Account
2012/13
Looking after you locally
2
Quality Account 2012/13
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
members of dedicated
NHS staff across
the county
NCH&C receives
16,500
referrals from GPs and
other healthcare
professionals
every month
More than
3,000
patients per year
are admitted to
our community
hospitals
We have
around
300
patient beds
in Norfolk
Our School
Nurses hold
1,300
face-to-face
appointments
with children
each year
We deliver
more than
70
different services
in and around
Norfolk
Norfolk Community Health and Care NHS Trust
3
Contents
1.1 Message from the Chairman
4
3.8.5 Local surveys
1.2 Statement from the Chief Executive
5
1.3Statement from the Director of
Nursing, Quality & Operations
3.8.6Patient Environment Action Team (PEAT) Assessment 2012
52
7
3.9Patient Safety – learning from incidents and complaints
54
3.9.1Introduction
54
2.1 Priorities for Quality Improvement (2013/2014) 10
3.9.2Complaints, claims and compliments
54
2.2 Quality Goals for 2013/14
3.9.3Serious Incidents Requiring Investigation (SIRIs)
55
1.4 Introduction to Norfolk Community Health and Care NHS Trust (NCH&C)
8
11
2.3 Health & Social Care Integration
50
2.4Transformation Programme for 2013/14
15
3.9.4 Never Events
57
2.5Statements of Assurance from the Board
16
2.5.1 Review of services
16
3.9.5National Patient Safety Agency Report (NPSA)
57
2.5.2 Participation in clinical audit
18
3.9.6 Safety Alerts
58
2.5.3 Participation in clinical research
21
2.5.4 Goals agreed with commissioners
22
3.9.7Reducing the level of harm of medication incidents
58
2.5.5 Statement from the Care Quality
Commission (CQC)
3.9.8 Patient falls
60
23
3.9.9Infection prevention and control
61
2.5.6 Data quality
25
2.5.7 Information Governance Toolkit attainment levels
3.9.10 P atient safety and quality benchmarking data
62
26
2.5.8 Clinical coding error rate
26
3.9.11 S afeguarding vulnerable adults
and children
63
2.5.9National Quality Indicators
27
3.10Effectiveness of Care
64
3.10.1Introduction
64
3.10.2National Institute for Health and Clinical Excellence (NICE)
64
3.10.3The Colman Centre for Specialist Rehabilitation (CCSRS)
66
3.10.4Podiatric Surgery – PASCOM 10 audit system
67
3.10.5Research and Development
68
34
3.10.6Clinical Audit Plan 2012/13
69
35
4Explanation of who has been involved and engaged with
3.1 Review of Quality Performance in 2012/13
29
3.2 Our Workforce
30
3.2.1National Staff Survey 2012
31
3.2.2 Mandatory training
32
3.2.3Appraisals
32
3.2.4Staff achievements and awards
33
3.2.5A selection of compliments and ‘thank yous’
3.3Performance Highlights over 2012/13
3.4Commissioning for Quality and Innovation (CQuIN) Scheme 2012/13
38
4.1Comments from Norfolk Healthwatch
(previously Norfolk LINk)
70
4.2Comments from Norfolk Health Overview and Scrutiny Committee
3.5Clinical Quality and Quality Goals for 2012/13 40
3.6Monitor’s Quality Governance Framework
44
3.7 Quality Assessment Visits
46
3.8 Patient Experience
47
3.8.1Introduction
47
3.8.2 The ‘Friends and Family Test’
48
3.8.3 Patient Stories
49
3.8.4 Patient Opinion
50
70
70
4.3Comments from South Norfolk Clinical Commissioning Group
71
5
Declaration by all Directors
72
4
Quality Account 2012/13
1.1 Message from the Chairman
It is with confidence
and pride that NCH&C
presents its Quality
Account for 2012/13.
The coming year
will see a number of
transformational changes
in the way that we deliver
our community based
services. Building on the
great work that has been
completed in 2012/13, improving the quality of our
services, we now look towards getting even better
through our transformation programme.
The recent report of the Mid Staffordshire NHS
Foundation Trust Public Inquiry chaired by Robert Francis
QC (herein referred to as the Francis Report) offers a
timely reminder of those things each and every one of
us within the NHS needs to remember in everything
we do. We need to make sure that patients are and
continue to be our first and foremost consideration.
We need to continue to listen to our patients and staff,
encouraging openness and honesty, and monitoring our
performance carefully. Our approach to transformation
and further improvements to quality are, and will
always be, delivered in the framework for delivery as set
out by Francis.
High quality patient care continues to be at the centre of
all we do. A major challenge will be finding new ways
of working to help us meet increasing demand, within
a constrained funding envelope. Our Transformation
Programme will enable us to be fit for the future and
help us to keep people in their homes, and cared for in
the community by embracing technology; empowering
our people; and reviewing our systems.
We, the Board of NCH&C, with and on behalf of all
our staff, commit ourselves to continuing to deliver
high quality patient care, in order to realise our vision,
‘Looking after you locally’.
Ken Applegate
Norfolk Community Health and Care NHS Trust
5
1.2 Statement from the
Chief Executive
NCH&C will deliver against its
vision of improving the quality
of people’s lives through the best
in integrated health and care...
The vision of Norfolk Community Health and Care NHS
Trust (NCH&C) is to improve the quality of people’s lives,
in their homes and community by providing the best in
integrated health and social care. This is summarised by
the Trust’s strapline “Looking after you locally”.
The golden thread running through 2012/13 has been
the measurable improvement in quality across the
portfolio of our services.
In summary we have:
• Been building strong relationships with the emerging
Clinical Commissioning Groups (CCGs) and Norfolk
County Council (NCC)
• Performed very well against our quality goals
• Implemented newly defined services, such as
a new CCG led specification for community
nursing and therapy
• Engaged our partner local providers
• Delivered a cost improvement programme of
£7.44m recurrent savings
• Achieved financial balance and delivered our
planned surplus
• Worked hard to engage our staff, as is evidenced
by improved staff survey results
• Successfully addressed areas of service
underperformance
• Been an active partner in the development of
system-wide plans for quality, innovation,
productivity and prevention (QIPP)
Our improvements have resulted in us progressing on
the journey to foundation trust (FT) status, and in the
strengthening of our governance arrangements.
The themes of the recent Francis Report will form the
cornerstone of our work this year. Patients are the
first and foremost consideration of NCH&C. We will
continue to listen to our patients and staff, encouraging
openness, transparency and candour. We will ensure
senior and professional accountability through the
measurement and understanding of performance,
addressing any issues immediately. We will continue on
our journey to FT status, not as an end in itself, but as
a key enabler to the continued delivery of high quality,
safe patient care.
6
NCH&C will be a strong, independent and expert
community provider that offers competitive services, in
an increasingly challenging and changing environment.
This will help us deliver our vision of ‘improving the
quality of people’s lives through the best in integrated
health and care’. The result will be to support us and
our GP, social care and secondary care partners in
the development of integrated care pathways and
integrated services. We will have a secure platform for
exploring opportunities to extend into the delivery of
Continuing Care.
NCH&C has been making good progress on discussions
with Norfolk County Council (NCC) in relation to the
integration of adult health and social care. This builds on
our existing Integrated Care Organisation (ICO) work and
pilot work in the west of the county. We are exploring
what the next stage may look like and are going to be
considering a range of options. NCH&C staff are being
encouraged to feedback their early views.
Transformation and further improving quality will be the
familiar day-to-day experience of our patients, carers,
customers and staff in 2013/14.
I hope you will find our Quality Account for 2012/13
informative and helpful in reviewing our progress
against our key priorities for the forthcoming year.
Declaration and endorsement
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 Healthwatch and Norfolk County
Council’s Health Overview and Scrutiny Committee.
In line with recommendations made in the Francis
Report, this Quality Account is accompanied by a
declaration signed by all directors in office at the date
of the account certifying that they believe the contents
to be true or, alternatively, a statement of explanation
as to the reason any such director is unable, or has
refused to, sign such a declaration.
Michael Scott
Quality Account 2012/13
Norfolk Community Health and Care NHS Trust
7
1.3 Statement from the Director of
Nursing, Quality & Operations
We are committed to
high quality care...
High Quality Care is about ensuring that those who use
our services get the right care, when they need it, by the
right person and that it is delivered with compassion.
The recently published Francis Report into Mid
Staffordshire Hospital has sent shockwaves throughout
the NHS.
We have taken the report very seriously and although
we are confident that we do provide high quality
care, we are not complacent. We are in the process of
holding a number of staff engagement workshops to
discuss the Francis Report and hear directly from our
staff what we can do to continue to develop our
quality culture.
We have already undertaken a significant amount of
work to identify our organisational values and have
made a concerted effort to recruit people who share
those values. We also know that recruiting people
for their values on its own isn’t enough - we need to
support them to live those values by creating the culture
for safe and compassionate care – enabling staff to do
the right thing.
We believe that there is an inextricable link between
quality, values and behaviour – where these are aligned,
then patients will have better outcomes and a better
experience and perspective of the care they received. In
order to achieve this, we are investing in staff training,
supervision and development and using a behavioural
competency framework to support this.
We are raising the awareness of the importance of
providing compassionate care and promoting a safety
culture - looking beneath the surface to identify and
learn from ‘near misses’ as well as learning from
things when they go wrong. Part of our learning from
incidents is to share information ‘when things go
wrong’ with our patients to gain their experience of
care. Francis highlights the need for doctors and nurses
to be transparent about the care they give and this is
being formalised in a new ‘duty of candour’.
We are also promoting the importance of being
proactive and considering what could potentially go
wrong, so that we can plan for and mitigate any risks.
In order to achieve a high quality culture we also
recognise the need to embrace a continuous
improvement mindset – this means actively seeking out
best practice and identifying new and improved ways of
providing care.
By investing in the wellbeing and professional
development of our staff, they can then fulfil their
calling by providing outstanding care for patients.
Anna Morgan
8
Quality Account 2012/13
1.4 Introduction to Norfolk
Community Health and Care
NHS Trust (NCH&C)
The vision of Norfolk Community Health and Care NHS
Trust (NCH&C) is to improve the quality of people’s lives,
in their homes and community by providing the best in
integrated health and social care. This is summarised in
the Trust’s strap-line “Looking after you locally”.
Our business units provide:
1.Children’s Services, which includes prevention and
health promotion services
2.Specialist Services, such as neurological rehabilitation
or re-ablement services
3.Adult community services delivered on a locality
basis coterminous with the areas covered by Clinical
Commissioning Groups (CCGs) and working in an
integrated way with social care
NCH&C in summary:
1.Serves 750,000 people, across Norfolk and Waveney
2.Provides services for West Norfolk, North Norfolk,
South Norfolk and Norwich CCGs and Norfolk
County Council
3.Employs 2,201.26 whole time equivalent staff
4.Delivers care in people’s homes, as well as from
over 200 different locations, and through over
400 schools
5.Manages 11 community hospitals, with12 wards
and 223 beds (this increases with winter pressure beds)
6.Shows results for the Net Promoter test of NCH&C
in the top quartile (71 or over) consistently with the
exception of one month
7.Our income in 2012/13 was £124.8m
The starting point for NCH&C is always the
patient – providing individualised care and focusing on
maintaining independence. This means that quality is at
the heart of everything NCH&C does.
The Trust’s services are built up around the patient
working closely with GPs as partners, whether as
commissioners and thereby customers, or as fellow
providers. The unique role of a community trust
provides continuity of care on an ongoing basis, treats
people at the earliest intervention possible, close to
or in their own homes and place of their choosing.
As a community trust we aim to lead out of hospital
community healthcare, giving children a better start and
adults greater independence. We will typically do so in
their own home or place of choosing. This, combined
with the fact that we are a major employer and operate
from multiple sites, means that we are both ‘in’ and ‘of’
the community.
The Trust and its commissioners believe that a strong
and independent community services provider can be
a catalyst for systemic change, enabling commissioners
to drive improvements in productivity, quality and
outcomes, yet in the context of financial constraint.
Becoming a foundation trust is a means of accelerating
and embedding the Trust’s values and its aspiration
for a highly engaged workforce, proud of the services
it delivers, their local presence and local delivery. The
Trust’s approach to Membership and Governors enables
a stronger involvement of patients and the public.
Norfolk Community Health and Care NHS Trust
Highlights from
2012/13 include
18 week wait – referral to
treatment target
During 2012/13 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 for Referral to Treatment (RTT), where 95% 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
improvements with most services either exceeding the
target on a consistent basis, or achieving 100%.
Infection prevention and control
In 2012/13, there were three reported cases of
Clostridium Difficile against an annual ceiling of nine
cases. All reported cases have been subject to Root
Cause Analysis (RCA) to review lessons learned.
Despite high levels of Norovirus within the general
community, NCH&C has only suffered one cluster of
Norovirus. This was quickly and efficiently contained
with only four patients affected. The ward did not need
to close and their patients were managed within side
rooms and a bay. Ultimately it is staff vigilance that has
kept NCH&C levels of Norovirus so low over the season.
9
Patient safety – Falls causing harm
The Trust agreed an annual ceiling of no more than 4.0
injurious falls per 1,000 Occupied Bed Days (OBDs).
Despite in-month variation across the Trust’s inpatient
units, the number of falls per 1,000 OBDs was 3.41, a
clear improvement on the previous year’s rate of 4.03.
Patient safety – Venousthromboembolism (VTE) assessments
All community service providers are required to
report the level of Venous-Thromboembolism (VTE)
assessments for patients admitted to its community
hospitals who are at risk of developing a VTE. The Trust
established a locally agreed trajectory for 2012/13,
against which it would be monitored, and to then
achieve the national target of 95% compliance by
December 2012. By August 2012, the 95% target had
been achieved and since maintained across the Trust.
10
Quality Account 2012/13
2.1 Priorities for Quality
Improvement (2013/2014)
A range of different methods will be used to support
delivery of our Integrated Business Plan’s (IBP)
aspiration of ‘attaining the best patient experience
in the East of England’.
We will continue to use the ‘Friends and Family’ test
in our inpatient units, asking patients if they would
recommend the service to their friends and family and
asking for their comments. This process will be rolled
out across our community services during 2013/14.
Patient Opinion is a website: www.patientopinion.org.
uk where the public can publish their experiences (good
or bad) of local health services. The website allows
health service staff to interact with these patients to
help improve care. There is also the option of giving
patients a hard copy feedback card or they can call a
freephone number and tell their story over the phone.
NCH&C commenced a small pilot in early March 2013
in four services to trial Patient Opinion. 23 stories were
posted on the website during April and these stories
had been viewed 820 times. There has been some
excellent feedback about all of the services included
in the pilot and service leads are being encouraged
to respond to comments regardless of content to
demonstrate that we are actively engaging with their
feedback to improve care.
Our responses to the Winterbourne and Francis reports will
be enacted with a particular focus on patient safety during
2013/14. For example, a series of Francis Report workshops
have been scheduled during May and June 2013 in light of
the Robert Francis Inquiry into the care provided to patients
at Mid Staffordshire Hospital and will be led by members
of the Executive Director team. These workshops aim to
identify actions we can take to continue to ensure the
quality and safety of our services in the future.
Norfolk Community Health and Care NHS Trust
11
2.2 Quality Goals for 2013/14
To realise our vision of ‘Improving the quality of people’s
lives by providing the best in integrated health and
social care’, we will focus on a number of priorities
which include our quality goals.
High quality care means care that is as safe and
effective as possible, where patients are in control and
are treated with compassion, dignity and respect; their
experience of care being as important as the outcomes
of care. High quality care also means focusing on the
prevention of illness.
Within NCH&C, we believe that everyone within the
organisation has a role to play in supporting this ethos –
this is not just about clinical staff and how they care for
patients. Administrative and support staff are also able
to contribute in a number of ways – simple things like
answering a phone for a colleague can make a
real difference.
The three domains of high quality care have been
defined as being:
• P
atient Safety: The first dimension of quality must be
that we do no harm to patients. This means ensuring
that the environment is safe and clean, and reducing
avoidable harm, such as excessive drug errors
• P
atient Experience: Quality of care includes the
quality of caring. This means how personal care is
delivered, the compassion, dignity and respect with
which patients are treated. It can only be improved
by analysing and understanding patient satisfaction
levels and experience
• Effectiveness of Care: This means understanding
the success rates of different treatments for
different conditions. Assessing this will include
clinical measures, such as mortality or survival
rates, complication rates and measures of clinical
improvement. Just as important is the effectiveness
of care from the patient’s own perspective. Examples
include, improvement in pain scores or returning
to work after treatment. Clinical effectiveness may
also extend to people’s wellbeing and ability to live
independent lives
In order to support high quality care, each year we
focus on key Quality Goals. These goals are intended to
inform the practice of each member of staff across all
three domains of quality. After consultation with staff,
we have developed the following goals for 2013/14.
At this stage, the goals are of a strategic nature, but
it is expected that local teams will identify what each
goal means for them and their practice.
Our Quality Goals will help us deliver excellent and
harm free care and are also designed to reflect the
learning from the Francis Report and include the Chief
Nursing Officer’s 6 C’s (care, compassion, competence,
communication, courage and commitment). These six
fundamental values are underpinned by the following
key actions to support healthcare professionals deliver
excellent care and include:
1.Helping people to stay independent, maximising
wellbeing and improving health outcomes
2.Working with people to provide a positive
experience of care
3.Delivering high quality care and measuring the
impact of care
4.Building and strengthening leadership
5.Ensuring we have the right staff, with the right skills,
in the right place
6.Supporting positive staff experience
The quality goals also include meeting our
commissioner’s quality indicators as set out in
the CQuIN schedule and together will build on
improvements made during 2012/13.
12
Quality Account 2012/13
1. To continue to embed a culture of compassionate care (the 6 Cs) and act on learning from the
Francis Report
We will continue to demonstrate this by:
a. Treating all our patients with care and compassion
Experience
b. Ensuring that every patient is treated with respect, privacy and dignity
Experience
c. Ensuring the safety of patients / service users in our care
Experience / Safety
d. Raise the organisational visibility of all our vulnerable adults and children to improve
their safety
Safety
e. Being open and transparent
Safety / Experience
f. Implementing regular mortality reviews
Safety / Effectiveness
2. Developing and promoting our approach to clinical effectiveness
This year we want to engage with clinicians across NCH&C so that every service has an
agreed and shared set of clinical effectiveness measures they can use to demonstrate
improved patient care and drive improvement. We will achieve this by attaining goals
that our patients want by reducing length of stay and preventing admission to hospital
Effectiveness
We will also be reviewing the programme of clinical audit
3. Meeting our Commissioning for Quality and Innovation (CQuIN) goals
a. Friends and Family Test – To improve the experience of patients in line with Domain 4 of
the NHS Outcomes Framework. The Friends and Family Test will provide timely, granular
feedback from patients about their experience. To roll-out to community services
Experience
b. NHS Safety Thermometer – Data collection of the 4 harms: pressure ulcers, falls,
catheter acquired urinary tract infections and venous thromboembolism assessments
Safety
c. Dementia – To incentivise the identification of patients with dementia and other
causes of cognitive impairment alongside their other medical conditions, to prompt
appropriate referral and follow up after they leave hospital and to ensure that
hospitals deliver high quality care to people with dementia and support their carers.
Continuation of the care pathway and clinical leadership
Safety / Experience
d. Venous Thromboembolism (VTE) – To reduce avoidable death, disability and chronic
ill health from VTE through assessments of patients at risk
Safety / Effectiveness
e. System-wide assurance process – Regarding admission avoidance
NHS England Local
Area Team
f. Breastfeeding initiative – NCH&C’s contribution across Norfolk to help increase the
numbers of women initiating breastfeeding in line with the Department of Health
target of 2% increase per annum
NHS England Local
Area Team
g. Lymphoedema – Roll out of specialist service to include pre-assessment dopplers in
the west locality. This will improve patient experience bringing care closer to home
to reduce unnecessary admissions
Partnership working
h. Neurology – Expansion of existing service to provide specialist nurse for patients
with Multiple Sclerosis. This service will support patients experiencing problems with
relapse, ongoing symptoms and worsening of their condition who would otherwise
be admitted to hospital
Safety / Experience
i. Continuing Healthcare – Exploration of expansion of the Community Nursing Team
in the south to cover the social care element for new continuing healthcare patients.
This would provide seamless and uninterrupted care for those patients
Safety / Experience
Norfolk Community Health and Care NHS Trust
13
2.3 Health & Social Care Integration
“People shouldn’t have to worry about how their health and social care is
delivered; they just need to know where to get the help that they need,
when they need it. Making sure that’s as easy as possible is our job...”
Why do we need joined up services?
Delivering what patients want
We know that people are living longer than ever before,
that there has been a rise in the number of people
with life-long conditions, such as diabetes, and that
people often have a number of different conditions
or health issues.
Our patients tell us that joined up health and social care
is important to them, saying:
This means that you may need to receive care from a
range of different experts, including nurses, therapists,
social workers, GPs, or other professional staff.
• They want one person to act as their key worker
and know their story
So by joining up different services, wherever possible,
we can ensure that the patient only has to tell their
story once to get the right support from different health
and social care experts.
• They want clear easy to use information, such as a
single telephone number
How does joined up care work?
Staff from NCH&C and NCC are working side-by-side
so we can be more informed about exactly what our
patients need.
This means we can make sure that they receive precisely
the right care and enjoy a better experience when
accessing our health and social care services.
• They want better co-ordination of services
• Use their General Practice as the natural focus for
local care
• They do not want to have repeat assessments
• Be treated with courtesy and respect
Our joined up approach will increasingly make this
a reality.
14
Building on recent success
NCH&C and NCC already have a very good record of
joined up working.
Along with GPs and a number of other local
organisations, we took part in a national pilot which
was run by the Department of Health.
This saw us all working together to create innovative
ways of improving the care provided to local people.
These were so successful that many of the initiatives are
still in place today.
Offering patients more choice
Health and social care staff work closely together to help
prevent the need for separate visits and assessments.
This also enables the care professionals to work in
partnership with their patients to ensure that services
continue to meet individual people’s needs and are
delivered in their preferred place of care, which may be
at home.
Plans for 2013/14
Currently NCH&C and Norfolk County Council are
seeking to agree the next stage of adult health and
social care provision. They are exploring what the next
stage may look like and are going to be considering
a range of options. The options appraisal will look at
the benefits and risks of moving further on integration
or continuing with our current joint management
arrangements across the county.
Quality Account 2012/13
Norfolk Community Health and Care NHS Trust
15
2.4 Transformation Programme
for 2013/14
During 2012 clinical and managerial teams worked
together to develop a three year programme of
transformational change. In 2013/14 we will deliver
our transformation programme in support of further
improving quality. Transformation with strong quality
achievement will make NCH&C well placed to continue
to deliver against commissioner expectations and
respond to new business opportunities. Our membership
of the Aspiring Community Foundation Trust Network
facilitates a deeper understanding of variation across
our community services portfolio and learning from
best practice to make further quality improvements.
Like all NHS organisations we have a number of
challenges, such as reducing costs, safeguarding the
quality of patient care and working to continually
improve the quality of our services. Whilst we have
had cost improvement programmes in previous years,
we recognise that delivery year on year becomes more
challenging and the nature of the change moves from
incremental to more transformational, which will come
together to achieve our service development objectives
for the year.
Our Transformation Programme, which has been
internally developed, but is being externally validated,
covers improvements, such as workforce productivity
through new roles and mobile working, supply chain
management and planned Estate Rationalisation, which
form the basis of our Cost Improvement Programme.
But they are also the basis for improving quality through
releasing clinicians to have more face-to-face time to
care. They draw on clinical engagement in their design
and implementation with a view to increasing overall
staff engagement.
• Mobile working
The Programme is sponsored by the Executive Team,
with Senior Managers from the operational services
as the programme owners. Cost Improvement Plans
for 2013/14 are subject to a current validation process
externally validated by PricewaterhouseCoopers and
culminated in formal Board sign off in March 2013.
These plans will have been reviewed and approved by
the Trust’s medical and nursing directors as part of the
quality impact assessment process.
Our transformational programme comes under the
following themes:
• Streamlined systems
• Workforce planning
• Supply chain management
• Travel / Estates
16
Quality Account 2012/13
2.5 Statements of Assurance
from the Board
2.5.1 Review of services
During the period April 2012 to March 2013 Norfolk
Community Health & Care NHS Trust (NCH&C) provided
and/or sub-contracted 31 NHS services.
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.
NCH&C has reviewed all the data available to them on
the quality of the care in all 31 of these NHS services.
Green rating – (score 0-10)
No action required, re-assess area next month
The income generated by the NHS services reviewed
in 2012/2013 represents 100% per cent of the total
income generated from the provision of NHS services by
NCH&C for 2012/2013.
Amber rating – (score 11-15)
Undertake full risk assessment and agree action plan for
red items within one month. Add to local risk register
All clinical services are subject to monthly risk
assessment through the use of an Early Warning
Trigger Tool (EWTT). The implementation of the tool
was intended 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.
Red rating – (score 16 or more)
Inform line manager immediately and undertake full
risk assessment within one week. Produce action plan
for red items within one week. Escalate to Executive
Director Team
The data from the tool is reviewed monthly to identify
services with potential issues, as well as identifying key
themes common to a number of teams or departments.
Several teams which have flagged as ‘Red’ have been
subject to visits and action plans, which have helped to
address specific operational issues and reduce the level
of risk accordingly.
The Trust Board receives a monthly Integrated
Performance Report (IPR), which focuses on a number
of domains, including patient experience, safety, quality
and risk. The data is presented in a dashboard format,
using Red-Amber-Green (RAG) ratings to highlight
any areas of adverse performance against agreed
targets, standards and thresholds and is supported by
a narrative explaining the reason for the variance, and
actions being taken to mitigate future risks impacting
on performance.
Norfolk Community Health and Care NHS Trust
The Board also receives a monthly 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 causing harm
• Pressure Ulcers
• Infection rates
• Clinical audit and effectiveness
• Patient Experience surveys (including the Friends &
Family Test and Patient Opinion)
• Complaints and compliments
• Results of external scrutiny (eg, Care Quality
Commission, NHS Litigation Authority, National
Patient Safety Agency)
Information is given over time, where available, to enable
comparisons in reporting levels, improved analysis and
identification of themes, trends and learning to improve
the safety and quality of care delivery.
17
Quality Account 2012/13
18
2.5.2 Participation in
clinical audit
During April 2012 – March 2013, three national clinical
audits and one confidential enquiry covered NHS
services that NCH&C provides.
During that period NCH&C participated in 33%
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 2012 – March 2013 are as follows:
Name of National Audit
Lead Organisation
Included participation
from NCH&C?
Diabetes (Adult) ND(A), includes
National Diabetes Inpatient Audit
(NADIA)
Health and Social Care
Information Centre
Yes, joint collection of data
with GP surgeries
Sentinel Stroke
Royal College of Physicians, London
No – due to capacity
The stroke unit is registering
NCH&C for 2013/14
Child Health Programme (CHR-UK)
Royal College of Paediatrics and
Child Health
This audit was registered and
led by the Norfolk and Norwich
University Hospitals NHS
Foundation Trust (NNUH)
Title of National
Confidential Enquiry
Applicable to NCH&C?
Included participation from
NCH&C?
National Review of Asthma Deaths
(NRAD)
Yes
No. There were no asthma deaths
recorded from within NCH&C care
during 2012/13
National Audit Programme (SSNAP)
– (combining the Sentinel stroke
audit (2010/11, 2012/13), and the
Stroke improvement national audit
project (2011/12, 2012/13)
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 2012 –
March 2013, are listed below alongside the number
of cases submitted to each audit or enquiry as a
percentage of the number of registered cases required
by the terms of that audit or enquiry.
Name
Lead
Organisation
Percentage
Diabetes (Adult)
ND(A), includes
National Diabetes
Inpatient Audit
(NADIA)
Health and
Social Care
Information
Centre
Information is
not currently
available
19
The report of two national clinical audits National
(Adult) Diabetes Audit, and the National Falls and Bone
Health in Older People 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:
(Diabetes) Description of actions:
Our Diabetes Practice Educator holds quarterly meetings
with our Link Nurses and Community Matrons across
the Trust and within these sessions learning from this
national report (primary care based) is shared. Where
training needs are identified, this is provided to our
community staff in order to continue to provide the
best possible care for our diabetic patients with the
long term goal of them achieving improved HbA1C
results (long term blood glucose stability).
(Falls) Description of actions:
A gap analysis of patient need versus staff capacity
was undertaken following publication of the 2011/12
National Falls audit report, and this was included in
a business case to our commissioners, to support the
development of a robust and sustainable ‘Falls pathway’
between primary, community, acute, and social care
services. Part of the funding bid was outlining the
need to make the community integrated team’s ‘Falls
champion’s’ substantive roles within our Trust.
Following this bid for funding, ongoing work was
designed to further develop and establish the
‘Falls pathway’.
20
Local clinical audits
The reports of 74 local clinical audits were reviewed
by the provider during the period from April 2012 to
March 2013 and NCH&C intends to take the following
actions to improve the quality of healthcare provided.
The following is a description of a selection of actions
and assurances provided. These assurances are in line
with the Clinical Audit Policy; (‘high assurance’ over
85% compliance, ‘moderate’ between 60% - 84%
compliance, and ‘low’ as below 59% compliance
against clinical audit standards). See section 3.10.6 for
more information.
a. Record Keeping/Management, Trust-wide,
annual, mandatory clinical audit
(High assurance achieved)
Good record keeping is an integral part of clinical
practice, and is essential to the provision of safe and
effective care. This audit has been designed to measure compliance with best practice standards and to identify
areas where practice should be shared or improved.
Following overall achievement of ‘high Trust-wide
assurance’ in this audit, next year re-audits will focus
locally on any areas of moderate or low compliance.
Quality Account 2012/13
b. Resuscitation (policy monitoring) clinical audit
(High assurance achieved)
This audit was conducted because NCH&C recognises
and accepts its responsibility to patients, employees,
families, carers and the general public to ensure that
the requirements for resuscitation (HSC 2000/28) are
satisfied and that best practice is maintained.
Actions include:
1.A nominated training lead to monitor compliance
with resuscitation training at Ogden Court
2.Learning, Education And Development (LEAD) to
provide a resuscitation training session on-site to
capture majority of staff members, to maintain
up-to-date training for staff
c. Auditing attendance at Priscilla Bacon Lodge
(PBL) inpatient, community and day unit –
multi-disciplinary team (MDT) meetings
(Moderate assurance achieved)
The aim of this audit was to ensure that in line with the
‘Manual for Cancer Services: Specialist Palliative Care
Measures version 1.0 May 2012’, weekly meeting were
held recording core member attendance. This manual
states that core members should attend at least 66% of
MDT meetings.
1.Move to adopting an electronic MDT attendance
record to avoid data collection errors
2.Identify a dedicated MDT Co-ordinator and cover
3.Move to a combined weekly MDT meeting to enable
core members to attend more easily
4.Repeat audit 1 year (June 2013)
Norfolk Community Health and Care NHS Trust
d. Administration of Buccal Midazalam and rectal
diazepam (Low assurance achieved)
The aim of this audit was to monitor our Trust’s epilepsy
service compliance with this element of the NICE
epilepsy pathway.
A confidence level and margin of error for this report’s
results were unable to be determined due to it not
being possible to estimate the total patient population,
but with the development of the Epilepsy Care Plan
template on SystmOne, this should be available for
future use. An action from this audit is to continue to
monitor whether care plans have been signed by the
relevant Doctor or manager.
e. Audit of medical summaries produced for the
adoption unit (Moderate assurance achieved)
The aims of this audit were to:
1.Ensure guidelines for producing child permanence
reports are being followed
2.To assess the quality of information provided
3.To assess the appropriateness of investigations
for children whose parents were known
substance mis-users
The main recommendations were to include any
negatives in the reports and to follow a guideline to
encourage medical staff to include as much information
as possible.
1.The letter template was changed to ensure recording
of which forms had been received or not
2.This needs re-auditing within the next year to see if
we have improved
3.The audit tool needs revising for next year to look at
a narrower scope of standards in greater detail
21
2.5.3 Participation in
clinical research
The number of patients receiving NHS services provided
or sub-contracted by NCH&C in 2012/13 that were
recruited during that period to participate in research
approved by a research ethics committee, was 773
(compared with 690 in 2011/12).
Participation in clinical research demonstrates NCH&C’s
commitment to improving the quality of care we
offer and to making our contribution to wider health
improvement. Our clinical staff stay abreast of the latest
possible treatment possibilities and active participation
in research leads to successful patient outcomes.
We were involved in 59 research studies during
2012/13, an increase of 20% on 2011/12 figures, this
includes 19 studies that were new in 2012/13 and
40 studies ongoing from previous years. The National
Institute for Health Research (NIHR) supported 70% of
these studies through its research networks, an increase
of 5% on 2011/12.
The median approval time for achieving NHS permission
for studies new to NCH&C in 2012/13 was 26 days,
well within the national target of 30 days, and showing
a significant improvement over the median of 36 days
achieved in 2011/12.
Throughout 2012/13 we have taken steps to embed
research as core Trust activity and encourage staff to
engage with the local clinical research networks. In line
with this we are developing a Trust research strategy
aligned with the NIHR high level objectives; successfully
applied for a second year of funding to continue our
Research Site Initiation (RSI) Scheme in 2012/13; and
embedded research in our key clinical forums.
The RSI funding has helped teams to develop their
research capability and capacity to host NIHR supported
research across a number of different clinical areas
including stroke, paediatrics, specialist palliative care
and adult learning disabilities and almost half of all new
studies hosted by NCH&C were in these areas.
22
Quality Account 2012/13
A new clinical forum recently set-up for musculoskeletal
staff successfully engaged with the local Primary Care
Research Network to identify and maximise on research
opportunities in the area of musculo-skeletal therapies,
resulting in the set up of a new NIHR funded study in
this area, which is just starting to recruit.
2.5.4 Goals agreed with
commissioners
We have continued to work with partner organisations
to help develop research ideas and questions of interest
to community care. Three NCH&C staff are currently
in receipt of research bursaries, and we continue to
support these staff to develop their research ideas into
fully funded research proposals.
A proportion of NCH&C’s income during April 2012
and March 2013 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. Details of NCH&C’s achievements against
the agreed CQuIN indicators for April 2012 to March
2013 are set out in Part 3 of this Quality Account.
A further seven NCH&C staff were also involved as
co-applicants on five separate research grants that were
submitted to the NIHR for funding in 12/13, and NCH&C
are collaborators on two ‘Research for Patient Benefit’
grants held by partner organisations in the areas of
stroke rehabilitation and social anxiety and stuttering.
Use of the Commissioning for Quality and Innovation
(CQuIN) payment framework.
The CQuIN indicators agreed with our commissioners
for the forthcoming year, (April 2013 to March 2014)
can be found in Part 2 under ‘Quality Goals’.
Norfolk Community Health and Care NHS Trust
23
2.5.5 Statement from
the Care Quality
Commission (CQC)
Norfolk Community Health & Care NHS Trust is required
to register with the CQC and its current registration
certificate issued on October 12, 2012, confirms
that the Trust is registered to provide the following
Regulated Activities:
1.Assessment or medical treatment for persons
detained under the Mental Health Act 1983
2.Diagnostic and screening procedures
3.Family planning
4.Surgical procedures
5.Treatment of disease, disorder or injury
The only conditions of registration are that these
regulated activities may only be provided from the
following registered locations:
Registered Locations
Regulated Activity No.
(see above)
Cranmer House
1, 2, 5
Little Acorns
5
Adult Learning
Disabilities, Mill Close
5
Provider Services HQ
1, 2, 3, 5
Squirrels
5
Benjamin Court
1, 2, 5
Colman Hospital
1, 2, 5
This community hospital was found to have met the
following essential standards of quality and safety as
listed below:
Dereham Hospital
1, 2, 5
Outcome 2
Kelling Hospital
1, 2, 5
North Walsham Hospital
1, 2, 5
Outcome 4Care and welfare of people who use
services
Norwich Community
Hospital
1, 2, 4, 5
Outcome 7Safeguarding people who use services
from abuse
Ogden Court
1, 2, 5
Outcome 14 Supporting staff
Swaffham Community
Hospital
1, 2, 5
Outcome 16Assessing and monitoring the quality of
service provision
The Care Quality Commission has not taken
enforcement action against NCH&C during the period
April 2012 and March 2013.
NCH&C has participated in five routine inspections
undertaken by the Care Quality Commission relating to
the following areas during April 2012 and March 2013:
One routine inspection was carried out at
Benjamin Court, Community Hospital, Cromer,
Norfolk (RY330) in November 2012.
Consent to care and treatment
24
Quality Account 2012/13
Routine inspections were undertaken at four of our
Joint Community Learning Disability Teams (which are
all registered by Norfolk County Council) during the
period April 2012 and March 2013 as follows:
1. Eastern Learning Disability Team, Ferry House,
Great Yarmouth (November 2012)
This LD team were found to have met the following
essential standards of quality and safety as listed below
and the formal report was sent to Norfolk County Council:
Outcome 1Respecting and involving people who
use services
3. West Norfolk Learning Disability Service,
King’s Lynn (March 2013)
This LD team were found to have met the following
essential standards of quality and safety as listed below
and the formal report was sent to Norfolk County Council:
Outcome 2
Consent to care and treatment
Outcome 4Care and welfare of people who
use services
Outcome 6
Cooperating with other providers
Outcome 10 Safety and suitability of premises
Outcome 4Care and welfare of people who
use services
Outcome 14 Supporting staff
Outcome 7Safeguarding people who use services
from abuse
4. Northern Learning Disability Service,
Blickling (March 2013)
Outcome 14 Supporting staff
Outcome 16Assessing and monitoring the quality of
service provision
This LD team were found to have met the following
essential standards of quality and safety as listed below
and the formal report was sent to Norfolk County Council:
2. South Norfolk Learning Disability Service,
Attleborough (January 2013)
Outcome 1 Respecting and involving people who
use services
This LD team were found to have met the following
essential standards of quality and safety as listed below
and the formal report was sent to Norfolk County Council:
Outcome 4 Care and welfare of people who
use services
Outcome10 Safety and suitability of premises
Outcome 2
Outcome 12 Requirements relating to workers
Consent to care and treatment
Outcome 4Care and welfare of people who
use services
Outcome 7Safeguarding people who use services
from abuse
Outcome 14 Supporting staff
Outcome 16Assessing and monitoring the quality of
service provision
Outcome 17Complaints
Outcome 16 Assessing and monitoring the quality of
service provision
Norfolk Community Health and Care NHS Trust
2.5.6 Data quality
High quality information underpins the effective and
safe delivery of patient care and is key if improvements
in quality of care are to be made. Improving data
quality, which includes the quality of demographic,
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 range of data quality reports have been designed
to monitor a range of key performance indicators on
a weekly and monthly basis
• The Secondary Uses Service (SUS) dashboards are
reviewed regularly in relation to a number of national
key indicators
25
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 10 for 2013/14 and the need to
introduce and monitor the Community Information
Data Set (CIDS).
This strategy is underpinned by a Data Quality Policy
which is subject to annual review. The purpose of this
policy is to ensure the highest standards of data quality
throughout NCH&C are achieved and maintained. 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.
The Trust is also reviewing its formal structures for
monitoring data quality ensuring its Data Quality
Forum has the necessary membership and coverage to
continue to drive improvements in data quality.
• A selection of these indicators are also reported to
monthly business unit performance meetings where
operational services are held to account for the
quality of data held on the Patient Administration
System (PAS) and SystmOne
NHS Number and General Medical
Practice Code Validity
• These reports are held on a networked drive and can
also be viewed on an Intranet portal to ensure they
are accessible to key staff involved in the monitoring
and reporting of performance and activity data
NCH&C submitted records during 2012/13 to the SUS
for inclusion in the Hospital Episode Statistics (HES)
which are included in the latest published data under
the organisation code RY3.
The percentage of records in the published data which:
1.Included the patient’s valid NHS Number was:
100% for admitted patient care (APC)
100% for out patient care
2.Included the patient’s valid General Medical Practice
Code was:
100% for (APC)
100% for out-patient care
Quality Account 2012/13
26
2.5.7 Information
Governance Toolkit
attainment levels
NCH&C Information Governance Assessment Report
overall score for 2012/2013 was 66% at Level 2 and
was graded green:
Assessment
Level 2
Exempt
Total Req’ts
Overall Score
Grade
Version 10 (2012-13)
38
1
39
66%
Satisfactory
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.
2.5.8 Clinical coding
error rate
NCH&C was not subject to the Payment by Results
(PbR) clinical coding audit during 2012/2013 by the
Audit Commission.
Norfolk Community Health and Care NHS Trust
27
2.5.9 National Quality
Indicators
All trusts requirement:
The data made available to the National Health Service
trust or NHS foundation trust by the Health and Social
Care Information Centre with regard to the number and,
where available, rate of patient safety incidents reported
within the trust during the reporting period, and the
numbers and percentage of such patient safety incidents
that resulted avoidable harm in severe harm or death.
All trusts requirement:
The data made available to the National Health Service
trust or NHS foundation trust by the Health and Social
Care Information Centre with regard to the percentage
of patients aged (i) 0 to 14 and (ii) 15 or over, readmitted
to a hospital which forms part of the trust within 28 days
of being discharged from a hospital which forms part of
the trust during the reporting period.
The Trust considers that this data is as described for the
following reasons: It represents the rate of incidents
reported against the number of face-to-face contacts
with patients, expressed as a rate per 1,000.
NCH&C does not re-admit patients aged 15 or over
following discharge. All admissions to the Trust’s beds
are received from acute trusts or from the patient’s
usual place of residence.
The Trust has taken the following actions to improve
this number and rate, and so the quality of its services,
by actively reporting all incidents through its DATIX
incident reporting database, whether they result in
harm or otherwise, ensuring that appropriate staff are
suitably trained to report and record all incidents, and
identifying trends, patterns and risk factors, in order to
use this information to improve the quality and safety
of our services.
Number of incidents (total NCH&C)
Apr
2012
May
2012
Jun
2012
Jul
2012
Aug
2012
Sep
2012
Oct
2012
Nov
2012
Dec
2012
Jan
2013
Feb
2013
Mar
2013
No harm
243
314
253
297
333
324
285
266
315
322
319
379
Low harm
289
359
303
432
390
348
402
387
337
434
364
396
Moderate
harm
58
67
41
81
85
54
72
77
80
92
82
86
Severe
harm
9
4
10
10
6
4
10
1
4
6
3
7
Death
3
0
1
2
3
3
4
6
1
3
4
0
Total
602
744
608
822
817
733
773
737
737
857
772
868
6.86
6.23
7.08
8.87
8.82
8.83
6.58
Total incidents in clinical areas per 1,000 contacts
5.96
7.29
5.90
8.46
7.21
28
All trusts requirement:
The data made available to the National Health Service
trust or NHS foundation trust by the Health and Social
Care Information Centre with regard to the percentage
of staff employed by, or under contract to, the trust
during the reporting period who would recommend the
trust as a provider of care to their family or friends.
KF24. Staff recommendation of the trust as a place
to work or receive treatment
On a scale of 0 – 5 (the higher the score the better)
2011 Results: 3.22
2012 Results: 3.39
Showing that staff experience has improved within
NCH&C (although worse than average when compared
with other community trusts - 0.2%).
NCH&C are encouraged that this score has improved
this year and is much closer to the average score for
community trusts. The Trust now has a process in place
to survey all staff twice a year by location on a rolling
basis so that a survey happens to one of our business
units each month to compliment the national staff
survey. The focus is on generating locally responsive
actions. The KF24 question is also asked within this
process, and where local issues are highlighted,
they are addressed.
Following this year’s national survey we ran a series
of sessions with staff to obtain more information
regarding this issue and are currently reviewing the
results. This information will continue to inform our
staff engagement plan.
Quality Account 2012/13
Norfolk Community Health and Care NHS Trust
29
3.1 Review of Quality Performance
in 2012/13
Chief Executive hails staff for “Trust’s best ever year”
Michael Scott thanked NCH&C’s staff for helping the
Trust to make significant progress
over the last financial year...
2012/13 has been a year of really focusing on patient
quality. We have measurably improved the quality
of our services in 2012/13, delivering better health
outcomes, high standards of safety, leading to excellent
patient experience.
A key objective for our Trust was to reduce levels of
patient harm and we are delighted to report that we
have seen a drastic reduction in the level of pressure
ulcers seen locally.
Whilst we did not completely eliminate avoidable
pressure ulcers, we have only had one in our inpatient
units in the last four months. Similarly, we have
had very low levels of falls and health care acquired
infections, which all contribute to our goal of delivering
harm-free care.
Central to this success, as well as so many of our
others, is the hard work and dedication of our excellent
staff. Many of our colleagues have been recognised for
their exemplary work over the last year, such as those
given the title of “Queen’s Nurse’ and ‘NHS Hero’.
Enabling our Trust to take ‘temperature checks’ from
our staff about what is working well and what needs
to be addressed has also been improved thanks to
our new Short Staff Surveys. Recent feedback from
colleagues shows that things are improving, with seven
of the questions consistently scoring at least 5% higher
than in the 2011 NHS Staff survey.
We know that things are still not perfect, but we are
confident that progress is being made and that we
can continue to improve together. Receiving prompt
feedback from our staff is key to our ongoing success,
so we will keep this dialogue going to see how we can
further improve in the coming year.
As a community-based Trust, Community Nursing and
Therapy (CN&T) is one of our flagship services and a
key local NHS provision. It is also highly rated by our
patients, with nine out of ten CN&T patients saying they
are satisfied with the care they receive. It is therefore
important that GPs see the value of this service too.
Accessibility of our services has also greatly improved
this year. For example our Podiatric Surgery Service
has become compliant with our 18 weeks referral
to treatment targets thanks to much hard work from
the service’s staff. Similarly, our MSK Physiotherapy
Service and our Wheelchairs Service have also greatly
improved their accessibility. Today, almost every single
patient, across each of our services, is seen within the
18 week target.
30
Quality Account 2012/13
3.2 Our Workforce
Our overarching view is that an engaged, empowered
and compassionate workforce will have a direct impact
on the quality of care received by our patients. The
Francis Report highlights the importance of listening
to the workforce and addressing concerns and issues
raised in a timely and effective manner. They are the
eyes and ears of the organisation and passionate about
patient care, driven by a desire to continuously improve
the quality of care provided.
With this in mind, increasing staff engagement,
summed up as an annual priority for 2012/13 as ‘To
truly inspire our staff’ has been a major focus for the
year. Our engagement score increased from 3.5 in 2011
to 3.61 in 2012 which is close to the national average
of 3.69 for community trusts and the 4th highest
improvement compared to 21 community trusts. The
Directors have provided a series of roadshows giving
up to date information on strategic direction and
performance. In 2011, 60% of staff said they knew
who the senior managers in the Trust were. In 2012,
that figure had risen to 80%.
The Trust remodelled some of its services during the
year to ensure that they remain efficient and cost
effective. In this year we have redesigned our IM&T
service, reviewed administrative and clerical roles and
restructured corporate management functions.
Our voluntary turnover rate for the 12 months to
February 2013 is 9.2% which sits within our target
of 12% (plus or minus 5%), and is under our annual
plan target of 10%. This indicates a good retention
of experienced staff and is within the tolerances for a
healthy turnover of workforce.
The Trust sees effective leadership as an important
enabler in delivering this annual plan. The Trust has
a number of internal leadership and management
programmes that are formally evaluated and highly
valued by staff. 89% of participant managers, surveyed
three months after completing our REAL programme
say it had a significantly positive impact on the
participants behaviour.
The Trust also draws on training provided by the
Norfolk and Suffolk Leadership Academy as well as SHA
provided leadership programmes for the national Top
Leaders. Development programmes are also in place
for the Executive Directors as well as the whole Board,
incorporating externally facilitated 360 degree feedback.
Absence management within NCH&C has continued
to be a challenge against the back drop of increasing
demand and capacity.
We have increased the uptake of flu vaccinations
in 2012/13 but will want to see further uptake in
2013/14. 25% of staff receiving flu vaccinations: an
increase from 20% in 2011/12, whilst falling short of
the internally agreed target of 50%.
We set our sickness target at April 2012 to be 4.5%,
decreasing to 4.0% by March 2013. Our actual rolling
12 month sickness rate for the Trust stands at 5.02%
at February 2013. We have focussed on complex
sickness cases in an effort to meet our target: long
term sicknesses (eg, musculo-skeletal conditions,
stress, anxiety) account for approximately 60% of
our current sickness.
Norfolk Community Health and Care NHS Trust
31
3.2.1 National Staff
Survey 2012
The National Staff Survey 2012 shows NCH&C as
one of the most improving community trusts, albeit
with further work to do in 2013. Engagement and
satisfaction scores are up as is recommendation of the
Trust as a place to work or receive treatment.
The 2012 full staff survey was carried out from October
to December 2012 and sent to a sample of 778 staff.
Our 59% response rate was a 6% improvement on
2011 and compares favourably with the top national
response rate of 60%.
We improved by a statistically significant amount in five
of the 21 Key Findings that could be compared with the
2011 survey. They included the recommendation for the
Trust as a place to work or receive treatment from 3.22
out of 5 to 3.39 although this is still below the average
of 3.58; effective team working 3.71 to 3.85; number
of staff having had appraisals 87 to 92%; contribution
to improvements at work from 62% to 72% and the
staff experiencing discrimination at work decreased
from 11% to 5%.
We deteriorated in three key findings. Of the three Key
Findings since 2011 we are better than average in one
and average in two compared with other community
trusts. Two of the areas in which our scores deteriorated
related to training in the last 12 months. Health and
safety and equality training are specifically mentioned
in the national survey, but are only refreshed in the
Trust every three years. As a result we would expect
fluctuations in this result
The overall engagement score for NCH&C improved
from 3.5 in 2011 to 3.61 in 2012. The most recent
short staff survey in the south shows an engagement
score of 3.65.
Staff satisfaction improved from 3.38 in 2011 to 3.55
in 2012. The most recent short staff survey in the south
shows satisfaction of 3.60 showing a continuing rise in
engagement and satisfaction across NCH&C.
Only three of 21 community trusts improved their
engagement score compared to 2011 by more than we
did and only three had a higher number of improved
significant key findings compared to 2011. Including
improvements in staff satisfaction and the increase in
the proportion of staff who would recommend the
Trust as a place to work or receive treatment, we are on
these measures, arguably in the top five most improving
community trusts.
We set ourselves an annual objective to half the number
of below average scores. We did not meet this goal.
Last year we had 23 below average scores. This year we
had 15, a reduction by 8/23. Of those below average
measures, four were within 1% of the average of the
21 community trust scores.
During the year we introduced a short staff survey. This
includes themes from the annual national staff survey and
builds on research from the Gallop organisation. Following
each survey, the relevant business area is then tasked
with creating an action plan to address issues raised.
32
Quality Account 2012/13
3.2.2 Mandatory training
3.2.3 Appraisals
We remain committed to mandatory training in order
to ensure that new and existing staff are equipped
for delivering patient centred care. We are aiming
for 90% uptake.
We are similarly committed to ensuring that all our staff
have appraisal completion. We are taking a variety of
approaches to achieving our target of 90%.
The Trust has reviewed how it delivers mandatory
training to staff to ensure that it is accessible and
meaningful to them. We have developed a patient
centric approach to training for inpatient areas, which
is now bring remodelled to make it appropriate for
community based staff as well. This involves setting up
of training over a two day period covering a range of
topics, delivered in the ward environment based around
a figurative ‘patient in a bed’. We have also added it
to induction to make sure that staff are fully skilled at
the point that they join the organisation. In addition,
we are creating a number of distance learning training
courses to be used locally by staff and managers. Due
to these improved delivery methods, mandatory training
compliance has remained strong and currently stands at
80% against a target of 90%. This is an increase from
74% at the same point last year
The Trust has improved the way that it collects
information on appraisal rates and has seen significant
improvement in compliance as demonstrated in the
accompanying chart. The current appraisal completion
rate is at 80% against a target of 90% although our
survey results show a higher achievement. The last
national staff survey reported a higher rate of 93%.
At the equivalent point last year appraisal compliance
stood at 61%.
Norfolk Community Health and Care NHS Trust
3.2.4 Staff achievements
and awards
Queen’s Honours – Childrens expert
Sian Larrington, one of our Children’s Centre Service
Managers will receive an MBE from Her Majesty the
Queen after being included in this year’s Birthday
Honours list.
The honours aim to recognise people who have
dedicated their lives to improving those of others. The
list of latest recipients was announced in June and Sian
received acknowledgment for services to children.
She said: “I am absolutely delighted and really proud to
accept the honour.”
33
Becky receives ‘Queen’s Nurse’ Award
A community neurology Specialist Nurse has been
awarded the title of ‘Queen’s Nurse’ in recognition of
her long-standing commitment to delivering excellent
community-based care to local patients.
Rebecca ‘Becky’ Hipkin works in our Community
Neurology Team, based at St James’ Clinic, King’s Lynn.
The title was awarded by the Queen’s Nursing Institute,
a community nurses’ charity which aims to recognise
nurses who have shown high standards of care and to
encourage them to champion new ways of delivering
innovative support to patients.
Becky has cared for people in Norfolk since 1980, when
she started her career as a ward nurse at the Queen
Elizabeth Hospital, King’s Lynn. She has also worked in
the evening nursing service team, as a palliative care
nurse, and a community nurse.
In her current role, which she has held since 2004,
Becky provides care to patients in west Norfolk who
have Parkinson’s Disease, multiple sclerosis, and motor
neurone disease.
She visits patients in their own homes, as well as seeing
them within community-based clinics in King’s Lynn and
Downham Market, where she helps them to manage
their symptoms.
34
Quality Account 2012/13
3.2.5 A selection of
compliments and
‘thank yous’
Compliments and thanks received from patients are also
measured and this year the Trust has received in excess
of 955 compliments and thank you’s. The dedication
and commitment of our frontline staff is a recurring
theme of the compliments received
City 2 Integrated Team
I would like to compliment the nurse for the
excellent way she looked after my wife.
She was very pleased to be treated in this way.
She is a first class person and a credit to
your department...
Grimston District Nurses, King’s Lynn
I do not take such sterling high standards
for granted, I would like to hope, that this
summary of a job well done goes some way to
officially recognising their critical role in my
recovery, and their contribution to the
community at large...
Priscilla Bacon Lodge, Norwich
We could not have wished for better end
of life care that you all gave so freely...
Thank you for all the kindness you
have shown and give me.
I didn’t really want to leave...
We really appreciated being allowed
to stay and shall never forget the care
and compassion shown to us all...
Thank you all for the love and dedication
given. We know he felt safe and well looked
after. He never lost his smile with you...
Beech Ward, Norwich Community Hospital
Excellent service...
Well looked after...
King’s Lynn South Integrated Team
We cannot thank you for all that you
have done for mum/wife. You have all
went beyond the call of duty. We were very
happy that she was in safe hands...
Swaffham District Nursing
Thank you for all the care that you
gave my father. He had the very
best of everything from you all...
Four individuals and teams from our Trust have been
recognised by members of the public, patients,
and fellow NHS Colleagues. They have each shown
exceptional compassion, kindness, and skill above and
beyond the call of everyday duty.
The NHS Winter Heroes scheme was a chance for
people to nominate the NHS staff who ‘ploughed
through’ this winter, despite adverse weather and
winter pressures.
The scheme celebrates the role that all staff - whether
they be doctors, nurses, therapists, support staff,
managers, receptionists, or porters - play in improving
the lives of patients.
The winter campaign follows the NHS Heroes
campaign, which was held last summer and saw a
number of colleagues from our Trust nominated.
Our NHS Winter Heroes were invited to receive a
certificate and congratulations at a Board meeting
and are:
• Integrated Nursing Team, City One, Norwich
• Integrated Nursing Team, St James’, King’s Lynn
• Kevin Rix, Gardener, Colman Hospital, Norwich
Norfolk Community Health and Care NHS Trust
35
3.3 Performance Highlights
over 2012/13
Areas of achievement
During 2012/13 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 95% 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
improvements with most services either exceeding the
target on a consistent basis, or achieving 100%.
However, in year, four services experienced short periods
of below expected performance, and in each case, robust
action plans and calculated trajectories were established
in order to correct performance and return service
performance above target. These services were:
• Consultant-led community paediatric services
• Musculoskeletal physiotherapy
• Adult Speech and Language Therapy
• Wheelchair services
In 2012/13, there were three reported cases of
Clostridium Difficile against an annual ceiling of nine
cases. All reported cases have been subject to Root
Cause Analysis (RCA) to review lessons learned.
Despite high levels of Norovirus within the general
community, NCH&C only suffered one cluster of
Norovirus. This was quickly and efficiently contained
with only four patients affected. The ward did not need
to close and their patients were managed within side
rooms and a bay. Ultimately it is staff vigilance that has
kept NCH&C levels of Norovirus so low over the season.
The Trust agreed an annual ceiling of no more than
4.0 injurious falls per 1,000 Occupied Bed Days (OBDs).
Despite in-month variation across the Trust’s inpatient
units, the number of falls per 1,000 OBDs was 3.41, a
clear improvement on the previous year’s rate of 4.03.
All community service providers are required to
report the level of Venous-Thromboembolism (VTE)
assessments for patients admitted to its community
hospitals who are at risk of developing a VTE. The Trust
established a locally agreed trajectory for 2012/13,
against which it would be monitored, and to then
achieve the national target of 95% compliance by
December 2012. By August 2012, the 95% target had
been achieved and since maintained across the Trust.
36
Quality Account 2012/13
Meeting targets
Indicator
Target or upper ceiling
Annual performance
Trend
MRSA Screening –
elective patients
100% of patients having planned
surgery screened for MRSA
100%
Stable
Clostridium difficile
Nine cases or less during 2012/13
(cumulative)
3
Decreasing
Injurious falls
Number of falls resulting in harm
per 1,000 Occupied Bed Days to
be less than 4.0
3.41
Decreasing
Venous Thromboembolism
(VTE) assessments
At least 95% of admissions have a
VTE assessment
96.7%
Stable
18 week wait referral to
treatment
95% patients receiving definitive
treatment within 18 weeks of
referral
98.4%
Increasing
Health visiting
Over 95% of mothers receiving a
New Birth Visit within 28 days
97.9%
Stable
Norfolk Community Health and Care NHS Trust
Areas of non-delivery
In the early part of 2012/13, the Trust reported two cases
of MRSA bacteraemias, against an annual ceiling of
one case. Both were subject to robust RCAs to identify
lessons learned, particularly as the Trust had no cases the
previous year, (see section 3 for more information).
Throughout the year, the number of patients whose
discharge was delayed for non-medical reasons
occupied an increasing number of the Trust’s
community hospital beds. Over the period of the
year, 5.4% of beds were occupied by patients whose
discharge was delayed, compared to 4.1% the previous
year. Whilst there are no contractual targets in place
for this performance measure, analysis of the data has
shown delays have been attributable to both health
service related reasons (including patient and family
choice), as well as social care delays.
37
The Smoking Cessation service agreed an annual
target for 2012/13 of 2,000 quits with NHS Norfolk
and Waveney. Despite a comprehensive restructure
of the service the previous year and the engagement
with the Smoking Cessation service in Great Yarmouth
& Waveney to deliver the quit target, achieving the
necessary level of referrals supported by a strong
conversion rate, again, proved challenging. It became
apparent during the autumn that the Trust was starting
to negatively deviate from its trajectory and a number
of actions were established to improve referrals rates.
However, the number of subsequent referrals generated
were not sufficient to recover the level of quits required,
and as such the Trust failed this target, with a forecast
outturn of 1,600 quits.
Missing targets 2012/13
Indicator
Target or upper ceiling
Annual performance
Trend
MRSA Bacteraemia
Annual ceiling of no more
than one case
2 cases
Stable
Delayed transfers of care
No more than 3.7% of beds occupied
by patients whose discharge is delayed
for non-medical reasons
5.4%
Increasing
Smoking cessation
To achieve 2,000 successful quits
during 2012/13
1,606
Decreasing
38
Quality Account 2012/13
3.4 Commissioning for Quality
and Innovation (CQuIN)
Scheme 2012/13
NCH&C has made excellent progress against is CQuIN
Scheme in 2012/13 bringing our total CQuIN earnings
for the last financial year to £1.597million.
CQuIN are contractual commitments, some are
nationally mandated and some are developed in
partnership with our commissioners. They are intended
to encourage progress to be made within key areas of
local services.
As a reward to meeting these commitments our
Trust will now receive significant investment from our
commissioners which is additional funding that can be
used to make further improvements in the future.
Norfolk Community Health and Care NHS Trust
39
CQUiN indicators and achievements for 2012/13
No
Description of Indicator
Quality domain
% Achievement
1
To reduce avoidable death, disability and chronic ill health
from Venous-thromboembolism (VTE)
Safety
100%
2
To improve responsiveness to personal needs of
patients/carers
Patient experience
100%
3
Improve collection of data in relation to pressure ulcers, falls,
urinary tract infection in those with a catheter, and VTE
Patient safety
100%
4
Development of the care pathway for patients risk
assessed as having dementia within the north locality
inpatients units
Patient safety
Effectiveness
Experience
100%
5
Patient satisfaction; “How likely is it that you would
recommend this service to friends and family?
Patient experience
100%
6
Partnership working
As part of the health system-wide drive to reduce the rate
of avoidable emergency admissions (EMAs) 1% of the total
value of CQUIN for 2012/13 has been allocated to
system-wide initiatives designed to reduce EMAs.
Patient Safety
100%
7
Provision of a dedicated community nurse for each GP
practice to support admission avoidance
Patient experience
Effectiveness
100%
8
Pharmaceutical care plans for “at risk” patients
Safety
100%
9
EoL – For NCH&C care home facilitators to roll out training
for ACP/PPoC and ensuring PPoC is utilised where clinically
appropriate. 15 Care homes will be targeted and supported
Patient experience
100%
10
Improve the care of paediatric patients in the community
through scoping of activities to be transferred into a
community setting from the acute sector and producing
a model of community paediatric care to include IV
Patient experience
Effectiveness
100%
11
Achieve improved outcomes for patients of the community
nursing and therapy service in five key areas
Effectiveness
58%
12
Avoid acute hospital admissions through effective case
management of those at greater risk of admission
Effectiveness
100%
40
Quality Account 2012/13
3.5 Clinical Quality and Quality
Goals for 2012/13
Quality remained top of our agenda in 2012/13,
with a focus on delivering an ambitious set of
planned quality goals.
Our Quality Goals for 2012/13 were developed through
the annual planning process and a series of workshops
with clinical staff. They are reported in the forwardlooking section of last year’s Quality Account for
2011/12 and are listed as follows:
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 2012/13 under the following headings:
1.Implement safety thermometer targets in four
key areas
• Patient experience – listening to what our
service users think
• Achieve 95% Venous Thromboembolism assessment
(VTE) for inpatients by December 2012
• Patient safety – protecting people from harm
• 50% reduction in catheter acquired urinary tract
infections by December 2012
• Effectiveness of care – promoting a culture of
continuous improvement through audit and research
projects and implementing NICE guidance
• Reduction in the levels of injurious falls in our
inpatient units to 4.0 per 1,000 occupied bed days
• Eradication of avoidable pressure ulcers (as detailed
in 2 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
meeting 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
Norfolk Community Health and Care NHS Trust
Quality Goal 1
Implement safety thermometer
targets in four key areas
The Safety Thermometer data collection tool is now
in place, showing a level of ‘no harm’ of 89.9% at
March 2013.
To achieve 95% Venous Thromboembolism
assessment for inpatients by December 2012
Performance over the year is demonstrated in the graph
below showing that we have been ahead of the 95% of
patients assessed for VTE consistently since August 2012.
GRAPH
% Assessed for VTE
Ward level monitoring is carried out and an escalation
process is in place to the Medical Director. A report
99%
which calculates compliance, is being pre-empted by
98%
a review each month of Patient data on the Inpatient
97%
spreadsheet by Ward Clerks with a view to validating
96%
figures
before they are calculated.
100%
95%
For
the forthcoming year we will be undertaking
94%
clinical
93% audits to ensure that assessments and
treatments
were effective.
92%
A
pr
-1
M 2
ay
-1
Ju 2
n1
Ju 2
l-1
A 2
ug
-1
Se 2
p1
O 2
ct
-1
N 2
ov
-1
D 2
ec
-1
Ja 2
n1
Fe 3
b1
M 3
ar
-1
3
91%
% Assessed
Linear (% Assessed)
41
50% reduction in catheter acquired urinary tract
infections (CAUTI)
An analysis of all laboratory positive catheter urine
specimens has helped to establish a baseline and
trajectory for NCH&C, which will be monitored
internally via the CAUTI Steering Group.
For November and December we met the target
reduction and were well ahead of schedule and
remained ahead of trajectory for the remainder of the
year, (see section 3.9.9 for more details).
Reduction in the level of injurious falls in our
inpatient units (4.0 per 1,000 occupied bed days)
Injurious patient falls have been below 4.0 per 1,000
occupied bed days since April 2012 our average over
the year is 3.41 per 1000 occupied bed days, (see
section 3.9.8 for more details).
42
Quality Account 2012/13
Quality Goal 2
Deliver zero avoidable pressure
ulcers by December 2012
There were no avoidable pressure ulcers within our
inpatient settings at the end of December 2012 as a
result of our staff’s effort to reduce patient harm. This
achievement means our inpatient areas successfully met
our ambition to eliminate avoidable pressure ulcers by
the end of 2012.
However, we reported eight avoidable pressure ulcers
within our community settings, though the trajectory
continues on a downward trend.
Over the last year, we have worked closely with staff
to tackle pressure ulcers, developed a best practice
policy, and introduced new tools, documentation,
and support materials.
Key activities during 2012/13 to train staff and prevent
the incidence of pressure ulcers were:
• 40 pressure ulcer champions identified across
NCH&C
• A quarter of our staff attended dedicated pressure
ulcer prevention and management training events
• We delivered 35% more pressure relieving
equipment in October 12, than we had done
six months earlier
• Transfer of care protocol agreed with our main
acute partner
Quality Goals 3 and 4
Improve patient satisfaction
We continue to show steady progress in eradicating
avoidable pressure ulcers in both our inpatient units
and in the community of which at least 50% occur in
care homes. Our latest position for March 2013 shows
a total of four avoidable pressure ulcers all occurring in
the community, (including care homes).
In service specific surveys carried out during 2012/13,
we achieved very high patient satisfaction levels, eg,
86% users of Community Nursing and Therapy service
‘very satisfied’ and 87% of our Wheelchair Services
users, (see section 3.8 for more details).
Our aims for the year 2013/14 are to maintain zero
avoidable pressure ulcers across all our inpatient units
and to eliminate avoidable pressure ulcers in the
community by quarter 4.
As part of this objective, we will be working with our
‘top 10’ care homes to improve prevention interventions.
The Net Promoter score system has been implemented.
These results remain in the top quartile of 71 or more
with the exception of December (58). Results were
lower in December than all previous months due to a
higher number of neutral/passive scores being received.
By March 2013 the score had risen again to 75, (see
section 3.8 for more details).
Norfolk Community Health and Care NHS Trust
Quality Goals 5 and 6
Children Services
You’re Welcome accreditation
A self-assessment against the ‘You’re Welcome’
accreditation in the school nursing service has
taken place in 2012/13 Q4, but the method for
accreditation remains unclear due to the recent changes
in commissioner responsibilities. An action plan will be
produced and implemented in 2013/14.
UNICEF Baby Friendly accreditation
We have not yet achieved UNICEF Baby Friendly
accreditation at level 2, but will be reassessing against
the standard in 2013/14. Two out of thirteen indicators
require further assessment. An action plan is in place.
Staff are also being encouraged to make use of the
latest breastfeeding resources, which are now available
to download from our intranet. The breastfeeding
page includes mandatory annual practical skills review
paperwork, supplementary materials to support this
process, and links to best practice information and
video clips.
This new information and resources will support staff,
particularly our health visitors, nursery nurses and
children’s centre staff, to deliver the very best care to
local families. This will also help us to achieve Stage Two
Baby Friendly status.
43
Quality Account 2012/13
44
3.6 Monitor’s Quality
Governance Framework
Monitor describes quality governance as the combination
of structures and processes at and below board level to
lead on Trust-wide quality performance, including:
• Ensuring required standards are achieved (or exceeded)
• Investigation and taking action on
sub-standard performance
• Planning and driving continuous improvement
• Identifying, sharing and ensuring delivery
of best-practice
• Identifying and managing risks to quality of care
The arrangements for quality governance will
complement and be fully integrated with all
the other governance arrangements in place to
ensure the Board is competent in fulfilling all of
its statutory responsibilities.
Ultimately, the Trust Board is responsible for the quality
of care delivered across all services provided by NCH&C;
however, responsibility will be delegated right through
to individual staff members ensuring that quality
improvement is at the heart of everything that the
organisation does.
The Board will create a culture of openness and
transparency from the operational services to the
board. All Managers will be expected to continuously
improve care by listening to service users and learning
from incidents. Engagement and involvement of staff
and patients at all levels will ensure that areas for
improvement are continuously identified.
The Trust has undertaken a robust self-assessment
against the 10 quality questions (see below) using
Monitor’s risk rating and scoring matrix as follows:
Risk Rating
Scoring
Definition
Evidence
Green
0.0
Meets or exceeds expectations
Many elements of good practice and
there are no major omissions
Amber/Green
0.5
Partially meets expectations but
confident in management’s capacity
to deliver green performance within a
reasonable timeframe
Some elements of good practice, has
no major omissions and robust action
plans to address perceived shortfalls
with proven track record of delivery
Amber/Red
1.0
Partially meets expectations but with
some concerns on capacity to deliver
within a reasonable timeframe
Some elements of good practice, has
no major omissions. Action plans to
address perceived shortfalls are in early
stage of development with limited
evidence of track record of delivery
Red
4.0
Does not meet expectations
Major omission in quality governance
identified. Significant volume of action
plans required and concerns as to
management capacity to deliver
Norfolk Community Health and Care NHS Trust
45
A review by KPMG, an external auditor, in March 2012,
confirmed our self-assessment rating as 3.5 which is
within Monitor’s compliance framework threshold of 4.0.
Our Executive Director Team (EDT) has reviewed the
QGF each quarter during 2012/13, prior to discussion
and approval by the Trust Board and during this time
we have moved from a 3.5 rating in Q1 to 1.5 rating
in Q4. Following the publication of the Francis review
and the increased focus on quality we have decided
to refresh this work with a series of Board seminars to
review our current position. KPMG will undertake a
further review in June 2013.
Monitor’s 10 Quality Questions:
Strategy
Capabilities
Processes and
structures
Measurement
1a Does quality drive the
Trust’s strategy?
2a Does the Board have
the necessary leadership,
skills and knowledge to
ensure delivery of the
quality agenda
3a Are there clear roles
and accountabilities
in relation to quality
governance?
4a Is appropriate quality
information being
analysed and challenged?
1b Is the Board sufficiently
aware of potential risk
to quality?
2b Does the Board
promote a quality-focused
culture throughout the
Trust?
3b Are there clearly
defined, well understood
processes for escalating
and resolving issues
and managing quality
performance?
4b Is the Board assured
of the robustness of the
quality information?
3c Does the Board actively
engage patients, staff and
other key stakeholders on
quality?
4c Is quality information
used effectively?
46
Quality Account 2012/13
3.7 Quality Assessment Visits
A series of visits to assess the quality of services in all
our Community Rehabilitation Units and compliance
with CQC outcomes was introduced in February 2013
and undertaken by the Deputy Director of Nursing,
together with our Quality Assurance Managers.
The assessment visits are focusing on five of the
CQC standards and outcomes:
• Involvement and information
Outcome 2: Consent to care and treatment
• Personalised care, treatment and support
Outcome 4: Care and welfare of people who
use services
Outcome 5: Meeting nutritional needs
• Suitability of staffing
Outcome 14: Supporting workers
• Quality and management
Outcome 16: Assessing and monitoring the
quality of service provision
• Safeguarding and Safety
Outcome 7: Safeguarding people who use
services from abuse
Overall the assessors have been impressed by the
quality of care offered to patients by the Community
Rehabilitation Units. The patients and relatives who were
spoken to said they were extremely pleased with the care
they or their relatives received. One patient said: “staff
are always eager to please and I couldn’t fault them”.
Staff report they are proud of their wards and value the
support provided by their colleagues and managers.
The assessors have observed effective multi-disciplinary
and multi-agency working to ensure the best outcomes
for our patients throughout their care pathway.
The quality assessment visits have produced baseline
evidence against CQC outcomes. The assessors have
identified factors which could make the outcomes for
patients even better.
There have been two key themes emerging; visibility of
name badges and concerns about the effectiveness and
volume of documentation which will require addressing
from an organisational perspective and will be linked to
a transformation project.
The assessment reports have been finalised and shared
with the Assistant Directors. The Assistant Directors
will work with their staff to review the reports and
develop action plans which will be monitored on a
monthly basis by the Quality Assurance Managers for
each locality. Any moderate or major concerns will be
escalated appropriately for action and reported to the
Quality and Risk Assurance Committee (QRAC).
Plans are in place to roll-out these quality assessment
visits to our community teams during the summer and
will form the basis of the work of the new posts of
Quality Assurance Managers.
Norfolk Community Health and Care NHS Trust
47
3.8 Patient Experience
3.8.1 Introduction
As a healthcare organisation we have the privilege
of serving people at their most vulnerable. We know
it is important that the care they receive is safe and
helps them to get better or effectively maintain their
condition. It’s also important that in receiving that care
our patients are treated with care and compassion
by skilled people and in those circumstances we are
committed to delivering the best experience of care
that we can. To help us do that we ask our patients
what they think of the care we deliver and in response
celebrate things that go well as well as put right things
that haven’t gone as we would like.
We learn from patients in a variety ways, for example
we asked our patients on discharge from our
community rehabilitation units “how likely is it that you
would recommend this service to friends and family”,
surveyed patients accessing other services and listened
to a ‘patient’s voice’ at our Board meetings.
48
Quality Account 2012/13
3.8.2 The ‘Friends and
Family Test’
Overall the comments being received by patients
through NPS are very positive, although there are some
areas for action, improvement or monitoring.
Quality Goal and CQuIN:
Implement Friends and Family
test using the (NPS) Net Promoter
Score, results to be above 63
Top 4 Themes from ‘promoters’ comments
(Score of 9 or 10 out of 10)
The Friends and Family test, asking all inpatients on
discharge from our community hospitals, “How likely is
it that you would recommend this service to friends and
family?” went live during May 2012. Patients have been
given a feedback card on the day of discharge to rate
their score between 1 and 10 and leave any comments
as to why they gave that score. A minimum survey size
of 10% of all inpatients discharged was set and this has
been achieved and exceeded every month to date.
• Very clean
Results from July 2012 – March 2013 are as follows
NPS Scores
• High standard of care and treatment
• Caring, kind and compassionate staff
• Good food
Top 3 Themes from ‘detractors’ (score of 6 out
of 10 or less) (although often the comments
are fairly positive)
• I received good care
• I was satisfied with the services
• I was refused meals on wheels just because I could
put stuff in the microwave, a good thing because
I felt much better going private
90
Top 5 Themes from ‘neutral/passives’ comments
(Score of 7 or 8 out of 10)
80
• Positive experience
70
• More staff needed, visit too brief
60
• Food needs improving - general flavouring
50
• Comfortable and clean
40
• Treated well by staff
30
20
10
3
M
ar
-1
13
bFe
13
n-
2
Ja
2
ec
-1
D
ov
-1
12
No of responses
N
ct
-
2
12
O
pSe
-1
ug
A
Ju
l-1
2
0
NPS score
These results remain in the top quartile of 71 or more
(the target set for acute hospitals for 2012/13) with
the exception of December. Results were lower in
December than all previous months due to a higher
number of neutral/passive scores being received
(patients scoring 7 or 8 out of 10) although the majority
of comments were still very positive.
Norfolk Community Health and Care NHS Trust
3.8.3 Patient stories
Patient Feedback Challenge
NCH&C continues to be involved in a joint project with
the NNUH in collecting patient and carer feedback
throughout the stroke pathway through the use of
Patient Stories. The cohort of six stories have been
collected and next steps will be to bring staff from both
NCH&C and NNUH together to review the finding from
the stories and develop any actions as a result.
Patient Voice at the Board
Patient stories are a key feature of the ambition to
‘Revolutionise Patient and Customer Experience’, whereby
Boards are being asked to capture, use and triangulate
intelligence pertaining to patient and carer experience
from a variety of different sources. Patient Stories provide
a focus on how through listening and learning from the
patient voice. NCH&C’s Board confirmed that as part
of its commitment to strengthen the patient voice it
wished to receive and consider a patient story at each of
its Board meetings. The stories heard so far have mostly
been told by a member of staff from the relevant service
used by the patient to give a ‘case study’ style story. There
have been a couple of occasions when the patient has
attended and told their story personally.
49
For example, a member of staff from Sure Start
Children’s Centre, Thetford and a Norfolk LINk
Volunteer attended NCH&C Board meeting in
December 2012 describing how they have used Patient
Stories to collect feedback from the parents attending
a “Babystart” group. Using Patient Stories has been a
positive experience for the team, reinforcing they are
“getting it right” , boosting morale and understanding
what parents and their children really benefit from but
also finding out what could be improved.
The team are already working on actions as a result of
doing the stories which include:
• Increase publicity about the Children’s Centre and
groups offered through liaison with health visitors,
midwives and local libraries
• Rotation of a range of toys and play equipment
both inside and outside groups
A programme of using Patient Stories to improve
care in targeted areas has been developed, allocating
a trained volunteer or member of staff to work with
the following services:
• Podiatric surgery
• Wheelchair services
• North Norfolk Older People
• Stroke pathway (as part of the NHS Patient
Feedback Challenge project with NNUH)
50
Quality Account 2012/13
3.8.4 Patient Opinion
3.8.5 Local surveys
Patient Opinion is a website: www.patientopinion.org.
uk where the public can publish their experiences (good
or bad) of local health services. The website allows
health service staff to interact with these patients to
help improve care. There is also the option of giving
patients a hard copy feedback card or they can call a
freephone number and tell their story over the phone.
Quality Goal: Improve patient
satisfaction to 70% ‘very satisfied’ no area <50%
NCH&C commenced a small pilot in early March 2013
in four services to trial Patient Opinion. 23 stories were
posted on the website during April and these stories
had been viewed 820 times.
There has been some excellent feedback about all
of the services included in the pilot and service leads
are being encouraged to respond to comments
regardless of content to demonstrate that we are
actively engaging with their feedback to improve care.
Service leads are also being encouraged to link into an
online training session offered by Patient Opinion to
support raising awareness with patients, responding to
comments and how to use reports within the service
and organisation. During this pilot phase, work is
ongoing to develop processes ensuring Patient Opinion
is monitored, reviewed and linked in to other patient
feedback systems.
a) Cardiac Assessment Service
The ‘Cardiac Assessment Service’ was set up as a new
initiative in 2004, with the aim to promote efficiency
of the pathway delivering care to patients with Acute
Coronary Syndrome (Heart Attack and Unstable
Angina). This efficiency translated into reduction of
length of stay (LOS) in the acute trust with reduction in
re-admission rates.
One of the aims of the service is to educate and support
patients and their relatives to equip them to take
responsibility for their long term condition, so helping
to promote, improve their quality of life and reduce
acute events requiring admission to hospital.
In the Cardiac Assessment Service (CAS), patients are
often seen as a ‘one off’ acute assessment within the
acute admissions area. Questionnaires were distributed
to each patient with the instruction to complete and
place in the clearly marked NCH&C official collection
box. The box was then collected later in the day to
allow private consideration of the questionnaire,
confidential completion and return to the box.
All 30 questionnaires were returned. The feedback was
very positive and overall demonstrates that the CAS is
highly valued by patients and their relatives.
100% of respondents felt they understood the role
of the service/ felt they were treated with dignity and
respect/ felt the service helped them to understand their
condition and allowed them the opportunity to have
questions answered, with the conclusion that they all
benefited from improved understanding of their long
term condition.
Norfolk Community Health and Care NHS Trust
Issues Arising
87% said that the assessment helped them make
lifestyle changes to manage their condition; however,
13% did feel they needed some on going advice,
one mentioning the access of written information.
These patients do, however, receive a referral on to
an outpatient Cardiac Rehabilitation Service or CVD
Specialist Nurse for advice and support.
ACTION:
• Issue British Heart Foundation (BHF) booklets in
addition to those which will be given in a pack by the
Cardiac Rehabilitation Nurses where appropriate
• Issue BHF booklets to those patients not falling under
the remit of the Cardiac Rehabilitation Nurses
• Refer on to the Community CVD Specialist Nurse for
further support and advice on risk factors as appropriate
97% felt re-assured by the cardiac assessment nurse,
however surprisingly low (only one patient) still had
concerns about what is a life threatening condition.
ACTION:
51
c) Wheelchair Services Patient
Experience Survey
A patient experience survey was carried out to gather
feedback from patients on Wheelchair Services from
September 1 to October 31, 2012.
All patients who attended the centre for an
appointment between September 1 to October 31,
2012 were given a hard copy of the survey to complete.
Boxes were also provided in the waiting area for
patients to post their completed surveys.
104 surveys were completed by patients, approximately
50% of all patients attending an appointment during
that period.
Conclusions:
Overall, the feedback from patients is very positive
on the service they received with 94.2% of patients
saying they were very satisfied (86.5%) or fairly satisfied
(7.7%). Similar levels of satisfaction were received on
the helpfulness of reception staff and clinical staff.
• Inpatients requiring ongoing support, refer to
CVD Specialist Nurse in the Community for
follow-up telephone call, as appropriate
100% of patients who answered the three environment
questions agreed that they had enough privacy, felt
physically safe and were satisfied with the cleanliness
of the centre.
b) Community Nursing & Therapy
Service Patient Satisfaction Survey
99% felt involved as much as they wanted to be in
decisions about their care.
As part of CQuIN indicator 11, the Trust has carried out
a patient satisfaction survey within Community Nursing
and Therapy.
The results from the survey indicated 94% of patients
were satisfied overall with the service provided by the
CN&T Teams. Specifically 86% very satisfied and 8%
were fairly satisfied.
NCH&C intend to survey again using the same survey and
methodology during quarter 4 and although no specific
target has been set by commissioners, NCH&C have set
an internal target to maintain satisfaction levels at 94%.
22 patients have expressed an interest in potentially
being part of a patient user group and 31 expressed
an interest in undertaking a one to one patient story.
Further comments were received from 35 patients.
There were two comments around waiting times
but no other common themes emerging from these.
Recommendations:
1. Look in more detail at waiting times
(two comments received)
2.Contact patients regarding joining a Patient
User Group
3.Contact patients regarding undertaking a
Patient Story
52
Quality Account 2012/13
d) Catering Survey within the
community hospitals
The purpose of the patient satisfaction survey is to
measure the quality and standards of the catering service
within the community hospitals setting, to identify issues
that occur within it and where possible, rectify them.
The survey is divided into five sections, Menu options,
Food, Beverages, Environment and Support. Each
subsection has three or more questions that require
answering. Measurements range from Very Poor to
Excellent on the Food and Environment sections, while
the remaining three sections range from Never to All
the Time. Patients indicate their preference by ticking
the appropriate box they feel meets their perception
and level of satisfaction.
From the results of the surveys, it shows that standards
have increased slightly from the survey conducted in
July 2012 from a satisfaction rate of 84% to 89.3% of
‘Excellent’ and ‘Good’ responses.
The fair responses have remained the same at 8.3%, with
‘Poor’ and ‘Very Poor’ making up the rest with 2.5%.
The overall completion rate has decreased from 63%
in July 2012 to 48% in November 2012. Some units
continue to have low completion rates; this could be
due to the types of patients and the nature and number
of questions of the new survey. Several surveys were
incomplete. One unit was also closed for refurbishment
during the time of the survey.
Having reviewed the results per section, the standout
areas are:
• Improvement in virtually all aspects of the service
from the last survey in July, for example, in the Food
section: taste up to 78% from 71%, appearance up
to 88% from 75%, and helpfulness of staff up to
98% from 91%
• The overall satisfaction rate increased significantly
from 77% in July, to 84% in November, considerably
higher than the 73% recorded in the Picker Institute
survey undertaken in May 2011
• Where negative feedback has been received,
these will be incorporated into an action plan for
the appropriate Housekeeper to follow up and
implement, within a specific time frame
3.8.6 Patient Environment
Action Team (PEAT)
Assessment 2012
The NHS Information Centre (NHS IC) requires trusts to
self-assess their patient environment annually using an
assessment tool which reflects the needs of its various
stakeholders and the policy priorities of Ministers and
the Care Quality Commission (CQC).
As a result of feedback from users, the Department of
Health, CQC and other organisations, changes were
made to the assessment for 2012. Changes included
questions on laundry services, security arrangements for
the storage of drugs and additional questions on the
Infection Control section.
The assessments took place across our nine inpatient
services between January and March 2012 with formal
reporting to the NHS IC by 14th March 2012 and the
Trust Board on 29th August 2012. The PEAT assessment
team was led by the Estates and Facilities Officer and
included representation from Estates, Infection Control,
Norfolk LINk and a Matron or site representative for
each site.
The table below provides an overview of the ratings
achieved by each unit in 2012, these have been
confirmed in a letter to the CEO. Ratings for 2011 are
given in brackets. The final ratings produced by the NHS
IC have been calculated using the scores committed by
the Trust, weighted against the National Standards of
Cleanliness scores for each unit.
Norfolk Community Health and Care NHS Trust
53
Site Name
Environment
score
Food Score
Privacy and
Dignity Score
Colman Hospital
Good (G)
Good (G)
Good (G)
Norwich Community Hospital
Good (g)
Excellent (G)
Good (G)
Dereham Hospital
Good (A)
Excellent (E)
Good (G)
St. Michaels Hospital
Acceptable (G)
Good (G)
Good (E)
Kelling Hospital
Good (A)
Good (G)
Good (G)
Swaffham Community Hospital
Good (A)
Excellent (E)
Good (G)
Ogden Court, Wymondham
Good (G)
Good (G)
Good (E)
Cranmer House, Fakenham
Good (G)
Excellent (E)
Excellent (E)
Benjamin Court, Cromer
Good (G)
Good (G)
Good (E)
Key: (G) Good (E) Excellent (A) Acceptable
Overall, there was an improvement in four out of the
27 scores with 19 remaining the same (of which four
were excellent), a drop in 1 from good to acceptable
under environment and 3 from excellent to good under
privacy and dignity.
A progress report was provided to the Board in February
2013 together with a comprehensive action plan arising
from the assessment. The improvement works required
were conducted either as part of the 2012/13 capital
programme or minor works programme.
In accordance with the Prime Minister’s commitment
to give patients a real voice in assessing the quality
of healthcare, including the environment for care,
the Department of Health and NHS Commissioning
Board have reviewed the efficacy and value of PEAT
assessments and from 2013 have introduced a more
patient-led assessment called PLACE. The outcome of
the assessments will be published as Official Statistics
and will be shared with the following organisations:
• Care Quality Commission
• Department of Health
• NHS Commissioning Board
• Clinical Commissioning Groups
• National Audit Office
54
Quality Account 2012/13
3.9 Patient Safety – learning from
incidents and complaints
3.9.1 Introduction
NCH&C aims to provide harm free care for all its
patients and is committed to learn when things go
wrong. We use complaints and incidents to positively
identify where changes need to be made and
improvements implemented in a culture that is both
supportive and open.
3.9.2 Complaints, claims
and compliments
During the period April 2012 to March 2013, 170
complaints were received from service users or their
relatives. This represents a 15% decrease on last year’s
figure of 202. 94 of these complaints were partially or
wholly upheld following investigation.
MPs were involved in 10 complaints this year and
GPs were involved in 11 complaints. 14 complaints
were investigated jointly with other agencies (eg, NHS
Norfolk & Waveney, Norfolk & Norwich University
Hospital and Norfolk County Council Social Services)
under the agreed Joint Protocol for Norfolk.
Complainants who are unhappy with the Trust’s
response may ask the Parliamentary and Health Service
Ombudsman to review their case. We were notified of
three such requests this year; however, the Ombudsman
declined to review any of these cases.
Complaints by subject
15%
1%
14%
62%
4%
22%
12%
13%
27%
Care and Treatment
Personal Records
Appointment
Policy
Aids / Equipment
Discharge
Other
Communication
Staff Attitude
Norfolk Community Health and Care NHS Trust
a) Complainant feedback
15 complainants returned feedback questionnaires
during the year. 10 of these stated they were satisfied
or mainly satisfied with the complaints process and the
outcome of their complaint. All stated that their aim in
making the complaint was to prevent others suffering
the same problem and/or to receive an apology or
explanation. Three complainants (less than 2%)
expressed a wish that staff should be disciplined.
b) Summary of learning and actions taken
Learning from complaints is collated from the service
managers following an investigation and communicated
across the organisation via the Quality and Risk
monthly report (seen at the Quality and 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 discussed
by senior management and, where appropriate, are
included in the clinical audit forward plan.
c) Clinical claims
Notification was received of seven possible claims
for clinical negligence during the year. Formal letters
of claim have been received for two of these; one
concerned the death of a patient in an inpatient unit
and the other a delay in family being advised of a
diagnosis in respect of a child.
Two claims were settled – one in respect of podiatric
surgery and one settled jointly with the Medical
Defence Union (representing the GP) respect of late
diagnosis of hip displacement of a child. Two claims
were discontinued because of a lack of response from
the claimant or their solicitor.
d) Compliments
Compliments and thanks received from patients are also
measured and this year the Trust has received in excess
of 955 compliments. The dedication and commitment
of our frontline staff is a recurring theme of the
compliments received, (see section 3.2.5 for a summary
of quotations)
55
3.9.3 Serious Incidents
Requiring
Investigation (SIRIs)
Serious incidents are reported into a central team, with
information being collected via a SIRI log and DATIX a
web-based risk management tool.
The Executive Team are made aware of serious incidents
as they occur and are able to ensure that support for
investigations is given to operational teams where required.
The Trust Board are informed on a monthly basis of all
new SIRIs occurring and the resulting recommendations
/ actions identified as part of the full investigations into
SIRIs. In addition, a quarterly SIRI meeting is held with
the Non-Executive Directors of the Board where each of
the SIRIs is discussed in more detail.
Themes from serious incidents inform learning events,
which are attended by a wide range of staff. The topics
for learning events held within the last year:
• Enabling people to die with dignity
(including do not resuscitate orders)
• Information Governance –
Negotiating the minefield of social networking
• Record keeping – if it isn’t documented –
it didn’t happen
From 1 April 2012 to 31 March 2013, NCH&C reported
349 SIRIs. During this time, there were two changes to
the SIRI reporting requirements:
• May 2012 – all Grade 3 & 4 Pressure Ulcers became
SIRI reportable irrespective of whether they were
acquired within the care of NCH&C or outside the
care of NCH&C
• October 2012 – Grade 3 & 4 Pressure Ulcers acquired
outside the care of NCH&C no longer SIRI reportable
Quality Account 2012/13
56
The following table identifies the type of SIRI reporting
from April 2012 to March 2013:
SIRI - Type
Number
reported
Pressure Ulcer - Acquired whilst patient
under the care of NCH&C – Grade 3
215
Pressure Ulcer - Acquired whilst patient
under the care of NCH&C – Grade 4
24
Pressure Ulcer - Acquired outside the
care of NCH&C – Grade 3 & 4
70
Unexpected death
15
Information Governance
6
Infection Control
3
Accident
13
Clinical assessment & treatment
1
Missing patient
1
Staff competence
1
Medication
1
Allegation of abuse
1
Total
349
Learning from a review
of unexpected deaths in
community hospitals
During a four month period from June to September
2012 NCH&C reported and reviewed five patients who
died unexpectedly within a community hospital. The
aim was to understand the root cause of the incidents,
and to review all aspects of quality assurance within
the particular inpatient unit. The review also considered
in depth, the current clinical practice across all of the
Trust’s inpatient units and identified the continuous
programme and systems of audit and assurance.
Following root cause analysis investigations into each
of the deaths, a further clinical review was undertaken
by two senior medical consultants who reviewed each
of the cases and concluded that of the five deaths only
one was, in their opinion, ‘unexpected’. A summary of
each case was provided which identified key themes,
learning and some notable practice.
One of the key findings included the increasing
complexity of patients admitted both from the
community and the acute units. We are therefore
expediting our current plan to introduce an enhanced
medical and nursing model of care. An analysis of
the workforce was also included which looked at the
potential impact of staff absence, turnover, training and
appraisal levels and included the medical input.
This investigation confirmed that these deaths do not
represent a failure of service delivery nor of patient
safety. However, the incidents have identified areas of
service delivery which can be improved.
A further strategic review to consider the findings from
the report more broadly across other similar units within
NCH&C has been completed and the report was taken
to the public Trust Board meeting in February 2013
(see our website for the full report in our Board papers:
www.norfolkcommunityhealthandcare.nhs.uk)
A strategic action plan has been developed and
approved by the Board and a steering group has been
formed to ensure the delivery of the agreed actions.
Implementation of the action plan is being monitored
by the Quality and Risk Assurance Committee and the
Norfolk Clinical Commissioning Groups.
Norfolk Community Health and Care NHS Trust
57
3.9.5 National Patient
Safety Agency
Report (NPSA)
The latest report in respect of incidents reported to the
NPSA between 1 April 2012 and 31 September 2012
was published in March 2013.
This report shows that NCH&C has slipped from being
within the highest 25% of reporters to the middle 50%
of reporters. The number of incidents reported to NPSA
during this period equated to 58.3 incidents per 1000
beds days (compared to 147.3 incidents per 1000 bed
days in the previous report). This reduction was expected
due to the delays in the final incident approval process
and backlog of incidents awaiting final approval which
has delayed incidents being forwarded to NPSA.
3.9.4 Never Events
The Department of Health (DH) published a Never
Events Policy Framework in October 2012 which is
an update to the Never Events policy and provides
greater clarity around never events and how to respond
to them. The DH said, “Protecting patients from
avoidable harm is something on which there is universal
agreement. How we achieve this is often more complex.
With ‘Never Events’ there are clearly defined processes
and procedures to follow to help ensure that these
incidents never happen.”
Never Events are serious, largely preventable patient
safety incidents that should not occur if the available
preventative measures have been implemented by
healthcare providers and result in severe harm or death
(or have the potential to result in severe harm or death).
NCH&C has undertaken a review of the Never Events
which could occur within this organisation and has
asked staff to provide assurance that there are adequate
controls in place to mitigate them.
The Trust is pleased to report that it has had no
‘Never Events’ during 2012/13.
It is important to note that the reduction in the number
of incidents reported to NPSA is not reflective of the
number of incidents that we report within the Trust, as
our incident reporting continues to grow.
It is difficult to analyse and make comparisons
within the latest report. For example, we have given
priority to final approval of severe incidents, pressure
ulcers and slips / trips and falls, and therefore the
breadth of incidents that we have reported to NPSA
has been limited, it therefore appears that a high
percentage (69%) of NCH&C incidents are reported
as “implementation of care and ongoing monitoring
/ review” which is the category pressure ulcers are
reported within, compared to the average of 29%;
however, as we have not reported to NPSA many other
incident types this is not an appropriate comparison.
As with the previous NPSA report, it was noted that there
is a delay in NCH&C reporting incidents to NPSA, 50% of
all incidents where submitted to NPSA more than 30 days
after the incident occurred with 50% being submitted
more than 45 days after the incident occurred. It has
been agreed to allocate a member of staff to specifically
tackle the backlog of incidents awaiting final approval,
while the new posts of Quality Assurance Manager, (who
will work alongside operational teams) will maintain the
approval of current incidents.
58
Quality Account 2012/13
3.9.6 Safety alerts
3.9.7 Reducing the
level of harm of
medication incidents
Alerts originating from the Medicines and Healthcare
Products Regulatory Agency (MHRA), National Patient
Safety Agency (NPSA), Chief Medical Officer (CMO)
and Department of Health Estates are broadcast via
the Central Alert System (CAS) in England. These alerts
must be disseminated in a timely manner throughout
NHS Trusts to ensure all staff affected by the safety alert
have timely access to relevant information.
Continuing the success of work done the previous year
the Trust reported 8 moderate harm or above incidents
in 2012/13, compared to 13 the year before.
The graph below show the trend of no harm, low harm
and moderate harm incidents during 2012/13. The
reporting data was complicated by NCH&C ceasing
to provide healthcare services into the three Norfolk
Prisons in April, re-opening of North Walsham Hospital
in May and the closure of Dereham Hospital for
improvements from October 2012 to January 2013. It is
therefore difficult to compare month to month due to
these variations.
The Health, Safety and Fire Officer is the nominated
recipient of CAS alerts and employs an electronic
system of dissemination of alerts to all NCH&C localities
and business units and other relevant departments.
NCH&C also employs an electronic response system
which tracks the acknowledgement of alerts and
informs the Health Safety and Fire Officer whether
action by the locality, business unit or department is
required in response to the alert.
60
50
40
30
20
10
-1
2
Ju
n12
Ju
l-1
2
A
ug
-1
2
Se
p12
O
ct
-1
2
N
ov
-1
2
D
ec
-1
2
Ja
n13
Fe
b1
M 3
ar
-1
3
M
ay
pr
-1
2
0
A
Number
The Health and Safety Committee monitors the
implementation of all relevant alerts and the Executive
Director team receives a monthly report on all open
or overdue alerts supporting remedial actions, where
required, to achieve closure.
Breakdown of number of incidents by severity, with trends
No harm
Moderate harm
Low harm
Norfolk Community Health and Care NHS Trust
Controlled drug incidents
There were 80 controlled drug incidents reported
in 2012/13 which, after accounting for the exit of
prison services, is in line with previous years. The
graph below shows the trend for controlled drug
incident reporting. These incidents covered a range of
issues, such as missed doses, syringe driver incidents,
difficulty in obtaining stocks, stock balance issues and
administration incidents.
Number of controlled drug incidents by month and severity
25
Number
25
20
15
10
5
No harm
Low harm
2
-1
12
M
ar
12
b-
b-
Fe
Fe
1
12
n-
Ja
-1
1
D
ec
1
-1
ov
N
11
-1
O
ct
1
Se
p-
1
-1
l-1
ug
Ju
A
1
11
n-
Ju
-1
ay
A
M
pr
-1
1
0
Moderate harm
CQUIN Indicator 8
Pharmaceutical care plans
The aim of this project was to use a patient-led
pharmaceutical care plan to improve medicines
adherence and the transfer of information on discharge
(and potentially on any subsequent readmission) from
NCH&C inpatient units.
The care plan was successfully introduced into all Trust
inpatient units and 76% of the patients in the target
group were discharged with a “My Medicines” booklet,
which detailed their medicines and how and why they
take them.
59
60
Quality Account 2012/13
3.9.8 Patient falls
Inpatient - Patient falls reported by Degree of Harm
Quality Goal: Reduction in the levels
of injurious falls in our inpatient units
to 4.0 per 1,000 occupied bed days
80
40
Number
The second graph shows the level of falls causing harm
per 1000 occupied bed days (target being 4.0).
40
40
20
Actions currently underway include, regular monitoring
of the data and targeted interventions, eg, intentional
rounding. Falls representatives from each unit report
Root Cause Analysis (RCA) to improve learning and
access the locality. Regular Falls meetings led by a
dedicated lead clinician.
12
l-1
2
A
ug
-1
Se 2
p1
O 2
ct
-1
N 2
ov
-1
D 2
ec
-1
Ja 2
n1
Fe 3
b1
M 3
ar
-1
3
2
Ju
n-
Ju
-1
ay
M
A
pr
-1
2
0
No harm
Moderate harm
Low harm
Severe harm
Falls/OBD performance - inpatient units
Ju 2
n12
Ju
l-1
2
A
ug
-1
Se 2
p1
O 2
ct
-1
N 2
ov
-1
D 2
ec
-1
Ja 2
n1
Fe 3
b1
M 3
ar
-1
3
M
ay
-1
2
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
pr
-1
Falls/1,000 OBD
Matrons have reported an increasing number of
patients being admitted to the units either with a
diagnosis of dementia or with symptoms of confusion
during February and March 2013. More equipment
for falls prevention including use of ‘Hi-Lo’ beds and
crash mats were also in place in this period. We will be
undertaking an analysis of the rehabilitation complexity
score to better understand this trend.
60
A
The graph right shows all categories of patient falls
over the past year.
100
2012/13 Performance
2012/13 Target
Norfolk Community Health and Care NHS Trust
3.9.9 Infection prevention
and control
a) Reduction in Healthcare
Acquired Infections
i) Norovirus
The Infection Prevention and Control (IPAC) team have
continued to work with the Norfolk health economy
throughout 2012/13 to improve communication
regarding incidence of Norovirus in order to reduce the
issues it causes across the system. All acute, community
and mental health providers in the county now
populate a shared database detailing clusters/outbreaks
of Norovirus across the county. The Health Protection
Unit host this database and input details of clusters/
outbreaks in any private healthcare facility or school
thereby ensuring all information is shared throughout.
This provides us with the best opportunity to manage
and contain any episodes of Norovirus in our settings.
Despite high levels of Norovirus within the general
community, NCH&C have only suffered one cluster of
Norovirus. This was quickly and efficiently contained
with only four patients affected. The ward did not need
to close and their patients were managed within side
rooms and a bay. Ultimately it is staff vigilance that has
kept NCH&C levels of Norovirus so low over the season.
The role of IPAC liaison has now been developed in
conjunction with Public Health and this will see further
investigation of cases of infection within the wider
community along with assistance for Primary Care in
the management of their patients with either MRSA or
Clostridium difficile. The aim of this post is to identify
trends in the wider community and bridge the gap in
IPAC which currently exists between acute/community
providers and Primary Care.
61
ii) Catheter Acquired Urinary Tract Infection (CAUTI)
Avoiding CAUTI is of great importance to maintain the
health and independence of our patients. The Trust’s
aim throughout 2012-13 was to reduce CAUTI by 50%
by December 2012. Through the work of a clinical
task force including IPAC and continence teams this
ambition was achieved earlier than planned.
iii) To reduce levels of attributable
Clostridium difficile (C. diff)
NCH&C saw a period of seven months without a
case of C. diff at which point a case was reported in
September 2012. The total reportable for 2012/13
was three cases against an annual ceiling of 9. This
compares to 5 cases in 2011/12 and 9 cases in 2010/11.
iv) To reduce levels of MRSA bacteraemia
There were two cases of MRSA bacteraemia in
2012/13, which compares to no cases in 2011/12 and
1 case in 2010/11. As a result of these cases the IPAC
team have prepared documentation for all wards to
ensure a patient with any history of MRSA will receive
octenisan antimicrobial wash throughout their inpatient
admission. The IPAC team are working with all ward
areas to ensure they are able to identify these patients
quickly and easily.
The IPAC team continue to monitor and review all
results of hand hygiene and cleaning audits. The focus
of the IPAC teams auditing programme is due to alter
to concentrate on clinical practice on a more regular
basis. This will ensure NCH&C staff have the assistance
and support to work safely within the constraints of
their environments.
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Quality Account 2012/13
3.9.10 Patient safety
and quality
benchmarking data
Aspirant community foundation
trust benchmarking report – period
August 2012 to January 2013
NCH&C are part of a group of community trusts
on a journey to achieve foundation trust status in
the future and 11 trusts have agreed to share data in
order to benchmark performance against one another
to stimulate debate and identify opportunities for
sharing best practice. This benchmarking report
covering the period August 2012 to January 2013
presents data on quality, financial and workforce
indicators and includes a benchmark figure and an
average score for each indicator.
The following results are taken from the Patient Safety and Quality section:
Description
Benchmark
Average
NCH&C
New Serious Incidents Requiring Investigation (SIRIs) reported per
month (excluding pressure ulcers which are reported separately)
4.0
4.2
2.8
4.5%
4.1%
Percentage of deaths compared to all discharges (excluding end
of life and palliative care units and specialties)
Rate of injurious falls per 1,000 occupied bed days
4.0
7.05
3.36
Rate of incidents (injurious and non-injurious) per 1,000 contacts
3.46
3.92
7.27
Rate of complaints per 1,000 contacts
0.16
0.16
0.14
Rate of compliments per 1,000 contacts
0.50
1.35
0.80
Net Promoter Score (NPS)
62
62.6
68.9
Safety Thermometer – Harm free care
82%
90.3%
89.54%
Reported Clostridium difficile cases per 1,000 occupied bed days
0.135
0.063
0.026
New Grade 3 or above Pressure Ulcers reported per month
whether or not acquired under the care of the provider
12
13
25
Norfolk Community Health and Care NHS Trust
3.9.11 Safeguarding
vulnerable adults
and children
NCH&C has designated leads for safeguarding adults
and children who liaise with their counterparts at
Norfolk County Council (NCC) who are the lead
organisation on safeguarding and who chair the
safeguarding adults and children Boards in Norfolk.
A quarterly progress report against the various work
plans is provided to the Quality and Risk Assurance
Committee and a strategic quarterly report is provided
to the Board. The following items are some of the issues
arising over the past year.
Response to the Savile Allegations
Following a letter from the Chief Executive of the NHS,
David Nicholson, a number of areas were specified for
review including:
• Safeguarding arrangements and practices
• Access to patients, including that afforded to
volunteers or celebrities
• Listening to and acting on patient concerns
MASH (multi-agency
safeguarding hub)
This group disbanded on 31/12/12 with the project
becoming part of usual business for NCC. The childrens’
aspect of the service had been the most successful.
Child Sexual Exploitation – the Norfolk Safeguarding
Children Board is leading local multiagency work in
addressing this growing area of concern.
63
Safeguarding adults
Recent referrals have lead to a number of outcomes:
• Sessions held on mental capacity
• Financial seminars available to identify fraud
management of this type of abuse
• Domestic abuse awareness campaign
• Update on DOLS with Specialist Services
• Agreement on health specific DOLS training from
Social Services
Safeguarding training
• There has been a consistent rise in the uptake
of safeguarding adults training and we are now
achieving above 80%
• A programme of advanced Mental Capacity Act
training for clinical staff has been offered for the
next three months
• Safeguarding Children training is currently at
79.5% with plans to improve this further
• Prevent - training has now commenced. A six month
training schedule is in place with three members
of staff having undertaken two-days of training to
support the rollout of the programme
OFSTED report
Following the recent Ofsted report into the multi-agency
arrangements for safeguarding children, the Director of
Nursing, Quality and Operations and the Safeguarding
Team are working closely with the local authority’s
children services to implement the recommendations.
Summary
The safeguarding team continues to demonstrate
assurance through the quarterly board report,
evidencing that policies are adhered to and national and
local recommendations and campaigns are supported
and implemented.
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Quality Account 2012/13
3.10 Effectiveness of Care
3.10.1 Introduction
Quality care can be described as care which is delivered
according to the best evidence as to what is clinically
effective in improving an individual’s health outcomes.
NICE provides advice and support on putting NICE
guidance and standards into practice through its
implementation programme, and it collates and
accredits high quality health guidance, research and
information to help health and social care professionals
deliver the best patient care through NHS Evidence.
3.10.2 National Institute for
Health and Clinical
Excellence (NICE)
All NICE guidance is received by the Clinical Audit and
Effectiveness committee on a monthly basis in order
to ensure that appropriate action is taken, where
necessary, to implement the guidance.
The Clinical Audit Committee proposed an update to
the NICE implementation process, essentially adapting
the process to take into account the multiplicity of
services in localities.
The key stages are:
• Assessment of new NICE guidance for applicability
to the Trust
• Dissemination of relevant guidance for an assessment
of impact on the Trust by the services affected
• Collation of the localities assessments and decision
of implementation strategy / actions and risks by the
clinical audit committee
• Delegation of monitoring to relevant committees (eg,
locality governance meeting if only local applicability,
or medicines management, infection control etc) and
nomination of Trust lead for key relevant guidance
Norfolk Community Health and Care NHS Trust
65
CG142 – Autism in adults
Learning Disability (LD) services have provided a trust
wide action plan for LD services
The following are examples of NICE guidance that has
resulted in a clinical audit (or re-audit)
a) NICE guidance TA98 and CG72 –
Attention deficit hyperactivity disorder (ADHD)
management in the community
A re-audit working with the Norfolk and Norwich
University Hospital to review whether best practice
National Institute for Health and Clinical Excellence
(NICE) guidelines for management of ADHD are
being followed in terms of medication; namely –
methylphenidate, atomoxetine and dexamfetamine.
CG145 – Spasticity in children and
young people
This guidance was assessed jointly by services in NCH&C
and the Norfolk and Norwich University Hospital in
December 2012 as partially compliant – requiring
work in developing networks and pathway of care,
upper limb spasticity service, transition programme,
occupational therapy services.
Proposed actions:
• Development of network arrangements
• Development of pathways
- Children with spasticity/cerebral palsy without
other medical or developmental disorders
- Medically complex children with spasticity as one
of a number of related problems
- Hip surveillance
- Upper Limb assessment and treatment
- Transition to adult services
• Upper limb assessment and treatment service
• Occupational therapy services for children
with spasticity
SystmOne template needs to plot blood pressure of
the patient as well as height and weight. For hand held
notes – Ensure clinic stickers are in notes, add heart
rate to the proforma, print observational graph and
highlight if patient is out of normal limits. For clinician –
document compliance and considerations to misuse of
drugs, and record medication change rational.
b) NICE guidance, CG 137 – Epilepsy Care Plan
Audit Adult Services
The aim of the audit was to measure against a quality
standard (NICE), in order to identify the minimum
standards required for Epilepsy Care Plans, ensuring
that the service was significantly exceeding these.
This service is currently undergoing a commissioning
review due to a large increase in demand. An action
from this audit was to liaise with the SystmOne team in
order to establish Epilepsy Care Plan templates for use
by staff, and ease of access, for medical/therapy/nursing
and future clinical audit needs.
66
3.10.3 T
he Colman Centre
for Specialist
Rehabilitation (CCSRS)
The Colman Centre for Specialist Rehabilitation
(CCSRS), which is a specialist rehabilitation service in
NCH&C, works towards providing an environment to
enable, educate and support service users and their
families, who have complex disabilities following an
acquired brain injury or amputations of limbs to achieve
an optimal level of physical, psychological and social
wellbeing. The CCSRS provides an interdisciplinary
rehabilitation focused on patient and family centred
goals through the world health organisations (WHO),
international classification of functioning (ICF)
framework as well as the ethical framework.
They have a workforce that is competent, committed,
caring, compassionate and well-motivated to enable a
culture of empowerment to the service user and their
family. The team deliver a clearly defined goal oriented
holistic interdisciplinary rehabilitation programme, which
empower service users and their family to make positive
health and lifestyle choices that will help to improve
the quality of their lives. The CCSRS team strives to
develop integrated pathways of care with existing and
new partners which helps with supporting the ongoing
rehabilitation needs of service users. They try to access a
comprehensive range of assistive technologies, orthotics,
specialist wheelchair, augmentive communication aids
and other equipments to enhance the patients care and
support the rehabilitation process. The team ensure
the service adheres to CQC and NICE quality standards
and to demonstrate continuous quality improvements
through audits and learning from incident reports.
Quality Account 2012/13
The outcome tools used are matched to the NHS
outcome framework are:
• Enhancing quality of life for people following an
injury and supporting patients and families to
manage their condition (domain 2): Use of goal
attainment scale for all admissions
• Helping people to recover their independence and
functional ability following an injury (domain 3):
Changes in UK FIM/FAM and Northwick park
dependency scores from admission to discharge
• Ensuring that people have a positive experience of
care (domain 4): The friends and family test
• Treating and caring for people in a safe environment
(domain 5): Patient safety incident reports, incidence
of medication errors, NHS thermometer
Norfolk Community Health and Care NHS Trust
3.10.4 Podiatric Surgery –
PASCOM 10
audit system
This is a national audit tool that podiatric surgery
departments have access to that enables each
department to monitor their activity and check their
results against other departments around the country.
The audit tool is used to record key points within
the patient’s pathway from referral to discharge;
measurable criteria can be used to make an objective
judgement on the treatment strategy deployed. The
Consultant Podiatric Surgeon at the centre has designed
a retrospective admin-controlled data entry system that
attempts to reduce variability and improve validity of
the data for the whole department.
Currently the team use the system to monitor data,
such as change in patient reported outcome measures
(MOXFQ), patient satisfaction scores (PATSAT), postoperative complications and surgical activity. There are
many other facets of the audit tool that will enable the
department to audit data, such as usage of specific
medicines, type of local anaesthetic block used, type of
tourniquet used and duration of use, etc.
67
In a review of 507 cases of data entered at six months
post-operation the following results were noted for the
Norfolk Foot Surgery Centre:
• PSQ-10 score - 86.53/100 (a score of patient
satisfaction based on 10 questions, with the national
benchmark being set at 75/100)
• MOXFQ scores (3 domains, the first being a score of
a patient’s functional outcomes/ improved mobility,
the second being an improvement in pain level,
and the third being an improvement in the patient’s
social activities associated with their foot problem):
35.8, 35.69 and 34.06. Each of these improvements
is above the minimal clinically important difference
level as described in the research/ validation studies
for the associated outcome tool
• Of the 507 cases, 61 post operative complications
were noted. These ranged from five cases of
prolonged swelling following foot surgery to one
case of a confirmed deep vein thrombosis
Along with benchmarking, the tool can be used to
provide data, such as success rates and percentage of
post-op complications per specific surgical procedure
for patient information leaflets. This can also be used
on an individual basis (per surgeon), if desired. Along
with real world patient reported outcomes, such as
direct compliments and complaints, PASCOM provides
an objective data set that goes some way towards
monitoring activity, providing assurance and directing
reflection on practice in the podiatric surgery centre.
Although there are only approximately 500 cases on the
system so far, the data for the centre so far show that
the whole unit has favourable results when compared
to two other similar centres elsewhere in England. It
is hoped that the podiatric surgeons will build upon
this recent success as the tool continues to provide this
important data.
Quality Account 2012/13
68
3.10.5 Research and Development
The following are a summary of a selection of studies that have patients actively recruited to and are underway.
Study Title
Aim
A randomised controlled
trial of self-help materials for
the prevention of smoking
relapse- 2011GC01
To investigate the effect of a set of self-help educational materials for the
prevention of smoking relapse in the NHS Stop Smoking Service. This is a national
portfolio study running from the UEA, but has had involvement in the design of
the study from both NHS Norfolk and Norfolk Community Health & Care.
The stop smoking service will recruit 1400 participants between August 2011 and
April 2013, and each participant will be in the study for one year.
Supported Communication
to Improve Participation in
Rehabilitation of people with
moderate-severe aphasia
after a first stroke: a pilot
study (SCIP-R) - 2010GC11
To examine the feasibility and provide initial evidence of clinical efficacy and value of
a supported communication intervention for people with moderate-severe aphasia
after a first stroke, in order to strengthen the design of a subsequent Phase III trial.
Clinical efficacy of functional
strength training for
upper limb motor recovery
early after stroke: neural
correlates and prognostic
indicators – FAST INDICATE–
2012GC11
Does functional strength training in addition to conventional physical therapy
(FST+CPT) commenced early after stroke produce greater improvements in upper
limb (arm and hand) motor recovery than CPT+CPT? T.
Clinical efficacy of the
Soft-Scotch Walking
Initial Foot (SWIFT) cast
on walking recovery early
after stroke and the neuralbiomechanical correlates
of response 2009MFE07
Revised Feb11
Does the use of a SWIFT CAST provided as an adjunct to Conventional Physical
Therapy enhance walking recovery early after stroke more than CPT given alone?
Keeping Children Safe
at Home from Accidents
– 2009PAED05 – Revised
Nov09
To find out whether a range of safety behaviours, safety equipment use and
home hazards affect the risk of falls, poisonings and scalds in children under five
years of age.
This is a national portfolio study which is being sponsored by NHS Norfolk, has been
developed and will run in Norfolk Community Health & Care. 100 participants are
hoped to be recruited across the two centres (the 2nd centre is in Cambridge), of
which about half will be from NCH&C (Beech ward, Norwich Community Hospital).
The Cambridge centre will be the control centre (standard care only), whereas
NCH&C will be the experimental centre (standard care plus intervention).
This is a national portfolio study which will be run at three sites in the UK and is
looking for a total of 288 participants. Locally, this study will happen at Beech ward
and in the Early Supported Discharge Team (ESD) in NCH, and the study team are
looking for 5 recruits per month for 20 months (total of 96 participants in NCH).
This is a national portfolio study which will be happening at Norfolk Community
Health & Care (NCH&C) and the Norfolk and Norwich University Hospital (NNUH),
as well as two sites in Scotland. There will be 120 participants in this study, with
60 coming from Norfolk sites and 60 from Scotland. Around 30 participants can
be expected to be recruited from NCH&C hospitals, although there may be more
if patients are discharged into NCH&C from NNUH. The results of this study will
inform the need for a larger scale study.
This is a national portfolio study consisting of one main study (study A), and three
nested studies (Studies B, C and G). Nationally it is hoped to recruit 3794 case
participants and 15176 control participants (4 controls per case) across four centres
in the UK (Norfolk, Suffolk and Great Yarmouth & Waveney is classed as one centre).
Norfolk Community Health and Care NHS Trust
3.10.6 Clinical Audit Plan
2012/13
69
30%
33%
High
85 of the 143 (59%) audits on the audit plan were
clinical audits. Of the 85 clinical audits proposed in
2012/13, 27 were completed in full (32%).
The clinical audit plan subdivides audits by priority
status aligning priority 1 and 2 to the Board Assurance
Framework in terms of ‘risk’ and assigning priority 3 and 4
to locality based risk register priorities, and exact division of
these responsibilities is demonstrated in the table below:
Types of
project
Examples
No.
% of
total
clinical
audits
Priority 1 –
Internal ‘must
do’ audits
NICE Technology
Appraisals (TAs),
Commissioning
(eg, CQUIN audits),
Internal service
evaluation
12
44%
Priority 2 –
External ‘must
do’ audits
National Audits,
National Service
Frameworks
1
4%
Priority 3 –
Operational
locality audits
Service specific,
baseline audits for
business cases etc
8
30%
Priority 4 –
Clinical
interest audits
Clinical specialty
audits (other
than technology
appraisals – TAs)
6
22%
The completed clinical audits reports in line with the
clinical audit policy recognise ‘high assurance’ as over
85% compliance, ‘moderate’ as between 60% – 84%
compliance, and ‘low’ as below 59% compliance
against clinical audit standards.
Moderate
Low
37%
30% gave high assurance, including: clinical record
keeping/management, Essence of Care – bowel
and bladder management, reducing avoidable
death, disability and chronic ill health from Venousthromboembolism, administration of Beccal Midazalam
and rectal diazepam, UNICEF Baby friendly initiative
(stage 2), resuscitation (policy monitoring), service
response times (Priscilla Bacon Lodge – Palliative Care).
37% gave moderate assurance, including, Community
Intra-venous re-audit (west locality), re-audit to
demonstrate attendance at multi-disciplinary team
meetings (Priscilla Bacon Lodge), management of
constipation, Methadone – to review adherence
to service guidelines, attention deficit hyperactivity
disorder (ADHD) management in the community,
SystmOne record keeping in respect of child protection
records (Safeguarding team), preferred place of
death, timing of consultant review following inpatient
admission to Priscilla Bacon Lodge (PBL).
33% gave low assurance, including, re-audit of
pain management at Priscilla Bacon Lodge, cuffed
tracheostomy care audit to assess if a training programme
needs to be organized at Caroline House, auditing
operational compliance with the National Institute for
Health and Clinical Excellence (NICE) policy, auditing
operational compliance with the Clinical Audit policy.
70
Quality Account 2012/13
4. Explanation of who has been
involved and engaged with
Norfolk LINk and Public involvement at Trust Board
meetings and other committees, including Quality and
Risk Assurance Committee, Patient Experience Steering
Group and PEAT inspections.
Development of the annual plan and quality goals by
Executive Directors, Assistant Directors, heads of service
and clinicians through workshops and management fora.
Third party commentary received from Norfolk
Healthwatch, Norfolk County Council Health Overview
and Scrutiny Committee and South Norfolk Clinical
Commissioning Group (our main commissioners) is
presented below.
4.1 Comments from Norfolk
Healthwatch (previously
Norfolk LINk)
Norfolk Healthwatch can confirm that it has reviewed
the Quality Accounts for 2012-13. However, due to
Norfolk Healthwatch only becoming operational from
April 1, 2013 we do not believe it is appropriate for us
to provide any detailed observations at this time but we
will be working closely with Norfolk Community Health
and Care NHS Trust and therefore will provide detailed
and constructive comments on the Quality Accounts
for 2013-14.
4.2 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 2012-13 and
would like to stress that this should in no way be taken
as a negative comment.
Norfolk Community Health and Care NHS Trust
4.3 Comments from
South Norfolk Clinical
Commissioning Group
Statement of Information Verification within the
Quality Account submitted to South Norfolk Clinical
Commissioning Group (SNCCG) by Norfolk Community
Health & Care NHS Trust May 2013.
South Norfolk Clinical Commissioning Group, as lead
commissioner for the Trust, acknowledges Norfolk
Community Health & Care NHS Trust in it’s publication
of a Quality Account for 2012/13.
We have reviewed the mandatory data elements
required within this account and can confirm that those
included are consistent with that known to SNCCG.
The report presents detailed and comprehensive
information relating to quality and safety of care
delivered within the prioritised areas identified by the
Trust. The quality goals for 2013/14 are relevant and are
substantiated by involvement with the clinical quality
and patient safety agenda via the Commissioning for
Quality and 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.
SNCCG 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.
71
Work continues with the ambition of reducing
avoidable pressure ulcers. This has been achieved in the
inpatient setting in December 2012, with additional
work on-going for the community settings.
The Trust acknowledges the learning that arose from the
review of the series of unexpected deaths in a community
hospital. The Trust outlines where the learning has led to
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 commitment to working with and
building strong relationships with the five Norfolk
CCG’s as well as Norfolk County Council as a part of
the health and social care integration agenda. We
look forward to working alongside our providers in
supporting quality initiatives in the coming year.
Yours sincerely,
Ann Donkin
Chief Officer
South Norfolk Clinical Commissioning Group
72
Quality Account 2012/13
5.Declaration by all Directors
The following is a declaration; signed by all directors
in office at the date of the account, certifying that
they believe the contents to be true, or a statement
of explanation as to the reasons any such Director is
unable or has refused to sign such a declaration.
I believe the contents of this Quality Account 2012/13
to be true:
Executive Directors
Name: Michael Scott
Designation: Chief Executive
Name: Roy Clarke
Designation: Director of Finance
Name: Dr Rosalyn Proops
Designation: Medical Director
Name: Anna Morgan
Designation: Director of Nursing,
Quality and Operations
Name: Paul Cracknell
Designation: Director of Strategy
and Transformation
Name: Matt Colmer
Designation: Director of Performance
and Information
Non-Executive Directors
Name: Ken Applegate
Designation: Chairman
Name: James Ross
Designation: Non-Executive Director
Name: Alex Robinson
Designation: Non-Executive Director
Name: Vivienne Clifford-Jackson
Designation: Non-Executive Director
Name: Lisa Gamble
Designation: Non-Executive Director
Name: Neil Harrison
Designation: Non-Executive Director
Head Office: Elliot House, 130 Ber Street, Norwich NR1 3FR
Online: www.norfolkcommunityhealthandcare.nhs.uk
Telephone: 01603 697300