38
Quality Account Norfolk Community Health and Care NHS Trust
Research Achievements
NCH&C has increased its research activity by more than
a third compared with the previous year’s activity.
‘Portfolio’ research has also increased this year and now
makes up more than 50% (53.2) of total research
studies which are active in the Trust. This shows that
NCH&C is actively engaging in studies that have been
developed and funded through open competition, peer­
reviewed and vetted by the National Institute for Health
Research (NIHR) to assure the studies deliver quality
research outcomes which can benefit patients and the
NHS. Research activity and staff engagement is high in
the following areas:
Learning Disability Services
8 studies
Stroke Rehabilitation
7 studies
Community Nursing
6 studies
Children’s Services
5 studies
Prison Healthcare
3 studies
Speech and Language Therapy
3 studies
Portfolio research studies such as VenUS 1V
A Randomised Control Trial (RCT) of compression
bandaging versus compression hosiery in the treatment
of venous leg ulcers has had an impact on the care and
treatment of our patients. Community nurses have
commented on the greater compliance by patients
with treatments as a result of being part of the study.
The study has increased the use of compression hosiery
leading to a reduction in cost and staff seeing patients
in the trial healing quicker than patients who are not
eligible to take part.
Research bursaries for staff
A total of £30,000 has been awarded to our staff
who were successful in bidding for research bursaries.
Five members of NCH&C have received £6,000 each
to support themselves in a number of ways to develop
a research proposal to be submitted to NIHR for
nationally­competitive research funds, such as Research
for Patient Benefit (RfPB). Some of the applicants use the
money to ‘buy themselves out of clinical time’ so that
they can devote themselves appropriately to research.
Research Site Initiative Scheme
Research highlights from 2010­11 include:
Stroke Rehabilitation and Early
Supported Discharge Service
This service has incorporated research into their care
they deliver to local patients in a fundamental way
since they opened in Beech Ward, at the Mulberry
Rehabilitation Unit, Norwich in January 2010. High
numbers of patients going through the service are
eligible to participate in research studies. NCH&C has a
strong collaboration with the University of East Anglia
(UEA), Norfolk & Norwich University Hospitals NHS
Foundation Trust and Trent Stroke Research Network.
Current and new collaborations with academics and
clinicians working at the acute end of the Stroke Care
Pathway have led to excellent research collaborations
which have had a positive impact on patient care in
terms of opportunities to receive new and innovative
rehabilitation treatments as a result of taking part in
locally based research studies.
This is a new research initiative being piloted at NCH&C
which aims to provide clinical teams the opportunity to
increase their research capacity. By signing up to a
contract which contains a set of outcomes, the teams
should be able to develop an even more skilled research
workforce with greater capacity to host NIHR portfolio
research. It is designed to assist teams with ‘buying out’
time to complete research skills training and to develop
the research infrastructure within their service.
Six teams are involved from Children’s Services,
Specialist Palliative Care Services, Learning Disability
Services, the Stroke Rehabilitation Service and one
Integrated Care Team.
£20,000 of funding has been provided throughout
Norfolk & Suffolk Comprehensive Local Research
Network (CLRN) to support the initiative. We hope
that it will have an impact on our Trust’s capacity
to host more portfolio research over the next 12
months and beyond.
Part 3 3.1 Review of Quality Achievements in 2010/2011
3.1.6 Effectiveness of Care
3.1.7 Patient experience
39
Loyola Weeks, NCH&C’s Director of Quality and Risk,
said: “I am delighted that this feedback has shown that
patients continue to benefit from our excellent health
and care services. I would like to thank all of our staff
whose commitment to delivering these services across
Norfolk has made these further improvements possible
and I commend them for their efforts. The year­on­year
improvements which have been highlighted by patients
show that we are continuing to offer excellent health
and care provision to our patients.”
Patient Experience
Ipsos MORI Survey 2010
All teams are being asked to build on the excellent
progress made so far and to assess how we can make
further improvements in the future.
Patients praise NCH&C’s
staff and services
Patients have highly rated
our health and care services
in a recent survey. More
than 90% of people have
expressed their satisfaction
with our Trust’s services in
a recent Service User
Experience Survey, with two­
out­of­three people giving
the highest rating possible.
The results of the
independent survey, managed
by Ipsos MORI, have also shown
a significant improvement in
patient/user satisfaction with our
services over the past 12 months
with ‘fairly good’ scores having
been transformed into ‘very
good’ scores in many areas.
People were particularly
positive about how their
care was joined up between
services (continuity of care),
an increase in choice, how
supported they felt by staff in
making healthcare decisions,
and the helpfulness of staff.
Two­out­of­three
of the 1,139 people (67%)
taking part in the survey said they
were ‘very satisfied’ (the highest
rating possible) with our services,
which is an increase of 2% on the
previous year, with a combined
score of 91% being either
‘fairly’ or ‘very satisfied’
with our services
Three quarters
of people (75%) rated the
helpfulness of our healthcare staff
as ‘very good’ and 62%
of people rated the helpfulness
of our admin staff as
‘very good’
86%
of those who took part would be
‘likely’ to recommend our
services to a friend or relative;
two­out­of­three people (66%)
were ‘very likely’ to
recommend NCH&C and 20%
were ‘fairly likely’
69%
of those surveyed felt our
services had improved or
stayed the same over the
past year; with 34% saying
things had improved
40
Quality Account Norfolk Community Health and Care NHS Trust
Delivering Same­Sex Accommodation
Essence of Care: Privacy and Dignity
NCH&C is proud to confirm that mixed sex
accommodation has been virtually eliminated in all
of our community hospitals.
Our inpatient units carried out a benchmarking exercise
against ‘Essence of Care; Privacy & Dignity’ in the
summer of 2009.
At the beginning of 2009 we started a programme
of work in response to the Department of Health
commitment to eradicate mixed sex accommodation
(Same Sex Accommodation: Your Privacy, Our
Responsibility).
In the following year there has been considerable work
across the units in relation to privacy and dignity and
meeting the same sex agenda. This has included: staff
developing unit plans to identify gender allocation for
bathrooms and toilets; clear labelling of hygiene facilities;
the development of a reporting system for mixed sex
occurrences; the creation of a Privacy and Dignity Steering
Group which meets regularly; and the roll out of a Privacy
and Dignity training package and Personal Care Policy.
Since this launch we have delivered this agenda
and 2010 has seen the privacy and dignity philosophy
embedded into day­to­day practice for patients
admitted to our community hospitals. Patients
can expect to find the following in relation to
same sex accommodation:
• The bedded rooms will only have
patients of the same sex
• Toilets and bathrooms will be just for
one gender, and will be near to the bed area
While there will be both men and women patients on
the ward, they will not share the same sleeping area.
Men and women may have to cross a ward corridor to
reach their bathroom, but they will not have to walk
through opposite­sex bedded areas.
A self­assessment has been undertaken focusing on
four key areas:
1 Patient experience
2 Estates
3 Systems and processes
4 Staff culture
If our care should fall short of the required standard,
we will report it. We will also set up an audit
mechanism to make sure that we do not misclassify
any of our reports and we will publish the results of
that audit on our website.
The original 2009 benchmarking exercise also required
staff to create and work through action plans in
response to any identified weaknesses.
This benchmarking exercise was repeated in
September 2010.
Method:
Each unit was given a prepared pack and score card.
This pack set out the seven ‘Essence of Care’ key factors
for the Privacy and Dignity benchmark with supporting
statements which enabled the unit staff to consider
practice and re­score themselves on a score from A to E.
It also included the 2009 results so staff could reflect on
the changes made during the year. The scores were
entered on a matrix and returned for collating and review.
Conclusion:
It is clear that all areas have either scored themselves as
having stayed at the same high level (two units
remained at 85% A scores) or have improved in the
year 2009/2010.
Across the units the overall percentages of A and B
scores have increased and very few factors fall below
these high scores.
One unit ­ Beech Ward, Mulberry Rehabilitation Unit ­
opened in January 2010 and therefore had not
previously been through this process. This team
identified areas which could be improved and is creating
an action plan to take this improvement work forward.
Part 3 3.1 Review of Quality Achievements in 2010/2011
3.1.7 Patient Experience
The two main issues that have been revealed by this
benchmarking are:
1 Communication: Understanding of how to
access INTRAN.
Action: Contact details have been re­circulated
to all Modern Matrons.
2 Availability of an area for privacy:
The design of the estate and the inability of
the older un­refurbished buildings to provide
an environment conducive to maintaining the
privacy and dignity of our patients.
Action: Estates issues are flagged up at all
opportunities and have been built into the capital
bids programme. This is monitored via the Patient
Environment Action Team (PEAT) inspections and
areas are achieving high scores despite the limited
nature of the estate.
41
Outstanding Patient Environment Action Team
(PEAT) Results
Health facilities at NCH&C were assessed by the PEAT
programme during 2010. Ten of the healthcare facilities
that we manage were assessed and achieved
outstanding results in all three categories: environment,
food, and privacy and dignity.
Every healthcare facility in England with 10 or more
inpatient beds is assessed annually and given a rating of
excellent, good, acceptable, poor or unacceptable.
We obtained six ‘excellent’ scores and the remainder all
achieved ‘good’ ratings. Congratulations were passed
on to the staff at these sites for aiding in the effort to
continuously maintain a high level of standards.
This is a vast improvement on last year’s results, as we
received no ‘acceptable’ scores.
For more information about this year’s PEAT scores, please
visit: www.nrls.npsa.nhs.uk/patient­safety­data/peat
NCH&C PEAT Scores for 2010/11
Site Name
Environmental
score
Food
score
Privacy and Dignity
score
Colman Hospital, Norwich
Good
Good
Good
Norwich Community Hospital
Good
Good
Good
Dereham Hospital
Good
Excellent
Good
North Walsham Hospital
Good
Good
Good
St Michael’s Hospital, Aylsham
Good
Good
Good
Kelling Hospital
Good
Good
Good
Swaffham Community Hospital
Good
Good
Excellent
Ogden Court, Wymondham
Good
Good
Excellent
Cranmer House, Fakenham
Good
Good
Excellent
Benjamin Court, Cromer
Good
Excellent
Excellent
42
Quality Account Norfolk Community Health and Care NHS Trust
Real time data collection ­
Patient Experience Tracker (PET) Pilot
The three themes of environment, food and privacy and
dignity were included in questionnaires developed for
the PET pilot, which ran from May ­ December 2010.
The questionnaires developed for inpatients also
included elements of ‘Essence of Care’ and the
Productive Community Ward programme.
1%
4%
4%
NCH&C services involved in the pilot were asked to
create their own questionnaire for the pilot, however,
there were a number of questions common to all.
Below are some examples of the results:
2% 3%
2%
Key
9%
Excellent
14%
Very Good
Involving you in
decisions about
your care
or treatment
48%
The explanations
given to you during
your appointment
Good
Average
Poor
Very Poor
29%
84%
9%
2%
2%
3%
5%
6%
2%
10%
5%
The overall
experience of your
appointment
55%
The way the
staff communicated
with you
24%
77%
Part 3 3.1 Review of Quality Achievements in 2010/2011
3.1.7 Patient Experience
Learning from complaints and incidents
From January ­ December 2010 a total of 203
complaints were received by NCH&C.
Number of complaints
60
58
56
54
52
50
48
46
44
42
40
43
3 Changes in the procedure for clinical referrals in
prison healthcare will ensure timely clinical review.
• Changes have also been made in the distribution
medication to ensure all prison patients can collect
before leaving the landing in the morning
• Within the Learning Disabilities Service’s respite
care provision, all faxed requests to pharmacy for
medication will be confirmed by telephone to
ensure prompt dispensing and delivery
Learning event ­ 5 October 2010
Q4 2009/10 Q1 2010/11 Q2 2010/11 Q3 2010/11
NCH&C use complaints as a positive means of learning
and where necessary, making improvements. Some of
the themes or learnings from these are as follows:
1 Various aspects of communication with patients
were highlighted, including:
• Appointment systems
• Clarity of access criteria, pre­access information
required and management of patient expectations
• Problems were also identified in the way in which
clinicians communicate with patients or
carers/families
Appointment systems and patient information
are being reviewed. Clinicians communications are
under review through reflective practice.
2 Complaints about failures of community nurses to
carry out scheduled home visits has resulted in a
review of the methods of logging, allocating and
confirming home visits.
• Changes in how counselling sessions are
managed have resulted from a complaint.
The importance of a holistic approach was
emphasised with staff involved
• It was identified that some community nurses
require specialist training in post­operative care
for patients and this is being addressed
A learning event organised by the Quality and Risk
Management Team was attended by 61 members of
NCH&C staff. The aim was to enable staff to share the
learning from Serious Incidents Requiring Investigation
(SIRIs) and complaints. This included a keynote speaker
from NHS East of England on the learning from the Mid
Staffordshire Inquiry and the commissioning perspective
from NHS Norfolk. NCH&C staff presented the root
cause analysis information from SIRIs and compaints
over the past 12 months. The workshop closed with a
session entitled ‘Celebrating Success from Learning’
which all delegates were invited to contribute to. Our
internal auditors, PriceWaterhouse Cooper, attended
the event and advised that further similar events should
be welcomed across the organisation. Staff who
attended have brought the information back to their
teams. There will also be further local risk and learning
events at team level.
44
Quality Account Norfolk Community Health and Care NHS Trust
Compliments
From April ­ December 2010, 462 compliments were passed to the Complaints and Claims Manager for recording,
which demonstrate how the care, treatment, advice and support offered by all NCH&C staff is appreciated by the
patients we serve and their relatives, friends and carers. A selection of these include:
Physiotherapy, Dereham Hospital:
Pineheath Ward, Kelling Hospital:
I came here with mixed feelings about what
would be achieved. I have been very pleased with
the end result... now I have the quality of life
I have wanted for a good number of years...
I am writing to say what excellent care my husband
received on Pineheath Ward. The standard of nursing
was very high and done with care and compassion.
Nothing was ever too much trouble. The ward
was kept very clean which was good to see...
Community Nursing & Therapy:
I write to thank you and your team for the
extraordinary support you gave my late sister during
her last few days of life. She was able to say goodbye to
all her friends and family in her own surroundings and
was truly happy to be able to die peacefully and with
dignity, in the comfort of her own home thanks to
your wonderful standard of care...
The community nurses have looked after my
mother for the past eight years and me for the
past two weeks. They are all very professional, very
kind and friendly. People should appreciate how
lucky we are to have them...
My husband and I attended the Parkinson’s
Disease Education Group at Kelling Hospital.
It was very informative and well organised with
very friendly staff. We both looked forward to
those Monday afternoons...
Occupational Therapy:
Two nice young ladies came and measured me for
two sticks, which have been so useful, and
they advised me on walking and exercises.
Thank you...
Orthopaedic Outreach:
Within an hour of contacting my doctor I had
received a call from the Orthopaedic Outreach
Team, in Wymondham, and within three hours they
were at my house providing a whole range of
equipment and advice about my surrounds.
The service was well beyond my expectation
and the team was extremely professional...
Rapid Response Team:
I would like to offer our thanks to this team
which gave such fantastic care and support to us
as a family. The service you provide is second to
none and we don’t know what we would have
done without you all...
Part 3 3.1 Review of Quality Achievements in 2010/2011
3.1.7 Patient Experience
3.1.8 Commissioning for Quality and Innovation (CQuIN)
45
Commissioning for Quality and Innovation
(CQuIN) 2010/2011
NCH&C and NHS Norfolk agreed a set of quality measures which were assessed as part of the CQuIN initiative, and
which focused on the following areas for 2010/11 and represented 1.5% of the contract value:
CQuIN indicator description
Patient
Experience
Patient
Safety
Indicator
Effectiveness weighting
To improve the recording of referrals to Smokefree Norfolk
and increase health promotion in the community
3%
Introduction of a health promotion campaign
which will improve the sexual health of the
local population (15­24 year­olds)
2%
Increase the number and use of community ‘step­up beds’
10%
Set up processes to increase the number patients
provided with assistive technology support in
the community, community hospitals and care homes
10%
Review admissions to community hospitals to inform
the requirement for increasing or standardising hours
5%
To improve the care and access to services for
patients with dementia
10%
To improve the care and access to palliative
care services in the community
5%
Improve end of life care by increasing the use of Liverpool
Care Pathway (LCP) for those entering the last days of life
5%
Improve the discharge planning and referrals to
ongoing care organisations for prisoners
5%
Utilisation of Quality Outcomes Framework (QOF) to
inform and support the care and treatment of
prisoners accessing healthcare
5%
All inpatients to have their medicines reconciled within
72 hours of admission and discharge policy developed
5%
Reduced cancellation rates to community paediatrician
5%
Improve Patient Experience based on review of data
from Ipsos MORI survey
15%
Improve outcomes for patients in the community
through active review and analysis of adverse events
10%
Improve care and access to services for
patients with learning disabilities
5%
NCH&C forecast an overall delivery of 70% of the £1.5 million available through the 2010/11 CQuIN scheme
46
Quality Account Norfolk Community Health and Care NHS Trust
NCH&C Quality Account
2010/2011: Involvement
and Engagement
• Presentation of Quality Account process at the Norfolk
LINks Strategic meeting on 2 February 2011
• LINks and Public Involvement at Board and other
committees, including Quality and Risk Assurance
Committee, Patient Experience Steering Group,
Patient Environment Action Team and
Nutrition Group
• Development of the Integrated Business Plan
(IBP) by Trust Board members and the Clinical
Reference Group
• Development of the Annual Plan by Executive
Directors and Assistant Directors and their teams
• Quality and Risk Assurance Committee provides
assurance to the Board and has a LINk
representative in attendance
• Patient Experience Steering Group’s LINk representative
said: “I am already inspired by the innovative work
that, in conjunction with Norfolk LINk members,
NCH&C are currently doing to identify their own
shortcomings and thereby improve their services.”
• Third party commentary requested from Norfolk
LINk, Health Overview and Scrutiny Committee
and NHS Norfolk
Third Party Statements
Norfolk
NHS Norfolk
“NHS Norfolk, as lead commissioner for the Trust, notes
receipt of Norfolk Community Health and Care NHS
Trust’s publication of a Quality Account for 2010/11.
We have reviewed the mandatory data required within
this account and can confirm that some of the
information provided does not meet the national
requirements in terms of narrative. NHS Norfolk have
shared these areas with you so that amendments can
be made.
The report presents detailed and comprehensive
information relating to quality and safety of care
delivered within the prioritised areas identified by the
Trust. The quality goals for 2011/12 are relevant and are
substantiated by involvement with the clinical quality
and patient safety agenda via the Commissioning for
Quality & Innovation payment framework (CQuIN) and
the Quality, Innovation, Productivity and Prevention
(QIPP) initiatives. We commend staff for their work to
improve outcomes within these areas.
We look forward to the inclusion of an update on
achievements in the identified priority areas as part of
the reporting within next year’s quality account.
The patient satisfaction survey provided valuable
feedback for the Trust and identified areas of work
required to address the issues raised, building on the
progress made so far.
We will continue to work with you on all matters
relating to the quality of the services that you provide.
This includes topics or services not covered by your
2010/11 report.”
Andrew Morgan, Chief Executive, NHS Norfolk
Part 3 3.2 NCH&C Quality Account 2010/2011: Involvement and Engagement
3.2.1 Third party statements
Norfolk LINk
“A LINk member has a non voting place on the board.
The member is encouraged to voice the opinion of the
patients and public. Both Executive and Non Executive
members spend time outside these meetings explaining
policies and strategies and answering any questions.
“A LINk member has a place on the CFT Programme
Board and is also involved in the communications work
of that board to ensure that Patient and Public
involvement will be at the centre of the Community
Foundation Trust. A LINk member will sit on the
governing board of the new Trust.
“LINk recognises the excellent work that NCH&C are
undertaking in various parts of the county, however it
recognises that some of these services are not available
throughout the whole county and will continue to
monitor these services to ensure an equality of service
throughout Norfolk.
“Whilst services in the prisons appear to be improving
slowly, LINk will continue to monitor the service to ensure
that this improvement is maintained and strengthened.
“LINk recognises the value of the NCH&C vision for the
future, and hopes that the vision of working in new
geographies will not distract from the present workload.
“LINk members have been involved in the annual PEAT
inspections and can confirm that the standards remain
high in all hospitals. Any suggestions made by LINk
members have been evaluated and where possible have
been accepted. A member sits on the PEAT/PENG
working group to ensure that the highest standards are
being maintained throughout the service.
47
“LINk members are following progress of the frail
elderly focus, including dementia care and palliative
care and again want to ensure that this will be a county
wide service as soon as possible.
“LINk notes the improvement in service delivery for
wheelchairs, continuing healthcare and podiatric
surgery, but recognises that not all targets have been
achieved and will continue to monitor their progress.
“A LINk member has contributed to the estates
strategy to ensure that needs of the patients and
public will be considered.
“A Norfolk LINk member sits on the (NCH&C) Patient
Experience Steering Group that meets at bi­monthly
intervals. We acknowledge the commitment that
NCH&C has made to involving their staff in gathering
patient feedback and studying and trialling a number
of different methods of obtaining this. NCH&C also
has a comprehensive complaints system, reports from
which discussed regularly at Patient Experience
Steering Group meetings.”
Norfolk LINk 15th June 2011
Norfolk Health Overview & Scrutiny Committee
“The Norfolk Health Overview and Scrutiny Committee
has decided not to comment on any of the Norfolk
NHS Trusts' Quality Accounts for 2010­11 and would
like to stress that this should in no way be taken as
a negative statement”.
Head Office: Elliot House, 130 Ber Street, Norwich NR1 3FR
Online: www.norfolkcommunityhealthandcare.nhs.uk
Telephone: 01603 697300