Quality
Account
2011/12
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
face-to-face 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
face-to-face
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
Part 2
2.1
Priorities for quality improvement
(2012/2013)
Review of quality performance
in 2011/12
24
3.1.1
Overview
24
3.1.2
Summary of positive achievements
in the last year
24
7
3.1.3
Staff achievements
25
3.1.4
Commissioning for Quality and Innovation
27
3.1.5
Performance highlights
28
3.1.6
Clinical quality and Quality Goals
31
3.1.7
Patient experience
37
3.1.8
Learning from incidents and complaints
44
Safeguarding adults and children
49
2.1.1
Annual priorities and Quality Goals
for 2012/2013
7
2.1.2
Patient experience in 2012/13
8
2.1.3
Commissioning for Quality, Innovation,
Productivity, Prevention (QIPP)
9
2.1.4
3.1
Our staff - workforce planning
and development
11
3.1.9
2.1.5
Performance monitoring for 2012/13
12
3.1.10 Effectiveness of care
2.2
Statements of assurance from the Board
14
3.2
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
Data quality
21
2.2.7
Information Governance
Toolkit attainment levels
23
Clinical coding error rate
23
2.2.8
3.2.1
51
Explanation of who has been
involved and engaged with
56
Third Party Statements
56
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
1.1 Statement on quality
Welcome to Norfolk Community Health & Care
NHS Trust’s (NCH&C) Quality Account for 2011/12.
We hope that you enjoy reading about our activities
and achievements over the previous year and that you
gain some valuable insight into our plans and priorities
for the next year.
NCH&C is an independent health and care organisation
which is part of the National Health Service (NHS),
employs NHS staff and provides NHS health and care
to local people.
We serve a population of around 870,000 people in
and around Norfolk, making us one of the largest
providers of NHS community health and care services
in the country. Our aim is to constantly improve our
patients’ lives by providing you with the best care,
close to where you live.
We currently employ over 2,300 whole time equivalent
substantive members of staff. 80% of these are
clinicians; healthcare professionals such as doctors,
dentists, nurses, health visitors and physiotherapists. The
remainder are the people who help to keep our services
running, or who support our patients and clients during
their stay with us or in planning their appointments.
Specialised care for all
Our specialist teams all across Norfolk provide
personalised health and care services for everyone,
from babies to the elderly.
Our health visitors provide services covering pregnancy
and the first 5 years of life, while children are cared for
in schools by our school nurses. We help to keep people
healthy with our Smokefree Norfolk service, and work
with patients to regain their independence and quality
of life after a brain injury, stroke or fall. We also provide
end-of-life care services within people’s homes or
specialist inpatient units, to allow people to pass away
comfortably and with dignity.
We care for the most disadvantaged and vulnerable in
our communities who can find it very difficult or
daunting to access the right healthcare, for example sex
workers and homeless people, and we support people
of all ages with Learning Disabilities, empowering them
to live healthy and independent lives.
Range of services
The trust delivers a diverse range of 34 clinical services
that are organised into 3 main business units; children’s
services, specialist services and a locality unit
(comprising north, south, west and central localities)
through which the bulk of NCH&C’s services are
provided. This new structure is a result of a
reorganisation that took place in January 2012 to
ensure that our services operate from the same area as
the new GP Clinical Commissioning Group boundaries
across Norfolk to better serve the population.
Frail Older People
Many of the Trust’s targets for 2011/12 were specifically
aimed at the care of patients within this group and
included clinical improvements in patient safety in a
number of areas. These include; catheter acquired
urinary tract infections, reduction of avoidable pressure
ulcers, end of life care, personal health planning,
nutritional care, and admissions avoidance for patients
over 65 years old on a case manager/community
matrons case load.
Telehealth and telecare are active components of
managing case load numbers and helping the elderly
with long term conditions manage their health. In
2011/12 a significant programme of work has been
delivered in the community specifically around the use
of telehealth home pods by community teams and
currently 170 telehealth units are deployed with
NCH&C patients. This technology has been well
received by patients and many of our clinicians,
ensuring patients can be supported at home in
managing their long term condition. The Trust has
Part 1 1.1 Statement on quality
worked collaboratively with the Norfolk and Norwich
University Hospital Foundation Trust to deliver this
programme. We recognise that there is still more work
to do to improve our IT communication systems to
support the practical application of telehealth care. We
will continue to engage clinicians in the development
and implementation of telehealth care to ensure that
the benefits of this new technology bring to patients
are fully realised. During 2012/13 we will continue to
build on existing achievements and learning from our
experiences in 2011/12.
Telecare is also integral to the falls and dementia
pathways. NCH&C has recently recruited four ‘Falls
Champions’ to support the work of preventing injurious
falls. They have received training for Telecare from
Norfolk County Council and are also receiving dementia
awareness training from Norfolk and Suffolk NHS
Foundation Trust. In turn, the champions are in the
process of delivering training to the community
integrated teams to widen awareness of dementia care
and falls prevention across the Trust.
Dementia care
As part of a Norfolk-wide initiative NCH&C approached
a wide range of key stakeholders and partners over the
past year to help inform the design of the first stage of
an integrated community dementia pathway across
Norfolk. Partners in this process have included
commissioners, social services, Norfolk and Suffolk NHS
Foundation Trust, 3rd sector (Age UK, Alzheimer’s
Society), Healthwatch and acute provider organisations.
The fundamental aim of this pathway design has been
to deliver against the Department of Health’s nine
outcomes for dementia which captured what people
with dementia say about their expectations of health
and social care systems.
The integrated community dementia pathway steering
group have designed a pathway which following a
successful pilot, is now being implemented across all the
localities within Norfolk. Critical to this success has been
the joint care approach between both NCH&C integrated
community teams and community mental health teams.
This ensures that the patient and carer have an
appropriate Care Co-ordinator or Case Manager.
5
To ensure that the increase in prevalence of dementia is
recognised and that patients are treated with respect
and dignity by skilled staff, NCH&C is in the process of
implementing an extensive training programme. The
Trust is also a partner of a Health Innovation and
Education Cluster (HIEC) with private and public sector
partners whose focus is dementia. Our palliative care
co-ordinators have trained over 500 staff on dementia
and end of life care whilst working in partnership with
Age UK and the Alzheimer’s Society. This work has been
shared at national end of life conferences.
Admission avoidance
NCH&C plays a significant role in the local health
economy. Our Trust has helped local people to avoid
over 1,000 acute hospital admissions in less than five
months for those patients over 65 years old who are on
a Case Manager’s or Community Matron’s caseload.
This equates to one avoided emergency admission per
GP practice, per week.
Our Trust will continue to offer excellent service to
people 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 work
to bring expertise and good ideas from across the UK
to Norfolk, allowing our patients to benefit
from best practice from across the NHS.
6
Quality Account Norfolk Community Health and Care NHS Trust
1.2 Our vision for the future
More and more people in Norfolk and surrounding
areas are living with long term conditions, such as
diabetes and heart disease. Our population of frail and
elderly people is also growing. As the population ages,
and more people are affected by illnesses caused by
lifestyle choices, such as smoking, the types of services
needed by our community is changing.
We will aim to 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.
We want to help keep our patients well – providing care
as early as possible, to help them avoid having to stay in
an acute hospital, or supporting them to return home
as quickly and safely as possible after a hospital stay.
This Quality Account has been developed in conjunction
with our annual planning processes which has produced
the Annual Plan for 2012/13 and is part of the Trust’s
Annual Report.
The content of this Quality Account has been endorsed
by the Trust Board and has taken into account
feedback, where provided from our lead commissioners,
our local population via Norfolk LINks and Norfolk
County Council’s Health Overview and Scrutiny
Committee. I hope you will find our Quality Account
informative and helpful in reviewing our progress
against our key priorities for the forthcoming year.
The information supporting the content of this Quality
Account is, to my knowledge, accurate and
published by the Board on 27th June 2012.
As a provider of community based health and care, we
can act as the ‘glue’ between different services provided
by the NHS, social care and others, so our patients can
benefit from joined up care.
Michael Scott
Chief Executive
Part 2 2.1 Priorities for quality improvement (2012/13)
2.1.1 Annual priorities and Quality Goals for 2012/13
7
2.1 Priorities for quality
improvement (2012/13)
The Trust’s vision is to “Look after you locally”. We will improve
the quality of people’s lives, in their homes and community,
through providing the best in ‘joined up’ care. The starting point
for the Trust is the patient which means that quality is at the heart
of everything NCH&C does. Our vision is supported by the way
the Trust structures its services and wherever possible, our
services are delivered in an integrated way with social care.
The Trust was a successful pilot of Integrated Care
Organisations (ICOs) with GPs and social care and we will
continue to build on this foundation and increase its scale.
The Trust’s vision will also be delivered through the
achievement of a number of corporate objectives and
its commercial strategy.
The Trust’s longer term corporate objectives are:
• Improving quality for patients and the public
and offering the best patient experience in the
East of England
• Transforming services – being the commissioners’
first choice provider and being the positive alternative
to acute hospital care
• Building the organisation – The Trust wants to be
the first choice employer for staff and be a clinically
led, high performing organisation
• Building sustainability – to deliver a long term
financial model that demonstrates value for money,
delivers innovative services and meets the
requirements of the Trust’s regulators
• Building reputation – to be the first choice for
patients, Clinical Commissioning Groups and play a
leading role within the local health economy
2.1.1 Annual priorities
and Quality Goals
for 2012/13
The Trust Board identified seven priorities for
2012/13 that bring together our strategies and service
developments which go towards achieving the Trust’s
objectives. These annual priorities are;
1. To improve the quality of the Trust’s services for patients
2. To deliver excellent services and delight our customers
3. To truly inspire our staff
4. To embed the locality based service model
5. To achieve the Trust’s Financial Targets
6. To grow the Trust’s services and focus on the
right services
7. To achieve Foundation Trust status
Each of these priorities is supported by a number of
objectives and more detailed milestones. Both the
priorities and milestones were developed after involving
clinicians and managers outside of the Board.
8
Quality Account Norfolk Community Health and Care NHS Trust
The Quality Goals for NCH&C
for 2012/13
2.1.2 Patient experience
in 2012/13
The Trust is utilising the Safety Thermometer, a national
data collection programme to measure four potential
‘harms’; venous thromboembolism (VTE), pressure ulcers,
catheter acquired infections and falls. The first submission
was made in March 2012. The data gives a snapshot in
time and cannot show trends at this stage, but it is
recognised that its value will increase in future and the
Trust will participate in the programme fully this year.
Our vision for Patient Experience and Involvement is
that NCH&C is a patient focused organisation actively
seeking the views of our patients and carers and
engaging them in shaping and developing our services
whilst consistently providing high level, quality care. We
want our patients to have the very best experience of
community services in the East of England.
The Quality Goals for 2012/13 are:
1. Implement safety thermometer targets in four
key areas:
• Achieve 95% Venous Thrombo-embolism
assessments for inpatients by December 2012
• 50% reduction in Catheter acquired urinary tract
infections by December 2012
• Reduction in the levels of injurious falls in our
inpatient units to four per 1,000 OBDs
• Eradication of avoidable pressure ulcers (as below)
2. Deliver zero avoidable Pressure Ulcer target by
December 2012 (Grades 2–4)
3. Improve patient satisfaction to 70% very satisfied
and no area < 50%
4. Implement the net promoter score system and meet
target set for inpatients
5. To achieve ‘you’re welcome’ accreditation in school
nursing service
6. To achieve UNICEF ‘baby friendly’ accreditation at
level 2
We genuinely want to work with our patients and local
community so that together we make a difference to
the experiences of our current and future patients and
design and provide our services around their needs.
In 2012/13 the Trust aims to build on an excellent year
of patient experience in 2011/12 (see section 3.1.7) by
implementing the following projects:
• Demonstrate improvements in patient experience
using the “Net Promoter Score”
• Review results from the Community Services Survey
and implement actions as required
• Continue to embed patient stories within NCH&C
ensuring the methodology is utilised where there is a
targeted need for in depth information, deliver more
training and consider involving Healthwatch members
as interviewers alongside NCH&C staff
• Work in partnership with services to support locally
managed surveys and other methodologies for
capturing patient/carer experiences
• Work in partnership with NCH&C members and
external voluntary organisations ensuring effective
patient engagement/involvement
• Work in partnership with NCH&C Learning Education
and Development Team ensuring staff have the core
skills, beliefs and values necessary for a good patient
or carer experience
• Work with Kings College, London to participate in a
research project to seek views of parents into the
health visiting service
Part 2 2.1 Priorities for quality improvement (2012/13)
2.1.3 Commissioning for Quality and Innovation Scheme for 2012/13
Advocacy - Net Promoter
NCH&C has made good progress in the use of the net
promoter methodology in 2011/12 and will continue
to develop this tool as a key indicator of patient
satisfaction and service quality. This is a standardised
approach with a single metric to obtain real-time
monitoring of patient experience. The ‘net promoter’
score captures perceptions of the local population
about the health care they have received. The score is
the difference between the proportion of people
surveyed who said they would recommend the local
service and the proportion who said they would not.
Net promoter methodology remains in its infancy within
the Trust and it will be further developed within the
next year. All NCH&C inpatient units will participate in
the survey from April 2012 to March 2013. A minimum
of 10% of the weekly footfall of patients will be asked
the question on the day of discharge or up to 48 hours
post discharge. They will also have the opportunity to
leave any comments. A baseline net promoter score
will be established during month 1 and a 10 point
improvement score agreed over the next year. Alongside
this survey, a methodology will be developed for use
within community based services and implemented later
in the year.
9
2.1.3 Commissioning
for Quality and
Innovation (CQuIN)
Scheme for 2012/13
The CQuIN scheme requires Primary Care Trusts (PCTs)
to commission for quality and innovation through
discussing, agreeing and monitoring quality indicators
with providers. A CQUIN scheme is the locally agreed
package of quality improvement goals and indicators,
which in total, if achieved, enables the provider to earn
its full CQUIN payment.
A CQUIN scheme should address the three domains of
quality: safety, effectiveness and patient experience; and
reflect innovation. Indicators should be realistic so that a
provider is able to have a reasonable expectation that
they can achieve the requirements. Achieving the
indicator set will enable providers to receive a quality
based payment. The monies to meet the cost of this
payment will come from incentivising a proportion of
annual uplift of contract values of 2.5% for 2012/13
divided into three elements;
• 0.5% for four national indicators
• 1.0% for locally agreed indicators
• 1.0% for a system wide indicator based on reducing
emergency admissions into the acute hospitals
These indicators will be set within the contract as part
of the established quality schedule and monitored by
the PCT through clinical review.
10
Quality Account Norfolk Community Health and Care NHS Trust
NCH&C and NHS Norfolk & Waveney have agreed a set
of quality measures to be assessed as part of the CQUIN
initiative which focus on the following areas for 2012/13:
Goal Description of Goal
No
Quality
Domains
Indicator Name
National/Local/System-wide
1
To reduce avoidable death, disability and chronic
ill health from Venous-thromboembolism (VTE)
Safety
VTE risk assessment
and prophylaxis
National
2
To improve responsiveness to personal needs of
patients/carers
Patient
experience
VOICES survey
Local
3
Improve collection of data in relation to pressure ulcers,
falls, urinary tract infection in those with a catheter, VTE
Safety
NHS Safety Thermometer
National
4
Development of the Care pathway for patients risk
assessed as having dementia by the acute providers
in collaboration with other providers
Patient safety
Effectiveness
Experience
Dementia Pathway
National
5
Patient satisfaction: “How likely is it that you would
recommend this service to friends and family?
Patient
experience
Net promoter
National
6
Partnership Working
Safety
Assurance process
System wide
7
Provision of a dedicated community nurse for each
GP practice to support admission avoidance
Patient
experience
Effectiveness
Dedicated community nurse
for GP practices
Local
8
Pharmaceutical care plans for “at risk” patients
Safety
Medicines Management
Local
9
End of Life care - For NCH&C care home facilitators to roll
out training for ACP/Preferred place of care (PPoc) and
ensure that PPoC is utilised where clinically appropriate.
20 Care homes will be targeted and supported.
Patient
experience
End of Life care
Local
10
Improve the care of paediatric patients in the
community through the introduction of an
Intravenous therapy (IV) service
Patient
experience
Effectiveness
Paediatric care
Local
11
Achieve improved outcomes for patients of the
community nursing and therapy service in 5 key areas
Effectiveness
Community nursing and
therapy outcome indicators
Local
12
Avoid acute hospital admissions through effective case
management of those at greater risk of admission
Effectiveness
Case Management of high
risk patients
Local
Part 2 2.1 Priorities for quality improvement (2012/13)
2.1.4 Our staff - workforce planning and development
11
2.1.4 Our staff - workforce
planning and
development
The NCH&C Trust Board has approved a Workforce
Strategy that provides a long term strategic framework
under which exists a number of more detailed workforce
plans and strategies such as Organisational Development,
Talent and Leadership and Health and Wellbeing. The
Workforce Strategy contributes to our overall strategy
and is integrated with other supporting strategies such
as our Clinical Strategy, Estates Strategy and Information
Management and Technology (IM&T) strategy.
The Workforce Strategy is to ensure that we have a
workforce that is affordable, the right shape and has
the capacity and capability to deliver excellent health
care for the people we serve. It outlines the range of
interventions that will provide the workforce with the
skills, knowledge and development to sustain the
organisation, ensure they are committed and aligned
to our strategic objectives and enable them to have
fulfilling careers.
Staff engagement is at the centre of achieving
our aspiration to deliver high quality patient care.
Our response to the staff survey results is to prioritise
staff engagement.
The workforce strategy contains a number of
strategic objectives:
Develop clinically led workforce planning
The Trust aims to establish clinically led workforce
planning with full integration between corporate
and operational services. Recently more integrated
workforce planning has taken place for example with
project teams set up to support tenders. This model
was particularly successful in our winning Sure Start bid.
We will encourage and build on this model in all our
workforce planning activities.
Provide quality education and development
opportunities for all our staff
The strategy describes how the Trust will provide high
quality education, training and development for the
workforce, ensuring that skills are developed to support
the provision of high quality, patient focused care. The
Trust’s approach to training includes a focus on care,
compassion and personalised care and technical skills
as well as leadership and management.
To truly inspire our staff
The Trust’s Organisational Development (OD) Strategy
will ensure the processes, structures, systems and
culture necessary to achieve our vision is achieved.
Central to this strategy is staff engagement.
The Trust has well developed and shared organisational
values including a supporting behaviour framework.
Promote staff health and well being
The Trust’s Health and Well Being Strategy supports the
Workforce Strategy and acknowledges that the work,
health and well being of our employees are interlinked.
The Trust will ensure that managers have the key skills,
knowledge and ability to support employees at work, to
manage absence and also work with staff to ensure
issues which may impact negatively on staff health are
identified and minimised.
Quality Account Norfolk Community Health and Care NHS Trust
Where possible, and where common data is available,
we will be looking to benchmark against other
community trusts.
The functionality of the Trust’s ICARUS reporting system
will continue to be developed during 2012/13.
Incorporating data from other departments, such as
Human Resources and from other systems (such as
DATIX) will be actively explored to enhance the scope
of reporting performance information.
2.1.5.1 Planned changes to
performance reporting for
2012/13 Quality Accounts
The National Quality Board has recently considered how
to foster readers’ understanding of comparative
performance whilst maintaining local ownership. They
have subsequently recommended the introduction of
mandatory reporting against a small set of quality
indicators for inclusion in Quality Accounts that are
due to be published in June 2013. The intention is
that trusts will be required to report:
• Their performance against these indicators
As shown below, as at March 2012 the Trust has
achieved 90.4% against the national target of 90% VTE
assessments. For 2012/13 the target will be 95% by
December 2012. The Trust’s aim is to maintain its
excellent performance and ensure that any under
performance is escalated quickly and effectively to the
Trust’s Medical Director. The increase to 95% will be
supported by location specific plans led by the Modern
Matron in charge of the inpatient units.
Percentage of VTE assessments completed
on admission to NCH&C inpatient units
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
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NCH&C will be ensuring that our reporting systems will
report at locality level and align with our Clinical
Commissioning Groups (CCGs).
Percentage of admitted patients risk-assessment
for Venous Thromboembolism (VTE)
M
2.1.5 Performance
monitoring for 2012/13
A
12
Actual cumulative
Local standard in month: 90%
Actual:
Reporting against the indicators is not mandatory
for 2011/12, however, NCH&C have reviewed the
indicators and have provided a summary against those
that are relevant to our organisation and for which we
have current data under ‘Domain 5: Treating and caring
for people in a safe environment and protecting them
from avoidable harm’.
83.6% total year to date
90.4% March 2012
• The national average
• A supporting commentary, which may explain
variation from the national average and any steps
taken or planned to improve quality
Service spec trajectory
Local performance:
Achieving
Part 2 2.1 Priorities for quality improvement (2012/13)
2.1.5 Performance monitoring
Rate of patient safety incidents and percentage
resulting in severe harm or death
Reduction in harm incidents
The table below shows incident data collected via DATIXweb from April 2011 to March 2012 and a reduction in
the number of severe harm incidents is noted.
These figures demonstrate that only 2.14% of incidents
over the period April 2011 to March 2012 resulted in
severe harm or unexpected death.
13
The National Patient Safety Agency (NPSA) report from
1 April to 30 September 2011 states that NCH&C’s
reporting rate = 102.3 incidents reported per 1,000 bed
days (compared with other community trusts) places the
organisation in the highest 25% of reporters compared
with 19 primary care organisations with inpatient
provision in the East of England.
The NPSA states: “Organisations that report more
incidents usually have a better and more effective safety
culture. You can’t learn and improve if you don’t know
what the problems are.”
Month
April May
June July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Total
No Harm
157
147
191
208
184
181
180
200
193
208
264
215
2328
Low
97
125
150
183
193
171
204
236
231
248
254
282
2374
Moderate
21
35
32
38
35
27
32
37
27
34
40
33
381
Severe
4
6
7
10
14
10
11
10
5
8
4
5
94
Unexpected
death
1
0
0
3
3
2
0
2
1
1
4
0
17
Total
280
313
380
432
429
391
427
485
457
499
566
535
5194
14
Quality Account Norfolk Community Health and Care NHS Trust
2.2 Statements of assurance
from the Board
2.2.1 Review of services
During the period April 2011 to March 2012 Norfolk
Community Health & Care NHS Trust (NCH&C) provided
and/or sub-contracted 34 NHS services.
NCH&C has reviewed all the data available to them on
the quality of the care in 34 of these NHS services.
The income generated by the NHS services reviewed in
2011/12 represents 97% per cent of the total income
generated from the provision of NHS services by
NCH&C for 2011/12.
All services are subject to monthly risk assessment
through the use of an Early Warning Trigger Tool
(EWTT). The Trust has introduced it to act as an early
warning system to flag up potential quality and patient
safety issues before they occur. Implementation of the
tool should reduce the number of Serious Incidents
Requiring Investigation (SIRIs), reduce the risk of an
unfavourable CQC report and prevent services going
into crisis.
The original tool was produced by the National Patient
Safety Agency (NPSA) in response to the quality of care
at Mid Staffordshire NHS Foundation Trust and has been
adapted locally to better reflect community services.
Patient views and experience are integral to the tool
and is reflected in the use of patient surveys and the
level of complaints received.
Since September 2011 staff across community teams
and the inpatient units assess their areas against a
checklist with weighted scores, which resulted in an
overall RAG-rated score and an indication of what
action is required:
Green rating (score of 10 or less)
No action required, re-assess area next month
Amber rating (a score between 11 and 15)
Undertake full risk assessment and agree action plan for
‘red’ items within one month. Add to local risk register
Red rating (a score of 16 or more)
Inform line manager immediately and undertake full risk
assessment within one week. Produce an action plan
for red items within one week
The data from the tool is reviewed monthly in order to
identify services with potential issues, as well as
identifying key themes common to a number of teams
or departments. Key risks are escalated to the Trust’s
Management Team and Executive Directors. (see section
3.1.8 for more details)
The Trust Board also receives a monthly Integrated
Performance Report, which focuses on a number of
domains including patient safety, quality and risk. The
data is presented in a dashboard format, using RedAmber-Green (RAG) ratings to highlight any areas of
adverse performance supported by a narrative
explaining the reason for the variance, and actions
being taken to mitigate future risks impacting on
performance. The Board also receives a Quality and Risk
report which provides more operational detail on those
areas reported in the IPR. This report is also presented to
the Quality and Risk Assurance Committee, and
includes the following areas;
• Serious Incidents requiring investigation (SIRIs)
• Medication Incidents
• Falls
• Pressure Ulcers
• Infection rates
• Complaints and compliments
Part 2 2.2 Statements of assurance from the Board
2.2.1 Review of services
2.2.2 Participation in clinical audits
15
2.2.2 Participation in
clinical audits
During April 2011 – March 2012, 6 national clinical audits
and 1 confidential enquiry covered NHS services that
NCH&C provides.
During that period NCH&C participated in 33.3%
of national clinical audits and 0% of 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 2011 – March 2012 are as follows:
Name of National Audit
Lead organisation
Participation from NCH&C?
Epilepsy12
Royal College of Paediatrics
and Child Health
Yes
National Diabetes Audit
NHS Information Centre
Yes
Heart Failure Audit
National Institute for clinical
outcome research (NICOR)
No – there was no applicable data
available within collection period
Sentinal Stroke Audit
Royal College of Physicians
No – there was no applicable data
available within collection period
(Led by the Norfolk & Norwich Hospital)
Continence Care Audit
Royal College of Physicians
No – there was no applicable data
available within collection period
Stroke improvement national audit
Royal College of Physicians
No – there was no applicable data
available within collection period
Name of National Confidential Enquiry
Applicable to NCH&C?
Participation from NCH&C?
National Confidential Enquiry into
Patient Outcome and Death (NCEPOD)
Yes
No - there was no applicable data
available within the collection period.
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Quality Account Norfolk Community Health and Care NHS Trust
The national clinical audits and national confidential
enquiries that NCH&C participated in, and for which
data collection was completed during April 2011 –
March 2012, 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
Epilepsy12
Royal College of Paediatrics This is a retrospective audit reviewing data from
and Child Health
2010/11 which the acute trusts collect
National Diabetes Audit
NHS Information Centre
The report of two clinical audits – Epilepsy12, and the
National Diabetes Audit were reviewed by the provider
in April 2011 – March 2012 and NCH&C intends to
take the following actions to improve the quality of
healthcare provided:
Description of actions:
• Epilepsy12 – training for all consultant paediatricians
who work across the pathway covered by NCH&C,
the Norfolk and Norwich University Hospitals NHS
Foundation Trust, and the Queen Elizabeth Hospital
King’s Lynn NHS Foundation Trust
• National Diabetes Audit – The 2010/11 Audit
is currently in progress. The NDA report will be
published in June 2012 (the NHS Information Centre
for Health and Social Care)
Number of cases submitted or percentage of
numbers of registered cases required
Unable to quantify as data collected and cases
submitted by GP practices across Norfolk
Part 2 2.2 Statements of assurance from the Board
2.2.2 Participation in clinical audits
Local clinical audits
The reports of 32 local clinical audits were reviewed by
the provider during the period from April 2011 to
March 2012 and NCH&C intends to take the following
actions to improve the quality of healthcare provided:
Description of a selection of actions:
• Reducing harm from omitted or delayed delivery
of medicines in hospital – has achieved the
following results:
• Reduced the number of patients experiencing an
omitted or delayed dose (from 65% to 48%)
• Reduced the average number of omitted or delayed
doses occurring (from 4.34 doses/patient to 2.06
doses/patient)
• Reduced the potential harm caused by omissions
or delays in the administration of medicines
(from an average risk score of 5.75 to 3.06)
• Improved practices around the administration
of medicines
• Increased awareness amongst staff about this issue
and the need for accurate and complete records of
medicines administration.
17
• Essence of Care – Dignity and Respect, local
consent form devised and implemented
• Paracentesis (procedure to drain fluid from the
abdomen), Guidelines updated to include that it is
appropriate to consider draining to dryness in patients
with peripheral oedema
• Pressure Ulcer (annual, mandatory), a standardised
process implemented to ensure a patient has a
Waterlow assessment completed within 6 hours
of admission and baseline risk assessments of the
MUST nutrition tool are completed, continence and
mobility/moving and handling assessments are also
completed for all patients
• Safeguarding Supervisor’s (Children’s Services),
the safeguarding team to arrange a workshop on
group supervision and group dynamics
• Vestibular baseline audit, following initial gap
analysis findings, to re-audit and develop a business
case to present to our commissioners to expedite the
diagnosis and management of ‘dizzy’ patient’s within
NCH&C care
• Falls assessment audit, an audit was carried out in
November 2011 to determine the number of patients
who had a Falls Assessment within 48 hours of
admission to our inpatient units. The results from this
audit demonstrate that we achieved 92%, a 11%
improvement on our quarter two audit results
• Hand hygiene audits, the Infection Control Team
conduct monthly ‘hand hygiene’ audits at localities
and in 2011/12 results across the trust provided a
high level of assurance of 99% compliance across
the organisation
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Quality Account Norfolk Community Health and Care NHS Trust
2.2.3 Participation in
clinical research
The number of patients receiving NHS services provided
or sub-contracted by NCH&C in 2011/12 that were
recruited during that period to participate in research
approved by a research ethics committee was 690.
This is an increase of 42% compared with 2010/11
period and shows evidence of NCH&C’s expanding
research portfolio.
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.
NCH&C were involved in conducting 49 research
studies during 2011/12 showing a moderate (5%)
increase compared with the 2010/11 reporting period.
However 65% of studies were national portfolio,
compared with 35% in the previous year. 18 of these
studies were new projects which were given permission
to start in 2011/12. Median approval time was 36 days
which is an improvement on last year’s median approval
time of 47 days.
During 2011/12 five of our clinical teams have been
supported in their clinical research activity by the
Comprehensive Local Research Network (CLRN) funded
Research Site Initiative Scheme, which aims to develop
research activity within community care teams and
enable teams to host national portfolio research studies
to recruit to time and target. All but one of the five
teams has been successful in hosting at least one
national portfolio study in 2011/12. It is anticipated that
teams will build on this success during 2012/13, and that
the outcomes of these studies will, in the future, help to
inform innovations in the delivery of high-quality care to
improve the health and well-being of our patients.
There were 29 clinical staff participating in research (as
participants) approved by a research ethics committee
at NCH&C during 2011/12. This represents an increase
of 62% on last year’s figures.
Stroke Research Studies
Over the 2011/12 period NCH&C conducted seven
clinical research studies within the area of stroke
(care/rehabilitation). Over the same period, mortality
amenable to mortality rate from causes preventable
in stroke rehabilitation changed from the previous year
by 2.5%. The improvement in patient health outcomes
in the area of stroke rehabilitation at NCH&C
demonstrates that a commitment to clinical research
can lead to better treatments for patients.
Research bursaries
Research bursaries are awarded to enable staff to
develop their research ideas with academic partners
into fully funded research proposals Two of last year’s
(2010/11) research bursaries awarded to staff at
NCH&C have resulted in full applications for funding
to the National Institute for Health Research (NIHR)
Research for Patient Benefit Scheme in 2011/12 in
the area of Person Centered Care for dementia, and
complicated grief for people with learning difficulties;
the outcome for both is awaited. Two further research
bursaries have been awarded in 2011/12.
For the 2011/12 period NCH&C has not recorded
any publications that have arisen as a result of our
involvement in NIHR research. We plan to collect such
information during 2012/13 and will be able to report
on this activity in next year’s Quality Account.
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)
2.2.4 Goals agreed with
commissioners
Use of the Commissioning for Quality and Innovation
(CQuIN) payment framework
A proportion of NCH&C’s income during April 2011
to March 2012 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 with for the
provision of NHS services, through the CQuIN
payment framework.
Further details of the agreed goals for April 2011 to
March 2012 are set out in Part 3 of the Quality Account
and for the period April 2012 to March 2013 can be
found in Part 2.1
19
2.2.5 Statement from
the Care Quality
Commission
NCH&C is required to register with the Care Quality
Commission (CQC) and its current registration status
is ‘registered without restrictive conditions’.
From April 2011 to October 2011 NCH&C had the
following conditions on its registration:
April 2011 – Registration with the CQC was confirmed,
we were however registered with the following
conditions:
a. The Registered provider must not carry on the
regulated activity “Treatment of Disease Disorder or
Injury” in the Local Discharge Unit at HMP Norwich,
Knox Road, Norwich, Norfolk, NR1 4LU.
This condition was in place following a visit the CQC
undertook at HMP Norwich when authorising another
provider’s registration. They found that the Discharge
Unit did not comply with the regulations because it
did not protect people’s right to privacy, dignity, choice
and confidentiality.
b. 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 was imposed as the CQC confirmed that
this regulated activity must be managed by a ‘registered
manager’ as the service is seen to have a social care
aspect. There were three Locations affected by this
condition, (Mill Close an adult respite unit, Little Acorns
and Squirrels both children’s respite units).
20
Quality Account Norfolk Community Health and Care NHS Trust
And has taken the following actions:
Condition a) To ensure privacy and dignity is
maintained at all times, NCH&C ensured that the room
is only utilised by one clinician at any time. Two benches
have been installed in the recess outside the
adjudication room providing a waiting area a few
metres away from the consultation room. It will not be
possible for any waiting prisoners to overhear any
consultations. Privacy screens have also been allocated
to the room to protect peoples privacy and dignity. By
making the above changes we now protect people's
rights to privacy, dignity, choice and confidentiality
3rd June 2011 – NCH&C had confirmation from the
Care Quality Commission through issue of a Notice of
Decision that the condition applied to our registration,
restricting it from providing “Treatment of Disease
Disorder or Injury” from the treatment room in the Local
Discharge Unit at HMP Norwich, has now been lifted.
Condition b) Registered Managers at each of our [3]
respite units were appropriately registered with the
CQC and the condition regarding these respite units
was removed in September 2011
23rd November 2011 – our most recent and up-todate Certificate of Registration was issued without
restrictive conditions
The Care Quality Commission has not taken
enforcement action against NCH&C during the period
April 2011 to March 2012.
NCH&C has participated in special reviews or
investigations by the Care Quality Commission relating to
the following areas during April 2011 and March 2012:
Three inspections were made within our Joint
Community Learning Disability Teams (which are
registered through Norfolk County Council) and one
within our Learning Disability Adult Respite Unit during
the period April 2011 to March 2012. The results are as
follows:
• Western Joint Community Learning Disability Team was
meeting all the essential standards of quality and safety
• City Joint Community Learning Disability Team was
meeting all the essential standards of quality and safety
• North Joint Community Learning Disability Team was
meeting all the essential standards of quality and
safety but to maintain this it was suggested that we
made improvements to ensure we have local systems
in place to monitor the quality of the service
• Mill Close Adult Respite Unit was found to be
meeting the essential standards of quality and safety
as listed below:
• Outcome 1: People should be treated with
Dignity and Respect
• Outcome 4: People should receive safe,
appropriate care
• Outcome 7: People should be protected from abuse
• Outcome 16: The service should have quality
checking systems in place
NCH&C intends to take the following action to address
the conclusions or requirements reported by the CQC:
• Develop a local feedback questionnaire which will be
sent to users of the service with a pre-paid envelope.
NCH&C has made the following progress by 31st March
2012 in taking such action:
• A local feedback questionnaire has been developed
which will be sent to users of the service with a pre-paid
envelope. In addition there is established Norfolk
County Council feedback systems in place, whereby
clients and carers can comment on care /services
received. Both Norfolk County Council and NCH&C also
have compliments and complaints pathways in place
Part 2 2.2 Statements of assurance from the Board
2.2.6 Data quality
2.2.6 Data quality
Good quality information underpins the effective
delivery of patient care and is essential if improvements
in quality of care are to be made. Improving data
quality, which includes the quality of ethnicity and
other equality data, should improve patient care and
improve value for money.
NCH&C will be taking the following actions to improve
data quality:
A number of 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 national
key indicators. A selection of these indicators are also
reported to monthly performance meetings where
operational services are held to account for the quality
of data held on SystmOne and the Patient
Administration System (PAS). These reports are held on
a networked drive to ensure they are accessible to key
staff involved in the monitoring and reporting of
performance and activity data.
The Trust has a Data Quality Strategy which will be
critical to a number of the Trust’s priorities and
objectives, including improving the quality of patient
care, compliance with the Information Governance
Toolkit version 9 and the need to introduce and monitor
the Community Information Data Set (CIDS). This
strategy is underpinned by a Data Quality Policy. The
purpose of this policy is to ensure the highest standards
of data quality throughout NCH&C are achieved. This
policy is for all staff collecting and using data and they
must adhere to the local and national standards as laid
out in this policy.
21
22
Quality Account Norfolk Community Health and Care NHS Trust
The Trust has established a Data Quality Forum (DFQ)
chaired by the Assistant Director for Performance.
The purpose of this forum is:
• To assist NCH&C to work to a common set of
principles over 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 collectively-agreed data quality initiatives
• To assist business units and corporate functions in
raising the profile of data quality at a local level and
making the linkages with the wider agenda outlined
in above
• To provide a forum for co-ordination 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 the necessary actions required
• 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 role and function of the DQF has been recently
reviewed to ensure it meets the Trust’s strategic and
policy objectives in relation to data quality
• External validation of our information systems has
been undertaken during 2011/12 by our internal
auditors and action plans have been developed to
further improve these systems
NHS Number and General Medical
Practice Code Validity
NCH&C submitted records during 2011/12 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 out patient care
• included the patient’s valid General Medical Practice
code was:
• 100% for admitted patient care
• 100% for out patient care
Part 2 2.2 Statements of assurance from the Board
2.2.7 Information Governance Toolkit attainment levels
2.2.8 Clinical coding error rate
23
2.2.7 Information
Governance Toolkit
attainment levels
NCH&C Information Governance Assessment Report
overall score for 2011/12 was 66% thereby achieving
compliance at Level 2 and was graded by NHS
Connecting for Health as follows:
Assessment
Level 2
Exempt
Total requests
Overall score
Grade
Version 9 (2011-12)
40
1
41
66%*
Satisfactory
* 66% is the target score for achieving level 2 as set by
NHS Connecting for Health and represents a % of all
requirements met which are individually weighted
The Information Governance toolkit is available on the
Connecting for Health website:
www.igt.connectingforhealth.nhs.uk
The Information Quality and Records Management
attainment levels assessed within the Information
Governance Toolkit provide an overall measure of the
quality of data systems, standards and processes within
an organisation.
2.2.8 Clinical coding
error rate
NCH&C was not subject to the Payment by Results
(PbR) clinical coding audit during 2011/12 by the
Audit Commission.
24
Quality Account Norfolk Community Health and Care NHS Trust
3.1 Review of quality performance
in 2011/12
3.1.1 Overview
The Trust has had a challenging year on a number of
fronts that are described in detail below. An external
review was published into a service previously run by
the Trust that offered a number of criticisms and which
has significantly shaped the efforts of the Trust during
the year. Nevertheless, the year has also seen significant
achievements such as high patient satisfaction, a
significant tender win and the introduction of new roles
to support admissions avoidance to an acute hospital.
3.1.2 Summary of positive
achievements in the
last year
The Trust is proud of its many achievements in the last
year. Building on its values of pioneering, personalised
care delivered closer to people’s homes, the Trust has
delivered exciting and challenging projects and
celebrated growth in nationally recognised services.
The Trust was proud to be designated as an Early
Implementer Site for the national health visiting
programme. This designation recognised the high
quality of our services and the Trust’s ability to innovate
within the field of service redesign.
In 2011/12 the Trust continued to deliver significant
capital development projects in partnership with
commissioners and local communities. New building
projects were commenced and/or completed at both
North Walsham and Aylsham that will bring a new
range of services closer to these communities.
Continuing the theme of innovation, one of the Trust’s
school nurses received an award for innovation from
Anglia Ruskin University for his invention that is
designed to help children taking their medication for
asthma. The Trust’s Falls Service also received a runner
up commendation from the East of England as part of
their Celebrating Success Awards.
The Trust was awarded a contract worth in excess of
£21m for the delivery of 31 Sure Start Children’s
Centres that were tendered by Norfolk County Council.
This award built on the Ofsted rated ‘outstanding’
delivery of the Trust’s current 3 centres.
Part 3 3.1 Review of quality performance in 2011/12
3.1.1 Overview
3.1.2 Summary of positive achievements in the last year
3.1.3 Staff achievements
25
3.1.3 Staff achievements
Living our values awards spanned a range of roles
within NCH&C from consultants, community nurses,
technical instructors and occupational therapists to
education facilitators. The award categories are
reflective of our Trust’s four values:
1. Home and Community – Someone who regularly
demonstrates that they exist to improve the lives of
our patients, whenever and wherever needed
Winner – Community Integrated Team,
North Walsham
2. Pioneering – Someone who looks for innovative and
more efficient ways of delivering care to our patients
Winners – Palliative Care Coordinators
3. Personalised care – They strive to understand each
individual patient’s total needs and join up their
health and care requirements
Winner – Occupational Therapist, City 4 Team
4. Enabling our people – This colleague is an
incredible motivator or encourages others to
be the best they can
Winner – Education Facilitator (Palliative Care)
Colman Hospital
I would like to offer my congratulations to each
of the winners, as well as the nominees. They
truly embody our Trust’s values and I would like to
congratulate them on receiving this recognition...
I have been deeply impressed by the many examples
of colleagues striving to deliver the best possible
care and to further improve services for our patients.
These dedicated staff are true
ambassadors of NCH&C…”
Michael Scott, Chief Executive
Finalist at national awards
A community nurse and care manager was named
as a finalist in the national General Practice Awards,
‘Nurse of the Year’ category. Based at Sapphire House,
Norwich, Tracey Blazey was one of just over 200
nominations in this category put forward by colleagues.
Tracey, who has 30 years’ NHS experience was
nominated for the consistently high-quality of care
she provides to adults who have learning disabilities.
Queen’s Nurse honour
A Specialist Neurology Nurse was awarded the title of
‘Queen’s Nurse’ in recognition of her commitment to
delivering further improved community-based care.
Katrine ‘Trine’ Kiertzner, who has 25 years’ nursing
experience, received the title from community nurses’
charity the Queen’s Nursing Institute. The title aims to
unite nurses who have promoted high standards of care
and encourages them to champion new ways of
delivering innovative practices.
26
Quality Account Norfolk Community Health and Care NHS Trust
Improving teenagers’ mental health
School Nurse, Bernadette Osterberg, is rolling out a trial
project to provide innovative care for high school
students who have a history of self-harm, substance
abuse and risk-taking behaviours. Bernadette aims to
improve their mental wellbeing by facilitating joined
up care, working with partners such as Child and
Adolescent Mental Health Services (CAMHS) and the
Mancroft Advice Project (MAP) to enable young people
to get access to counsellors, youth workers, and advisers.
Family praises ‘absolutely fantastic’
Community Matron
A Community Matron has been hailed as ‘an amazing
ambassador of the NHS and mankind’ by the family of a
former patient. Fiona Baldwin received the praise after
caring for the patient at their home for over a year. In a
letter, the family said “Fiona showed such competence,
care and support to the whole family… and despite
mum’s poor health, she would perk up at just the sound
of Fiona’s voice... As a person I think she is a truly
wonderful lady… and my family extend our warmest
thanks to her.”
Certificates of recognition
Each month we celebrate the commitment of our staff
to the continued delivery of excellent care and support.
Staff receive a Certificate of Recognition at the
Management Forum and are named in the staff
newsletter, ‘The Exchange’.
Compliments and ‘Thank you’s’
to our staff
Below are selections of the hundreds of compliments
our staff receive over the course of a year:
Beech Ward, NCH
Many small acts of kindness noticed.
All added to the tranquil, positive
atmosphere of the ward...
Pulmonary Rehab Service, Kelling Hospital
I can bend to put my socks on which
I couldn’t before. A very good team,
which I hope will continue to
help a lot more old codgers...
Cranmer House, Fakenham
My husband was very lucky to have landed
within your ‘embrace’. You run
a superb ship. Congratulations...
Alder Ward, NCH
Dads last days were made so much
better than they could have been...
Staff at the Mulberry Unit, NCH
You are all earth angels...
Community Nursing and Therapy team, NCH
You all smile which means a lot to
us old ‘uns’ Patient aged 92 ½...
District Nursing
Thank you so much for your support in
making Dad’s last days easier for him
to bear, at home, with loved ones…
Foxley Ward, Dereham Hospital
Thanks for all the staff for all their help and
friendship for my speedy recovery.
I have enjoyed my time with you…
Speech and Language Therapy Team
The support I received was excellent and
my speech has improved greatly. I still
have difficulties recalling words, but
I continue to use the helpful
strategies that you taught me...
Part 3 3.1 Review of quality performance in 2011/12
3.1.4 Commissioning for Quality and Innovation (CQUIN)
27
3.1.4 Commissioning
for Quality and
Innovation (CQUIN)
NCH&C has made excellent progress against its CQUIN
Scheme by quarter in 2011/12 bringing our total CQUIN
earnings for the last financial year to circa £1.25m.
CQUINs are contractual commitments which encourage
progress to be made within key areas of local services.
As a reward for meeting these commitments our Trust
will now receive significant investment from our
commissioners which is funding that can be used to
make further improvements in the future.
Indicator
Quarter 1
Achievement/Outcome
Quarter 2
Quarter 3
Quarter 4
Increase number of patients provided
with telehealth in the community and
audit the outcomes
85%
100%
100%
TBC
Use of the End of Life,
Gold standard framework
100%
66%
No payment due
100%
Use of the End of Life,
Liverpool Care pathway
100%
100%
100%
TBC
Medicines management
100%
100%
100%
100%
Patient satisfaction - Adults
100%
100%
No payment due
100%
Patient satisfaction – Children’s services
100%
100%
No payment due
75%
Reduction in injurious falls
No payment due
No payment due
No payment due
100%
Improve carer experience - Adults
100%
100%
100%
100%
Improve carer experience – Children’s
100%
100%
100%
100%
Achieve UNICEF accreditation stage 1
No payment due
No payment due
100%
100%
TOTAL
96%
98%
100%
TBC
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Quality Account Norfolk Community Health and Care NHS Trust
3.1.5 Performance
highlights
Areas of achievement
During 2011/12 the Trust had a number of important
targets to achieve or maintain. One of the key
performance targets to be achieved was the 18 week
wait Referral to Treatment (RTT) target, where 100%
of admitted and non-admitted patients had to receive
a definitive treatment or intervention within 18 weeks
of referral.
Throughout the year, NCH&C made significant
improvement with most services either achieving the
target on a consistent basis, or being close to 100%.
The one service that did not meet this until the end of
March 2012, was podiatric surgery.
Throughout the year, and in line with the previous year,
NCH&C maintained low levels of delayed transfers of
care. On average, patients whose discharge was
delayed for non-medical reasons occupied only 4.1% of
beds, compared to 4.4% the previous year. There are
no contractual targets in place for this measure. This
improvement in the discharge process is as a result of
the implementation of the ‘Productive Ward’ across
NCH&C’s community hospitals. Analysis of the data
from Norfolk and Norwich University Hospitals NHS
Foundation Trust (NNUH) suggests there may be
circumstances that cause regular and significant peaks
in demand for community beds. If the peak in demand
is unavoidable, the commissioner will need to decide
whether to increase capacity or accept delays will occur.
In 2010/11 the Trust experienced nine cases of C.diff.
For 2011/12, NCH&C had a ceiling of no more than
nine cases for C.diff and one for MRSA bacteraemias.
By the end of March 2012, there were eight reported
cases of C.diff and no MRSA bacteraemias. All reported
cases have been subject to Root Cause Analysis (RCA)
to review lessons learned.
As part of the Provider Management Regime (PMR)
with NHS Midlands and East, NCH&C is required to
report the number of items delivered to patients from
its Central Equipment Store. Throughout the year, the
Trust delivered in excess of 23,600 items of which more
than 99.3% were delivered within seven days of receipt
of a referral. The SHA target is 100% of items delivered
within seven days.
From April 2011, the NHS East of England (prior
to the clustering of strategic health authorities),
requested that the Trust commence reporting of
Venous Thromboembolism (VTE) assessments for
patients admitted to its community hospitals.
The Trust established a locally agreed trajectory,
against which it would be monitored, and to then
achieve the national target of 90% compliance by
February 2012. By January 2012 the 90% target
was achieved.
Part 3 3.1 Review of quality performance in 2011/12
3.1.5 Performance highlights
29
Meeting targets 2011/12
Indicator
Target or upper ceiling
2011/12
performance
Trend
MRSA bacteraemia
No more than one case during 2011/12
0 cases
Stable
MRSA screening
- elective patients
100% of patients having planned
surgery screened for MRSA
100%
Stable
Clostridium difficile
No more than nine cases during 2011/12
8 cases
Stable
Delayed transfers of care
No more than 6% of beds occupied by patients
whose discharge is delayed for non-medical reasons
4.1%
Stable
Venous Thromboembolism Percentage of admissions who had a VTE
(VTE) assessments
assessment undertaken
90.4%
Increasing
Community equipment
store
>99% of items delivered within seven days of receipt
(CES) response within seven days
99.4%
of a referral
Stable
Health visiting
95% or more of mothers receiving a New Birth Visit
within 28 days of birth
97.1%
Stable
Injurious falls
Achieve a reduction in the number of falls resulting
in harm per 1,000 Occupied Bed Days
4.03
Declining
30
Quality Account Norfolk Community Health and Care NHS Trust
Areas of non-delivery
There was one consistent variant to 18 week
performance. This was within the Podiatric Surgery
Service. During the year a number of operational
actions were introduced and underpinned by
comprehensive analysis and modelling of demand,
capacity, backlog and activity. This enabled the service
to work towards full compliance with the 18 week
wait target. A performance notice and exception
notice were issued (without incurred financial penalty)
which remains in place at the time of writing.
This service has been 18 week compliant since
April 2012.
The Smoking Cessation service agreed an annual target
for 2011/12 with NHS Norfolk of 2,700 quits. Despite a
comprehensive restructure of the service to deliver the
quit target, achieving the necessary level of referrals
supported by a strong conversion rate proved
challenging. It became apparent during the year that
the Trust was starting to deviate from its trajectory and
a number of actions were established to improve
referrals rates. However, the subsequent referrals
generated were not sufficient to recover the level of
quits required, and as such the Trust failed this target.
For 2012/13, the Trust will work in partnership with
NHS Norfolk and Waveney to understand the
demographic context of the targets and look at new
ways of working with partner organisations to improve
quit rates and referrals. A target of 2000 quits has been
set for 2012/13 by the commissioners. The focus for the
service for the coming year will be to achieve its target
of 2000 quits including an impact on target groups
such as routine manual workers and to demonstrate
how it has supported the wider health system in
achieving their overall target of 6000 (see section
3.1.10 (d) research project).
The Trust was commissioned by NHS Norfolk and
Waveney to provide a Continuing Health Care
assessment service. Throughout the year, the Trust failed
to achieve NHS Norfolk and Waveney’s target of 100%
of assessments undertaken within 28 days of referral.
Although this was in part, compounded by factors
related to external agencies, the management of the
service transferred to NHS Norfolk and Waveney in
February 2012 in order that they may take control
of a wider strategy around continuing care.
Missing targets 2011/12
Indicator
Target or upper ceiling
2011/12
performance
Trend
18 weeks Referral
to Treatment
100% of patients seen within 18 weeks of referral
98.7%
Stable
Smoking cessation
To achieve 2,700 successful quits during 2011/12
2,051
Declining
Part 3 3.1 Review of quality performance in 2011/12
3.1.6 Clinical quality and Quality Goals
3.1.6 Clinical quality and
Quality Goals
This section outlines the Trust’s progress against
national and regional quality improvement priorities as
well as the Trust’s own priorities and Quality Goals from
2011/12 under the following headings;
• Patient safety – protecting people from harm
• Effectiveness of care – promoting a culture of
continuous improvement through audit and research
projects and implementing NICE guidance
• Patient experience – listening to what our service
users think
Our Quality Goals for 2011/12 were developed through
the annual planning process and reported in the
forward-looking section of our Quality Account
for 2010/11 and linked to the Trust’s Quality
Improvement Strategy. They are listed as follows:
1. To reduce levels of pressure ulcers
2. To reduce levels of attributal clostridium difficile (C. Diff)
3. To reduce levels of MRSA bacteraemia
4. To reduce levels of falls resulting in serious harm
5. To reduce levels of medication errors
Under the Patient Experience heading we also set the
following goals (see section 3.1.7 for details):
1. Establishment of a patient experience tracker tool
(CQuIN indicator 5)
2. Carer satisfaction surveys (CQuIN indicator 7)
3. Improvement of the Ipsos Mori areas that scored
<50% (Communication, Environment, Information
and involvement)
31
Quality Goal 1 - To reduce levels of
pressure ulcers
The Trust is committed to achieving the aim of
eliminating all avoidable pressure ulcers by December
2012 and this is our top clinical improvement priority
for 2012/13.
To achieve this aim the Trust has set up a strategy group
which is chaired by our Chief Executive and has clinical
and corporate support on the steering group. To
support this activity, the following task and finish
groups have been formed:
• Clinical improvement and outcomes
• Partnership working and patient engagement
• Performance and improvement
• Education, clinical competencies and skills training
During 2011/12 NCH&Creported 111 serious incidents
requiring investigation (SIRIs) of grade 3 and 4 pressure
ulcers. The Trust has sought to encourage a positive
reporting culture and has held a number of learning
events to raise awareness of the positive effects of
reporting all incidents and Pressure Ulcers specifically.
At the beginning of 2011, NCH&C agreed a variation
on deadlines for pressure ulcer reporting with NHS
Norfolk and Waveney (NHSN&W). It was agreed that
the full root cause analysis 45 day report would not be
required but instead a more detailed seven day update
would be submitted.
In order to closely monitor the ambition to eliminate
Grade 2, 3 & 4 avoidable pressure ulcers, a change in
SIRI reporting requirements to NHSN&W and the
Midlands and East Strategic Health Authority has been
agreed as from May 2012.
32
Quality Account Norfolk Community Health and Care NHS Trust
Three workshops have been held across the county to
launch the new Prevention and Management of Pressure
Ulcer policy which were well attended by our clinical
staff. Each of the three sessions included shared learning,
e-learning, incident reporting, the use of pressure relief
equipment, Nutrition Malnutrition Universal Screening
Tool (MUST) tool and Waterlow scoring training. An
important outcome of the workshop was to resource
the clinical leaders to train their teams in the use of the
management tools. This was achieved. This is being
followed up through the provision of a number of
‘roadshows’ for all teams in 2012/13.
In the last year, the Trust set a target of 100% of older
people identified as at risk to be assessed within 48
hours of admission using the MUST tool in line with the
local QIPP target. Against this 48 hour assessment target
whilst quarter 4 results were lower than quarter 3 we
can report an overall improvement for the year of 8%:
Qtr 1: 80.5%
Qtr 2: 85.4%
Qtr 3: 90.3%
Qtr 4: 87.6%
Outcomes from the recent organisation-wide pressure
ulcer audit will be used to inform the focus of the
clinical improvement programme. The Trust has also
engaged with the SHA Expert Pressure Ulcer Group and
the Tissue Viability Network Group, and is seeking to
implement a tissue viability team through additional
commissioning income and via internal resources.
Going forward, the Trust will continue roll out of
the Safety Thermometer for the four ‘harms’ which
includes the recording of pressure ulcer data (see 2.1.1
for more information).
Quality Goal 2 – Reduction in
healthcare acquired infections (HCAI)
During 2011/12 the Infection Prevention and Control
(IPC) team have worked closely with NHS Norfolk to
further develop key information packs for MRSA and
Norovirus which are in use within NCH&C and the
community generally. We have endeavoured to work
closely with all healthcare providers within Norfolk to
develop a joint response to Norovirus and the issues it
causes across the health economy. Following the Chief
Nursing Officer’s letter of March 2011 and as discussed
below we have developed a Clostridium Difficile (C.diff)
scrutiny group which will allow us to more accurately
report our levels of C.diff.
In the future (2012/13) the Trust plans to work with
NHS Norfolk to develop a business case for an IPC
liaison nurse to develop IPAC within primary care
ensuring high risk patients are identified and treated for
MRSA and closely monitor patients at risk of a relapse
of C.diff. The IPC team also hope to further engage
with primary care in protecting patients from healthcare
acquired infections across Norfolk.
Part 3 3.1 Review of quality performance in 2011/12
3.1.6 Clinical quality and Quality Goals
33
b. To reduce levels of attributable Clostridium
difficile (C.diff)
Following a period of four months with no C.diff cases
occurring, NCH&C has reported one new case for
January 2012. This brings our total for the year April
2011 to March 2012 to eight cases against an annual
ceiling of nine. This compares to nine cases in 2010/11.
• An Infection Control Nurse attends a pan Norfolk
meeting regularly to update on progress
• A Catheter Care Policy: Competencies and Guidelines
has been completed and is awaiting approval
• Regular training has been organised for staff via the
Trust’s Training Department
C.diff cases against a monthly trajectory April 2011
2
to March 2012
6
5
4
3
2
1
0
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• A working definition of CAUTI has been agreed with
the Consultant Microbiologist
A scrutiny group is convened, for each case of C.diff,
which discusses the findings of the root cause analysis.
Number of Cases
The monitoring of catheter acquired infections is of
high importance to NCH&C. The Trust aims to reduce
catheter acquired infections by 50% by December 2012
in line with a local QIPP target. In working towards this
target a clinical task force has achieved the following
outputs in the last year:
A
a. Catheter Acquired Urinary Tract Infection (CAUTI)
NCH&C has a robust procedure in place which dictates
that all C.diff positive specimens are also tested for
lactoferrin, in line with national guidance. A positive
lactorferrin result indicates an inflammatory response
within the bowel, ie, a true infection rather than
colonization. This ensures only true cases of C.diff
infection are reported and not cases of colonization.
2011-12 Trajectory
• A pathway has been completed and approval is
awaited for a ‘trial without catheters’ to be carried
out by the continence team
• Intermittent self catheterisation assessment and
training is ongoing as per NICE guidelines
• A catheter care plan has been completed
• Appropriate measures and baselines have been put
in place to inform work going forward. This was
required before a formal target could be put in place
2010-11 Actual
2011-12 Actual
c. To reduce levels of MRSA bacteraemia
There were no cases of MRSA bacteraemia in 2011/12.
This compares to one case in 2010/11.
Quality Account Norfolk Community Health and Care NHS Trust
Inpatient falls reported by degree of harm
100
60
40
20
No harm
Moderate harm
Low harm
Severe harm
12
ar
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2
bFe
M
1
12
n-
Ja
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ec
-1
1
-1
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ov
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O
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1
11
1
-1
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Number
80
This improvement has been a result of significant and
ongoing work around reducing falls across units to the
point that further significant reductions are not
expected as current evidence-based interventions and
improvement techniques have now been put in place.
The evidence seems to back this up suggesting there
was a step change earlier in the year at which point the
average has stabilised rather than continuing to
improve. As such performance is expected to remain at
this level if techniques are continued and with no other
changes arising (e.g. change in patient profile).
Falls/1000 OBD performance - inpatient units
7.0
6.5
6.0
5.5
5.0
4.5
4.0
3.5
3.0
2.5
2.0
pr
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2
The graph below shows the degree of harm of patient
falls from April 2011 to March 2012.
M
The aim for 2011/12 was to improve outcomes for
patients in inpatient units through the reduction of
falls to meet or be below 4.4 per 1000 Occupied Bed
Days (OBD).
The graph below demonstrates the inpatient falls
compared to 1000 OBD for April 2011 to March 2012.
March saw average Injurious Falls/OBD results again
fall well below last year’s performance and significantly
below the CQuIN target of 4.4. This has led to a final
year average against the CQuIN marker of 4.0 Injurious
Falls/1000 OBD down from 5.2 last year. There remains
significant variation month by month, and unit by unit,
as even a small number of falls can raise this figure
very quickly.
A
Quality Goal 3 – To reduce levels
of falls resulting in serious harm
Falls/1,000 OBD
34
2011/12 Performance
2011/12 Target
2011/12 Average
Part 3 3.1 Review of quality performance in 2011/12
3.1.6 Clinical quality and Quality Goals
Clinical Audit
An audit was carried in November 2011 to determine the
number of patients who had a falls assessment within
48 hours of admission to our inpatient units. The results
from this audit demonstrate that we achieved 92%, an
11% improvement on our quarter two audit results.
An action plan was produced in quarter one following
the guidance from Patient Safety First. The action plan
has been updated demonstrating the actions carried
out during quarter three, such as a programme of
training, an environment review, an assistive technology
pilot on one of the wards and the roll-out of the
‘intentional rounding’ pilot.
Falls Service named ‘runner up’
NCH&C’s Falls Prevention Service was named as runner
up at the NHS East of England Strategic Health
Authority’s ‘Celebrating our Success’ Awards last year.
The service was shortlisted in the ‘Whole Health
Economy Engagement’ category for its work to help
people avoid a fall by providing proactive interventions
and support to at-risk patients. The team ensured over
444 unnecessary hospital admissions due to falls were
avoided between April and June 2011. They developed
a joined up approach alongside other NCH&C services
and partners – such as GPs, Norfolk County Council,
NHS Norfolk and care homes – to identify and provide
care to patients at risk of suffering a fall. Falls
Champions have also been introduced to deliver
training to other clinicians to help them to identify
causes of falls and consider effective interventions.
The corporate objective of fewer than 20 incidents of
moderate harm or above has been achieved with 13
occurring in the period April 2011 to March 2012.
The following graph shows the trend of severity since
April 2011, and indicates that moderate harm incidents
are stable at between 1 to 3 per month (mean = 1), low
harm incidents increasing very gradually, and no harm
incidents increasing steadily, indicating the continuing
development of a healthy reporting culture. This still
represents a very small proportion of the activity involving
medicines within the Trust.
Breakdown of incidents by severity, with trends
80
70
60
50
40
30
20
10
0
pr
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The low rate of falls within our inpatient units
demonstrates that patients are continuing to receive high
quality and safe services from our Trust. Injurious falls
present a significant risk to the health and independence
of patients as they can extend a patient’s length of stay
or even result in an acute hospital admission.
Quality Goal 4 – To reduce levels of
medication incidents
A
Patient safety
35
No harm
Moderate harm
Low harm
The dip in no harm incidents reported in March needs
further investigation. The number of incidents in the
prison setting has reduced since a peak in November;
30 incidents were reported in November, and only 13
in March. This gradual reduction was off-set by an
increase in the in-patient units due to a focus on
reporting all incidents of delayed or omitted doses,
which related to ongoing audits as part of the CQUIN
scheme. However, in-patient units reported 41 no harm
incidents in February, but only 16 in March. The
reduction in no harm incidents may also be related to
other factors such as low staffing numbers or end of
year tasks that have taken the focus off incident
reporting were there was no harm.
The split of medication incidents across the Trust is mostly
in proportion with previous months, with the majority
being reported in the prisons and inpatient units.
36
Quality Account Norfolk Community Health and Care NHS Trust
Controlled Drugs Incidents
The incidents occurring involved a range of different
issues, including missed doses, syringe driver issues,
wrong patient administration and management of
CD stocks. For quarter 4 (January 2012 – March 2012)
there were no incidents resulting in moderate harm.
Controlled drug incidents by month and severity
• Reduced the number of patients experiencing
a omitted or delayed dose (from 65% to 48%)
• Reduced the average number of omitted or delayed
doses occurring (from 4.34 doses/patient to 2.06
doses/patient)
• Reduced the potential harm caused by omissions
or delays in the administration of medicines
(from an average risk score of 5.75 to 3.06)
25
20
Number
This campaign has, over the course of the last
12 months, demonstrably:
• Improved practices around the administration
of medicines
15
10
• Increased awareness amongst staff about this issue
and the need for accurate and complete records of
medicines administration.
5
Percentage change in mean risk score
M
ar
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2
12
12
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O
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Ju
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7
Moderate harm
6
5
4
Clinical Audit: Reducing harm from omitted or
delayed delivery of medicines in hospital:
3
2
In February 2010 the NPSA issued an alert warning of
the risks of delaying or omitting the administration of
medicines in inpatient units. To ensure that this alert was
embedded thoroughly into practice and there was a
demonstrable improvement, it was decided that the
inpatient units would be audited and a campaign run to
raise staff awareness and implement the required actions.
The audit found that there is much good practice
occurring and the vast majority of medicines were
administered at the right time and recorded correctly
and appropriately.
1
0
Q2
Q3
Q4
Target
This graph shows that the mean risk score has reduced
from an average of 5.75 in the baseline audit to 3.06 in
the quarter 4 audit. This is very close to the target of 3.
The units that have not yet achieved the agreed targets
for this audit will be asked to produce an action plan
to remedy their local issues. These units will then be
re-audited within 3 months to check progress. All units
will be re-audited annually to ensure that this issue
remains high on the agenda.
There are still areas where the Trust can improve,
such as reducing interruptions during medicine rounds,
ensuring robust systems are in place for recording
administration and reviewing prescription charts, and
these should continue to be monitored locally. There
should also be an annual audit of prescription charts
with the audit targets set in this campaign as the
baseline standard.
Part 3 3.1 Review of quality performance in 2011/12
3.1.7 Patient experience
37
3.1.7 Patient experience
3.1.7.1 Patient and carer surveys
Patient experience is a main pillar of NCH&C’s strategy
to keep the patient at the centre of all that we do. The
following patient and carer experience survey work has
taken place as part of the delivery of NCH&C Patient
Experience and Involvement Strategy April 2011 –
March 2013. Work will continue into 2012/13 before a
refreshed strategy based on findings from this period
will be implemented. Early studies show some excellent
results for the Trust and are described below.
Picker Inpatient Survey Results
NCH&C commissioned the Picker Institute Europe to
conduct a survey among inpatients staying in the Trust’s
community hospitals. Face-to-face interviews were
conducted in 13 community hospitals by professional
market research interviewers during February 2011.
A total of 122 (48%) of patients from participating
hospitals took part in the survey which is an excellent
response rate.
The overall ratings were as follows:
• 97% of respondents rated care as excellent, very good
or good (39% excellent, 45% very good, 13% good)
• 97% said they would recommend the hospital to
others (83% said definitely while 14% said probably)
• 90% of respondents felt they were always treated
with respect and dignity by hospital staff
• Almost nine out of ten patients (86%) felt that the nurses
caring for them were always responsive to their needs
• 89% felt they were involved in decisions about their care
and treatment (67% definitely and 23% to some extent)
The Trust has taken a number of actions as a result
of recommendations:
• Healthy food options are always available and
nutritional booklets are utilised with the patient to
support them in selecting healthy food options and the
catering satisfaction survey has been updated to include
a question about healthy food options being available.
• Provision of ward information on admission and
a general patient information booklet has been
developed and agreed. Unit specific detailed
information is currently being developed based
on an agreed template.
38
Quality Account Norfolk Community Health and Care NHS Trust
Local Patient Experience Surveys
Adult services
3551 local surveys were completed to gather feedback
and subsequently improve patient experience focusing
attention on adult services at Norwich Community
Hospital and St James Clinic, King’s Lynn; Orthopaedic
Triage, MSK Physiotherapy, Podiatry and Biomechanics.
The methodology used to collect data was through the
patient experience software system Meridian where
information is collected in a variety of ways:
• electronically through email
• through a touch-screen kiosk
• through paper surveys
The reporting of all results was service specific. There
were three key themes for the survey; information/
involvement, environment and communication as well
as ‘general’ covering overall satisfaction and would you
recommend this service.
All surveys went live on 1 July 2011 and continued until
end February 2012. The key results are show below:
3551
surveys
completed
Survey Theme
97.4%
overall
satisfaction
across all
surveys
Overall satisfaction
rating
General
96%
Information/Involvement
95%
Environment
100%
Communication
98%
The comments received resulted in a number of actions:
• Improved service specific information has been
developed including information on what to expect at
first appointment. Patient Information leaflets have
been produced for all four services and are sent with
appointment letters
• Improved directions and parking information at
Norwich Community Hospital is now issued; a new
site map has been produced giving clearer details on
parking and directions to the site and once on site
• Improved signage at Norwich Community Hospital
has been put up from the car park to main reception
for clinics and clearer signage once inside the main
building for clinic areas has been added
• Improved Biomechanics and Orthopaedic Triage
waiting areas at Norwich Community Hospital
through both areas being de-cluttered, clear notices
now being displayed in Biomechanics welcoming
patients to the service and the reception staffed
regularly, notice board displays have been updated in
Orthopaedic Triage. This work is in progress currently
Part 3 3.1 Review of quality performance in 2011/12
3.1.7 Patient experience
39
Children’s Services
The comments received resulted in a number of actions:
A programme to gather and improve information to
be used to improve children and families experience
focusing attention on clinics provided at Upton Road
Children’s Centre, Norwich was delivered during 2011/12.
• Existing Patient Information leaflets have all been
updated to include additional information requested
prior to first appointment
The methodology used to collect data was through
the patient experience software system Meridian’
where information is collected in a variety of ways;
electronically through email, through a touch-screen
kiosk or paper surveys with the reporting of all results
service specific. There were three key themes for the
survey; information/involvement, environment and
communication as well as ‘general’ covering overall
satisfaction and would you recommend this service.
All surveys went live on 1 July 2011 and continued
until end February 2012.
The results of this survey are shown below:
1015
surveys
completed
95.2%
overall
satisfaction
across all
surveys
• Improved waiting area for children of all ages;
additional toys acquired
• A more accessible version of the survey was
developed via an easy-read format
Local Carer’s Experience Surveys
Within the Trust a holistic approach to care is
championed and carer and family feedback is of
significant importance to us in measuring our overall
performance. Two surveys were delivered in 2011/12
with this group specifically in mind.
A carer’s satisfaction survey was carried out focussing
on interactions with Case Managers and in the Trust’s
residential short breaks service for children.
The methodology used in both surveys was a system
called ‘health feedback’ consisting of a very simple A5
size survey card completed manually, online or via a free
phone number. The surveys commenced in July 2011
and ran to December 2011.
In addition to the survey questions respondents were also
asked for their comments. The findings were as follows:
Adult services:
Survey Theme
Overall satisfaction
rating
General
92%
Information/Involvement
91%
Environment
99%
Communication
96%
•100% felt they were always or usually treated with
respect by staff
• 99% of carers felt they were involved as they wanted
to be
• 99% felt the information they were given had been
very or fairly helpful
• 95% felt very satisfied with the overall experience,
5% fairly satisfied
• 91% felt they were very satisfied with the way staff
communicated with them
40
Quality Account Norfolk Community Health and Care NHS Trust
As a result of this survey, the following key actions have
been taken:
As a result of this survey, the following key actions have
been taken:
• Improved information leaflets have been drafted and
will be personalised to each area
• Improved involvement of parent/carers in the planning
of care for the child; each child will have a full review
of their short breaks care package six monthly
• Commitment has been taken to ensure a change of
Community Matron will be well communicated and
explained to carers
• A carers focus group took place in March
2012 to discuss survey results, actions and
future recommendations
• Named member of staff responsible for organising the
booking with Parents/carers contacted by phone if
their booking needs to be amended giving them as
much notice as possible
• A privacy and dignity action plan is being written for
each unit. To maintain this during personal care
“stop” and “go” signs have been placed on toilet and
bathroom doors. Each child will also have a name
plate and a photograph on their room during each
stay to identify personal space
• Increased communication is aided through a
newsletter which has been developed to improve
communication between parents/carers and the units
• A re-survey took during March 2012 to determine if
actions put in place have improved satisfaction
Community Services Survey – February 2012
Children’s services:
• 96% parents/carers felt very or fairly involved in the
planning of care for their child
• 65% said there had been no changes to their
booking with 35% saying it had been changed
only once or twice
• 55% said they were very satisfied with the allocation
change, 25% fairly, 15% neither satisfied nor dissatisfied
• 74% felt their child had always been treated with
respect with 26% saying usually
• 52% felt very confident their child’s individual needs
had been met, 43% fairly
• 70% said staff had been very helpful with 30%
saying fairly helpful
• 70% were very satisfied with their overall experience
of the service and 30% were fairly satisfied
NCH&C took part in a community services survey,
coordinated by Hounslow and Richmond Community
Healthcare for all community trusts. Patient Perspective
has been commissioned to conduct the survey and
provide analysis and reporting to each participating
trust. The survey focused on Podiatric Surgery,
Continence, Paediatric Speech and Language Therapy
(SALT), Adult SALT and Wheelchair Services. The survey
closed at the end of March 2012 and results show
comparative data for NCH&C with five other
community trusts. Scores for privacy, dignity and respect
gave the highest scores for NCH&C, closely followed by
the quality of service received and inclusion in
discussions about care. Lower comparative scores were
recieved for patients being told how long the time of
waiting for an appointment was likely to be, transport
to and from hospital and the opening hours of services.
Part 3 3.1 Review of quality performance in 2011/12
3.1.7 Patient experience
41
3.1.7.2 Patient Stories
Advocacy – Net Promoter
A key objective within NCH&C Patient Experience &
Involvement Strategy April 2011 to March 2013 is to
“embed patient stories as an in-depth qualitative
methodology in NCH&C”. The Trust has made a number
of service improvements as a result of this work.
NCH&C has made good progress in the use of the net
promoter methodology in 2011/12 and will continue to
develop this tool as a key indicator of patient satisfaction
and service quality. The results from 2011/12 specifically
relating to net promoter are as follows:
• SureStart Children’s Centre at Bowthorpe, West
Earlham and Costessey has increased communication
within GP surgeries, local libraries and schools about
services offered at the Centre. The content of a “Stay
and Play” session had been altered to meet the
requested needs of parents attending with their
children. The centre was assessed in 2011 as
“outstanding” by Ofsted and commended on their use
of parent stories, requesting more were conducted.
From the Picker Institute Survey 2011
• Starfish West Learning Disability & Behaviour team
have a new service leaflet designed for parents/carers
and have improved the referral process from
Paediatricians into the service.
• Colman Centre for Specialist Rehabilitation Services
has involved patients more in the discharge planning
process and has improved transition processes from
in-patients to outpatient services.
97% said they would recommend the hospital to others
(83% said definitely while 14% said probably). 3% said
they would not.
From the Adult Services Survey 2011/12
94.5% said they would recommend the service to a
friend or relative if they needed similar treatment, care or
advice (85.5% very likely while 9% said fairly likely). Just
under 1% were very or fairly unlikely to recommend.
From the Children’s Services Survey 2011/12
95% said they would recommend the service to a friend
or relative if they needed similar treatment, care or
advice (79.5% very likely while 15.5% said fairly likely).
3% were very or fairly unlikely to recommend.
Comparison to results in 2010
Survey results from 2011/12 show a significant
improvement compared to the results of the Ipsos MORI
Patient Experience Survey in 2010 where 68% of
patients were very likely to recommend and 58%
of parent/guardians.
42
Quality Account Norfolk Community Health and Care NHS Trust
3.1.7.3 Six Lives Programme –
improving access to
healthcare for people
with a learning disability
The Trust has embraced the challenge of implementing
the Six Lives programme with commitment. Several
projects have been delivered to improve the quality of
care given to patients with a learning disability and their
experience of the Trust’s services.
A new protocol ‘Improving Access to Healthcare for
People with a Learning Disability’ has been developed and
the ‘Information for Patients’ policy has been reviewed
and reflects the requirement to provide accessible
information to all patients. Both documents have been
launched and are available on the Trust’s intranet.
A three-tiered approach to staff training has
been agreed:
3. Learning Disability Champions – the development
of a full day programme is underway
The Patient Experience and Involvement Team will adopt
a range of approaches to ensure both patient and carer
satisfaction and involvement in service development is
embedded within processes. This has commenced with
one focus group already being held and a programme of
activity is planned during 2012 whereby representatives
will attend the existing Carer’s Forums across the county
to listen to views and action plan accordingly. The
patient story methodology will also be used to capture
experiences of patients with learning disabilities and
their carers which will provide depth to the data
captured and further strengthen the evaluation process.
A process for flagging patients with a learning disability
on electronic patient systems is available. These
processes also prompt staff to document any reasonable
adjustments that are made to meet individual needs.
Work is underway to develop a system for those services
not currently using these electronic systems.
The Project Lead will continue with monthly steering
group meetings to ensure actions against the evaluation
phase of this project are carried out and reported on as
appropriate e.g. patient and carer experience surveys,
Essence of Care audits. A programme of specific audits
will also be conducted, commencing in June 2012.
1. Basic learning disability awareness – provided as
part of Trust induction and all existing staff have
received a basic awareness information sheet
2. Learning disability awareness – two hour training
session available to all staff but as a minimum all
Team Leaders are required to attend and cascade to
their teams (over 300 staff have attended to date)
A programme of work for the next 12 months will
embed into practice the policies and processes that
have been developed to support compliance against Six
Lives and ensure sustainability. This programme includes
the review of care planning documentation to facilitate
the recording of any reasonable adjustments that are
being made within the in-patient units and training for
teams using SystmOne so that the method adopted to
flag patients and record any reasonable adjustments is
clearly communicated.
3.1.7.4 Single Sex Accommodation
The Trust continues to prioritise patient privacy and
dignity. During 2011/12 there have been no breaches of
any milestones as set out in NCH&C’s Eliminating Mixed
Sex Accommodation (EMSA) plan and therefore no
financial penalties incurred.
Further, there were no reportable breaches of single sex
accommodation. The Trust expects this performance to
continue into 2012/13.
Part 3 3.1 Review of quality performance in 2011/12
3.1.7 Patient experience
43
3.1.7.5 Patient Environment Action
Team (PEAT) Results for 2011
It should be noted that as from 10 May 2012
St Michaels hospital closed and services were
transferred to the new build North Walsham Hospital.
In April 2012, the National Patient Safety Agency
confirmed NCH&C’s PEAT results 2011 for environment,
food and privacy and dignity for each hospital within
our organisation as follows:
Any required improvements to the buildings/
environment will be conducted as part of the
2012/13 capital and minor works plan.
The results of PEAT are published on the NHS
Information Centre website www.ic.nhs.uk and are
also available to the public on www.data.gov.uk
Site Name
Environment Score
Food Score
Privacy and
Dignity Score
Colman Hospital
Good
Good
Good
Norwich Community Hospital
Good
Good
Good
Dereham Hospital
Acceptable
Excellent
Good
North Walsham Hospital
Acceptable
Good
Good
St Michaels Hospital
Good
Good
Excellent
Kelling Hospital
Acceptable
Good
Good
Swaffham Community Hospital
Acceptable
Excellent
Good
Ogden Court, Wymondham
Good
Good
Excellent
Cranmer House, Fakenham
Good
Excellent
Excellent
Benjamin Court, Cromer
Good
Good
Excellent
44
Quality Account Norfolk Community Health and Care NHS Trust
3.1.8 Learning from
incidents and
complaints
Complaints and Compliments
From April 2011 to March 2012 NCH&C received
192 complaints, in comparison to 195 during the year
2010/11. The Trust continues to use the number of
complaints as a clear indicator of patient satisfaction
alongside our patient experience programme. Two main
themes arising from analysis of complaints include the
single point of referral, which is under review, and
attitude of staff, which is also receiving attention from
our internal training team. New courses are under
development focussing on customer care and
professional behaviours.
Patient compliments are also measured and this year
the Trust has received around 335 compliments. The
dedication and commitment of our frontline staff is a
recurring theme of the compliments received. (see
section 3.1.3 for a summary)
Learning from complaints is collated from the
Service Managers following an investigation and
communicated across the organisation via the Quality
& Risk monthly report (seen at Quality & Risk Assurance
Committee and the Trust Board) which is published on
the Trust’s website and through the monthly staff
newsletter. Themes from complaints are taken to the
senior clinical management team (CMT) for discussion
and forward planning.
Serious Incidents Requiring
Investigation (SIRIs) and Never Events
Serious Incidents are reported into a central team and
information is collated via DATIX a web-based risk
management tool. The Executive team see every serious
incident and are able to ensure that corporate support
for investigations is given to operational teams where
required. Themes from serious incidents inform learning
events which are held quarterly and attended by senior
clinicians and management. The SIRI log and tracker are
presented at the Trust’s Clinical Management Team
monthly to share learning and information across all
clinical teams.
From April 2011 to March 2012 NCH&C have reported
136 SIRIs, these can be broken down as shown below.
From April 2011, NCH&C and NHS Norfolk made the
decision in line with national best practice to report all
grade 3 and 4 pressure ulcers as a SIRI. This led to an
increase in the numbers reported.
NCH&C reported two allegations of potential abuse.
One is still under investigation and a member of staff has
been dismissed for allegedly abusing an adult patient.
NCH&C reported on a competency issue which involved
an agency nurse. The nurse is currently under an interim
order by the Nursing and Midwifery Council (NMC) and
suspended from practice.
There were six unexpected deaths in the inpatient units
and all were investigated (four were referred to the
Coroner) and none identified as attributable to the care
or competence of the staff.
Part 3 3.1 Review of quality performance in 2011/12
3.1.8 Learning from incidents and complaints
Breakdown of SIRIs by type 2011/12
SIRI information
Total
Apr 2011 to
March 2012
45
National Patient Safety Agency
Report (NPSA)
Pressure Ulcer Acquired under
care of NCH&C - Grade 3
75
Pressure Ulcer Acquired under
care of NCH&C - Grade 4
36
The National Patient Safety Agency have recently
published its latest Patient Safety Incident Report.
The report demonstrates that NCH&C are amongst the
highest 25% of reporters within its cluster. The NPSA
states “That organisations that report more incidents
usually have a better and more effective safety culture.”
Abuse
2
Incident reporting across NCH&C has steadily increased
since the implementation of DATIX Web together with
increased training and awareness promoted throughout
the organisation.
Professional competence
1
Patient Accident
10
Unexpected Death
6
Medication
2
Information / Documentation
1
Child Protection
1
Infection control
1
IT
1
Pressure Ulcer Acquired outside
the care of NCH&C
Expected Death
Self harming behaviour
Media interest (potential)
Other
Total
136
Never Events
The Department of Health have produced an updated
list of 25 “never events” for use in the NHS in 2012/13.
These incidents are considered unacceptable and
eminently preventable.
The Trust is pleased to report it has had no ‘never
events’ during 2011/12.
The number of incidents under the type
“Implementation of care and ongoing monitoring /
review” is significantly higher than other organisations
within the cluster, this is largely due to the increase in
pressure ulcer reporting.
The NPSA state “not all organisations apply the national
coding of harm in a consistent way, which can make
comparison of harm profiles of organisations difficult”.
As part of the final approval process of incidents, the
Quality & Risk team ensure that the national coding of
harm is used in a correct and consistent way before
submission of incidents to the NPSA. We are assured that
the figures within the report accurately reflect the actual
degree of harm caused to patients as described by the
NPSA requirements. The report indicates that we have a
higher than average rate of low harm incidents however
we have a lower level of moderate harm incidents.
We also have a higher level of severe harm incidents,
this is mainly due to increased pressure ulcer reporting
as all Grade 4 pressure ulcers should be graded as
severe harm.
46
Quality Account Norfolk Community Health and Care NHS Trust
Learning from incidents
During 2011/12 the Quality & Risk team facilitated three
learning events for our clinical staff; the first was
regarding the prevention and management of pressure
ulcers, the second regarding insulin dependent patients
and patients requiring INR testing and management
and the third was aimed at ‘Enabling people to die in
comfort and with dignity’. Attendees heard from expert
speakers about how partnership working can deliver
the best patients outcomes in end of life care. It was
also an opportunity to discuss the new regional ‘Do Not
Attempt Cardio-Pulmonary Resuscitation’ form and
launch our Trust’s revised Resuscitation Policy.
The aim of these events is to share learning and good
practice across the Trust with the ultimate aim of
improving quality.
Four Learning Events are being arranged during 2012 to
celebrate ‘best practice’ and to give staff an opportunity
to discuss how further improvements can be delivered.
Each event will be themed around real-life incidents or
issues which have been reported by our staff and
patients and will be a chance to share the subsequent
learning from these issues.
The topic for the next event, due to take place in
May 2012 will be regarding the principles of good
record keeping and data quality which will also discuss
the results of the annual organisation-wide record
keeping audit.
Learning from Downham Market Health Centre
Arguably the most significant quality related event for
the Trust during 2011/12 was the publication of the
independent report by Collingham Healthcare
Education Centre (CHEC) (a consultancy specialising
in reviews into GP practice), into the circumstances
surrounding the Downham Market Health Centre.
This was a nurse led Primary Medical Service (PMS) GP
practice. There were four serious incidents requiring
investigation (SIRIs) that occurred within the practice in
March and July 2010 and January and February 2011.
The review concluded that the practice had fallen below
the managerial radar of the Trust and therefore the
standards of care fell below the excellent services we
would aspire to and patients should expect. The review
found no direct evidence of patient harm as a result of
the failings identified. The review concluded with a
number of recommendations for various organisations.
The recommendation for NCH&C was that the Trust
should reflect as an organisation on the contents of the
review, acknowledge its responsibility, put in place
robust measures to translate the findings into its
organisational culture and to ensure that failures
described here can never be repeated.
The circumstances and criticisms rightly informed the
organisation. Athough the Trust no longer provides
these services the Trust Board and teams have reflected
extensively and continues to do so on the circumstances
and their wider implications.
The Trust had already begun to address the concerns
identified in the CHEC report and had developed an
action plan that was later adapted into a wider project
to embed quality systems across the organisation. Key
interventions and improvements during the last year
include the introduction of monthly Business Unit
Performance Meetings. These triangulate in detail
quality, financial and performance information for
teams and services. A number of staff have moved on
and the medical leadership of the Trust has been
strengthened with the appointment of a substantive
experienced Medical Director with increased hours as
well as an experienced associate Medical Director.
A closure report detailing all the learning points and
actions taken was approved at the public Board
meeting in April 2012 and can be found on our
website: www.nchandc.co.uk
Part 3 3.1 Review of quality performance in 2011/12
3.1.8 Learning from incidents and complaints
47
Each month, staff across community teams and the
inpatient units assess their areas against a checklist with
weighted scores, which results in an overall RAG-rated
score and an indication of what action is required:
• Score of 10 or less - Green rating
No action required, re-assess area next month
• A score between 11 and 15 - Amber rating
Undertake full risk assessment and agree action
plan for red items within one month. Add to local
risk register
• A score of 16 or more - Red rating
Inform line manager immediately and undertake full
risk assessment within one week. Produce action plan
for red items within one week
The Trust now has six months’ of assessments of the
EWTT, and there are some clear recurring themes which
are common across many teams and units, and which
will need to be addressed at a local level. These include:
• Staff not updating clinical records within 24 hours of
the contact taking place
• No formal feedback obtained from patients during the
last 12 months (e.g. questionnaires or surveys)
Early Warning Trigger Tool
• Vacancy rate higher than 3% (2 points) or 6% (3 points)
In September 2011, the Trust introduced an Early
Warning Trigger Tool (EWTT) adapted from the NPSA’s
tool to be more relevant to a community setting, to act
as an early warning system to flag up potential quality
and patient safety issues before they occur. The
indicators explicitly capture the circumstances of
Downham Market such as change in senior clinicians
and staffing. The tool is completed by all teams on a
monthly basis. During the year the threshold for
escalation has been lowered to ensure more services are
subject to increased scrutiny. Implementation of the tool
should reduce the number of Serious Incidents
Requiring Investigation (SIRIs), reduce the risk of an
unfavourable CQC report and prevent services going
into crisis.
The chart on page 48 shows the frequency with which
themes were occurring in March 2012.
The Trust also reviewed those services that had the
potential to share possible characteristics with
Downham Market – such as small or geographical
isolated. The Board has also approved a Board
Assurance and Escalation framework to articulate
the process of how concerns and risks flow from the
frontline services to the Board. The Board also reviewed
its board assurance framework which identifies the
high level strategic risks which are linked to the Trust’s
obectives In addition, an extensive programme of
service visits has been completed by both Executive
and Non-Executive Directors and a programme for
2012/13 is being developed.
48
Quality Account Norfolk Community Health and Care NHS Trust
Early Warning Trigger Tool Trust-wide frequency of themes (March 2012)
Two or more formal complaints in a month
No evidence of resolution to recurring themes, eg, complaints,
medication errors, falls (excluding pressure ulcers)
New Serious Incidents Requiring Investigation
(SIRIs) reported in month
No evidence of effective multidisciplinary/multi-professional
team working
Extreme demands on service exceeding capacity to deliver
(eg, pandemic, norovirus, outbreak)
Unfilled shifts is higher than 6%
Cleanliness audits not performed
No monthly review of key quality indicators by
Business Unit meetings
No involvement of Team Leader in Business Unit
or Trust meetings
Hand hygiene audits not performed
Ongoing investigation or disciplinary investigation
(including RCAs & infection control RCAs)
Department/office appears untidy
More than 5% of shifts covered by bank, excess hours
and agency
Annual appraisals completed within last 12 months
below 88%
No evidence of adequate clinical supervision in place
Mandatory training compliance below 88%
Change or absence of a Lead Clinician
(within last six months)
Overspent against budget
New or no line manager in post (within last six months)
Sickness and maternity absence rate higher than 4.5%
Vacancy rate higher than 3% (2 points) or 6% (3 points)
No formal feedback obtained from patients during the last
12 months (eg, questionnaires or surveys)
Staff not updating clinical records within 24 hours
0
10
20
30
40
Frequency of theme occuring
50
60
Part 3 3.1 Review of quality performance in 2011/12
3.1.9 Safeguarding Adults and Children
3.1.9 Safeguarding Adults
and Children
‘Together we are stronger’ making vulnerable people
safer was an event aimed at keeping children and adults
in Norfolk safer by more joined up working between
our staff and others was held in October 2011. The
Department of Health Lead for Safeguarding Adults was
one of the keynote speakers at the event which aimed
to help the NHS, Police and Council staff share their
experiences on some of the complexities of dealing with
safeguarding issues and to find effective solutions.
Safeguarding Arrangements
in NCH&C
NCH&C has established Executive and Non-Executive
Leads for both Safeguarding Adults and Children
as follows:
• Director of Operations, Executive Lead for
Safeguarding both Adults and Children
• Non-Executive Lead for Safeguarding Children
• Non-Executive Lead for Safeguarding Adults
NCH&C has well established, highly experienced
operational Leads for safeguarding children who
provide comprehensive training and supervision for staff
and also provide expert interventions for reviews,
reports and clinical input.
The post of Head of Adult Safeguarding and Transfer of
Care was recruited to in May 2011 and will facilitate the
implementation of the No Secrets guidance within
clinical practice, it will also provide assurance to the
board through evidence reporting and by supporting
staff in the management of Safeguarding issues,
training and linking with external partner agencies.
Main Issues for Safeguarding Adults
Safeguarding Adults is an evolving area of practice;
whilst the severe cases of physical abuse is clearly
recognised by staff, areas such as neglect, poor care
and patient experience are not easily seen as reportable
safeguarding concerns.
The key issues for Safeguarding Adults in the last year
have been:
• Lack of recognition of abuse
• Not referring patients early enough to the
Multiagency Safeguarding Team
• Lack of understanding on management of
abuse victims
• Poor understanding of the Mental Capacity Act,
consent and Deprivation of Liberties
49
50
Quality Account Norfolk Community Health and Care NHS Trust
Organisational Learning
Opportunities
There are many ways in which NCH&C intends to raise
awareness of important safeguarding issues including,
formalising the organisational leadership and direction,
disseminating policies and procedures and implementing
training and supervision. NCH&C is committed to taking
all opportunities to share learning from safeguarding
activities and serious cases and is holding a conference
for NCH&C staff and our partners to raise awareness
and influence practice.
Main Issues for Safeguarding Children
The current key issues for safeguarding children in the
last year:
• Nationally and locally there has been a rise in the
number of looked-after children (LAC) and a rise in
the level of need across the tiers of intervention
• In line with changes to national guidance all
safeguarding children training has been reviewed
and a new training strategy enacted
• There have been two multi-agency management reviews
• Multiagency Safeguarding children and LAC
arrangements in Norfolk have been inspected by the
Office for Standards in Education (OFSTED) and the
Care Quality Commission (CQC) in June 2011
• The impact of reduction in support services offered by
other agencies due to financial constraints
The conference entitled “Together we are stronger”
took place on 5th October 2011 and 130 delegates,
including staff from other organisations, heard how
NHS, police, council, and voluntary sector staff can
implement even more effective support for vulnerable
adults and children. Shared learning from the event is
now being taken forward by our Safeguarding Team,
which will consider how we can further improve our
processes and staff training and work even more closely
with our partners.
NCH&C safeguarding teams have produced quarterly
reports for adults and children to the Trust Board this
year. These reports have identified the main issues and
NCH&C strategic approach to minimising the associated
risks for the organisation. It highlights the significant
progress made in strengthening the leadership for both
adults and children and the progress made against
compliance with national policy and guidelines. It also
details some of the priorities for the coming year.
Part 3 3.1 Review of quality performance in 2011/12
3.1.10 Effectiveness of care
3.1.10 Effectiveness of care
a. National Institute for Health and
Clinical Excellence (NICE)
NICE have devised a number of audit tools for new
guidance which is being released, and this has been
positively received by NCH&C clinicians as it provides
them with an ‘off the shelf’ resource for sharing new
guidance with colleagues.
NICE have also produced an online ’pathway tool’
which provides quick and easy access, topic by topic,
to the range of guidance from NICE, including quality
standards, technology appraisals, clinical and public
health guidance and NICE implementation tools. These
pathway tools are simple to navigate, and allow staff to
explore in increasing detail NICE recommendations and
advice, giving clinicians confidence that they are up to
date with everything NICE have recommended.
‘Hot topic’ pathways include; Diabetes, Dementia,
Hypertension, Chronic Obstructive Pulmonary Disease.
Six audits based upon NICE guidance were put into this
year’s clinical audit plan:
1. Transient Loss of Consciousness – CG109
2. Female continence (NCH&C audit proposal based on
CG97 – Lower Urinary Tract Infections in Men
3. Depression – NICE Clinical Guideline 90
4. Hypertension – NICE Clinical Guildeline127
5. Osteoporosis (re-audit) – NICE Technology
Appraisal161
6. Osteoarthritis – NICE Clinical Guideline 59
51
Two other pieces of NICE guidance were flagged as
being relevant to NCH&C services, but did not
necessarily initiate a clinical audit to be undertaken;
1. PH32 Skin Cancer Prevention – prevention using
public information, sun protection, resources and
changes to the environment (January 2011), this
guidance was used to implement a plan of action
by Children’s Services
• Undertake a baseline audit to determine level of
activity with regard to sun safety messages within
Health Visiting and School of Nursing services
• Review activities for sun safety within short-break
services, Sure Start Children’s Centres and Nurseries
• Develop plan for consistent delivery of seasonal
safety in the sun messages across all services
• Assess if there are any training needs to support
implementation of the guidance
2. CG133 Self Harm – Longer Term Management
(November 2011), this guidance was flagged as
relevant by prison healthcare services, and action
planning will follow.
52
Quality Account Norfolk Community Health and Care NHS Trust
b. National Clinical audits
Links with other organisations
Active participation in National Clinical Audits means
that we can review NCH&C’s performance against
similar community provider trusts, allowing us to
benchmark our performance as an organisation.
Participation in National audits are also reported in our
annual Quality Account which is a public document.
These national audits follow individual patient pathways
which cross primary and secondary care. To follow is a
brief description of how this worked for each of our
national audits:
Each year the majority of National Audits available on
the National Clinical Audit and Patient Outcome
Programme (NCAPOP) are ‘acute trust’ focused, but a
list of those which are applicable to us as a ‘provider’
trust are circulated to clinicians at the end of each year,
to establish interest and clinical commitment to conduct
these audits within NCH&C. Due to the size and remit
of these large national audits, data is collected over a
period of months and then collated and analysed by
either a Royal College or a nominated charity before
release of the final report in quarter 2 or 3 of the
following year.
Within 2011/12 NCH&C participated in 3 National
Audits, namely; National (Adult) Diabetes Audit,
Epilepsy12 (this was year 3 of 3 of this children’s
National audit), and the Parkinson’s National Audit
which was run by ‘Parkinson’s UK’. Reports from all
three of these national audits should be made available
in Q2/3 of 2012/13
Parkinson’s Audit – our Specialist Nurses provided
‘community data’ which was used to track the progress
of patients diagnosed with Parkinson’s Disease
following discharge from the Norfolk and Norwich
University Hospital NHS Foundation Trust hospital.
National Epilepsy12 (Children’s) audit – NCH&C
worked with the Paediatric specialists in the Norfolk and
Norwich University Hospital NHS Foundation Trust
hospital in order to follow patient pathways and
measure clinical care received in both the Acute and
community environment against best practice standards
produced by the Royal College of Paediatrics and Child
Health (RCPCH).
National Diabetes Audit (Adults) – our Diabetes
Specialist Nurse team in the west of the county worked
closely with GP consortia in order to record data against
adult Diabetic patients for the National Diabetes Audit
(Adults), and for the purposes of this audit this
information was used to demonstrate the effectiveness
of individual patient journeys through primary to
community care.
Part 3 3.1 Review of quality performance in 2011/12
3.1.10 Effectiveness of care
53
c. Local Clinical audit project
statistics for 2011/12
The table below demonstrates the breakdown of
projects registered by type between 1st April 2011
and 31st March 2012.
Type of project
Examples
Number
% of total
clinical audits
Priority 1 Internal ‘must do’ audits
CQuIN audits, Schedule 16 (Commissioning
Audits), NICE Technology Appraisals (TAs).
22
33%
Priority 2 ‘External ‘must do’ audits
National Clinical Audits, National Service
Framework Audits
8
12%
Priority 3 Operational business
unit priority audits
Service specific audits, baseline audits for
business case proposals etc
11
16%
Priority 4 Clinical interest audits
Clinical speciality led audits,
NICE (other than TAs)
26
39%
67
100%
Total
2011/12 saw a number of ‘service evaluation’ style
audits using ‘levels of assurance’ which are taken
from the 2012 NCH&C clinical audit template. They
recognise ‘high’ as over 85% compliance, ‘moderate’ as
between 60% - 84% compliance, and ‘low’ as below
59% compliance against clinical audit standards.
• 33% gave high assurance, including hand hygiene,
essential steps and the community hospitals
antibiotics audit
• 53% provided moderate assurance and these
included: safeguarding children’s supervision and
reducing harm from omitted and delayed medicines
14%
• Those audits providing low assurance were generally
due to small or insufficient sample sizes being audited
33%
High
Moderate
Low
53%
Of the 67 proposed audits, 33 were completed
during 2011/12:
54
Quality Account Norfolk Community Health and Care NHS Trust
A summary of these are as follows:
d. Research & Development
• “Safeguarding Children – Supervisors Audit”,
which provided moderate (73%) assurance, that
Safeguarding Supervisors working within Children’s
Services were receiving adequate support and training
in their professional roles (June 2011).
NCH&C patients with venous leg ulcers take part
in biggest ever leg ulcer study
• “Reduction of Falls/preventing falls and reducing harm
from falls”, which provided high (92%) assurance that
in-patient units within community hospitals were
completing a falls assessment within 48 hours of
admission, this service evaluation was a CQUIN target,
and was achieved.
• “Reducing the harm from omitted and delayed
medicines in hospital. A re-audit of NCH&C inpatient
units, December 2011”, provided moderate assurance
that teams and individuals were adhering to National
Patient Safety Agency (NPSA) guidance to reduce
occurrences of missed and delayed medicines given in
our community in-patient sites.
• The Infection Control Team conduct monthly ‘hand
hygiene’ audits at localities and in 2011/12 results
across the trust provided high assurance (99%)
Patients with venous leg ulcers under the care of
NCH&C’s community nursing teams in Norwich, Long
Stratton, Diss and Dereham have been involved in a
piece of research that is looking at two different
treatments used to treat this debilitating, long-term
condition. The study is the largest ever of its kind in the
UK, involving more than 30 Trusts. It will provide the
latest evidence on which treatment is most effective,
ie, has a faster healing time, by comparing four-layer
bandaging with compression hosiery (stockings).
The results, (due out in autumn 2012) will enable
community nurses to offer the best treatments to
patients, in line with this new evidence. As a result of
this it is hoped that the length of time patients need
to be treated for leg ulcers in the future will be
significantly reduced.
Part 3 3.1 Review of quality performance in 2011/12
3.1.10 Effectiveness of care
55
Norfolk Sure Start Centres involved in national
programme of research
Important research involving users of NCH&C’s
Stop Smoking service
Several Sure Start Children’s Centres run by NCH&C are
involved in a five-year national research programme
which aims to improve understanding of children’s
accidents and effect a change in behaviour with parents
and families around child safety. The project looks at
the following areas:
A study looking at the effectiveness and costeffectiveness of a set of eight booklets (called Forever
Free) designed for the prevention of smoking relapse
in people who have stopped smoking for at least four
weeks was launched in July 2011 at NCH&C. This large
study (it requires 1,400 people to take part) involves
Stop Smoking Advisors who will recruit four-week
quitters over a period of 21 months, with telephone
follow-ups at three and 12 months post quit. Study
participants are randomly allocated to receiving either
the intervention, the self-help booklets, or to usual
care, the current NHS leaflet. To date, 388 people
have been recruited.
• house fires
• falls
• scalds
• poisoning
As part of the research, an injury prevention briefing
(IPB) on specific aspects of injuries in the home to preschool children is being developed that will be tested in
a group of children’s centres, including Norwich. The
briefing will be sent to centres in four study areas:
Nottingham, Bristol, Newcastle and Norwich. Some will
also receive support from the project team to help them
take forward key messages in the IPB.
When the 12-month study has been completed the
study team will roll-out a revised briefing outside the
study areas. The research will show whether, as a result
of Centre staff using the briefing, there are changes in
some families’ home safety behaviour, and ultimately
this should result in a reduction in children’s injuries and
hospital admissions.
The study hopes to show that people receiving the new
booklets ‘stay quit’ for much longer than those who do
not. The booklets may prove to be a useful tool advisors
can use to help people who suffer smoking relapse
within six months of the end of NHS Stop Smoking
treatment to stay smoke-free.
Research study offers support for recovering stroke
patients who have communication difficulties
A study examining the effectiveness of specialist skills
for hospital staff in communicating with recovering
stroke patients with aphasia (a communication disorder
which affects speaking and understanding), has been
running for just over a year at NCH&C’s stroke unit.
The first phase of the study has provided staff training
in ‘supported communication’ techniques. The second
phase, beginning in late 2012, will involve patients in
Norfolk with moderate to severe aphasia after a first
stroke who will receive care from staff trained in
‘supported communication’ and compare their health
outcomes with a group of patients in Cambridge who
will receive normal care from their local stroke
rehabilitation therapy team.
The research findings will determine how effective
this new technique has been from both the staff and
patient perspective. It is hoped that the research will
lead to recommendations for a staff training protocol
for wider implementation across the NHS.
56
Quality Account Norfolk Community Health and Care NHS Trust
3.2 Explanation of who has been
involved and engaged with
• LINk and Public Involvement at Trust Board meetings
and other committees, including Quality & Risk
Assurance Committee, Patient Experience Steering
Group and PEAT inspections
• Development of the Integrated Business Plan (IBP) by
Board members and clinical reference group
• Development of the Annual Plan by Executive
Directors, Assistant Directors and clinicians
• Quality & Risk Assurance Committee provides
assurance to the Board and has a LINk representative
in attendance
• Third party commentary requested from Norfolk LINk,
NCC Health Overview and Scrutiny Committee and
NHS Norfolk & Waveney
Comments from Norfolk Health
Overview and Scrutiny Committee
The Norfolk Health Overview and Scrutiny Committee
has decided not to comment on any of the Norfolk
provider Trusts' Quality Accounts for 2011/12 and
would like to stress that this should in no way be taken
as a negative comment. The Committee has taken the
view that it is appropriate for Norfolk's Local
Involvement Network to consider the Quality Accounts
and comment accordingly.
Comments from Norfolk LINk
Norfolk LINk welcomes the Community Health and Care
Trust’s approach to improving services as set out in the
Quality Account. We agree with the priorities identified
for 2012/13. We hope that staffing levels are
commensurate with the activity needed to achieve the
Quality Goals.
The Trust has a very good approach to stakeholder
involvement. This is based on our experience of being
involved in meetings where service issues are discussed
in-depth; our ability to obtain information easily from
the Trust; and our involvement in ‘Patient Stories’. We
know that the Trust is also actively engaging with other
stakeholders such as Age UK Norfolk to gather the
views of patients from diverse backgrounds.
We are pleased that the Trust is looking towards indepth surveys for qualitative information about the
patient experience. Although it was only in 2012 that
the ‘Patient Stories’ initiative got off the ground, we
can confirm that this is now well-underway with LINk
volunteers being trained to record patient stories.
However Norfolk LINk is not convinced that “Net
Promoter” is a suitably valid tool for accurate
measurement of the patient experience where
respondent numbers are less than 60 per cent.
Regarding patient safety issues, the Trust is yet to act
on two safety issues that we raised with the Stroke
Rehabilitation Unit after a visit in November 2011.
These were around the absence of emergency/help pull
cords inside toilets and showers; and clear access to the
fire evacuation area.
We are pleased to see that the Account has several
examples of the outstanding staff working within the Trust
and can confirm that several initiatives are in progress, eg,
improving care for older people with dementia.
Part 3 3.2 Explanation of who has been involved and engaged with
Comments from NHS Norfolk
and Waveney
Statement of Information Verification within
the Quality Account submitted to NHS Norfolk
by Norfolk Community Health & Care NHS Trust
June 2012
NHS Norfolk and Waveney as lead commissioners for
Norfolk Community Health & Care NHS Trust are
pleased to support the Trust in its publication of the
2011/12 Quality Account.
We have reviewed the mandatory data elements
required within this account and can confirm that those
included are consistent with that known to NHSN&W.
The report presents detailed and comprehensive
information relating to the quality and safety of care
delivered within the prioritised areas identified by the
Trust. The Quality Goals for 2012/13 are relevant and
are substantiated by involvement with the clinical
quality and patient safety agenda via the
Commissioning for Quality & Innovation payment
framework (CQuIN) We commend staff for their work
to improve outcomes within these areas and we look
forward to the inclusion of an update on achievements
in these areas in next year’s Quality Account.
57
NHSN&W have appreciated the continued support of
the clinical quality review meetings which are vital in
assuring the local population that services contracted
from the Trust are safe and of good quality. They enable
discussions to take place concerning new initiatives and
current thinking and practice. They also facilitate
challenges regarding current performance.
With the elimination of avoidable Grade 2, 3 & 4
pressure ulcers being an ambition for NHS Midlands and
East, it is clear that through the implementation of data
collection via the NHS Safety Thermometer and the
Trust’s Pressure Ulcer Clinical Improvement Programme
that the Trust is supportive of this ambition.
The Trust acknowledges the learning that arose from the
Downham Market Health Centre enquiry and the
findings of the independent report commissioned by the
SHA. The Trust outlines where the learning has led to
significant changes in organisational processes in order
to assure that the failures described will not be repeated.
This has been a year in which the Trust has demonstrated
improvements in many areas and we look forward to
working alongside them in supporting their quality
initiatives in the coming year.
Andrew Morgan
Chief Executive Officer
NHS Norfolk & Waveney
Head Office: Elliot House, 130 Ber Street, Norwich NR1 3FR
Online: www.norfolkcommunityhealthandcare.nhs.uk
Telephone: 01603 697300