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Quality Report
Bolton NHS Foundation Trust
BOLTON NHS FOUNDATION TRUST
QUALITY ACCOUNT
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Quality Report
Bolton NHS Foundation Trust
Table of Contents
Title
Part One
Trust Profile
Statement on the Quality of Services from the Chief Executive
Statement of Director Responsibilities
Page
5
6
8
Part Two
How Quality is prioritised
Quality Improvement Strategy 2014 - 2017
Patient Experience Strategy 2014 - 2017
Achievement on priorities set out in the 2013/14 Quality Account
Monitoring Priorities at Bolton NHS Foundation Trust
Key Quality Priorities for 2014/15
Participation in Clinical Audits and research activity
Goals Agreed with the Commissioners (CQUIN)
Care Quality Commission Registration/ Reviews
Data Quality
Clinical Coding
10
10
11
12
16
17
18
23
26
27
28
Part Three
How we performed on Quality in 2013/14
What others say about Bolton NHS Foundation Trust
47
54
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Quality Report
Bolton NHS Foundation Trust
PART ONE
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Quality Report
Bolton NHS Foundation Trust
Trust Profile
Bolton NHS Foundation Trust is an integrated care organisation providing care and support in
the community at over 20 health centres and clinics, including the prestigious Bolton One
complex in the town centre, as well as services such as district and school nursing. We also
provide intermediate care in the community and a wide range of services at the Royal Bolton
Hospital. Our services are used by the people of Bolton and beyond and as at the end of March
2013 we employed 5300 staff.
At the end of March 2013 the Royal Bolton Hospital RBH had 626 inpatient beds, 32 day case
beds and 15 endoscopy (gastrointestinal exploration) beds. Of these 371 were medical beds
but included 24 beds which open only for the winter period. It is one of the busiest hospitals in
Greater Manchester for urgent care and is also a regional 'supercentre' for maternity services,
babies and children. We have an up to the minute delivery suite, a friendly and attractive
children's ward, and purpose built neonatal critical care and special care baby units.
Mental health services are provided on the Royal Bolton Hospital site but are managed by
Greater Manchester West Mental Health NHS Foundation Trust. Renal dialysis is provided and
managed by Salford Royal NHS Foundation Trust at a dedicated unit at the Royal Bolton
Hospital.
The Trust has three fundamental aims:
Best care for better health (for our patients and our community)

Responsible use of resources (for the taxpayer)

Valued, respected and proud (by our staff, patients and public).
We aim to:
Meet the health needs of our population

Improve the safety and quality of care

Improve patient experience

Make our services more efficient.
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Quality Report
Bolton NHS Foundation Trust
Statement of the Quality of Services from the Chief Executive
This Quality Account is an annual review of the quality of healthcare provided by Bolton NHS
Foundation Trust in 2013 – 14 and a forward look to outline the key priorities for 2014 – 15.
In part one we provide an overview of the organisation and the responsibilities of the Directors
of the Trust are outlined.
In part two of this report we set out our priorities for 2013/14. In our Annual Plan we have set
ourselves objectives for improvement, each of which is sub-divided into specific indicators as
shown below. We will report back on our progress against each of these in our report next
year.
Underpinning our service plans is a strategy for high quality care. Our priorities for the quality
of care were identified after consultation with staff across the Trust, building on the
improvements seen in the last five years.
To reduce mortality

Aiming to be in the top ten Trusts nationally on measures of hospital mortality and perinatal
mortality.
To prevent infection and harm

Aiming for a 50% reduction, year-on-year, in avoidable cases of clostridium difficile and
other healthcare acquired infections.

Working to ensure that “never events” don’t occur when patients are in our care.

Aiming to consistently achieve best practice standards for harm free care.
To respond and learn

Improving our complaints process.

Learning from clinical incidents.

Ensuring that we listen to patient voices in planning and delivering our services.
To deliver a better patient experience

Improving our monitoring systems.

Sharing best practice.

Aiming for the best ratings from all our patients, as measured by the national survey of
whether patients would recommend our services to friends and family.
Although these objectives are all important to us, the Board has agreed that our main ambition
is to be harm free and the first zero harm Trust in the North West. Just one fall or pressure
ulcer is one too many. Our aim is to provide services that are safe and that our staff would
happily recommend to their family and friends. In part three of this report we look back on
performance against the improvement priorities we set ourselves in 2013 -14.
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Quality Report
Bolton NHS Foundation Trust
We have worked with our stakeholders to develop this Quality Account – statements from
Bolton CCG, Bolton HealthWatch, our Council of Governors and the Overview and Scrutiny
Committee are included at appendix one. During 2013/14 we attended a series of meetings
with Bolton Healthwatch to provide updates on our progress against the 2013/14 objectives.
We will continue with these meetings in 2014/15, and details will be provided on our website
and through HealthWatch.
We have been working closely with our commissioners – Bolton CCG to develop the services we
deliver to the people of Bolton. An early draft of this report was shared with the CCG. They
provided some useful feedback on the issues which matter to them and this has been
incorporated into this final report. Our commissioners have been very supportive and we will
continue working closely with them to ensure we provide the best possible care to the
population we serve.
We aim to be open and transparent with the public we serve and will also provide updates on
our progress in our Board meetings and at our Governor meetings. We welcome feedback from
our patients and public and will use this to make improvements to the care we provide.
We have tried to use clear and understandable language wherever possible in this report
however the inclusion of some medical and healthcare terms is unavoidable. A glossary of
terms is provided and further information about health conditions and treatments is available
on the NHS Choices website.
Dr Jackie Bene
Chief Executive
29th May 2014
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Quality Report
Bolton NHS Foundation Trust
Statement of directors’ responsibilities
The directors are required under the Health Act 2009 and the National Health Service (Quality
Accounts) Regulations 2010 to prepare Quality Accounts for each financial year. Monitor has
issued guidance to NHS foundation trust boards on the form and content of annual Quality
Reports (which incorporate the above legal requirements) and on the arrangements that
foundation trust boards should put in place to support the data quality for the preparation of
the Quality Report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

the content of the Quality Report meets the requirements set out in the NHS
Foundation Trust Annual Reporting Manual;

the content of the Quality Report is not inconsistent with internal and external sources
of information including:
o Board minutes and papers for the period April 2013 to April 2014
o Papers relating to Quality reported to the Board over the period April 2013 to April
2014

Feedback from the commissioners dated

Feedback from governors

Feedback from local HealthWatch

The trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, May 2014

The 2013 national patient survey

The 2013 national staff survey

The Head of Internal Audit’s annual opinion over the trust’s control environment
o Care Quality Commission quality and risk profiles

the Quality Report presents a balanced picture of the NHS foundation trust’s performance
over the period covered;

the performance information reported in the Quality Report is reliable and accurate;

there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to
confirm that they are working effectively in practice;
the data underpinning the measures of performance reported in the Quality Report is robust
and reliable, conforms to specified data quality standards and prescribed definitions, is subject
to appropriate scrutiny and review; and the Quality Report has been prepared in accordance
with Monitor’s annual reporting guidance (which incorporates the Quality Accounts
regulations)
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Report.
By order of the Board
29th June 2014
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Quality Report
Bolton NHS Foundation Trust
Quality Account - part two
PART TWO
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Quality Report
Bolton NHS Foundation Trust
Quality Account - part two
How Quality Initiatives are prioritised in the Trust
This Quality account identifies the progress made against the Quality and Safety strategies this
year and identifies the Quality Improvement aims for 2014/15.
The Safety and Quality programme will enable the Trust to maintain a focus on the Quality and
Safety agenda, whilst delivering our clinical strategy to improve the health and outcomes of our
local population based on the values and principles set by the Board and in line with the NHS
outcomes framework.
Continuous improvement of clinical quality is further incentivized through the contracting
mechanisms that include quality schedules, penalties and CQUIN payments. NHS England
frameworks and the recently published Francis Report into Mid Staffordshire Hospitals also
highlight the focus on quality, and are now linked to the NHS Mandate and Constitution.
We will work with Commissioners to align our quality aims and to maximize the potential
delivery through these mechanisms. The Trusts improvement priorities for 2014/15 built upon
those reported in 2013/14 and performance in previous years. They were chosen because the
reflected key areas of development for the Trust – reflected Trust Board Priorities and Quality
Strategies these assigned from national and local mandated requirements, CQUIN priorities and
were informed of those Quality analyses by patient and staff engagement and feedback.
Quality Improvement Strategy 2014 – 2017
Delivery of our strategy will be through programme management of a series of work streams,
designed to underpin our fundamental aim - to provide caring, safe and effective services.
The work streams have been identified following wide consultation with clinical and managerial
staff and governors. They comprise four quality improvement work streams targeting specific
areas of improvement in clinical outcomes, patient safety and patient experience. They are
underpinned by three enabling work streams. Each work stream builds on existing work, but
adds focus and stronger performance management to ensure delivery.
Each work stream will have a clinical leader, supported by a multidisciplinary team and with a
wide range of capability and experience drawn from across the organisation. Key members of
each team will be patients and members of the public.
Each work stream will use a systematic approach and proven quality improvement tools,
including value stream analysis, strategy and policy deployment, visual management and plando-study-adjust (PDSA) cycles, to build continuous improvement. Teams will scope their work
at initial workshops, using external experts where necessary; produce a clear description of
their purpose and their plans; hold learning sessions and summits; and scale-up and spread
their learning. They will identify their priorities, the resources required, set out ambitious
annual goals, and define and track the relevant measures of progress.
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Quality Report
Bolton NHS Foundation Trust
Quality Account - part two
Patient Experience Strategy 2014 – 2017
This Strategy outlines how Bolton NHS Foundation Trust continues to see the experience of
patients as a major priority going forward to 2015 and beyond. It has been developed with the
support and collaboration of partner agencies and voluntary organisations and sets out our
Patient Experience vision. The priorities and outcomes cross both hospital and community
settings
The purpose and aims of this strategy are:

Raise standards and expectations of patient, family and carer experience at Bolton NHS
Foundation Trust.

Define the current national drivers and standards for patient experience

Define the action required by staff throughout Bolton NHS Foundation Trust to improve
patient, family and carer experience.

Provide a framework of action for the priorities and to clarify responsibility for action for
each identified outcome.

This strategy will link into the Bolton NHS foundation Trust Strategic Direction 2013 – 2019
document by implementing actions that will support delivery of the outlined aims in
relation to patient experience. These are:
o
Improving our monitoring our monitoring systems
o
Sharing Best Practice
o
Aiming for the best ratings from all our patients as measured by the national measure of
whether patients would recommend our services to friends and family.
Measuring the experience of our patients, families and carers
We have identified seven ‘outcomes’ with underpinning actions that are identified as ‘Always’
Events’. This will underpin the implementation of this strategy and provide a performance
framework in order to assess the outcomes of the strategy being delivered and implemented in
practice.
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Quality Report
Bolton NHS Foundation Trust
Achievement on priorities set out in the 2013/14 Quality Account
PRIORITY ONE: Reduce Infection from Clostridium Difficile
Achieved a 41.54% reduction in patients acquiring Clostridium
Difficile
What we did:
Although we achieved a reduction in relation to the number of patients acquiring Clostridium
Difficile with 38 patients in 2013/14 compared to 65 patients in 2012/13, this performance was
more than the target of 28 cases.
In March 2013 we worked jointly with our many commissioners (Bolton CCG) to commission an
external review of Clostridium difficile (C Difficile). We received the results of the review in
April 2013 and have developed a plan to address the actions required.
We have agreed a range of actions including:

Investment in new hand wash basins in areas identified as needing these closer to beds and
bays.

The provision of doors on bays in some of our older wards.

Hydrogen peroxide “fogging”.
decontamination.

Mattresses, pillows and commodes will be reviewed and replaced as necessary.

Formal root cause analysis will be held for each and every infection.

Continued close liaison with the commissioners Bolton CCG.
This is a procedure where the ward is closed for
Clostridium Difficile - Hospital Acquired
16
14
12
10
8
6
4
2
0
2012-13
2012-13
2013-14
2013-14 Target
Apr
4
7
2
May
14
5
2
Jun
9
4
2
Jul
1
3
2
2013-14
Aug
2
4
2
2013-14 Target
Sep
4
2
2
Oct
2
2
2
Nov
3
2
2
Dec
11
0
2
Jan
6
4
2
Feb
6
3
2
Mar
3
2
2
Total
65
38
28
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Quality Report
Bolton NHS Foundation Trust
Achievement on priorities set out in the 2013/14 Quality Account
PRIORITY TWO: Reduce Pressure Ulcers
Although we achieved an overall 13.64% reduction in patients
acquiring pressure ulcers in our care in the hospital and
community; unfortunately we recorded an increase in the number
of grade 3 and grade 4 pressure ulcers acquired in our care.
2012-13
2013-14
2013-14 Target
Apr
16
19
9
May
10
13
9
Jun
28
32
9
Jul
29
27
9
Aug
33
13
9
Sep
28
17
9
Oct
16
22
9
Nov
34
33
9
Dec
20
14
9
Jan
21
14
9
Feb
21
13
9
Mar
8
11
9
Total
264
228
109
Total of Pressure Damage 2+ (Community and Hospital)
40
35
30
25
20
15
10
5
0
2012-13
2013-14
2013-14 Target
The chart below represents the comparison of category 3 and 4 pressure ulcers for 2012/13
and 2013/14. This equates to a 40% increase in category 3 and 4 pressure ulcers for the year
2013/14. We continue to have a zero tolerance of all category 3 and 4 pressure ulcers through
the implementation of the Pressure Ulcer Prevention Strategy. We have improved our
reporting processes for category 3 and 4 pressure sores to ensure that all identified sores are
reported and receive a full root cause analysis and presented to panel.
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Quality Report
Bolton NHS Foundation Trust
Achievement on priorities set out in the 2013/14 Quality Account
2012-13 Hospital - Patients acquiring pressure damage (grade 3)
Hospital - Patients acquiring pressure damage (grade 4)
Community - Patients acquiring pressure damage (grade 3)
Community - Patients acquiring pressure damage (grade 4)
Total
Apr
1
2
1
0
4
May
0
0
1
0
1
Jun
1
0
3
1
5
Jul
1
1
0
1
3
Aug
3
1
1
3
8
Sep
1
1
2
1
5
Oct
0
0
4
0
4
Nov
2
0
0
0
2
Dec
1
0
1
0
2
Jan
1
0
3
3
7
Feb
1
0
2
1
4
Mar
2
0
0
0
2
Total
14
5
18
10
47
2013-14 Hospital - Patients acquiring pressure damage (grade 3)
Hospital - Patients acquiring pressure damage (grade 4)
Community - Patients acquiring pressure damage (grade 3)
Community - Patients acquiring pressure damage (grade 4)
2
2
1
0
1
1
3
0
2
0
1
0
4
0
0
1
2
0
0
1
2
1
2
1
3
1
4
3
4
0
4
4
4
0
1
0
3
0
3
2
2
0
1
0
0
0
0
0
29
5
20
12
5
5
3
5
3
6
11
12
5
8
3
0
66
Total
What we did:
In the period 2013/14 all category two, three and four pressure ulcers have had a root cause
analysis completed and the learning and recommendations shared with the teams concerned.
It is recognised that there are different challenges in the community settings when compared
to the hospital and that it is important to address these within the context of the diverse
settings in which we provide our services.
In addition to this we have implemented the following:

Revised the prevention of pressure ulcer policy to ensure all staff are clear about their
responsibilities in preventing pressure ulcers. This policy was launched in November 2013,
the incidence of grade 3 and 4 pressure ulcers reduced from December 2013 with zero
cases of grade 3 or 4 in March 2014.

Regular on-going education of staff by the Tissue Viability Team, achieving 85% of staff
trained.

The replacement of all hospital beds with electric profiling beds and a high quality mattress
to make moving and changing of position easier and more comfortable for patients. The
Trust also has a rental contract arrangement in place to provide special air mattresses to
reduce pressure damage for patients who are at most risk of harm.

Revised and strengthened the harm free care panel in so that all category two, three and
four pressure ulcers are presented to a multi professional panel. Any issues identified have
been subject to an action plan which is monitored by the Matron and Professional Lead.

Launched the Pressure Ulcer Prevention Strategy across the organisation
This area remains a high priority for the Trust with regular reports to the Board of Directors and
Quality Assurance Committee to provide assurance that the required actions have been taken
and are having the desired impact.
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Quality Report
Bolton NHS Foundation Trust
Achievement on priorities set out in the 2013/14 Quality Account
PRIORITY THREE: Reduce falls
Achieved a 15.75% reduction in patient falls
What we did:
Although the majority of falls result in no harm there are still significant challenges for the Trust
in managing our most vulnerable patients.
The Trust has implemented a number of measures to reduce the levels of harm and needs to
keep this as a high priority:

Review of the monthly Harm Free Care Panel where all falls subject to a root cause analysis
are presented ensures that all possible improvements are put in place.

In the past year 100% of falls resulting in moderate to severe harm have had a root cause
analysis completed and areas where improvement was identified have been communicated
back to the staff.

Ensure patients at risk of falls are provided with appropriate footwear if required.

Reviewed and improved the data and reporting systems to ensure information is more
robust and accurate.

Ensured the continuity of falls services across the hospital and community.

In September 2013 we launched the Falls Strategy for the organisation.
All Patient Falls (Safeguard)
140
120
100
80
60
40
20
0
2012-13
2012-13
2013-14
2013-14 Target
Apr
83
113
86
2013-14
May
87
97
86
2013-14 Target
Jun
73
80
86
Jul
126
77
86
Aug
99
73
86
Sep
90
79
86
Oct
78
84
86
Nov
91
77
86
Dec
103
65
86
Jan
111
68
86
Feb
108
62
86
Mar
100
93
86
Total
1149
968
1034
The figure reported in last year’s quality account was for falls to over 75s and is therefore not comparable.
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Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
Monitoring Priorities at Bolton NHS Foundation Trust
The constituent strategies relating to quality, safety, risk, governance, human resources and
finance come together through our integrated performance report and Heat Map which is
provided to the Trust Board and assurance committees. Work is now on-going to adapt this
and roll out to our community settings
The Trust uses qualitative and quantative data and information. This includes:

a systematic review of each new publication of the CQC Quality and Risk Profile

benchmarked information from CHKS

A review of the NHS North of England Quality dashboard

Transparency data

Profile of area/local market share/health profile/service review/initial mortality analysis

Outline performance of local providers

Mortality HSMR and SHMI

Patient experience ( annual patient experience surveys)

Safety and Workforce Profile

Clinical and operational effectiveness (National key performance indicators)

Comparison of Trust performance to other National Trusts and targets including PROMS
Collectively these provide assurance regarding the achievement of the key priorities outlined in
the 2013 -2014 Quality account.
Rationale for selection of priorities for 2014/15
The 2014/15 priorities have been aligned with the Trust’s Quality strategy. The three main
priorities for 2013/14 remain a key part of this strategy and have been revised in line with the
achievements and learning from 2013/14.
Page 16 of 55
Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
Key Quality Priorities for Improvement 2014/15
In setting out the key priorities for 2014/15 we have ensured that all of the priorities identified
link into the established strategies and strategic aims for the Organisation. The priorities for
this year’s quality account are clustered under the following headings;
 Quality and Safety
 Patient Experience
 Workforce
Key priorities and Measures
Quality and Safety
Indicator
Mortality
Infection Control
Harm Free Care
Medicines Management
Patient Experience
Friends and Family Test
Real Time Patient
Experience
Measure
 Standardised Hospital Mortality Index (SHMI) –
Preventing People from dying prematurely.
o Reduce SHIMI to less than 1.0
o Reduce crude mortality by 10%
 50% reduction in avoidable cases of C.Diff.
 Zero Tolerance of category 3 and 4 pressure Ulcers
 5% reduction in pressure ulcers categorised as
avoidable
 10% reduction in hospital acquired VTE episodes
 5% reduction in falls with severe harm.
 95% harm free reported through the medicines
safety thermometer




Lessons Learnt



Dementia
Workforce
Friends and Family Test




Sickness Management
Appraisal
Mandatory Training



Expansion of the areas utilising the FFT questions
5% increase in response rates
Implementation of ‘real time;’ data collection
processes.
Development of 10 patient experience questionnaire
processes across hospital and community
Development of you said we did processes for FFT
comments.
Evidence of lessons learnt being reported
throughout the divisions and corporate structures.
Development of Clinical Senate and MAPSAF
baseline assessment undertaken.
95% compliance with the Dementia Care bundle
10% improvement of the experience of patients with
dementia or their carers using services across the
hospital and community
Development of process to measure staff FFT
experience
5% decrease in negative comments from Quarter 1
baseline.
reduction in overall sickness rates to 3.75%
80% completion of appraisal information
100% of available staff have completed MT
Page 17 of 55
Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
Review of services
During 20013/14 Bolton NHS Foundation Trust provided and/or sub-contracted seven regulated
activities (as defined by the CQC) across 38 specialities.
Bolton NHS Foundation Trust has reviewed all the data available to it on the quality of care in
these NHS services.
The income generated by the relevant services reviewed in 2013/14 represents 100% of the
total income generated from the provision of NHS services by Bolton NHS foundation Trust in
2013/14
Participation in Clinical Audits and Research Activity
National clinical audits and national confidential enquiries are tools that NHS organisations use
to assess the quality of services provided, against the best available evidence based guidance
and standards.
At Bolton NHS Foundation Trust we undertake many clinical audits. We participate in all the
national audits which are applicable to the organisation. This allows us to benchmark against
other hospitals in England.
We also have a comprehensive programme of local clinical audits which clinical staff including
consultants, junior doctors, nurses and allied health professionals conduct regularly to improve
local areas of care.
During 2013/14 29 clinical audits and five national confidential enquiries covered relevant
health services that Bolton NHS Foundation Trust provides.
During that period Bolton NHS Foundation Trust participated in 100% national clinical audits
and 100% 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 enquires that Bolton NHS FT participated
in, and for which data collection was completed during 2013/2014 are listed in the tables below
(alongside the number of cases required by the terms of that audit or enquiry as a percentage
of the number of registered cases required by the terms of that audit or enquiry.
Audit
Case Mix Programme (CMP)
Emergency use of oxygen
Medical and surgical clinical outcome review
programme: National confidential enquiry
into patient outcome and death
National Audit of Seizures in Hospitals
(NASH)
National emergency laparotomy audit (NELA)
National Joint Registry (NJR)
Paracetamol overdose (care provided in
emergency departments)*
Specialty
Participated
Y/N
Audit Requirements
% Cases
Submitted
Acute
Y
All applicable
100%
Acute
Y
All applicable
partial
Acute
Y
All applicable
100%
Acute
Y
All applicable
Note: Started Jan 2014
partial
(22 cases)
Acute
Y
All applicable
100%
Acute
Y
All applicable
100%
(50 cases)
Acute
Page 18 of 55
Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
Audit
Severe sepsis & septic shock*
Severe trauma (Trauma Audit & Research
Network, TARN)
National Comparative Audit of Blood
Transfusion programme
Bowel cancer (NBOCAP)
Specialty
Participated
Y/N
Audit Requirements
Acute
Y
All applicable
Acute
Y
Blood and
Transplant
Submitted 171 cases
(Target 65% of 275)
All Applicable
National Comparative
Audit of Consent and
Information for
Transfusion – in
progress, we are aiming
for 24 cases
National Red Cell
Survey -2014 – in
progress, number of
cases will only be known
when data collection is
complete
National Comparative
Audit of the use of AntiD 2013 – 74 cases,
awaiting national report
National Comparative
Audit of Transfusion
sample collection and
labelling 327 cases
% Cases
Submitted
100%
(50 cases)
52%
100%
(327 cases)
Cancer
Y
All applicable
100%
Cancer
Cancer
Y
Y
All applicable
All applicable
100%
100%
Cancer
Y
All applicable
100%
Heart
Y
All applicable
100%
Cardiac Rhythm Management (CRM)
Congenital heart disease (Paediatric cardiac
surgery) (CHD)
Coronary angioplasty
Heart
Y
All applicable
100%
Heart
N
N/A
-
Heart
N
N/A
-
National Adult Cardiac Surgery Audit
Heart
N
N/A
National Cardiac Arrest Audit (NCAA)
Heart
Y
All applicable
National Heart Failure Audit
National Vascular Registry*
Pulmonary hypertension (Pulmonary
Hypertension Audit)
Diabetes (Adult) ND(A), includes National
Diabetes Inpatient Audit (NADIA)*
Heart
Heart
Y
Y
All applicable
All applicable
100%
(n=77 cases)
100%
100%
Heart
N
N/A
-
Long term
conditions
Y
All applicable
100%
Diabetes (Paediatric) (NPDA)
Long term
conditions
Long term
conditions
Y
All applicable
100%
Y
All applicable
100%
Y
All applicable
– on-going data
collection
100%
Head and neck oncology (DAHNO)
Lung cancer (NLCA)
Oesophago-gastric cancer (NAOGC)
Acute coronary syndrome or Acute
myocardial infarction (MINAP)
Inflammatory bowel disease (IBD)*
National Chronic Obstructive Pulmonary
Disease (COPD) Audit Programme*
Long term
conditions
Page 19 of 55
Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
Audit
Specialty
Participated
Y/N
Paediatric bronchiectasis*
Renal replacement therapy (Renal Registry)
Rheumatoid and early inflammatory
arthritis*
Mental health clinical outcome review
programme: National Confidential Inquiry
into Suicide and Homicide for people with
Mental Illness (NCISH)
National audit of schizophrenia (NAS)
Prescribing Observatory for Mental Health
(POMH)
Falls and Fragility Fractures Audit
Programme (FFFAP)
Sentinel Stroke National Audit Programme
(SSNAP)*
Elective surgery (National PROMs
Programme)
Child health clinical outcome review
programme (CHR-UK)*
Epilepsy 12 audit (Childhood Epilepsy)
Maternal, Newborn and Infant Clinical
Outcome Review Programme (MBRRACE-UK)
Moderate or severe asthma in children (care
provided in emergency departments)*
Neonatal intensive and special care (NNAP)
Paediatric asthma
Paediatric intensive care (PICANet)
Long term
conditions
N
Long term
conditions
N
Long term
conditions
Mental
Health
Y
Audit Requirements
Not applicable to Bolton
- joint care of patients
with RMCH
% Cases
Submitted
-
N/A
-
Bolton NHSFT
Registered. Delayed due
to national Web-based
audit tool problems.
Audit to start April 2014
partial
N
N/A
N
N/A
N
N/A
Older People
Y
All applicable
100%
Older People
Y
All applicable
partial (182
cases)
Other
?
Mental
Health
Mental
Health
Women’s &
Children’s
Health
Women’s &
Children’s
Health
Women’s &
Children’s
Health
Emergency
Care
Women’s &
Children’s
Health
Women’s &
Children’s
Health
Women’s &
Children’s
Health
N
Y
Y
TBC
Data collection extended
into Q1 of 2013/14 for
those who had not
completed in 12/13
audit year
All applicable
All applicable
TBC
100%
100%
Y
50
100%
Y
All admissions to
neonatal intensive &
special care
100%
Y
N
All applicable
100%
(n= 65 patients)
N/A
TBC
National Clinical Audits and National Confidential Enquiries 2013/2014
These are “inspections” that are carried out nationally to investigate areas of care where there
may have been problems nationally or where the patients may be particularly vulnerable. All
hospitals are asked to take part in them so that all care across England can be monitored.
Page 20 of 55
Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
National Confidential Enquiries into Patient Outcome and Death (NCEPOD)
Title
Start Date
Reporting
Tracheostomy care
October 2013
June 2014
Lower limb amputation
May 2013
November 2014
Gastro intestinal
haemorrhage
November 2013
June 2015
Progress
Data
sent
awaiting
report
Awaiting 50% clinician
data.
(n=3 reviews)
Data
collection
continuing
National Clinical Audit and Patient Outcomes Programme (NCAPOP)
Title
Start Date
National audit of
dementia
2013
Reporting
Progress
Completed
The reports of 2 national clinical audits were reviewed by the provider in 2013/14 and Bolton
NHS Foundation Trust took the following actions to improve the quality of healthcare provided.
National Cardiac Arrest Audit: Locally audited using Root Cause Analysis
Using data submitted to NCAA and collecting local data on Peri-Arrests. A group was
established case review all cardiac arrest and peri arrest within Bolton Hospital. The findings
for 2013 re-audit highlighted
1. Effective process of establishing lessons learned.
2. Becoming embedded in clinical governance structure coroner requesting to see them!
3. Effectively addressing DNAR policy
4. Following death, findings of RCAs fed back to families by consultants.
National Audit of seizure management in hospital (NASH2)
This was the second round of the audit, the first round that Royal Bolton Hospital has
participated. The results show that Bolton is very good at epilepsy/seizure management in our
Emergency department.
Local Audits:
The main purpose of clinical audit is to deliver improvements in clinical practice. A systematic
approach to the implementation of clinical audit action plans is therefore strongly advised.
Such an approach may include the identification of local barriers to change, and organisational
or resource constraints which preclude implementing change.
Not all clinical audits will require an action plan e.g. where an audit shows that standards are
met or guidance followed.
Page 21 of 55
Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
The reports of 84 local clinical audits were reviewed by the provider in 2013/14and Bolton
NHSFT has taken the following actions to improve the quality of healthcare provided:

Paediatric re-admission & re-attendance 2013 - Improve availability of written information
& advice, increase acute referral rate to Paediatric Community Nurses, address issues raised
with making PCN referrals

Acute Kidney Injury Audit - produced guidelines for junior doctors

Sepsis 6 - screen saver introduced, education around sepsis management, care bundle for
sepsis introduced

Discussion between clinical effectiveness department and clinical leads as to how to further
improve changes in practice

Escalating results to the Quality Assurance Committee (to highlight positive assurance)

Implementation of Quality Improvement work for local audits
Areas of Success

76% increase in registered audits per year at RBH

Increases in audits derived from standards: 68 to 100% (majority national)

Closure of audit loop: 28% to 58%
Information on Clinical Research
A total of 869 patients, receiving NHS services provided by Bolton NHS Foundation Trust, were
recruited to NIHR Portfolio Studies in 2013-14. The recruitment target set for this period by
GMCLRN of 661 was exceeded by +43%, giving the Trust a Green rating for recruitment.
NHS Permission for Research
A total of 24 NIHR Portfolio Studies were given NHS Permission at Bolton NHS Foundation Trust
in 2013-2014. Of the 24 studies submitted to this site, 17 were for full NHS Permission, and 7
for Patient Identification Centre (PIC) approvals.
NHS Permission benchmarking was applied to 15 eligible research studies.
73% of the eligible research studies were approved within the National Benchmark of 30 days
from receipt of a valid submission to approval (Amber rating).
From 1st April 2014, the governance review task for Bolton NHS Foundation Trust was
outsourced to Greater Manchester Comprehensive Local Research Network (GMCLRN), to
streamline NHS Permission processes. During a period of transition in Q1, delays in governance
processes were encountered. This improved across the year as communication channels were
established. By Q4 100% of Research Studies were approved within the 30 days benchmark.
Page 22 of 55
Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
Goals agreed with Commissioners
A proportion of Bolton NHS Foundation Trust income in 2013/14 was conditional on achieving
quality improvement and innovation goals agreed between the Trust and Bolton Clinical
Commissioning Group, through the Commissioning for Quality and Innovation payment
framework.
In 2013/14 Bolton NHS Foundation Trust achieved £3.9 million in CQUIN payments, against a
£4.4 million target. This was an improvement on the performance in 2012/13 when £2.3
million was achieved against a target of 4.6 million.
For further details of the agreed goals for 2013/14 and for the following 12 month period are
available electronically on our web site in the Board Report.
Performance against the 2013/14 CQUIN indicators is set out in the chart below;
Name
VTE prevention: risk assessment
CQUIN
VTE prevention: Quarterly target of RCA's to be completed is met
CQUIN
F&F test: Improve responsiveness to personal need of patientsphased expansion
CQUIN
F&F test: Improve responsiveness to personal need of patients increased response rate (A&E)
CQUIN
F&F test: Improve responsiveness to personal need of patients increased response rate (Inpatients)
CQUIN
Annual Target
>=95%
Year end
96.60%
100%
To roll out as
per national
timetable
Q4 response
is higher than
Q1 and 20 or
more
Q4 response
is higher than
Q1 and 20 or
more
100%
On plan
8.0%
25.3%
CQUIN
Improved
performance
or remaining
in top quartile
on the Staff
F&F test
Annual
staff
survey
Improved performance or remaining in top quartile on the Staff F&F
test (Inpatients)
CQUIN
Improved
performance
or remaining
in top quartile
on the Staff
F&F test
Annual
staff
survey
Dementia - screening
CQUIN
>=90%
91.3%
Dementia - risk assessment
CQUIN
>=90%
100%
Dementia - referral for specialist diagnosis
Clinical Leadership - named lead clinician for dementia and
appropriate training scheme for staff
Supporting Carers of people with Dementia - Monthly audit of carers
of people with dementia agreed with commissioners
Improve data collection - 3 consecutive quarterly submissions of
monthly survey data
CQUIN
>=90%
83.7%
CQUIN
Compliant
Named
CQUIN
Compliant
Compliant
CQUIN
Compliant
compliant
Improved performance or remaining in top quartile on the Staff F&F
test (A&E)
Page 23 of 55
Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
Name
Reduction in the prevalence of pressure ulcer - on a minimum of 6
consecutive monthly data points a max 6.6% prevalence
Advancing Quality - AMI (Appropriate Care Score) Apr 13-Mar 14
Advancing Quality - Heart Failure (Appropriate Care Score) Apr 13Mar 14
Advancing Quality - Hip & Knee (Appropriate Care Score) Apr 13-Mar
14
Advancing Quality - Pneumonia (Appropriate Care Score) Apr 13Mar 14
Advancing Quality - Stroke (Appropriate Care score) Apr 13-Mar 14
Annual Target
Year end
CQUIN
6.60%
3.0%
CQUIN
>=86.59%
99.5%
CQUIN
>=62.15%
73.1%
CQUIN
>=82.14%
93.3%
CQUIN
>=66.66%
72.9%
CQUIN
>=57.27%
70.1%
Commissioner assessment of providers achievement of 12 specific
actions
CQUIN
Compliant
Compliant
Monthly survey of all appropriate patients to collect data on four
medications safety issues which can result in harm
CQUIN
Compliant
Compliant
Reducing avoidable short stay <24 hour admissions
CQUIN
TBC
To carry out 2-3 Clinical Peer Reviews on areas of concern in relation
to transfers of care identified and agreed with commissioners
CQUIN
>=2
Compliant
Local protocol to be developed from Greater Manchester Hospital
Discharge (prevention of homelessness) protocol.
CQUIN
Compliant
Compliant
Reducing Alcohol Abuse:-Progress with action plan milestone
CQUIN
Compliant
Compliant
Reducing Alcohol Abuse:-Front line staff to undergone training
CQUIN
>=90%
Reducing Alcohol Abuse:-Patients to be screened
CQUIN
>=90%
Reducing Alcohol Abuse:-Appropriate patients to receive BIA
CQUIN
>=90%
Reducing Alcohol Abuse:-Increased number of referrals accepted by
the service
CQUIN
TBC
Compliant
All low weight babies (where appropriate) received timely TPN
CQUIN
>=95%
100%
Screening rate for retinopathy of prematurity
CQUIN
95%
100%
Timely data quality dashboard submission (Quarterly)
CQUIN
Compliant
Compliant
Carers of patients 75+ yrs with a LOS of 7+ days receive friends and
family test
CQUIN
Q2 &Q3
implement
data
implement
data
collection of
carer opinion.
Q4 increase in
carers
receiving
questionnaire.
Compliant
Achievement of stage 2 baby friendly accreditation
CQUIN
Compliant
Compliant
Evidence
submitted
CQUIN
To participate
in the Bolton
Health and
Social Care
Integration
work
Integration: To support the range of activities required to enable the
local health and social care economy to begin to fully achieve the
benefits of integration.
Page 24 of 55
Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
Name
Urgent Care: To support the local health economy to develop a new
model of care at the front end of A&E
CQUIN
Annual Target
To reduce in
appropriate
attendances
at A&E
Year end
Plan
submitted
End of Life Denominator: Number of pts identified as being in the
last 12 months of their life, who have died within the month, who
were on the GSF register, known to the District Nurse Service.
CQUIN
18
Compliant
End of Life Numerator: Number of pts identified as being in the last
12 months of their life, who have died within the month, who were
on the GSF register, known to the District Nurse Service and had an
ACP recorded. This information must be documented on the District
Nurse Supportive and palliative Care Register with the inclusion of
pts who have refused an ACP.
CQUIN
23
Compliant
End of Life - Denominator: Number of pts identified as being in the
last 12 months of their life, who have died within the month, who
were on the GSF register, known to the District Nurse Service and
had an ACP initiated.
CQUIN
23
Compliant
End of Life - Numerator: Number of pts identified as being in the
last 12 months of their life, who have died within the month, who
were on the GSF register, known to the District Nurse Service and
had an ACP initiated, who died within their preferred place of death
where this is recorded using the Advanced Care Plan.
CQUIN
5
Compliant
2014/15 CQUIN Goals
GM
Local
National
CQUIN
Indicator Name
Friends and Family Test – Implementation of staff FFT - NHS Trusts Only
Friends and Family Test - Early Implementation
Friends and Family Test -Phased expansion
Friends and Family Test - Increased or maintained Response Rate in Acute
Providers
Friends and Family Test - Reduction in Negative Responses in Acute Providers
Staff Friends and Family Test - Reduction in Negative Responses
NHS Safety Thermometer - Improvement Goal Specification
Dementia - Find, Assess, Investigate and Refer
Dementia - Clinical Leadership
Dementia - Supporting Carers of People with Dementia
Baby Friendly Accreditation
Provision of consultant clinician time to support virtual clinics
Patient Experience
Gastroscopy
Alcohol
Lessons Learned Once
Ambulatory Care
Clinical Effectiveness Community
Clinical Effectiveness Acute
Improving Learning Disability Patient User Experiences and Support
Indicator
Weighting
1.5%
1.5%
1.5%
1.0%
2.0%
1.50%
5.00%
3.00%
1.50%
1.50%
1.50%
25.00%
5.00%
10.00%
3.50%
5.00%
5.00%
5.00%
5.00%
5.00%
Page 25 of 55
Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
Care Quality Commission Registration
The Care Quality Commission (CQC) is the independent regulator of health and adult social care
services in England. This means that as well as checking individual services, they look at how
well the two sectors work together. There are many people who need to use both health and
social care services and it is important that their care is as ‘joined up’ as possible.
The CQC do this by:

Driving improvement across health and social care.

Putting people first and championing their rights.

Acting swiftly to remedy bad practice.

Gathering and using knowledge and expertise, and working.
The CQC registration system for health and adult social care aims to ensure that people can
expect services to meet essential standards of quality and safety that respect their dignity and
protect their rights.
If the CQC has concerns that a provider is not meeting essential standards of quality and safety,
they aim to act quickly, working closely with commissioners and others, and using their
enforcement powers.
The Trust is required to register with the Care Quality Commission and its current registration
status is registered without conditions. The Care Quality Commission has not taken
enforcement action against the Trust during 2013/14.
There are 16 standards of essential quality and safety and cover the following areas:

Respecting and involving people who use service

Consent to care and treatment

Care and welfare of services users

Meeting nutritional needs

Cooperating with other providers

Safeguarding people from abuse

Cleanliness and infection control

Management of medicines

Safety and suitability of premises

Safety, availability and suitability of equipment

Requirements relating to workers

Staffing

Supporting workers

Assessing and monitoring the quality of service provision

Complaints

Records
Page 26 of 55
Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
In April 2014 the CQC inspected Bolton NHS Foundation Trust in relation to the following
essential standards. This was in response to concerns that standards were not being met. The
results of the inspection are detailed in the table below:
Outcome Description
CQC Judgement
Care and Welfare of people who use services
Compliant
Safeguarding people who use services from Compliant
abuse
Cleanliness and infection control
Action Needed
Staffing
Action Needed
Assessing and monitoring the quality of
service provision
Action Needed
Following this inspection action plans were submitted to the CQC in relation to the areas
highlighted as not meeting the Essential Standards. A follow up inspection in relation the three
outstanding areas was conducted in September 2013 and covered the areas identified in the
chart below. On reassessment of the standard and the actions put in place the Trust was found
compliant in all areas with no remedial actions required.
Outcome Description
CQC Judgement
Cleanliness and infection control
Compliant
Staffing
Compliant
Assessing and monitoring the quality of
service provision
Compliant
The CQC Team observed how people were being cared for. They also reviewed records of
people who use our services and obtained feedback from people who use our services.
Their overall judgement was that the Trust was meeting all the essential standards of quality
and safety inspected.
Data Quality
The Trust submitted records during 2013/14 to the Secondary Uses service for inclusion in the
Hospital Episode Statistics which are included in the latest published data.
The percentage of records in the published data:
Page 27 of 55
Quality Report
Bolton NHS Foundation Trust
Statements of assurance from the board
— which included the patient’s valid NHS number was:

99.8% for admitted patient care;

99.9% for outpatient care; and

99.1% for accident and emergency care.
— which included the patient’s valid General Medical Practice Code was:

100% for admitted patient care;

100% for outpatient care; and

100% for accident and emergency care
PwC have recently conducted a data quality audit covering 5 main key performance indicators:
18 week wait for Inpatient Treatments

A&E 4 hour Target

Stroke patients spending 90% of time on a Stroke Unit

Patients waiting over 52 weeks for treatment

Two week wait target for urgent GP cancer referrals.
Whilst we are still awaiting the final reports, it is clear from feedback given that the reporting
systems in place are adequate and that the reported performance indicators are assessed as
reliable.
The Trust will be taking the following actions to improve data quality
Any errors highlighted will be investigated further and the Trust will determine the reasons for
these and where appropriate provide further training for staff.
Information Governance
The Trust Information Governance Assessment Report overall score for 2013/14 was 68% and
was graded green
Clinical Coding Audit
The Trust was not subject to the Payment by Results clinical coding audit during 2013/14 by the
Audit Commission.
Page 28 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Since 2012/13 NHS foundation trusts have been required to report performance against a core
set of indicators using data made available to the trust by the Health and Social Care
Information Centre (HSCIC).
Mortality
The value and banding of the summary hospital-level mortality indicator (“SHMI”) for the trust
for the reporting period
Bolton
National Average
Lowest
Highest
Oct 11 - Sept Oct 12 - Sept
12
13
1.006
1.078
1.000
1.000
0.685
0.630
1.2107
1.186
We consider that this data is as described for the following reasons:
The data has been obtained from the Health & Social Care Information Centre (HSCIC)
The Trust has planned the following actions to improve this indicator and so the quality of its
services, by:

Monthly mortality meeting chaired by the Medical Director

Implementation of level one facilities for monitoring patients within ward areas

Increase intensive care consultants within critical care

External critical care outreach.
Page 29 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Palliative care coding
The percentage of patient deaths with palliative care coded at either diagnosis or specialty level
for the trust for the reporting period.
%
Q2
11/12
Q3
11/12
Q4
11/12
Q1
12/13
Q2
12/13
Q3
12/13
Q4
12/13
Q1
13/14
Q2
13/14
Q3
13/14
Q4
13/14
Bolton
National
Average
16.5% 16.8% 17.2% 17.4% 18.9% 19.0% 19.7% 20.3% 19.9% 19.9% 21.0%
Lowest
0.1%
Highest
38.9% 40.1% 41.6% 41.7% 44.2% 46.3% 43.3% 42.7% 44.0% 44.1% 44.9%
16.7% 16.1% 16.6% 17.3% 18.1% 18.6% 19.2% 19.5% 20.4% 20.6% 21.3%
0.1%
0.0%
0.0%
0.0%
0.3%
0.2%
0.1%
0.1%
0.0%
0.0%
We consider that this data is as described for the following reasons:
The data has been obtained from the Health & Social Care Information Centre (HSCIC)
The Trust has taken the following actions to improve this indicator and so the quality of its
services, by:

Work has commenced to develop an End of Life Care strategy following g the withdrawal of
the Liverpool Care Pathway

Regular updates on End of Life Care are provided to the Quality Assurance Committee
Page 30 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Patient reported outcome measures
Groin hernia surgery
Overall Score
Apr 11 - March 12
Apr 12 - March 13
Apr 13 - Dec 13
Bolton
46.3%
35.2%
50.0%
National Average 51.0%
50.2%
50.7%
Lowest
14.3%
5.0%
14.3%
Highest
80.0%
84.2%
100.0%
Varicose vein surgery
Overall Score
Bolton
National Average
Lowest
Highest
Apr 11 - March 12
56.4%
53.6%
13.3%
100.0%
Apr 12 - March 13
30.8%
52.8%
23.5%
85.7%
Apr 13 - Dec 13
46.2%
52.8%
14.3%
88.9%
We consider that this data is as described for the following reasons:
The data has been obtained from the Health & Social Care Information Centre (HSCIC)
The Trust has taken the following actions to improve this indicator and so the quality of its
services, by:

Centralisation of pre-operative services to standardise information received,

In the event of telephone pre-op develop process for identifying and capturing patients on
the day of surgery,

Awareness campaign commenced February 2013
Page 31 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Patient reported outcome measures
Hip replacement surgery
Apr 11 - March
12
81.1%
87.5%
66.7%
100.0%
Overall Score
Bolton
National Average
Lowest
Highest
Apr 12 - March
13
85.9%
88.3%
37.6%
100.0%
Apr 13 - Dec 13
86.2%
89.1%
70.6%
100.0%
Knee replacement surgery
Overall Score
Apr 11 - March 12 Apr 12 - March 13 Apr 13 - Dec 13
Bolton
72.3%
77.1%
80.0%
National Average 78.8%
80.0%
81.8%
Lowest
53.9%
36.4%
35.7%
Highest
100.0%
100.0%
100.0%
We consider that this data is as described for the following reasons:
The data has been obtained from the Health & Social Care Information Centre (HSCIC)
The Trust has taken the following actions to improve this indicator and so the quality of its
services, by:

Work has commenced with the CCG in relation to thresholds for surgery

Continue to adhere to implant best practice
Page 32 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Readmissions within 28 days
The percentage of patients readmitted to hospital within 28 days of being discharged during
the reporting period.
Aged 0 to 15
Readmission
%
2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12
Bolton
National
Average
Lowest
8.66
10.00
14.29
13.25
14.39
13.29
13.37
14.02
13.78
12.82
9.54
9.63
9.78
9.64
9.78
9.72
9.44
9.52
9.32
9.50
5.87
5.97
6.18
5.92
5.93
4.95
5.10
6.33
5.87
5.10
Highest
13.83
13.58
15.80
18.49
14.99
18.61
17.34
14.20
13.78
13.58
Emergency Readmissions to Hospital Within 28 Days of Discharge:, 0-15 Years
Readmission %
20.00
15.00
Bolton
10.00
National Average
Lowest
5.00
Highest
0.00
Aged 16 or over
Readmission
%
2002/03
2003/04
2004/05
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
Bolton
National
Average
9.42
9.51
10.60
10.39
10.86
10.95
10.24
9.74
10.17
10.04
8.65
9.11
9.83
10.17
10.36
10.50
10.73
10.97
11.08
11.20
Lowest
6.30
7.14
7.47
8.42
7.82
8.07
7.92
7.34
7.68
8.96
Highest
11.01
11.84
13.74
12.56
12.99
13.32
13.08
13.30
13.00
13.50
Page 33 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Readmission %
Emergency Readmissions to Hospital Within 28 Days of Discharge: 16+ Years
16
14
12
10
8
6
4
2
0
Bolton
National Average
Lowest
Highest
We consider that this data is as described for the following reasons:
The data has been obtained from the Health & Social Care Information Centre (HSCIC)
The data shows the Trust to have a higher than average readmission rate for the 0 - 15 group,
we are reviewing our performance in this area but early indicators are that this reflects our
position as a regional neo natal centre and our practice of admitting ward reattenders.
Performance against this metric will be reviewed by the QA Committee.
The Trust has taken the following actions to improve this indicator and so the quality of its
services, by:

Established a clinically led readmission group

Working collaboratively with the CCG to carry out a follow up audit to determine causes

Further work is on-going around risk stratification of high risk patients with long term
conditions.
Page 34 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Responsiveness to patients’ personal needs
The trust’s responsiveness to the personal needs of its patients during the reporting period.-as
reported in the annual inpatient survey
Overall Score
Bolton
National Average
Lowest
Highest
2010/11
74.7
75.7
68.2
87.3
2011/12
77.6
75.6
67.4
87.8
2012/13
77.6
76.5
68
88.2
2013/14
79.5
76.9
67.1
87
Overall % Score
Responsiveness to Personal Needs of Patients
- Inpatient Survey
100
95
90
85
80
75
70
65
60
55
50
Bolton
National Average
Lowest
Highest
2010/11
2011/12
2012/13
2013/14
We consider that this data is as described for the following reasons:
The methodology follows exactly the detailed guidelines determined by the Survey Coordination Centre for the overall National Inpatient Survey programme.
The survey required a sample of 850 inpatients to be drawn from those patients being
discharged during June, July, or August 2013 who had had a stay of at least one night in
hospital. There were a number of categories of patients excluded from the survey e.g.
psychiatric patients and maternity patients.
The target response rate for the survey set nationally was to achieve at least 60% from the
usable sample, and the number of usable responses should be at least 500.
342 completed questionnaires were returned from the sample of 850 from Bolton NHS
Foundation Trust. A group of 37 patients were excluded from the sample for the following
reasons:

Moved / not known at this address 18

Deceased 19
The final response rate for the Trust was 42% (342 usable responses from a final sample of
813).
The Trust has planned the following actions to improve this indicator and so the quality of its
services, by:
Page 35 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators

Look at why some patients are saying there are high levels of noise from other patients. If
necessary, measure noise levels to ensure that staff are aware of actual levels and can take
action where needed.

Review provision and clarity of information that is given to patients about the medication
side-effects to watch for and what to do if they are worried.

Review the extent to which clinical staff provide the patient's family with adequate
information about caring for the patient.

Ensure that there are robust arrangements in place to provide patients with copies of
letters between clinical teams and the patient's GP, if this is what the patient wants.

Look for ways to improve patient feedback, as many patients would like to be asked about
their views on the quality of their care.

Ensure that information about how to complain (such as leaflets and posters) are available
for patients in hospital; staff are up to date on complaints procedures and able to explain
and easily communicate this to patients.

Triangulate the organisation’s staff and patient survey data with that from the CQC inpatient survey, which gives a more accurate method of identifying patient concerns. Data
from other surveys including the Friends and Family test can also be used to give a clearer
picture of patients’ concerns.
Page 36 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Family and friends
Staff
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.1
Overall Score
Bolton
National Average
Lowest
Highest
2012
56
65
35
86
2013
58
67
40
89
We recognise that our result in this area is below the national average. At the time of the staff
survey in October 2014 when this survey was conducted the organisation was in turnaround
with a significant impact on staff morale.
Inpatients
The number of patients who having been inpatients would recommend the Trust to their family
and friends. The Friends and Family test was formally introduced in April 2014, therefore prior
year comparator figures are not available
Overall Score
Bolton
National Average
Lowest
Highest
Apr13
78
71
35
95
May
-13
77
72
41
100
Jun13
78
72
43
100
Jul13
73
71
39
100
Aug13
79
72
45
97
Sep13
78
72
45
97
Oct13
76
73
41
96
Nov13
79
73
41
97
Dec13
79
72
37
100
Jan14
80
73
27
97
Feb14
84
72
18
94
Mar14
79
73
28
96
inpatients who would recommend the trust to friends or family
120
Overall Score
100
80
Bolton
60
National Average
40
Lowest
20
Highest
0
1
In last year’s Quality Account this figure was provided using different metrics, for comparative purposes we would advise
using the prior year figure included in this report.
Page 37 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Accident and Emergency
Overall Score
Bolton
National
Average
Lowest
Highest
Apr13
74
May13
71
Jun13
63
Jul13
57
Aug13
59
Sep13
67
Oct13
62
Nov13
75
Dec13
61
Jan14
59
Feb14
49
Mar14
44
49
0
100
55
0
94
54
4
100
54
0
91
56
6
85
53
0
89
56
12
93
56
9
92
57
10
96
57
0
92
55
0
90
54
1
90
Patients would recommend the trust to friends or family (A&E)
120
Overall Score
100
80
Bolton
60
National Average
40
Lowest
20
Highest
0
We consider that the friends and family data is as described for the following reasons:
The data has been obtained from the Health & Social Care Information Centre (HSCIC)
The Trust has taken the following actions to improve this indicator and so the quality of its
services, by:

Invested in alternative ways that patients could provide feedback. A text method service
has been introduced to increase the response rate.

Inpatient areas now receive monthly feedback of individual performance and comments

Comments are now displayed within ward areas

Development of Exemplar Star Status (ESSA)

Promotion of staff awards and staff recognition schemes to improve staff morale and
motivation.
Page 38 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Risk assessment for VTE
The percentage of patients who were admitted to hospital and who were risk assessed for
venous thromboembolism during the reporting period.
Overall %
Bolton
National
Average
Lowest
Highest
Apr13
May13
Jun13
Jul13
Aug13
Sep13
Oct13
Nov13
Dec13
Jan14
Feb14
Mar14
96.5
96.9
96.0
97.2
96.6
95.7
95.3
96.0
96.7
95.9
96.5
96.4
95.1
95.5
95.7
96.1
95.8
95.6
95.9
95.9
95.6
96.1
96.0
79.0
78.6
78.8
80.1
80.1
83.1
80.1
70.5
70.8
74.6
77.0
100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0
We consider that this data is as described for the following reasons:
The data has been obtained from the Health & Social Care Information Centre (HSCIC)
We have routinely reported performance in excess of 95% because we have processes in place
to risk assess all appropriate patients on admission. We have undertaken an audit of the case
notes on discharge of the patient from hospital. The results of the audits are the figures
reported monthly to the Trust Board and externally.
The Trust intends to take the following actions to improve this indicator and so the quality of its
services, by:

Using real-time capture of the data on admission to and throughout the stay rather than at
discharge only in relation to the percentage of patients that are risk assessed which we
believe to be routinely in excess of 95%.
Page 39 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Clostridium difficile
The rate per 100,000 bed days of cases of C.difficile infection reported within the trust amongst
patients aged 2 or over during the reporting period. (figures for highest and lowest are not
available)
Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13 Q1 13/14 Q2 13/14 Q3 13/14 Q4 13/14
Bolton
47.04
7.47
29.62
28.79
26.49
17.67
7.62
17.10
National
18.07
17.68
16.91
17.76
17.14
15.60
15.05
14.41
We consider that this data is as described for the following reasons:
The data has been obtained from the Health Protection Agency (HPA)
The Trust has taken the following actions to improve this indicator and so the quality of its
services, by:

Introduction of a deep cleaning programme

Handwashing basins now outside all ward areas

Weekly strategic meetings to discuss all cases

Improved scrutiny of antibiotic management

Investment in estate

Collaborative working across the health economy

Investment in the infection control and prevention team

Clear guidance and policy

External peer review
Page 40 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Patient safety incidents
The number and, rate of patient safety incidents reported within the trust during the reporting
period, and the number and percentage of such patient safety incidents that resulted in severe
harm or death.
Number and rate of Incidents
Number of incidents
Bolton
National Average
Lowest
Highest
Oct11-Mar12
1369
2454
745
4459
Apr12-Sep12
2260
2603
843
4552
Oct12-Mar13
2600
2871
631
5272
Apr13 - Sep13
2793
2896
1535
4888
Medium Acute organisations - Organisational incident data
Number of incidents
Number of incidents
6000
5000
4000
Bolton
3000
National Average
2000
Lowest
1000
Highest
0
Oct11-Mar12 Apr12-Sep12 Oct12-Mar13 Apr13 - Sep13
Rate per 100 admissions
Bolton
National Average
Lowest
Highest
Oct11-Mar12
3.56
6.56
2.21
10.54
Apr12-Sep12
5.49
6.87
3.11
14.44
Oct12-Mar13
6.32
7.59
1.68
16.73
Apr13 - Sep13
6.26
7.47
3.54
14.49
Rate per 100 admissions
Medium Acute organisations - Organisational incident data
Rate per 100 admissions
20.00
15.00
Bolton
National Average
10.00
Lowest
5.00
Highest
0.00
Oct11-Mar12 Apr12-Sep12 Oct12-Mar13 Apr13 - Sep13
Page 41 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Number and rate of incidents resulting in severe harm
Degree of harm - Severe
Bolton
National Average
Lowest
Highest
Oct11-Mar12
7
15
1
80
Apr12-Sep12
10
15
0
61
Oct12-Mar13
5
13
1
50
Apr13 - Sep13
25
14
0
69
Medium Acute organisations - Organisational incident data
Number of incidents - Severe
Number of incidents
100
80
Bolton
60
National Average
40
Lowest
20
Highest
0
Oct11-Mar12 Apr12-Sep12 Oct12-Mar13 Apr13 - Sep13
% Degree of harm Severe
Bolton
National Average
Lowest
Highest
Oct11-Mar12
Apr12-Sep12
Oct12-Mar13
Apr13 - Sep13
0.50
0.66
0.00
3.00
0.40
0.62
0.00
3.10
0.19
0.50
0.03
1.74
0.90
0.48
0.00
2.02
Medium Acute organisations - Organisational incident data
% - Severe Harm
3.50
3.00
%
2.50
Bolton
2.00
National Average
1.50
Lowest
1.00
Highest
0.50
0.00
Oct11-Mar12 Apr12-Sep12 Oct12-Mar13 Apr13 - Sep13
Page 42 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Number and rate of incidents resulting in death
Degree of harm - Death
Bolton
National Average
Lowest
Highest
Oct11-Mar12
1
4
0
14
Apr12-Sep12
0
5
0
34
Oct12-Mar13
4
5
0
32
Apr13 - Sep13
1
6
0
37
Number of incidents
Medium Acute organisations - Organisational incident data
Number of incidents - Death
40
35
30
25
20
15
10
5
0
Bolton
National Average
Lowest
Highest
Oct11-Mar12
% Degree of harm Death
Bolton
National Average
Lowest
Highest
Apr12-Sep12
Oct12-Mar13 Apr13 - Sep13
Oct11-Mar12
Apr12-Sep12
Oct12-Mar13
Apr13 - Sep13
0.10
0.18
0.00
0.60
0.00
0.20
0.00
1.30
0.20
0.24
0.00
3.01
0.04
0.20
0.00
1.08
Medium Acute organisations - Organisational incident data
% - Death
3.50
3.00
%
2.50
Bolton
2.00
National Average
1.50
Lowest
1.00
Highest
0.50
0.00
Oct11-Mar12 Apr12-Sep12 Oct12-Mar13 Apr13 - Sep13
Page 43 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Incidents/ SUI/ Never Events
We aim to increase the number of reported incidents whilst reducing harm associated with these.
2013-14 Data
Total number of New
SUIs received within
the month
Total Incidents
reported on Safeguard
Total number of
patient incidents
Total number of
patient incidents
reported per 100
admissions
Patient incidents that
resulted in severe
harm or death %
Total number of
medication incidents
Medication incidents
that resulted in severe
harm or death %
Apr12
May12
Jun12
Jul12
Aug12
Sep12
Oct12
Nov12
Dec12
Jan13
Feb13
Mar13
Total /
Average
3
2
0
1
2
3
2
0
0
0
1
0
14
756
693
662
753
706
727
773
792
712
766
723
786
8849
668
589
582
614
602
644
672
682
612
636
586
675
7562
9.4
8.4
8.8
8.6
8.9
9
9
10
9
9
9
8
106.98
0.9%
0.8%
1.2%
0.2%
0.7%
1.1%
1.1%
0.1%
0.9%
0.1%
0.3%
0.1%
0.6%
74
75
51
66
66
75
71
78
65
78
71
91
861
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0%
The figures reported above include one never event, this event which has been investigated on
and reported through the appropriate channels was classed as wrong site surgery. In 2012/13
we reported two never events both relating to retained swabs.
We consider that this data is as described for the following reasons:
The data has been obtained from the National Patient Safety Agency (NPSA)
The Trust has taken the following actions to improve this indicator and so the quality of its
services, by:

Introduction of new risk management strategy

Risk management training for clinical risk managers

New risk management committee established

Introduction of “harms” meeting to review incidents and ensure appropriate actions are
taken

External training programme for managers to undertake RCA training

Review of the current electronic
conclusion can be logged
incident reporting system to ensure investigation
Page 44 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
Post 48 hour MRSA Bacteraemia
We had reported two cases of post 48 hour MRSA bacteraemia in 2013/14 compared to five in
the previous year.
Indicator
Bolton
National
Lowest
Highest
Q1 12/13
1
1
0
16
Q2 12/13
2
1
0
9
Q3 12/13
0
1
0
7
Q4 12/13
2
2
0
7
Q1 13/14
0
1
0
5
Q2 13/14
0
1
0
4
Q3 13/14
1
1
0
5
Q4 13/14
1
1
0
6
MRSA - post-48 hour cases per quarter
18
16
Number of cases
14
12
Bolton
10
National
8
Lowest
6
Highest
4
2
0
Q1 12/13 Q2 12/13 Q3 12/13 Q4 12/13 Q1 13/14 Q2 13/14 Q3 13/14 Q4 13/14
We aim to continue this improvement through our infection control processes including
proactive screening of all elective patients for MRSA
Page 45 of 55
Quality Report
Bolton NHS Foundation Trust
Reporting against core indicators
PART THREE
Page 46 of 55
Quality Report
Bolton NHS Foundation Trust
Performance in 2013/14
How we performed on Quality and performance in 2013/14
This section indicates how some of the Quality Initiatives were progressed during 2013/14. The
indicators included were selected by the Board in consultation with the Council of Governors
and other stakeholders. Where these indicators have changed from these selected in 2012/13
this is reflects feedback from our stakeholders however we continue to monitor all previous
Quality Account indicators through our integrated performance report.
All of our data is benchmarked nationally using CHKS Methodology, in addition to this we see
assurance on the accuracy of our data quality through an annual report on non-financial data
from our internal auditors, a review of metrics included in this report performed as part of the
audit conducted by our external auditors and other external audit reports as appropriate.
For Patient Safety
o Reduction of pressure ulcers - page 13
o Reduction of clostridium difficile infection page 12
o Reducing patient falls page 15
For Effectiveness
o 62 day cancer waits – page 48
o Implementation of the ESSA framework - page 49
o Readmissions - page 33
For Patient Experience
o Patient experience feedback – the Friends and Family test page 37
o National inpatient survey responsiveness to patient needs page 35
o Complaints and concerns - page 51
Earlier in this report we set out our priorities for the coming year. These were agreed following
consultation with stakeholders who were keen to see us continue work on some of the
priorities agreed in the previous year.
Where these priorities are discussed elsewhere in the report we will refer to that data to avoid
repetition.
Page 47 of 55
Quality Report
Bolton NHS Foundation Trust
Performance in 2013/14
62 day cancer performance
The year-end 62 day cancer performance for the Trust is 86.7%. This figure is in line with
Greater Manchester and Cheshire Cancer Network agreed policy for the reallocation of
breaches to the referring Trust when it fails to refer the patient to the receiving Trust within the
agreed time frame. The performance shows that the Trust exceeded the 85% target for
patients with a diagnosis of cancer, to be treated within 62 days of their urgent GP referral for
suspected cancer.
%
performance
% quarterly
Apr
87.7
May
84.4
89.0
Jun
95.3
62 Day Reallocated RTT Performance
2013/14
Jul
Aug
Sep
Oct
Nov
Dec
85.3 95.1 86.0 88.6 84.1 81.2
86.8
Jan
84.4
84.3
Feb
85.4
Mar
85.7
85.2
Notes: The figure for May includes an additional breach identified as a result of the recent audit
by KPMG this figure is therefore different from previously reported.
62 Day (Urgent GP Referral to Treatment) waits for first treatment: All Cancers
There are a number of indicators where the Trust is benchmarked against other organisations –
this includes:
62 Day wait for first treatment – all cancers (provider data)
62 Day wait for first treatment – by cancer (provider data)
62 Day wait for first treatment from consultant upgrade – all cancers (provider data)
62 Day wait for first treatment from screening service referral – all cancers (provider data)
The data has been used from the following reports
http://transparency.dh.gov.uk/category/statistics/provider-waiting-cancer/
Page 48 of 55
Quality Report
Bolton NHS Foundation Trust
Performance in 2013/14
Implementation of the ESSA performance framework
During the final Quarter of 2014 the Exemplar Star System of Accreditation performance
framework was introduced in relation to providing assurance that wards were meeting the
expectations in relation to standards of care.
This system builds on the previous work undertaken through Exemplar and builds on this to
produce a systematic framework of performance management, which includes:

ESSA

ESSA practice Review Process

Matron and Ward Manager KPI Framework

Weekly KPI Monitoring proforma

SOP Ward Manager Supervisory Role
Exemplar Star System of Accreditation (ESSA)
The ESSA is a set of 13 standards against which a ward/ Department or community service is
measured against in relation to Quality and Safety. The standards are assessed by the following
methods;

Observation

Conversation with Staff and Patients

Examination of clinical records

Analysis of Complaints, Incidents, Safeguarding, infection control, appraisal, mandatory
training.
A star accreditation will be awarded to each area following assessment. Only when standards
of Quality and Safety have been maintained may an area apply for Exemplar status. A portfolio
of evidence will be presented to an executive panel that will then put the area forward, if
agreed by the panel, to the Trust Board to agree the Exemplar accreditation.
ESSA Practice review process
Currently if areas are under performing there is no systematic review process undertaken to
ensure improvement is made. The practice review process identifies a framework for reviewing
areas identified that need additional support.
It will assist the divisions in having a clear process in place to enable them to report back in a
consistent manor on improvements being made in challenging areas.
Matron/ Ward Manger KPI Framework
Clarity in roles and responsibilities is important to ensure clarity in relation to the priorities and
expectations of divisional and corporate teams.
Page 49 of 55
Quality Report
Bolton NHS Foundation Trust
Performance in 2013/14
This framework is aligned to the Trusts strategic aims and will be utilised to set clear objectives
and priorities for both the ward managers and matrons. It refers to both operational priorities
and quality and safety priorities ensuring that there is a balance between the two.
This tool will be used to set individual targets through both 1:1 meetings with the Professional
Leads or yearly objective setting and appraisal.
Weekly KPI Monitoring
It is proposed that this replaces the current system used in relation to the North West Care
Indicators. The monitoring will be undertaken on a Friday of each week and will be completed
for each appropriate patient. This will increase the assurance in relation to these KPI being met
and enable areas to be identified and actioned quickly should under performance be noted.
Standard Operating Procedure (SOP) Ward Manager Supervisory Role
In June 2013 Trust Board agreed with the decision to ensure the supervisory nature of the Ward
Manager role. The SOP identifies the key components of this role, to ensure that ward
management, role modelling, support and development occur through the investment in this
role.
Together these 5 components working together will provide a robust performance
management framework to ensure the delivery of safe and effective care across our wards,
departments and community.
Page 50 of 55
Quality Report
Bolton NHS Foundation Trust
Performance in 2013/14
Complaints and Concerns
The Trust has a Complaint Policy and Process which includes the management of informal
concerns and PALS contacts.
The number of recorded complaints on the annual KO41 Department of Health and reported in
the annual complaints report in 2013/14 is represented in the charts below.
By service Area
Hospital Acute Services: Inpatient
Total number of
written complaints
received
212
Total number of
written complaints
upheld
113
Hospital Acute Services: Outpatient
220
101
Hospital Acute Services: A&E
58
15
Elderly (Geriatric) Services
2
1
Mental Health Services
0
0
Maternity Services
46
19
Ambulance Services
2
2
Community Hospital Services
0
0
NHS Direct
0
0
Walk-In Centres
0
0
Other Community Health Services
12
4
CCG Commissioning
3
1
Other
9
6
TOTAL
By professional group
564
262
Medical and dental(including surgical)
311
117
Allied Health Professionals
17
7
Nursing, Midwifery and Health Visiting
154
95
Scientific, Technical and Professional
9
6
Ambulance crews (including paramedics)
0
0
Maintenance and Ancillary staff
CCG Administrative staff / members (exc
GP admin)
1
1
0
0
Trust Administrative staff / members
45
29
Other
TOTAL
18
7
564
262
Page 51 of 55
Quality Report
Bolton NHS Foundation Trust
Performance in 2013/14
Complaints by cause
Total number of
written complaints
received
Total number of
written complaints
upheld
31
21
6
3
61
39
3
1
88
40
303
121
43
25
3
2
2
0
11
5
7
4
Patient's status, discrimination
2
0
Transport (ambulances and other)
1
1
Hotel services (including food)
1
0
Other
2
0
TOTAL
564
262
Admissions, discharge and transfer
arrangements
Aids and appliances, equipment, premises
(including access)
Appointments, delay / cancellation
(outpatient)
Appointments, delay / cancellation
(inpatient)
Attitude of staff
All aspects of clinical treatment
Communication / information to patients
(written and oral)
Patients privacy and dignity
Patients property and expenses
Personal records (including medical and / or
complaints)
Failure to follow agreed procedures
Complaints have increased by 32% from 2012/13. This may be due to the review of complaints
procedures that took place in June 2013 leading to changes to our validation process. One of
the changes within this review was a change in the categorisation of PALS contacts and
complaints.
The Annual Complaints Record published under Regulation 18 of the Local Authority Social
Service and NHS Complaints Regulations 2009 provides more detailed analyses of these
complaints with a Qualitative and Quantitative analyses. This has been taken into
consideration in the preparation of this Quality Account and in setting Quality Priorities going
forward.
We believe that by listening and acting on feedback provided we can reduce the number of
complaints we receive. This will be achieved by learning from concerns and by getting the
patient experience right.
Page 52 of 55
Quality Report
Bolton NHS Foundation Trust
Performance in 2013/14
Achievement against the Monitor Risk Assessment Framework 2013/14
Indicator
Year-end
position
Target
Achieved
Referral to Waiting Times - Admitted
94.8%
90%
Yes
Referral to Waiting Times - Non Admitted
96.6%
95%
Yes
Referral to Waiting Times - incomplete
96.3%
92%
Yes
Maximum waiting time of four hours in A&E from arrival
to admission, transfer or discharge
96.5%
95%
Yes
86.7%
85%
Yes
93.0%
90%
Yes
Maximum waiting time of 31 days from diagnosis to
treatment of all cancers - surgery
99.3%
94%
Yes
Maximum waiting time of 31 days from diagnosis to
treatment of all cancers – anti cancer drug treatments
100.0%
98%
Yes
All cancers 31-day wait from diagnosis to first treatment
99.0%
96%
Yes
Cancer: two week wait from referral to first seen, all
cancers
94.9%
93%
Yes
Cancer: two week wait from referral to first seen,
symptomatic breast patients (cancer not initially
suspected)
96.2%
93%
Yes
38
28
No
Certification against compliance with requirements
regarding access to health care for people with a learning
disability
100%
100%
Yes
Data completeness community service referral to
treatment
99%
50%
Yes
Data completeness community services - referral
information
100%
50%
Yes
Data completeness: community services - treatment
activity information
100%
50%
Yes
Maximum waiting time of 62 days from urgent referral to
treatment for all cancers - from urgent GP referral to
treatment
Maximum waiting time of 62 days from urgent referral to
treatment for all cancers - from consultant screening
service referral
Clostridium difficile - meeting the C. difficile objective
Page 53 of 55
Quality Report
Bolton NHS Foundation Trust
Stakeholder Statements
Foundation Trust Governors
As Foundation Trust Governors we have worked closely with the Directors of the Trust and will
continue to do so during 2014/15.
We welcome the publication of the Quality Report and congratulate the Trust on the results
achieved particularly with regard to the four hour Accident and Emergency target, the
reduction in the number of cases of C Difficile and the implementation of the policies to reduce
harm from pressure ulcers and falls which are starting to show results.
We hope that the same effort and determination will continue in 2014/15 and look forward to
continuing to support the Trust in the coming year
Bolton NHS Foundation Trust Council of Governors
April 2014
Overview and Scrutiny Committee
On behalf of the Health Overview and Adult Social Care Scrutiny Committee I welcome the
opportunity to comment on the quality account for 2013/2014.
The Account is comprehensive in its coverage of the services and aspirations of the Trust. It is
good to see that the Trust is listening and learning from the service users and determined to
deliver an improved and accessible service.
The Quality Account describes the efforts to ensure that the delivering of high quality, patientcentred care remains central.
The Account provides a quality summary of achievements made and the work required to take
the priorities forward in 2014/2015.
Councillor A N Spencer Chairman 2013 /2014
May 2014
Page 54 of 55
Quality Report
Bolton NHS Foundation Trust
Stakeholder Statements
Bolton CCG
We have worked closely with Bolton FT throughout 2013/14 to gain assurances that the
services they delivered were safe, effective and personalised to service users. The CCG shares
the fundamental aims of the FT and supports their strategy to deliver high quality, harm free
care. We also note the development of an integrated performance report which provides
accurate quality assurance to the FTs Board.
We acknowledge the significant reduction in patients acquiring CDT and welcome the FT’s
contribution to the health economy in reducing infection rates. In spite of this year’s target
allowing for more cases, we expect that initiatives implemented to date will enable the FT to
both sustain and improve on the progress made last year.
We note the development of strategies for pressure ulcer care and falls and note that
improvements in both these areas have been achieved already. We have welcomed the
opportunity to join the FTs Harm Free Care Panels and the opportunity this has created to work
together to reduce harm across all health and social care sectors.
We have been disappointed with the response rates from the Friends and Family Tests,
particularly in A&E and Maternity. Although the scores have been generally positive we would
like to see a more ambitious increase in response rates than indicated in this report. We do
however note the other initiatives that are taking place to obtain real time patient feedback, in
line with the FTs Patient Experience Strategy.
We acknowledge the FTs adherence to the new reporting requirements for this year’s Account
and the actions described to improve the quality of services. We are pleased that the
information presented is consistent with information provided to the CCG throughout the year.
We are pleased to note the FTs 100% adherence to eligible National Clinical Audits and
Confidential Enquiries, providing evidence that the FT is committed to benchmarking its
performance against standards. We note the examples provided and would like to see further
examples of how these results have been translated in to improved outcomes for patients.
We are pleased to note the improvements made in the number of incidents reported as this
indicates an improving safety culture within the FT. We would like to see a further increase in
the numbers of ‘no harm’ incidents and ‘near misses’ reported and a sustained reduction in
severe harm incidents in line with the FTs new Risk Management Strategy. The CCG expected
to see reference to the Never Event that occurred within 13/14 and a focus on the quality
improvements that resulted from the investigation.
This Account indicates the FTs commitment to improving the quality of the services it provides.
We agree with the key priorities for improvement in 2014/15 but would like to see a greater
focus on community services and associated quality indicators reported in next year’s Account.
Where planned service changes are to take place the CCG expect stakeholder and patient
engagement to occur in the initial stages in order to inform the process and although we
acknowledge the challenges ahead for the entire health economy we believe that an open,
transparent and collaborative partnership with the FT will enable these challenges to be met.
Michael Robinson
Associate Director of Integrated Governance and Policy
Bolton CCG
Page 55 of 55
Quality Report
Bolton NHS Foundation Trust