2
Carly-Jane and Emma,
Community Nurses in Bourne
Lincolnshire Community Health Services NHS Trust

Bridge House
Unit 16, The Point
Lions Way
Sleaford
Lincolnshire
NG34 8GG
Tel: 01529 220300
Website: http://www.lincolnshirecommunityhealthservices.nhs.uk
For more information about communication activities happening across the
Trust please contact:
Tel: 01529 220407
E-mail: lchsecomms@lincs-chs.nhs.uk
For more information on our Trust Board please contact:
Bev Wormald
Trust Board Secretary
Tel: 01529 220376
E-mail: bev.wormald@lincs-chs.nhs.uk
Quality Account 2012-13
3

4
Trust Headquarters ................................................................................. 3
Communications ..................................................................................... 3
Trust Board Information .......................................................................... 3
Part 1 Welcome .................................................................................... 6
Our Services ............................................................................................ 7
Statement from the Chief Executive and the Board ................................. 8
Part 2 Our priorities for quality improvement in 2013/14 .............. 10
Clinical Effectiveness .............................................................................. 10
Development of Outcome measure for all core community services by
March 2014 ........................................................................................... 10
Clinical Record Keeping – all clinical record keeping will reflect professional and legal standards ................................................................................ 10
Patient Safety ......................................................................................... 11
Elimination of avoidable grade 2, 3 and 4 Pressure Ulcers ....................... 11
To reduce the harm from avoidable falls in Community Hospitals to 0 by
March 2014 ........................................................................................... 12
Eliminate all medication errors in Community Hospitals .......................... 13
Patient Experience.................................................................................. 14
To be in the Top 20% of community trusts nationally for staff engagement and to be in the top 20% for staff appraisals ......................................... 14
Increasing the number of patients who feel they have the information which they need communicated in a clear and understandable way ....... 14
Statements relating to quality of NHS services provided.......................... 15
Review of Services ................................................................................. 15
Participation in Clinical Audit .................................................................. 15
Participation in Clinical Research ............................................................ 15
Goals agreed with Commissioners ......................................................... 16
NICE Quality Standards .......................................................................... 16
Statement from the Care Quality Commission ........................................ 17
15 Steps Challenge ................................................................................ 18
Statement on Data Quality ..................................................................... 19
Review of the Priorities for Improvement 2012/13 .................................. 21
Patient Safety ......................................................................................... 21
Reduction in falls resulting in harm......................................................... 21
Reduction in medication errors .............................................................. 22
Patient Experience.................................................................................. 23
Reduction in avoidable Pressure Ulcers ................................................... 23
Clinical Effectiveness .............................................................................. 24
Record Keeping ..................................................................................... 24
Clinical Effectiveness and Patient Safety ................................................. 25
Improving Venous Thromboembolism (VTE) prophylaxis ......................... 25
Lincolnshire Community Health Services NHS Trust

Part 3 Review of Quality Performance 2012/13 ............................... 26
Quality Achievements in 2012/13 ........................................................... 28
PEAT Scores ........................................................................................... 28
Health Care Associated Infection ........................................................... 29
Staff Survey ........................................................................................... 30
Examples of Outstanding Practice .......................................................... 31
Queen’s Nurse Award ............................................................................ 31
NHS Heroes ........................................................................................... 31
Celebrating Success ............................................................................... 32
Baby Café celebrates birthday ................................................................ 33
Assisted Discharge Stroke Service Team NHS Winter Heroes Scheme ...... 34
NHS Innovation Challenge ..................................................................... 34
Complaints and Compliments ................................................................ 35
National Health Service Litigation Authority (NHSLA) ............................. 35
Involvement and engagement ................................................................ 36
Statement of changes to content of Quality Account post consultation .. 36
Statements from other bodies ................................................................ 37
Lincolnshire East Clinical Commissioning Group (Lead commissioner for
Lincolnshire Community Health Services NHS Trust)................................ 38
IV
LCHS
MRSA
NHS
NHSLA
NICE
PALS
PEAT
PLACE
SI
ULHT
Glossary
ADSS
AHP
CQC
CQUIN
Assisted Discharge Stroke Service
Allied Health Professional
Care Quality Commission
Commissioning for Quality and Innovation – a scheme to encourage improvement
Intravenous Therapy
Lincolnshire Community Health Services NHS Trust
Meticillin-resistant Staphylococcus Aureus
National Health Service
National Health Service Litigation Authority
National Institute for Health and Clinical Excellence
Patient Advice and Liaison Service
Patient Environment Action Team
Patient-Led Assessment of the Care Environment
Serious Incident
United Lincolnshire Hospitals Trust
Quality Account 2012-13
5

6
At Lincolnshire Community Health Services NHS Trust (LCHS) we provide community healthcare services for the population of Lincolnshire, one of the largest healthcare communities in the country, covering an area of
2,350 square miles and a population of 735,000.
Our 2,600 staff care for thousands of patients every day in our community hospitals, health clinics, walk in centres and minor injuries units. If you are housebound, we come to you at home or in your place of care. Health visitors and school nurses support our young families; we provide primary care services out of hours; our teams of nurses, therapists and specialists care for those across the county whether suffering from respiratory conditions, heart problems, diabetes, cancer, or wounds such as leg ulcers.
Our teams support rehabilitation following stroke or other illness/accident with physiotherapy, occupational therapy and speech and language difficulties; our sexual health teams provide a confidential and non- judgemental service to all who need it and our weight management and smoking cessation teams can help you improve your health. At the end of life, we are there to support you and your family with dignity at home if that is your preference.
Our Vision and Values are simply defined – we want to be your first choice for community health care. Our Patients First values say putting you first is at the heart of everything we do… and we embed this in every aspect of our services.
Lincolnshire Community Health Services NHS Trust

Family and
Healthy
Lifestyles
Community
Hospitals
Integrated
Community
Based
Services
Primary Care
Services
Infrastructure
Health Visiting and School
Nursing
Safeguarding
Vulnerable
Children and
Young People
Children’s
Therapy
Services
Smoking
Cessation,
Weight
Management
Sexual Health
Specialist Dental
Services
Services provided at the
4 Community
Hospitals,
County Hospital,
Louth,
Johnson
Hospital,
Spalding
John Coupland
Hospital
Gainsborough and Skegness
Hospital
Adult integrated
Teams
(Including
Community
Nursing,
Specialist
Nursing and
Community
Response, and
Rehabilitation)
Adult Therapy
Services,
(Physiotherapy,
Occupational
Therapy, Speech and Language
Therapy and
Podiatry)
Assisted
Discharge
Stroke Service
Anti
Coagulation
Service
Adults Electronic
Assistive
Technology
Service (EATS)
GP Practices
Walk in Centre
Out of Hours
Corporate
Services
Human
Resources and
Organisational
Development
Informatics and
Performance
Services
Finance
Communications
Clinical
Governance &
Risk
PALS
Patient & Public
Involvement &
Engagement
Care Quality
Commission and
NHS Litigation
Authority
Assurance
Business
Development and Tendering
Quality Account 2012-13
7

8
Ellen Armistead
Chief Executive
Dr Don White
Chairman
Throughout 2012/13 we have continued to progress our application to become a Community Foundation Trust and in March 2013 the Strategic
Health Authority approved our application to move in to the next phase of the authorisation process.
This part of the process involves the Trust Development Authority, which is the part of the NHS which has responsibility for ensuring NHS Trusts achieve
Foundation Trust status. This is great news as it is an important milestone for LCHS.
LCHS has a very strong track record of delivering high quality safe services and we are confident that we can continue to provide assurance to both our regulators and our public on this issue. The 2012/13 Quality Account demonstrates the achievements in quality improvement made over the past year and details the priorities that LCHS intends to focus on in 2013/14.
The Trust has undertaken a comprehensive gap analysis against all 290 recommendations of the Public Inquiry into the failings at Mid Staffordshire
Hospitals NHS Foundation Trust to identify key areas for focus for the
Trust over the coming months. This was presented to the Board and has refocused the Strategic Aims for 2013/2014 which are:
• Listen to our users, value their views and improve the patient
• experience
• Deliver safe services
• Deliver clinically effective services
• Deliver a quality driven financial strategy
• Develop and lead a workforce proud to be part of LCHS
• Ensure our services are reflective of the needs and wishes of the community
• Manage the reputation of the organisation, through effective
• engagement with our stakeholders
• Use technology to enhance patient experience and improve efficiency and effectiveness
• Ensure the environment is appropriate, fit for purpose and meets and
• exceeds the need and expectations of users
To the best of the knowledge of the Chief Executive the information reported in the Quality Account is accurate and a fair representation of the quality of healthcare services provided by LCHS.
Chief Executive……………………….................Date 25/06/13
Lincolnshire Community Health Services NHS Trust

Jenny works with vulnerable children and young people
Quality Account 2012-13
9

10
How we will measure this
Outcome measures will be put in place through the development of the community nursing specification and measured through the intervention requirements and time on caseload for patients.
Why this is a priority
Understanding the importance of clinical outcomes, measurement and reporting will help LCHS achieve excellence in the delivery of clinically effective services and provide assurance to patients about the standards of care they can expect to receive.
Board Sponsor: Sue Cousland, Director of Operations/Chief Nurse
Implementation/Programme Lead: Susan Ombler, Project Manager
All clinical record keeping will reflect professional and legal standards
How we will measure this
This will be measured by audit of patient records against the agreed national standards
Why this is a priority
Good record keeping is an integral part of nursing and practice, and is essential to the provision of safe and effective care (NMC 2010). Accurate record keeping is fundamental to high quality, safe patient care. This was a quality priority in 2012/13 but continues to be a focus for improvement in the trust.
Board Sponsor: Dr P Mitchell, Medical Director
Implementation/Programme Lead: Annie Burks/Kim Todd, Practitioner
Performance Managers
Lincolnshire Community Health Services NHS Trust

How we will measure this
Incident reporting and investigations of pressure ulcers
Why this is a priority
Most pressure ulcers, or bed sores, are a complication of illness however; with appropriate care these can be avoided. During 2012/13 we have improved our performance in reducing avoidable pressure ulcers however we have not yet achieved our ambition and this continues to remain a priority. This will be measured by incident reports and investigation into the causes of pressure ulcers.
Board Sponsor: Sue Cousland, Director of Operations/Chief Nurse
Implementation/Programme Lead: Di Rigby, Head of Clinical Services,
South West Business Unit
20
15
10
5
0
35
30
25
Grade 3 Avoidable
Grade 3 Unavoidable
10
8
6
4
2
0
Quality Account 2012-13
Grade 4 Avoidable
Grade 4 Unavoidable
Grade 3 pressure ulcers
Apr 2012
May 2012
June 2012
July 2012
Aug 2012
Sept 2012
Oct 2012
Nov 2012
Dec 2012
Jan 2013
Feb2013
Mar 2013
Grade 4 pressure ulcers
4
6
8
7
6
4
2
5
8
10 12
7 14
8 11
29
24
13
20
19
18
12
16
19
Apr 2012
May 2012
June 2012
July 2012
Aug 2012
Sept 2012
Oct 2012
Nov 2012
Dec 2012
Jan 2013
Feb2013
Mar 2013
0
0
0
2
0
3
0
1
2
2
2
3
An avoidable pressure ulcer is where we have failed to provide all the required care in line with national standards and best practice
11
0
2
4
2
0
9
0
6
2
2
3
6

Patient falls resulting in harm
Apr 2012 22
May 2012
June 2012
11
18
July 2012
Aug 2012
Sept 2012
Oct 2012
Nov 2012
Dec 2012
12
13
10
18
18
13
Jan 2013
Feb 2013
Mar 2013
23
11
19
25
20
15
10
5
0
How we will measure this
This will be measured by incident reports and investigations into the cause of falls
Why this is a priority
A fall can change your life. If you’re elderly, it can lead to disability and a loss of independence. Over recent years increasing attention has been paid to patient falls both in terms of harm and the number of falls. National evidence suggests that more could be done to protect patients from harm.
Although the level of harm from falls is low, we have decided to set ourselves the goal that all avoidable falls should be eliminated in our
Community Hospitals. This builds on improvements carried out in 2012/13.
Board Sponsor: Sue Cousland, Director of Operations/Chief Nurse
Implementation/ Programme Lead: Catherine Wylie, Head of Clinical
Services, North East Business Unit
Data
Median
The median is the middle observation in a set of data.
To find the Median, place the data in ascending order and find the middle number. Where there are an even number of data objects, the median is derived by summing the two middle values and dividing by two.
12
Lincolnshire Community Health Services NHS Trust

How we will measure this
This will be measured by clinical incident reporting and audit of patient records
Why this is a priority
Medication errors are broadly errors in prescribing, dispensing or administration of a drug. They are the single most preventable cause of patient harm (National Patient Safety Agency 2004). The level of harm from medication errors in LCHS is very low; however we have decided to set ourselves the goal of reducing the level of harm even further. This builds on the improvements made in 2012/13.
Board Sponsor: Dr P Mitchell, Medical Director
Implementation/Programme Lead: Petra Clarke, Medicines
Management Officer
Dr Philip Mitchell
Medical Director
6
5
4
3
2
1
0
Data
Median
Medication errors resulting in harm
Apr 2012 0
May 2012
June 2012
July 2012
Aug 2012
1
2
5
4
Sept 2012
Oct 2012
Nov 2012
Dec 2012
Jan 2013
Feb2013
Mar 2013
3
1
1
0
0
4
4
Quality Account 2012-13
13

14
Ian Warren
Director of Human
Resources and
Organisational
Development
How we will measure this
NHS staff survey results 2013/14
Why this is a priority
Research shows that there is a clear link between satisfied staff and the quality of patient care they deliver. Motivated and engaged staff feel more able to come up with innovative ideas to improve quality and efficiency at work, and they are more likely to want to stay working for us and to provide high quality care.
Appraisal is an important aspect of staff satisfaction and performance. It provides the opportunity to reflect on how well individuals have met agreed targets and objectives over the past year and identify any training needs and areas for personal development, in a structured and supportive way.
Board Sponsor: Ian Warren, Director of Human Resources and
Organisational Development
Implementation/Programme Lead: Emma Challans, Deputy Director of
Organisational Development and Transformation
How we will measure this
We will measure this through the completion and analysis of patient surveys and patient interviews
Why this is a priority
Our patients tell us that having the right information is critical to supporting their choices and their ability to participate in decisions about their own care
Board Sponsor: Sue Cousland, Director of Operations/Chief Nurse
Implementation/Programme Lead: Sarah Gec, Patient and Public
Involvement Manager
Lincolnshire Community Health Services NHS Trust

During 2012/13 Lincolnshire Community Health Services NHS Trust provided and/or sub-contracted 43 relevant health services.
LCHS has reviewed all the data available to them on the quality of care in 5 of these NHS services.
The income generated by the relevant health services reviewed in 2012/13 represents 14% of the total income generated from the provision of relevant health services by LCHS for 2012/13.
During 2012/13, 0 national clinical audits and 0 national confidential enquiries covered relevant health services that Lincolnshire Community
Health Services NHS Trust provides.
Lincolnshire Community Health Services NHS Trust did not participate in national clinical audits or national confidential enquiries during 2012/13 as the criteria for participation did not apply to the relevant health services provided by the organisation.
The number of patients receiving relevant health services provided or sub- contracted by Lincolnshire Community Health Services NHS Trust in 2012/13 that were recruited during that period to participate in research approved by a research ethics committee was 1083.
This figure includes all patient recruitment within LCHS and NHS
Lincolnshire, which were supported by the LCHS research team. Due to the current national data collection methods the figures cannot be accurately separated into LCHS and NHSL however all research activity is governed, promoted and supported by the LCHS Research & Development Team.
Quality Account 2012-13
15

A proportion of Lincolnshire Community Health Services NHS Trust’s income in 2012/13 was conditional on achieving quality improvement and innovation goals agreed between Lincolnshire Community Health Services
NHS Trust and NHS Lincolnshire, through the Commissioning for Quality and Innovation (CQUIN) payment framework. The Trust has self-assessed achievement at 85% of the total available funding, pending confirmation with commissioners.
The CQUIN in relation to Serious Incidents (SI) was not achieved for 2012/13 however processes have been altered and recent assurance has been provided to the Clinical Governance and Risk Committee that we are now compliant.
NICE quality standards measure NHS Trusts delivery of high-quality, cost- effective patient care. LCHS is committed to achieving these standards across the organisation’s services.
16
Ali, Speech and Language
Therapist based in Lincoln
Lincolnshire Community Health Services NHS Trust

Lincolnshire Community Health Services NHS Trust is required to register with the Care Quality Commission (CQC) and its current registration status is full and unconditional.
The Care Quality Commission has not taken enforcement action against
Lincolnshire Community Health Services NHS Trust during 2012/13.
LCHS is registered to carry out the following regulated activities:
• Treatment of Disease, Disorder or Injury
• Surgical Procedures
• Diagnostic and Screening Procedures
• Family Planning
• Nursing Care
LCHS has been subject to an unannounced visit across two sites from the CQC in 2012/13. This visit was conducted in February 2013 and encompassed John Coupland Hospital, Scotter Ward and Minor Injuries Unit and Trust Headquarters in order to review Community Nursing Services.
The outcomes reviewed were:
Outcome 1 – Respecting and Involving People who use services
Outcome 4 – Care and Welfare of people who use services
Outcome 7 – Safeguarding people who use services from abuse
Outcome 14 – Supporting Workers
Outcome 16 – Assessing and monitoring the quality of service provision
Sue Cousland
Director of Operations /
Chief Nurse
We inspected the following standards as part of a routine inspection. This is what we found:
Respecting and involving people who use services
Met this standard
Care and welfare of people who use services Met this standard
Safeguarding people who use services from abuse
Met this standard
Supporting workers Met this standard
Assessing and monitoring the quality of service provision
Met this standard
Quality Account 2012-13
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18
The outcome of the visit was very positive with no concerns noted by the
CQC. The full reports are available on the Trust website and an overview of the compliance from both reports can be seen in the tables below: www.lincolnshirecommunityhealthservices.nhs.uk
LCHS has not participated in any special reviews or investigations by the
Care Quality Commission during 2012/13.
As part of the continual quality review process Senior Managers within
LCHS along with public members have reviewed 22 services in line with the
15 Steps Challenge methodology.
The 15 Steps Challenge is a tool designed to help the NHS deliver its ambition to provide safe, good quality care delivered in welcoming and clean environments. The Productive Ward programme works with teams in
Trusts to identify time wasting activities, duplication and inefficiencies. The
15 Steps Challenge has been developed from working with staff and patients linked to the Productive Ward Programme.
What is the 15 Steps Challenge?
• It is a tool to help staff, patients and others to work together to identify improvements that can be made to enhance the patient experience
• Designed to provide a way of understanding the patient’s first
• impressions more clearly. It describes how a small Challenge team can explore what the patient is experiencing by undertaking ward walkarounds. The Challenge team can then give the Trust structured feedback and useful information
• The tool is designed to bring a stronger patient perspective into
• the care that we provide. The Challenge supports continuous improvement
• The information gained can then be acted on, creating positive
• improvements in the quality of care
• A collaborative process involving both staff and patient representatives
Lincolnshire Community Health Services NHS Trust

LCHS will be taking the following actions to improve data quality:
• Receive external assurance of the 2012/13 Quality Account to test the quality of the data information provided in the report.
This is not a mandated requirement of the Quality Account but will provide assurance to LCHS as an aspirant Foundation Trust and determine areas for improvement.
NHS Number and General Medical Practice Code Validity
LCHS submitted records during 2012/13 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data.
The percentage of records in the published data which included the patient’s valid NHS number was:
• 99.9% for admitted patient care
• 98.8% for accident rand emergency care
The percentage of records in the published data which included the patient’s valid General Practitioner Registration Code was:
• 100% for admitted patient care
• 100% for accident and emergency care
The percentage of readmissions to a hospital which forms part of LCHS within 28 days of a patient being discharged from a hospital which forms part of LCHS during the reporting period 2012/13 was 7.37%, actual 246.
National Mandated Indicator
The rate of patient safety incidents reported by LCHS in 2012/13 was 1752 of these 0% resulted in severe harm or death of a patient.
Information Governance Toolkit attainment levels
The Information Governance Toolkit is a performance tool produced by the Department of Health (DH). It draws together the legal rules and central guidance and presents them in one place as a set of information governance requirements. The organisation is required to carry out self- assessments of their compliance against the IG requirements.
Quality Account 2012-13
19

20
There are different sets of information governance requirements for different organisational types and the organisation is registered as a
Community Health Provider. However, all organisations have to assess themselves against requirements for:
• Management structures and responsibilities (e.g. assigning responsibility for carrying out the IG assessment, providing staff training, etc);
• Confidentiality and Data Protection; and
• Information security.
The purpose of the assessment is to enable the organisation to measure their compliance against the law and central guidance and to see whether information is handled correctly and protected from unauthorised access, loss, damage and destruction.
Where partial or non-compliance is revealed, the organisation must take appropriate measures, (e.g. put in place policies, procedures, processes and guidance for staff), with the aim of making cultural changes and raising information governance standards through year on year improvements.
This demonstrates the organisation can be trusted to maintain the confidentiality and security of personal information which in-turn increases public confidence that ‘the NHS’ and its partners can be trusted with personal data.
LCHS Information Governance Assessment Report overall score for 2012/13 was 71% and was graded green. Level 2 was achieved for all areas with the agreement that any outstanding actions/recommendations are completed by 30th June 2013.
Clinical Coding error rate
LCHS was not subject to the Payment by Results clinical coding audit during
2012/13 by the Audit Commission.
Due to the low numbers of uploaded Secondary Uses Service consultant led activity, LCHS was not subjected to nor requested to take part in an external audit. The Clinical Coding team have completed the foundation qualification and will have completed refresher training in the coming year.
An arrangement is in place with United Lincolnshire Hospitals Trust (ULHT) to support the team due to the numbers of staff.
Lincolnshire Community Health Services NHS Trust

• In 2012/13 there have been no patient falls resulting in severe injury or death
• The Improvement Team was introduced to test and pilot falls prevention
• strategies
• Clinical teams have implemented learning and prevention strategies for specific patient groups
• A shared learning programme has been introduced across community hospital staff
Clinical practice is underpinned by the falls prevention strategy. Risk assessments are conducted on all patients. Monthly monitoring of falls resulting in harm is reported to the Clinical Governance and Risk Committee and LCHS Trust Board through the Quality and Risk Report.
However; we recognise there is still work to do to reduce falls. The Clinical
Governance and Risk Committee undertake a detailed analysis of all falls reported on a monthly basis.
23
22
19
18 18 18
11
12
13
10
13
11
Quality Account 2012-13
NB: No patient falls have resulted in severe injury or death
21

22
• Medicines Management Lead has been established with high presence in all working environments
• Medicine Management improvement plan has been implemented
• All ‘provider’ community groups implemented a new method for greater access to palliative care medications
• Introduced “Improving Medication Methods” to reduce errors
• Competency framework for staff who make errors has been implemented
• Recognised improvement techniques have been established to analyse where and why medication errors occur
• Provision of clinical governance advice for SystmOne Medicines
Management
We recognise there is still work to do in relation to the reduction of medication errors. All medication errors are analysed in significant detail at the Medicines Management Committee and the Clinical Governance and Risk Committee. Further actions are being implemented by the organisation and as a consequence the reduction in medication errors continues to be a priority for the forthcoming year.
5
4
3
2
1 1 1
4 4
0 0 0
Lincolnshire Community Health Services NHS Trust

• 2012/13 has seen an improvement in avoidable Grade 4 pressure ulcers which are the most severe type
• Introduced internal benchmarking against the prevalence data from
• other Community Providers
• LCHS are below the Community Provider average prevalence of 1.34% at 1.3%
• All patients are assessed for their risk of developing a pressure ulcer;
• treatment plans have been put in place and are carefully monitored
• We have updated our pressure ulcer prevention treatment pathways and audit our compliance against patient assessments
• All Grade 3 and 4 pressure ulcers are reported as a Serious Incident
• and investigated through Root Cause Analysis
• Lessons learnt are used to improve practice
• Developed reporting systems.
• Revised the pressure ulcer prevention tool
• Developed a mandatory training package for all staff providing care
• Improved incident reporting; we publish performance outcomes on a team by team basis
Whilst we recognise there is still work to do in the reduction of avoidable pressure ulcers real progress has been made in the reduction of Grade 4 pressure ulcers, and the elimination of avoidable pressure ulcers remains a priority for the organisation.
4
19
7
18
6
29
AVOIDABLE PRESSURE ULCERS
UNAVOIDABLE PRESSURE ULCERS
24
19
20
16
12
13
10
12
14
6
8
5
8
5
7
8
11
2
AVOIDABLE PRESSURE ULCERS
UNAVOIDABLE PRESSURE ULCERS
1
6
2
3 3
6
2 2 2 2
3
9
0 0
2 2
0 0 0 0 0
2
0
4
23

4
19
7
18
6
29
AVOIDABLE PRESSURE ULCERS
UNAVOIDABLE PRESSURE ULCERS
24
19
20
16
12
13
10
12
14
6
8
5
8
5
7
8
11
2
An avoidable pressure ulcer is where we have failed to provide all the required care in line with national standards and best practice
AVOIDABLE PRESSURE ULCERS
UNAVOIDABLE PRESSURE ULCERS
1
6
2
3 3
6
2 2 2 2
3
9
0 0
2 2
0 0 0 0 0
2
0
4
We developed an audit tool which:
• Set clear standards for record keeping
• Is qualitative rather than quantitative data focused
• Holds individuals accountable for improving record keeping quality
• Record keeping compliance across the organisation was set at a trajectory of 79.1% at year end; this is currently showing at 80% as of
28th February 2013
To strengthen improvements in delivery, we developed a new training package on the principles of record keeping, including legal aspects and implications of accurate record keeping, piloted in Family & Health Lifestyles
Business Unit.
In 2013/14 we will be implementing a new Clinical Records Training package, which will be mandatory for all Clinicians.
24
Lincolnshire Community Health Services NHS Trust

During 2012/13 performance has consistently been in excess of 95% for the assessment process. Of those patients assessed 73% either received treatment or did not require treatment.
We achieved the performance rate through:-
• Introducing a programme of training in all Community hospitals to increase staff competency in VTE assessment and prevention
• Reviewing VTE audits monthly at Clinical Governance committee
• Introducing quarterly audits of risk assessments; outcomes reported and managed via Clinical Governance and Risk Committee and LCHS
Trust Board through the Quality and Risk Report
ti
3.7%
Pa ti ents assessed for risk of VTE
Pa ti ents not assessed for risk of VTE
96.3%
27%
26%
ti
47%
Pa ti ents who have received VTE treatment
Pa ti ents not requiring VTE treatment
Pa ti ents not recorded as either requiring or not requiring VTE treatment
Quality Account 2012-13
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26
LCHS has conducted a self-assessment of quality against Monitor’s Quality
Governance Framework. The Trust Board is responsible for overseeing the quality of care delivered across all of the services provided and to assure itself that quality and good health outcomes are achieved. The Quality Governance
Framework is part of the Foundation Trust application process and is defined as ‘the combination of structures and processes at and below board level to lead in trust wide quality performance’. In addition the self-assessment was reviewed by an independent third party, following the review a Quality
Governance Improvement Plan was developed and monitored by the Clinical
Governance and Risk Committee. A further self-assessment was carried out to ensure improvements were made. The outcome of the independent review and self-assessment are outlined below:
Risk Rating
(Score)
Definition
Green (0)
Amber/Green
(0.5)
Amber/Red
(1.0)
Red (4)
Meets or exceeds expectations
Partially meets expectations but confident in management’s capacity to deliver green performance within a reasonable timeframe
Partially meets expectations but some concerns on management’s capacity to deliver green performance within a reasonable timeframe
Does not meet expectations
Question Narrative
1 Does quality drive the Trust’s strategy?
LCHS Assessed
Score May
2012
0.0
RSM Tenon
Assessed Score
June 2012
0.0
LCHS
Reassessment
Sept 2012
0.0
2 Is the Board sufficiently aware of potential risks to quality?
3 Does the Board have the necessary leadership skills and knowledge to ensure delivery of the quality agenda?
4 Does the board promote a quality focused culture?
5 Are there clear roles and accountabilities in relation to Quality
Governance?
0.5
0.0
0.0
0.0
0.5
0.0
0.0
0.5
0.5
0.0
0.0
0.5
Lincolnshire Community Health Services NHS Trust

Question Narrative
6 Are there clearly defined, well understood processes for escalating and resolving issues and managing performance?
7 Does the Board actively engage patients, staff and other key stakeholders on quality?
8 Is appropriate quality information being analysed and challenged?
9 Is the board assured of the robustness of the quality information?
10 Is quality information being used effectively?
LCHS Assessed
Score May
2012
0.5
RSM Tenon
Assessed Score
June 2012
0.5
0.0
0.0
1.0
1.0
0.5
0.5
0.5
0.5
3.0
3.5
LCHS
Reassessment
Sept 2012
0.5
0.5
0.0
0.0
0.5
2.5
Quality Account 2012-13
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LCHS continues to make progress with regards to quality improvements in areas such as Single Sex Accommodation with no breaches reported in more than a year. Safeguarding training compliance for levels 1, 2 and
3 have increased and are over 90% for all staff. Clinical Leadership has been increased with the development and implementation of the Develop7 training programme and Behaviour Based appraisal.
PEAT is self-assessed and provides a framework for inspecting standards to demonstrate how well LCHS is performing in key areas including:
• Food
• Cleanliness
• Infection control
• Patient environment (including bathroom areas, lighting, floors and patient areas)
Assessments were carried out by various members of LCHS staff including nurses, matrons, doctors, estates and facilitates staff, executive and non- executive directors, dieticians and estates directors. Patients, patient representatives and members of the public are also part of this assessment process.
The PEAT inspections are carried out in the four Community Hospitals in
Gainsborough, Louth, Skegness and Spalding. Below a comparison of the
2011 and 2012 results are shown.
JCH
Environment
2011
Good
Johnson Excellent
2012
Acceptable
Good
Louth Good
Skegness Good
Acceptable
Good
Food
2011 2012
Acceptable Good
Excellent Excellent
Excellent
Excellent
Excellent
Good
Privacy and Dignity
2011
Excellent
2012
Good
Excellent Excellent
Good
Good
Acceptable
Good
Our community hospitals are audited for environmental cleanliness on a monthly basis and consistently achieve greater than the 90% target set for cleanliness.
From April 2013 PLACE will be replacing PEAT assessments. The assessment regime, will be known as Patient-Led Assessment of the Care Environment
Lincolnshire Community Health Services NHS Trust

(PLACE) and will apply to all hospitals delivering NHS-funded care, including day treatment centres and hospices. Like PEAT, it is an annual assessment and will cover the Community Hospitals run by LCHS and is voluntary.
PLACE covers broadly the same areas as PEAT – namely privacy and dignity, well-being, food, cleanliness and general maintenance and will provide an invaluable resource in assessing the care environment. It focuses entirely on the care environment and does not stray into clinical care provision or staff behaviours. It extends only to areas accessible to patients and the public - for example, wards, departments and common areas.
A key feature of PLACE is in the central role of patients in carrying out the assessments with at least half of the assessment team being made up by patients, Healthwatch Lincolnshire will be approached for their involvement in the process and training will be provided for all patient assessors.
After the assessment has been completed the results will be published following analysis by the HSCIC (Health and Social Care Information
Centre). An improvement plan indicating how the PLACE results will drive improvements will also be published.
LCHS ensures that the risk of avoidable spread of infections is minimised.
We monitor the environmental cleanliness across our healthcare premises in line with the NHS Cleaning Manual standards and report the audit results to the Board monthly. Throughout 2012/13 we consistently achieved the target of 90% or above.
We undertake surveillance for alert organisms and additionally screen all patient admissions for MRSA. Patients identified as MRSA positive receive
MRSA suppression therapy in line with a dedicated care pathway.
Performance in relation to MRSA screening is for the 2012/13 reporting period
Number of admissions
Number of screens completed
Number of MRSA positive screens
10/11 11/12 12/13
4838 3715 3504
4877 3691 3571
80 59 80
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The results from the 2012 staff survey have shown improvements in some of the key areas, the response rate for the survey was 59%, this is above the average response rate of 52% for community health care trusts.
The 2012 survey demonstrates that staff experience has improved most in the number of staff receiving equality and diversity training
The following results were reported as better than the national average:
• Staff witnessing potentially harmful errors, near misses or incidents
• Number of staff recommending the Trust as a place to work or receive treatment
• Staff motivation at work
• Staff believing the Trust provides equal opportunities for career progression or promotion
• Staff receiving health and safety training in the last 12 months
• Staff experiencing harassment, bullying or abuse from patients, relatives or the public in last 12 months Staff experiencing discrimination at work in the last 12 months
• Staff stating that hand washing materials are always available
Recommendations have been made and actions put in place to ensure further achievements are made including the following areas:
• Reduce work related stress
• Increase numbers of staff appraised to be in top 20% of Community
Trusts and improve quality and outcome of appraisals
• Achieve excellence in leadership
• Increase the available time of staff in the organisation and increase the available time clinicians can spend with patients
• Improve reporting of safety concerns
The title of Queen’s Nurse (QN) is open to individual nurses who want to demonstrate their commitment to patient-centred values and continually improving practice. Three of our nurses have achieved their ‘Queens
Nursing awards’ this year – Kai Brownhill – Lead Nurse, Education and
Support for Care Homes, Kerry Bareham – Clinical Team Leader/Complex
Case Manager and Janine Gargett – District Nurse.
Kerry Bareham, Clinical Team Leader/Complex Case Manager based in
Horncastle said. “I’m delighted to have been given the title. I am one person in a team of 15 and I’m very proud to have that team behind me so I can shine a light on the work we are doing every day. I hope that by raising the profile of what we do, we can encourage the brightest and the best to work with us and ensure nursing is a profession that people are proud to aspire to.”
It’s often the smallest, most considerate things that go beyond expectations to make a real difference to people’s lives. Like sharing some precious time, offering a hand to hold, a shoulder to lean on or a few words of comfort.
These are just a few of the things that thousands of NHS Heroes provide every day to make sure that each and every patient receives the very best care.
NHS Heroes 2013 is a national recognition scheme designed to celebrate the unsung heroes in the NHS family. Last year, patients, carers, staff and supporters of Lincolnshire Community Health Services nominated 12 special teams and individuals to shine a light on the great work they do. From the
Heart Failure Team, members of the Phoenix Stop Smoking Service and health visitors, through to community nurses and clinical nurse specialists, you told us why they meant so much to you.
This year, we’re asking you to once again let us know who makes the difference for you. If you know someone who goes the extra mile or gives that little bit extra, show them how much you care by nominating them as your NHS Hero today.
It will only take a few minutes of your time but the pride of being nominated will stay with your hero forever. Nominate your NHS Hero at www.nhsheroes.com and click on ‘nominate now’. You can also join in the conversation at www.facebook.com/nhsheroes
Lincolnshire Community Health Services NHS Trust

The title of Queen’s Nurse (QN) is open to individual nurses who want to demonstrate their commitment to patient-centred values and continually improving practice. Three of our nurses have achieved their ‘Queens
Nursing awards’ this year – Kai Brownhill – Lead Nurse, Education and
Support for Care Homes, Kerry Bareham – Clinical Team Leader/Complex
Case Manager and Janine Gargett – District Nurse.
Kerry Bareham, Clinical Team Leader/Complex Case Manager based in
Horncastle said. “I’m delighted to have been given the title. I am one person in a team of 15 and I’m very proud to have that team behind me so I can shine a light on the work we are doing every day. I hope that by raising the profile of what we do, we can encourage the brightest and the best to work with us and ensure nursing is a profession that people are proud to aspire to.”
It’s often the smallest, most considerate things that go beyond expectations to make a real difference to people’s lives. Like sharing some precious time, offering a hand to hold, a shoulder to lean on or a few words of comfort.
These are just a few of the things that thousands of NHS Heroes provide every day to make sure that each and every patient receives the very best care.
NHS Heroes 2013 is a national recognition scheme designed to celebrate the unsung heroes in the NHS family. Last year, patients, carers, staff and supporters of Lincolnshire Community Health Services nominated 12 special teams and individuals to shine a light on the great work they do. From the
Heart Failure Team, members of the Phoenix Stop Smoking Service and health visitors, through to community nurses and clinical nurse specialists, you told us why they meant so much to you.
This year, we’re asking you to once again let us know who makes the difference for you. If you know someone who goes the extra mile or gives that little bit extra, show them how much you care by nominating them as your NHS Hero today.
It will only take a few minutes of your time but the pride of being nominated will stay with your hero forever. Nominate your NHS Hero at www.nhsheroes.com and click on ‘nominate now’. You can also join in the conversation at www.facebook.com/nhsheroes
Quality Account 2012-13
31

Every validated nominee will receive a certificate. A shortlist of finalists chosen by the Daily Mail will be in with the chance of winning the Daily
Mail Health Hero Award 2013.
32
Our main Celebrating Success awards provided an ideal opportunity to recognise and celebrate those members of staff who made an outstanding contribution to the success of the Trust, and embraced our core values of
Quality, Value and Reputation.
The awards were based around LCHS’s strategic aims of Quality, Value and
Reputation.
The awards representing quality were; Improving Patient Experience,
Innovation through Technology and Equality and Diversity.
The awards representing value for money were; Quality, Innovation,
Productivity & Prevention and the Team that has shown the most improvement in productivity through new ways of working.
The awards representing reputation were; Leader of the Year, Care,
Courtesy
& Kindness, the Award for the Team/individual who has best represented and upheld the vision of their business unit, Chief Executive’s Award for
Personal Achievement and the Chairman’s Award - Going above and beyond.
Lincolnshire Community Health Services NHS Trust

Gainsborough’s Baby Café celebrated its third birthday in February 2013.
The café, which is run by Lincolnshire Community Health Services NHS
Trust, threw open its doors on February 5 to celebrate its third anniversary.
The Baby Café provides help and support from both skilled health professionals and other mums in a non-clinical cafe-style environment. Last year, the café allowed mums old and new to benefit from more than 1,000 face-to-face contacts with the health visiting team throughout 50 different group sessions. LCHS Health Care Coordinator Liz Hillman helped to set the project up in 2010. She said: “Feedback from mums has shown this
Baby Café is a real asset to the community in West Lindsey. Baby Cafés are a national initiative which are recognised as offering the gold standard in breastfeeding support to mums.
“Having a health visitor at every group session means we can give that expert advice and support in a relaxed atmosphere. Pregnant mums are also welcome to attend.”
“We can also hire out items such as baby slings, and give parents access to a library of books and resources.”
“We find mums are often so busy during the day that they often forget to eat lunch so these sessions are also an opportunity to recharge their batteries with a healthy snack, and meet new friends.”
The open day gave both old and new mums a chance to talk and share their experiences and find out more about what a Baby Café can offer them. Liz added: “It was a good celebration at the Baby Café. We welcomed about 20 mothers and babies at the group. There was a great atmosphere.”
Gainsborough’s Baby Cafe meets weekly on a Tuesday at Gainsborough
Children’s Centre, Market Arcade, Gainsborough, DN21 2DY, from 12-
1.30pm.
Quality Account 2012-13
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The Assisted Discharge Stroke Service (ADSS) and community nursing teams in Louth, Horncastle and Woodhall Spa found innovative ways to support their patients during adverse weather conditions during the winter period.
As a result, they have been recognised by the national NHS Winter Heroes scheme, which gives praise to individuals and teams who go above and beyond the call of duty. The ADSS staff trudged through snow on foot armed with equipment to deliver to patients, while in Louth they also took to pounding the pavement with a cheery smile. The Woodhall Spa team had volunteer 4x4 services on standby, and also a tractor belonging to a farmer in the team to support home visits.
Matron for Integrated Care in the north east for LCHS, Maria Storti, said: am very proud of all my community teams in the north east of Lincolnshire, who all worked so very hard, working above and beyond to ensure that all of their vulnerable patients were seen during the poor weather conditions.
“I am very proud to have such dedicated staff.”
Innovative work to share specialist nursing knowledge and training with care homes in Lincolnshire has received national recognition. Staff from
Lincolnshire Community Health Services have been ‘Highly Commended’ in the NHS Innovation Challenge Prize for their work. The project, which has been led by Kai Brownhill, has provided education to care homes to help share the skills of specialist nurses in the areas of preventing falls, avoiding pressure ulcers and supporting continence care. Health Secretary
Jeremy Hunt, NHS Chief Executive Sir David Nicholson and NHS Medical
Director Bruce Keogh were among the special guests to present prizes at a ceremony in London last week.
Kai, who is Lead Nurse for Education and Support for Nursing Homes, said:
“I am delighted to have been able to represent Lincolnshire at a national level and showcase the great work happening at LCHS. By sharing our advanced skills with staff in care homes, it could help reduce the number of GP and community nurse visits, and prevent otherwise avoidable hospital stays.”
Lincolnshire Community Health Services NHS Trust

LCHS responds to all complaints received from patients or carers and ensure that lessons are learnt from these to ensure that good quality services are delivered to the population of Lincolnshire.
During 2012/13 LCHS received 182 complaints, of the number of complaints received during this time period 2 have been reviewed by the Ombudsman
Feedback is awaited from the Ombudsman to advise if further action will be taken. LCHS ensures that all complaints are acknowledged within the set National Standard of 3 working days. When acknowledgment of the complaint is made a timeframe for the response is agreed with the complainant. This is usually agreed as 35 working days. If however the complaint is complex, an extension on the timeframe can be negotiated with the complainant.
During the reporting period 2012/13 the number of complaints rose by a total of 41 on the number received in the reporting period 2011/12. For the reporting period 2012/13, 328 contacts were made to Patient Advice and Liaison Service (PALS) with a number of concerns being addressed by services directly; this is an increase of 31 from the previous year. LCHS continue to take a proactive approach to address issues through PALS by ensuring that action is taken prior to a formal complaint being made.
Compliments are received directly by LCHS services from patients and carers. These compliments are recorded by the services and influence the monitoring of service quality.
The NHSLA regularly assess healthcare organisations against a range of standards and assessments. The standards that healthcare organisations are assessed against are available at: http://www.nhsla.com/
RiskManagement/.
To support improvements in safety for both patients and staff, the NHSLA produce risk management standards against which Trusts are regularly assessed in order to demonstrate compliance. During 2012 LCHS were awarded level one compliance and are now currently working towards their level two assessment, which is due to take place in 2014. Achievement of this award reflects the organisations continued commitment towards the development and implementation of policies designed to support the highest standards of care and safety for both patients and staff.
Quality Account 2012-13
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36
A number of stakeholders have been consulted with throughout the production of the Quality Account. These have included:
• Staff
• LCHS Members, including patients and carers
• The Public
• LCHS Readers Panel
• LCHS Staff Network Groups
• Health Overview Scrutiny Committee
• Healthwatch Lincolnshire
• NHS Lincolnshire
• Clinical Commissioning Groups (CCG)
Thank you to all those who contributed in the consultation process.
Changes to the Quality Account following the public consultation period will be detailed below in the final published document.
During the consultation period comments were received which included the request for further detail around the priorities for 2013/14 and for data to be included to demonstrate improvements made through the implementation of the 2012/13 priorities. Data has been included to demonstrate the current level of achievement and the improvements made throughout 2012/13.
In addition to further detail being requested it was identified that the translation at the back of the document to request in other language was incorrect. This has been updated to include the correct translation.
Lincolnshire Community Health Services NHS Trust

As part of the process for developing the Quality Account we were required to share a draft version with a range of other organisations and publish their comments. The responses from the organisations will be included below in the final published document.
Statement on Lincolnshire Community Health Services NHS
Trust’s Quality Account for 2012/13
This statement has been prepared jointly by the Health Scrutiny Committee for Lincolnshire and Healthwatch Lincolnshire.
Progress on Priorities for 2012-13
We are disappointed with the level of detail of the Quality Account as a whole. For this reason it is difficult to make a comment on the progress made on each of the five priorities. For example, it is not possible in each instance to ascertain whether the priority for improvement has been achieved.
We suggest that the Quality Account could be improved by including a clear statement as to whether each priority has been achieved; including information on the priority measure, both in actual numbers and percentages.
In relation to the priority relating to pressure ulcers, a statement that there is a downward trend in all grades of pressure ulcer implies that some progress has been made with this priority for improvement.
Our disappointment over the lack of information on priorities is pertinent in relation to the planned reduction in the number of falls resulting in harm to patients. As stated above, we would have liked to have seen defined and measured progress on this priority and whether it has been achieved.
Priorities for 2013-14
We note that the Trust is putting forward seven priorities for improvement for
2013-14. We wonder whether this number of priorities might be too ambitious for the Trust. Of the seven priorities, we welcome and support the inclusion of a priority relating to the elimination of grades 2, 3 and 4 pressure ulcers.
We are aware that there is a requirement that the Quality Account needs to include information on how the priorities for improvement will be measured, monitored and reported. Both the Health Scrutiny Committee and Healthwatch Lincolnshire are looking to engage with the Trust during the course of the year on how the progress with the priorities will be monitored and reported.
Quality Account 2012-13
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38
Francis Report
The Francis Report, published in February 2013, made a number of recommendations on how health services should prioritise the quality of patient care. We would have liked the Trust to have indicated in its Quality Account how it will be addressing the issues raised on the Francis Report, as these are likely to be relevant to the overall quality of care for patients, and possibly for the selection of the Trust’s priorities for improvement.
Achievements and Outstanding Practice
We would like to compliment the Trust on its achievements and outstanding practice during the last year.
Complaints and Compliments
We note the information included on the number of patient complaints and compliments and we welcome the reference to the actual number of complaints received. There appears to have been a significant increase in the number of complaints, compared to 2011-12. This is a cause for some concern.
We would like to stress the importance of using complaints as a means of improving and developing services and learning lessons, so that care can be improved.
Conclusion
We are grateful for the opportunity to make a statement on the draft Quality
Account. Both the Health Scrutiny Committee for Lincolnshire and Healthwatch
Lincolnshire will be seeking more engagement with the Trust during the coming year on the progress with its priorities and possibly the development of priorities for 2014-15.
Commissioning high quality, safe patient services is East Lincolnshire’s
Clinical Commissioning Groups (CCGs) highest priority. It is anticipated that the areas identified within Lincolnshire Community Health Services Quality
Account will enhance both the patient’s experience of health care, and improve patient safety and clinical outcomes. The focus the Trust is placing on developing outcome measures for all core community services will facilitate a clear and transparent mechanism to support the measurement of these improvements in service provision.
Lincolnshire Community Health Services NHS Trust

In terms of performance against the 2012/13 CQUIN indicators, the following indicators were achieved:
• Safety Thermometer
• Child Weight Management
• Making Every Contact Count
• Simple Telehealth
• VTE
• Dementia
The following CQUIN indicators were partially achieved:
• Pressure Ulcer Risk Assessment
• Patient Experience – Family & Friends Test
The following CQUIN indicator was not achieved:
• Serious Incident Reporting
East Lincolnshire CCG has been working in partnership with LCHS in supporting the continuous improvement in patient care through a sustained focus on the delivery of harm free care. The Trust has been working hard in
2012/13 to eliminate avoidable pressure ulcers at category 2, 3 and 4. This work has seen a considerable reduction in patients developing avoidable pressure ulcers, as well as a reduction in patients sustaining a fall with harm. This focus on improving patient care has seen the Trust achieve 93% harm free care.
During 2013 LCHS was subject to a unannounced inspection from the Care
Quality Commission (CQC). The inspection focused on John Coupland
Hospital in Gainsborough. The outcome of the inspection was positive with no concerns identified by the CQC.
East Lincolnshire CCG endorses the areas identified for improvement by
LCHS in 2013/14 and the associated initiatives as detailed within the Quality
Account as:
• Clinical Effectiveness
• Clinical Record Keeping
• Elimination of avoidable pressure ulcers at category 2, 3 and 4
• The elimination of falls with harm within community hospitals
• Elimination of medication errors in community hospitals
• The continued improvement of communication and enhancement of the patients experience
During 2012/13 LCHS has implemented a quality improvement strategy following a review of its quality governance systems. This means that
LCHS has improved the reporting of incidents, improve patient safety
Quality Account 2012-13
39

from ward to board, as well as develop a quality dashboard which is focused at both ward and team level. In addition to these improvements in quality governance, LCHS has identified that it will incorporate the recommendations from the Francis report (2013).
Additionally, the priorities identified by East Lincolnshire CCG as CQUIN indicators for 2013/14 include:
• Safety Thermometer
• Family & Friends Test
• Dementia
• VTE
• Admission avoidance integrated approach
• Making Every Contact Count
• Referral To Treatment improvement
• Cultural Barometer & enhanced safeguarding assurances
• Clinical Supervision
East Lincolnshire CCG endorses the accuracy of the information presented within the LCHS Quality Account and the overall quality programme performance will be reviewed through the formal contract quality review process.
Tracy Pilcher
Executive Nurse
East Lincolnshire CCG
40
Lincolnshire Community Health Services NHS Trust

The directors are required under the Health Act 2009 to prepare a Quality
Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the National
Health Service (Quality Accounts) Regulations 2012 (as amended by the
National Health Service (Quality Accounts) Amendment Regulations 2011 and the National Health Service (Quality Accounts) Amendment Regulations 2012).
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
• The quality Account presents a balanced picture of the Trust’s performance over the period covered;
• The performance information reported in the Quality Account is reliable and accurate;
• There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice;
• The data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and
• The Quality Account has been prepared in accordance with
Department of Health Guidance.
The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account.
By order of the Board
NB: sign and date in any colour ink except black
Chairman……………………………….............Date 25-06-13
Chief Executive………………………...............Date 25-06-13
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PALS is a confidential service that helps patients, their families and carers to find answers to questions or concerns regarding the care or treatment received from NHS Trusts in Lincolnshire.
As a patient, relative or carer you may sometimes need to turn to someone for on-the-spot help, advice and support. This is what the Patient Advice and Liaison Service does on a daily basis. We provide confidential advice and support, helping you to sort out any concerns you may have about the care provided by the NHS and guiding you through the different services available.
PALS can:
• give you information about local health services
• listen to any problems you may have in relation to your health care or the health care of a loved one or friend
• help you ask questions about your health care
• tell you about help and support groups for you or your carer
Tel: 0845 602 4384
Calls via Typetalk/Text Relay are welcome
Email: info@lincspals.nhs.uk
Write to us at:
Lincolnshire PALS
Greetwell Place
Lime Kiln Way
Greetwell Road
Lincoln
LN2 4US
A member of the team will be available Monday to Friday, 9am - 5pm
(Except Bank Holidays)
This service is confidential
Lincolnshire Community Health Services NHS Trust

For further details of how you can get involved with Lincolnshire
Community Health Services NHS Trust and to find out how you can become a member follow the link below: http://www.lincolnshirecommunityhealthservices.nhs.uk/Public/content/ lincolnshire-community-health-service-trust-membership
Quality Account 2012-13
43

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Lincolnshire Community Health Services NHS Trust
Bridge House, Unit 16, The Point
Lions Way, Sleaford
Lincolnshire, NG34 8GG
Tel: 01529 220300 http://www.lincolnshirecommunityhealthservices.nhs.uk/public/