Quality Accounts 2013/14 Section
Content
Page
Statement on Quality – A letter from our Chief Executive
4
Section 1 Priorities for Improvement in 2014/15
5
Section 2 Review of Quality Performance 2013/14
8
2.1 Patient Experience
9
2.1.1 Patient‐led assessments 9
2.1.2 Patient Experience Walk rounds 10
2.1.3 Same Sex Accommodation 11
2.1.4 NHS Choices, Patient Opinion and I Want Great Care 12
2.1.5 Maternity Survey 13
2.1.6 In‐patient survey 15
2.1.7 Friends and Family Test 17
2.1.8 Expert Patient Programme 18
2.1.9 Dementia Carers Survey 20
2.1.10 Compliments 21
2.1.11 Concerns 21
2.1.12 Complaints 23
2.1.13 Claims 27
2.1.14 National Cancer Patient Survey 30
2.2 Safety
31
2.2.1 World Health Organisation (WHO) Checklist 2.2.2 Venous thromboembolism (VTE) Risk Assessment 31
33
2.2.3 Theatres and Delivery Suite Ventilation 34
2.2.4 Serious Incidents Requiring Investigation 34
2.2.5 Safety Alerts: Central Alerting System (CAS) 36
2.2.6 Reportable Injuries Diseases Dangerous Occurrence Regulations (RIDDOR) 37
2.2.7 Pressure Ulcers 38
2.2.8 Incident Reporting 40
2.2.9 Infection Control 43
2.2.10 Medication Errors 44
2.2.11 Mortality and Care Bundles 45
2.2.12 Never Events 48
2.2.13 National Early Warning Scores (NEWS) 49
2
2.2.14 Patient Falls 50
2.2.15 Fire Compartmentalisation 52
2.3 Effectiveness
53
2.3.1 Re‐admission Rates 53
2.3.2 Clinical Audit 54
2.3.3 Commissioning for Quality and Innovation (CQUINs) 55
2.4 Staff Engagement
57
2.4.1 Staff Survey 58
2.4.2 Recruitment in Maternity, Health Visiting and Nursing 58
2.5 External Reviews
59
2.5.1 West Midlands Quality Review Service ‐ Acquired Brain Injury 59
2.5.2 Rapid Response and Care Quality Commission Review 60
2.5.3 Royal College of Obstetricians and Gynaecologists 61
(RCOG) Review Section 3 Mandatory Statements Relating to Quality of NHS
62
Services Provided
3.1 Review of Services 62
3.2 Participation in Clinical Audit 62
3.3 Participation in Clinical Research 76
3.4 Use of the CQUIN Payment Framework 76
3.5 Statements from the Care Quality Commission (CQC) 3.6 Statement on Relevance of Data Quality and Your 76
78
Actions to Improve Your Quality 3.7 NHS Number and General Medical Practice Code 79
Validity 3.8 Information Governance Toolkit Attainment Levels 3.9 Clinical Coding Error Rate 79
79
3
Statement on Quality –
A Letter from Our Chief Executive
Dear Patients, Relatives, Carers and Colleagues of Wye Valley NHS Trust
Welcome to the Quality Accounts 2013/14 for Wye Valley NHS Trust. Each NHS
organisation publishes Quality Accounts every year. The document sets out areas where we
have made improvements over the past 12 months and our priorities for the forthcoming
year.
This document is set out into 3 areas;
1. Priorities for Improvement
Our three key areas for improvement over the coming financial year
2. Review of Quality Performance 2013/14
Our quality performance over the past financial year.
3. Mandatory Statements Relating to Quality of Services
The Department of Health mandates statements we must produce in relation to the
quality of our services.
There have been a number of headlines in the local media about theatre ventilation and fire
compartmentalisation. We continue to be open about these challenges and our work to
improve them and you can read about what we are doing in Section 2.
We took part in a number of reviews during the last year, including a ‘Rapid Response
Review’, carried out by NHS England (NHSE) and the Care Quality Commission (CQC). A
number of recommendations were made (please see page 59). The Trust welcomes these
reviews and has taken swift action to improve services. There are a number of areas that are
still under development and these have been included in our priorities for 2014/15.
We welcome feedback on our Quality Accounts as well as any feedback on our services
(positive or negative). If you do have any feedback please do not hesitate to contact the
Quality & Safety Department on 01432 355444 x5820 or via email at safety@wvt.nhs.uk.
To the best of my knowledge the information in this report is a true and accurate reflection of
the current position of Wye Valley NHS Trust.
Yours sincerely
Richard Beeken
Chief Executive
4
Section 1: Priorities for Improvement in
2014/15
Introduction
The key to improving our services is recognising and acknowledging where we have not
performed well and where focussed efforts will truly benefit our patients. The Trust has
developed a new Quality Strategy in 2013/14 and within this focussed priorities have been
chosen for 2014 to 2017.
In developing the priorities for the Quality and Safety Improvement Strategy, which are
echoed as part of the Quality Accounts, a significant amount of consultation was undertaken
with the organisation’s stakeholders i.e. patients, staff members and external agencies. The
Trust has utilised feedback from surveys, focus groups and national reports to determine its
priorities for the quality and safety as set out in the Quality and Safety Improvement
Strategy. Appendix 1 details the comments made by external agencies.
The Trust’s priorities for the forthcoming year are;
Priority
Responsible Officer
Deadline
To achieve an improvement into the
top quartile for acute Trusts for the
CQC National Inpatient Survey.
To aim for 100% harm free care with a
minimum acceptable level of 94% harm
free care
To achieve an annualised HSMR and
SHMI of 100 or below (by March 2015)
Director of Nursing and
Quality
31st March 2015
Director of Nursing and
Quality
31st March 2015
Medical Director
31st March 2015 (It
is important to note
that rebased data in
relation to this time
period will not be
available until
August 2015)
To achieve a SHMI less than 100 (by
March 2015)
Patient Experience
Priority 1
To achieve an improvement into the top quartile for acute Trusts for the CQC National
Inpatient Survey.
Rationale
The CQC National Inpatient Survey is a national tool used to gather patient feedback on the
service they receive when admitted to an acute hospital as an adult inpatient. Using this
national tool will enable the Trust to benchmark not only against its previous performance
but also against other Trusts.
Baseline
Please refer to section 2.1.6.
Our Goal
The Trust aims to be within the top quartile of Trusts for the 2014 CQC National Inpatient
Survey.
How the goal will be achieved
5
A number of key actions and areas for improvement have been identified following the 2013
CQC National Inpatient Survey. The Trust will focus on these areas to improve services and
experience for patients and in turn improve the scores for the CQC National Inpatient
Survey.
Monitoring and Reporting
This priority will be monitored and progress reported to the Quality Committee on a quarterly
basis through the Patient Experience quarterly report.
Responsible Officer
Director of Nursing and Quality
Patient Safety
Priority 2
To aim for 100% harm free care with a minimum acceptable level of 94% harm free care
Rationale
The Safety Thermometer is a national tool used to measure harm free care. The four key
harms measured are;
 Pressure ulcers
 Falls
 Catheter/UTIs
 VTE
Using this national tool will enable to the Trust to benchmark not only against its previous
performance but also against other Trusts.
Baseline
Harm Free Care – April 2013 to March 2014
Our Goal
The Trust aims to increase harm free care to a minimum of 94% this year.
How the goal will be achieved
A number of improvements have been made which will have a positive impact on the harm
free care delivered by the Trust. This includes;
 A visual tool has been developed to be used to identify patients who are at risk of
pressure damage and at risk of falling. This is placed at the head of the bed in order
that staff can see at a glance which patients are more at risk.
 The SSKIN bundle tool and booklet have been used widely across the Trust and the
booklet has helped consistency of care once the patient is transferred/discharged
from hospital.
 A large purchase of new mattresses and other pressure redistributing equipment to
ensure that patients have access to the right preventative equipment as soon as they
are admitted.
6


The purchasing of alarms that are fitted to beds and chairs to alert staff that a patient
is trying to stand unassisted.
Continued monitoring of timely VTE risk assessments with all hospital acquired VTEs
being subject to an RCA investigation.
Monitoring and Reporting
Safety thermometer data will be monitored and progress reported to both the Quality
Committee and also the Herefordshire Clinical Commissioning Group as part of the Trusts
CQUINs for 2014/15. Reporting will occur on a quarterly.
Responsible Officer
Director of Nursing and Quality
Clinical Effectiveness
Priority 3
To achieve an annualised HSMR and SHMI of 100 or below (by March 2015)
To achieve a SHMI less than 100 (by March 2015)
Rationale
This priority links to the harm free care aspects of the Safety Thermometer however using
mortality rates as an indicator for areas where quality of care needs to be improved has
been an ongoing priority for the Trust and this has been reflected in previous Quality
Accounts.
Baseline
Our Goal
The Trust aims to achieve an annualised HSMR and SHMI of 100 or less. This would be in
line with the national average.
How the goal will be achieved
A number of key areas of improvement have been identified and acted upon over the past
12 months and the continuation of these will see an improvement in the services provided for
patients as well as mortality rates. These improvements include the introduction of care
bundles and NEWS. 2014/15 will see improved usage and knowledge of both the care
bundles and NEWS with audits being undertaken to monitor the effectiveness of these tools.
Monitoring and Reporting
Both HSMR and SHMI will be monitored and progress reported on a monthly basis at Quality
Committee.
Responsible Officer
Medical Director
7
Section 2: Review of Quality
Performance 2013/14
This section sets out our quality performance from 1 April 2013 to 31 March 2014 under the
following five areas:





Patient Experience
Safety
Effectiveness
Staff Engagement
External Reviews
This year we have standardised how we display this information and under each sub
heading you will find a brief introduction, the performance data, where we have performed
well and where further work is required.
Also included in this section is the progress we made against our priorities from our previous
Quality Accounts. These were:
Progress Against Our Priorities in 2013/14
Priority
Goal
1
To eliminate all avoidable category 2, 3 and 4 pressure ulcers.
Although the Trust did not achieve its target to eliminate category 2, 3 and 4
pressure ulcers, a 14% reduction in category 3 pressure ulcers was achieved.
This goal will continue to be monitored and reported on a monthly basis as
part of the Quality Overview Report to Quality Committee and Trust Board.
Further information is available in section 2.2.7.
2
To achieve a reduction in the Hospital Standardised Mortality Rate (HSMR)
and Summary Hospital-level Mortality Indicator (SHMI) in line with the
national average.
The Trust did not achieve this target in 2013/14 and to this end this goal
continues to be a priority for the Trust for the forthcoming year. A number of
actions have been put in place, including the introduction of care bundles,
which will contribute to the reduction in both HSMR and SHMI in 2014/15.
Further information is available in section 2.2.11.
3
To reduce diagnostic waiting times for patients waiting over 5 weeks.
The Trust did not achieve this target in 2013/14 and to this end diagnostic
waiting times for patients continues to be a focus for the Trust and this is
reflected in the Trusts Quality and Safety Improvement Strategy.
Diagnostic waiting times for patient will continue to be monitored and reported
as part of the monthly KPIs to Trust Board.
8
2.1 Patient Experience
2.1.1 Patient-led assessments of the care
environment (PLACE)
PLACE is a patient-led, annual snapshot that gives hospitals a clear picture of how their
environment is seen by those using it, and how they can improve it. It includes assessing
buildings and non-clinical services.
This new assessment replaces PEAT and reflects the move to give patients a real voice in
assessing the quality of healthcare and the environment it is provided in.
At least 50% of those people taking part in the PLACE assessment must meet the definition
of patient – in other words a user of, rather than a provider of, services. There are, however,
some exceptions; 
Former employees of the organisation who have left employment within the
preceding 2 years.

Anyone with a professional relationship with the organisation – e.g. as a facilities
service provider.

Members of the Trust Board of Governors and Trust Members can also act as
‘patient representatives’ because their primary role is to represent the interests of
patients and the public
Performance
The following table sets out how the Trust was assessed across all its sites.
Site Name
Site Type
Cleanliness Food and
Hydration
Leominster
Hospital
Community
97.11%
85.46%
Privacy,
Condition
Dignity and Appearance
Wellbeing
and
Maintenance
88.47%
96.01%
Bromyard
Community
Hospital
Ross
Community
Hospital
Hillside
Community
Intermediate
Care Centre
98.79%
86.57%
75.42%
89.67%
95.00%
84.96%
87.96%
93.39%
99.09%
85.13%
90.00%
88.60%
County
Hospital
Acute
95.29%
78.42%
87.03%
91.30%
National
Average
95.74%
84.98%
88.87%
88.75%
9
Key Better than average About average (within 2%) Below average Key Achievements
An action plan has been developed following the PLACE audits which took place in May and
June 2013, all identified actions were completed by February 2014
Lessons Learned/Areas identified for further improvement
We have worked with staff to ensure that service environment checks become a routine part
of our day-to-day work.
2.1.2 Patient Experience Walk Rounds
Patient Experience Walk Rounds have been carried out twice a month in outpatient,
inpatient and community areas. The walk round
team is made up of an Executive Lead, a NonExecutive Lead, a Quality & Safety representative
Volunteers Surveys
and an Infection Control representative. The team
speaks with both staff and patients and gathers
Volunteers visit the wards in the
views about how services can be further
Hospital on a weekly and monthly
improved.
basis asking the patients to
complete Hospital Feedback
Forms, once completed they are
Performance Data
given to the PALS Department for
In 2012-2013, 18 walk rounds were undertaken.
recording.
This year we have increased the number of walk
rounds to 22.
Key Achievements
In June 2013, the programme changed so that walk rounds are unannounced, this is to
ensure that the walk round team are able to experience what the patient sees on a day-byday, hour by hour basis.
In addition, each team member focuses on a particular area. The Executive Reviewer
focuses on patient experience, the Non-Executive Reviewer focuses on staff performance,
the Quality & Safety Reviewer looks at documentation and equipment and the Infection
Control Reviewer identifies any Infection Control issues.
Also, each participant is asked to consider their first impressions and to look at certain
aspects of care and the environment.
Lessons Learned/Areas identified for further improvement
In the final report, areas of improvement and areas of good practice are highlighted to
ensure that staff can share good practice and take action to address areas requiring
improvement.
10
Examples of where we have improved include:



Variation in collecting and recording medication fridge temperatures was identified.
Now, a new standard format has been developed and implemented in all areas.
Differences in supply of SSKIN bundle booklets (pressure area care information) to
patients were identified. Now there is a much greater focus on maintaining stock
levels to make sure that all patients can easily access the information.
A patient raised a concern regarding the disruptive noise the bin lids on the Intensive
Therapy Unit. This was particularly disruptive when patients are aware of their
surroundings but still critically ill. New bins with soft close lids have been installed.
Some examples of good practice identified:



The Non-Executive Director reviewer attended a ward staff meeting on Monnow
Ward. The positive, open nature of the meeting, where staff were actively
encouraged to ask questions and raise any concerns was noted. The Service
Delivery Manager was also in attendance at the meeting.
The Executive Reviewer spoke to a parent on Special Care Baby Unit (SCBU). The
parent was extremely happy with the care she had received, not only on SCBU, but
also on Delivery Suite. She commented that she felt very well taken care of and
would score the unit 10 out of 10 and would not want anything to be done differently.
As a result a member of staff was nominated and awarded our ‘Going the Extra Mile’
award.
A patient in A&E commented on the good nursing care received and how well the
medical staff kept them informed of what was happening during an anxious time.
2.1.3 Same Sex Accommodation
The NHS Operating Framework 2013/14 requires all providers of NHS funded care to
comply with the national definition ‘to eliminate mixed sex accommodation except whether it
is in the overall best interests of the patient, or reflects their patient choice’.
The Trust monitors compliance with this national indicator daily and reports on its
performance monthly to Service Units and the Trust Board.
Compliance is monitored via the Clinical Site Management Team, Ward and Department
Teams and regular patient surveys. If a breach or potential breach is identified, it is
escalated immediately to senior managers and the Chief Operating Officer, action is then
taken to avoid or address the breach.
Sharing with members of the opposite sex will only happen when clinically necessary in our
critical care areas.
Performance Data
In October 2013, the Trust took part in a Rapid Responsive Review. Fifteen mixed sex
breaches were reported. These were all within the Day Case Unit.
Key Achievements
Following the Rapid Responsive Review’s findings, immediate action was taken by the Trust:

Immediate removal of trolleys to avoid direct view of patients of the opposite sex.
11





Number of in-patient beds reduced to a maximum of 12 in the Day Case Unit only to
be used in times of exception.
Complete risk assessment to include mixed sex issues, patient experience, infection
control and patient flow has been undertaken.
New patient pathways to and from Theatre have been put in place to prevent passing
through an opposite sex area.
The use of the day case recovery area (recliners) has been reviewed and actions to
maintain privacy and dignity have been taken.
A Standard Operating Procedure has been introduced for the use of the Day Case
Unit.
Lessons Learned/Areas identified for further improvement
The Rapid Responsive Review (RRR) and Care Quality Commission (CQC) visit identified
an urgent need for the Trust to take action to improving the privacy and dignity of our
patients in our day case area. Immediate action was taken and the layout of the department
has been changed to ensure the privacy and dignity of our patients. 2.1.4 NHS Choices, Patient Opinion and I Want
Great Care
The NHS Choices feedback page is linked to the Patient Experience Team (PET) which
acknowledges, receives and actions any feedback logged on NHS Choices.
Patients using the site are encouraged to contact the team with any feedback, positive or
negative. The majority of comments received via NHS choices are positive. Comments
received by the PET are shared with the responsible managers. When postings are made
anonymously we reply thanking them for their comments and ask if they would like to contact
the PET to discuss their comments, this allows us to address concerns.
The majority of comments received are positive and complimentary - it is as important to use
information about where we are doing well, as well as where we need to improve.
In addition to comments relating to the Trust, we regularly receive comments relating to
services provided by other organisations such as West Midlands Ambulance Service,
General Practice and our Private Finance Initiative partners who are responsible for some of
the environmental issues, such as car parking and catering. These concerns are forwarded
to the correct organisations who send a reply back to PET and/or contact the person directly.
Performance Data
The table below demonstrates an increase in the use of NHS Choices over the past 12
months to log concerns; a possible cause is the increase in IT awareness and the use of the
NHS Choices site.
2014
2013
2012
2011
NHS Choices
8
44
-
-
Patient Opinion
0
7
5
5
12
Key Achievements
We receive, on average, more compliments through these sites than we receive concerns.
An example of a comment posted on NHS Choices can be seen below:
Superb service - I was referred to Ophthalmology late on a Friday afternoon
between Christmas and New Year so I was appreciative of any appointment.
This was my first visit to Hereford and I could not be more impressed by
everything I experienced - from the clean modern hospital to the friendly and
efficient registration at A&E. I was sent to Ophthalmology and attended to
immediately by the most pleasant nursing staff and later a thorough
examination by the Ophthalmologist and a surgeon a short while later. I have
lived abroad for many years and experienced excellent facilities (private and
state funded) but I can truly say Hereford is as good as you will find anywhere.
Something to be truly proud of. Congratulations!
Posted on 28 December 2013
The Trust replied on 30 December 2013
On behalf of the Wye Valley NHS Trust thank you for your complimentary
comments with reference to your recent experience here at the County Hospital,
Hereford.
We will pass your compliments on to the department mentioned in your email in
order for them to share with their staff and we hope that you have made a full
recovery.
Patient Experience Team
Lessons Learned/Areas identified for further improvement
An emerging theme in comments received is around communication, behaviour and attitude.
We are currently reviewing our Customer Care training with the aim of ensuring the areas
identified are addressed and our patients and their family/carers have the best possible
experience.
2.1.5 Maternity Survey
The CQC’s Maternity Survey was carried out by Patient Perspective on behalf of the Trust
between March and September 2013. The questionnaire was mailed to mothers that gave
13
birth in February 2013. This is a national survey and all NHS maternity services in England
take part in it.
The Maternity Survey attempts to measure mothers’ experience of maternity services by
capturing quantitative and qualitative data. As a summary measure for each question, the
researchers followed the approach adopted by the CQC in England for the National Patient
Experience Survey. This allows us to compare our results with existing data and results from
the previous survey, which was carried out in 2010.
Performance Data
The survey report was divided into six main
areas:






Response rates
Mean rating scores
Frequency tables
Trend charts
Patient Comments
Questionnaire
There were 146 direct questions relating to
aspects of care throughout the antenatal, intrapartum and postnatal periods. The response
rate for this Trust was 45.6%.
Responses to evaluative questions were then
ranked accordingly:





14 responses scored highly 90% - 100%
20 responses scored 80% - 90%
10 responses scored 70% - 80%
2 responses scored 60% - 70%
3 responses scored less than 50%
Scores were then set out by sections of care.
There were some wide variations in scores
within one or two sections of care. However,
some sections of care scored consistently high
on each aspect measured.
Caesearan Section Rates
The promotion of normal births is a high
priority for the Trust and as part of this
we monitor our caesarean section rates
closely. For 2013/14 the Trusts
emergency caesarean section rate was
17%, this is a 0.1% decrease from the
previous year. The Trusts elective care
caesarean section rate was 14.5% , this
is a 3% increase from the previous
year. The Trust has undertaken audits
of caesarean sections using the
nationally recognised Robson Ten
classification in order to identify any
areas where improvements can be
made. The results of these audits so far
have led to a number of actions being
taken to reduce caesarean section rates
in Wye Valley NHS Trust. These actions
include the introduction of working
groups to specifically focus on the
Robson Groups and also the
presentation of the results of the audits
to specific groups such as Service Unit
Governance meetings, Clinical
Excellence Group and Quality
Committee. 49 trend charts compared scores from this
Trust’s survey with the scores from the 2007
and the 2010 survey, the 2013 survey results can be found at
http://www.cqc.org.uk/survey/maternity/RLQ
Some scores were compared with 2010 scores only as the questions were new in 2010.
Also, some questions were new for 2013 and are represented by a single dot on the line
chart.
None of the comparisons with the surveys carried out in previous years were significantly
different. Some were slightly improved and some were slightly worse.
The second part of the report displays patient comments – qualitative data. The Trust scored
well on:
14



Ensuring new mothers had contact numbers for a midwife or the midwifery team
when they returned home.
Reminding women that they needed to arrange a postnatal check up with their GP,
for their own health.
Giving new mothers information about their own recovery after the birth and help and
advice from a midwife or health visitor about feeding their baby.
Key Achievements
The Trust scored very highly (80% -100%) in the following areas:




Communication and, in particular, that staff listen and are sensitive to the needs of
women.
Partners of women felt able to be involved as much as they wanted during
labour/birth.
Women felt involved in their care and felt that they were treated with kindness and
respect.
Providing alternative access to care, including postnatal clinics in Children's Centres
on weekdays and at the hospital at weekends.
Lessons Learned/Areas identified for further improvement
The Trusts maternity service has responded positively to the areas where improvement can
be made.
The areas highlighted by the survey requiring improvement, have already been identified
and are set out in the Service Unit’s improvement plans. These are monitored through the
clinical governance structure.
Areas specifically highlighted for improvement by low scoring questions are:



continuity of postnatal care
continuity of antenatal care
choice of venue for antenatal care
Addressing areas such as continuity of care has well documented benefits and leads to
better outcomes for women and babies.
Provision of choice of venue for antenatal care is related to access to care and also leads to
better outcomes for mothers and babies.
We are working towards a fully established Midwifery Service, which will improve continuity
of care. It will also free up midwifery time to focus on provision of continuity of care.
The Maternity Unit is making progress with the development of communication pathways
with users of the service, through virtual media, face-to-face meetings and real time
feedback following comments in the Friends and Family Test.
2.1.6 Inpatient Survey
The results of the National Patient Survey were released by the CQC on 16 April 2013. The
benchmarking report can be found here.
15
A full report has been presented to the Trust’s Quality Committee. The key points are:
 Performance is ‘About the Same’ as other Trusts nationally in all areas with the
exception of the questions in relation to emergency and A&E. Specifically, the Trust
scored below average in providing patients with information about their condition and
treatment in A&E.
 The Trust has been named in the top 20% of Trusts in eight key areas including
privacy and dignity, providing help to patients at meal times, shorter waiting times,
and providing clear information about patient medication
 Overall performance has improved significantly with the majority of results being
better than last year and the remainder at the same level, ranking it 54 out of a total
of 161 NHS trusts.
Performance Data
Trust Performance Comparisons
Compared to our 2011 survey results, we have improved significantly in relation to the
following 10 questions:
 Were you ever bothered by noise at night from other patients?
 Did you get enough help from staff to eat your meals?
 Did doctors talk in front of you as if you weren't there?
 Did you have confidence and trust in the nurses treating you?
 Did nurses talk in front of you as if you weren't there?
 Were you given enough privacy when being examined or treated?
 Did a member of staff explain the purpose of the medicines you were to take at home
in a way you could understand?
 Did a member of staff tell you about medication side effects to watch for when you
went home?
 Were you told how to take your medication in a way you could understand?
 Were you given clear written or printed information about your medicines?
Compared to our 2011 survey results, we have not performed significantly worse on any
questions.
National benchmarking
Compared to 2011/2012 a combined national result, we feature in the top 20% of Trusts on 8
questions:








How do you feel about the length of time you were on the waiting list?
Did you share a room with opposite sex patients?
Did you ever use the same bathroom or shower area as patients of the opposite sex?
Did you ever feel threatened during your stay in hospital by other patients or visitors?
Did you get enough help from staff to eat your meals?
Were you given enough privacy when discussing your condition or treatment?
Were you given enough privacy when being examined or treated?
Were you given clear written or printed information about your medicines?
Compared to the 2011/2012 combined national result, the Trust is in the bottom 20% of
acute and specialist NHS trusts in England on the following 2 question(s):


Were hand wash gels available for patients and visitors to use?
Were you offered a choice of food?
16
The Trust is working with its Private Finance Initiative (PFI) partners to make sure that these
are both improved.
Lessons Learned/Areas identified for further improvement
We are also focusing on:



Cleanliness of rooms and bed spaces
Pain control
Being able to talk to someone about hopes and fears
Reviews of these areas now form part of the regular ward walk rounds undertaken by Ward
Sisters who spend time talking to patients and their families/carers.
2.1.7 Friends and Family Test
The Friends and Family Test was introduced in Acute Inpatient Wards and A&E on 1 April
2013 and in Maternity Services on October 2013. It is the national tool for measuring
patient experience.
The question posed to Friends and Family is:
“How likely are you to recommend this ward / service to your Friends and Family should they
require similar care or treatment?”
There are five available responses:





Don’t know
Extremely likely (Promoter)
Likely (Passive)
Neither Likely or Unlikely
Unlikely or Extremely Unlikely (Detractors)
If a patient answers ‘Don’t know’ then their result is not included in one of the three
categories above BUT is included in the total number of responses a Trust has received
when calculating the overall response rate.



The Trust takes the total number of all responses (includes Detractors, Promoters,
and Passive)
It then calculates the proportion of Detractors in the total number of responses and
the proportion of Promoters in the total number of responses
The proportion of Detractors is then subtracted from the proportion of Promoters to
calculate the NHS Friends and Family Score
There is a free text option for completion by patients to give the reasons why they gave the
score, which is shared with staff in order to highlight where improvements can be made.
Performance Data
Since 1 April 2013 a total of 9,717 patients have completed the Friends and Family Test.
17
The roll out of the Friends and Family Test and achieving a combined response rate of 20%
by year end was a quality indicator set by NHS Herefordshire Clinical Commissioning Group
for Inpatients and A&E.
Key Achievements
We have:







Rolled out the Friends and Family Test in Maternity Services in October 2013 and
achieved one of the highest response rates nationally.
Rolled out the Friends and Family Test in community hospitals as a measure for
patient experience - this is now included in our monthly performance data.
Recruited volunteers, particularly young volunteers from colleges, to help us promote
the Friends and Family test.
Introduced Friends and Family Test T-shirts to raise awareness.
Improved response rates month on month.
Introduced “You Said, We Did” posters to promote improvements that have been
made.
Introduced a recognition scheme in January 2014 to reward wards that receive the
highest response rates, highest and most improved scores.
Lessons Learned/Areas identified for further improvement
Areas with low response rates tend to be where there is a quick turnround of patients, such
as A&E and Frome Ward (Acute Admissions Ward), or where patients are unable to
participate, such as Wye Ward (Stroke Ward).
A&E had a relatively low response rate compared to inpatient wards, but nationally our
response rates for A&E are above average.
2.1.8 Expert Patients Programme (EPP)
EPP is a generic self-management course for patients 18 years or over living with one or
more long-term or chronic health conditions. It consists of six weekly sessions lasting two
and a half hours per week.
Course sessions cover key topics such as managing symptoms, relaxation techniques,
dealing with stress, depression and low self-image, healthy eating, safe exercise,
communication skills, goal setting and problem solving. Participants are encouraged to
share experiences, learn from each other and develop ways of overcoming specific
difficulties. The course works on the principles that the patient knows best how their
condition affects them and, with proper support, can take the lead in managing their
condition.
The course is facilitated by trained volunteer tutors who live with long-term conditions
themselves and have attended the course prior to becoming a tutor. They understand the
challenges that participants face on a day-to-day basis. The tutors are fully trained and
accredited and are assessed annually to ensure compliance to the EPP quality framework.
In 2009, the Department of Health produced a six month study of feedback from 1000
participants of EPP which showed evidence of a 7% decrease in visits to GPs, 10% to
Outpatients, 16% in A&E attendances and 9% to Physiotherapists. Local evaluation supports
this evidence.
18
EPP is a copyrighted and scripted course developed by Stanford University, USA. It follows
the Stepping Stones to Quality framework, an audit tool developed by the Department of
Health for lay led self-management programmes to ensure courses are delivered to the
same standard nationally under the Stanford University Licence.
Performance Data
In 2013/14 16 courses comprising
177 participants on were run in
different locations across the
county
Key Achievements
Comments from EPP Users
“When I look back I realise I had given up hope of
ever being able to live a normal life…now thanks to
EPP I have a life!”
Key achievements include:




“I found the course enlightening, positive and very
beneficial. An empowering process for people
struggling to cope with a long-term condition. I’m
now active and have taken back control of my life”
An increase in the number
of courses being provided.
One of our volunteer
tutors was shortlisted for
“Before EPP my long term health condition used to
the Pride of Herefordshire
limit me. I now manage a short bus ride to visit my
award in. 2013. This was
eldest son whose home I have not been in for 2
positively reported in the
years – that to me is a great achievement”
media and also featured
other success stories of
EPP participants.
Courses have been held with local work-match organisations such as JHP/Learn
Direct and Pertemps to help people on long term sickness absence get back into
work.
Working with independent living organisations and GPs to promote the programme,
increase number of courses and ensure courses are available to a wider selection of
patients
Lessons Learned/Areas identified for further improvement
We would like to increase the number of volunteer tutors so that we can run more courses.
Potential tutors are required to have a long-term condition and have attended at least four
sessions of the course before applying to become a volunteer tutor. They also have to attend
an interview to assess suitability, attend a four day training course and undergo a CRB
check.
To help us realise this ambition we are:





Using current tutors, Co-ordinator and Assessors to identify potential tutors
Working with the Trust’s Communication team to promote the service
Working with local volunteer centres
Holding information and recruitment days for potential tutors
Writing to previous course participants to invite them to become volunteers and to
attend the information/recruitment days
 Using promotional stands at various local events
19
20
2.1.9 Dementia Carers Survey As part of the national CQUIN targets for 2013/14, we have developed a survey aimed at
carers of patients with a confirmed diagnosis of dementia. This survey seeks to test the
support services we provided to carers. The results from the surveys are collated monthly
and we have now developed an action plan to improve the services we offer.
Performance Data
We worked with partners to create the Dementia Working Group in April 2013. The group
agreed the content of the carers’ survey in May 2013. It was agreed that the best approach
was to initiate a two-stage process. Firstly, a short survey, made up of four questions to be
carried out when the patient was in hospital. It was acknowledged that carers' time was
precious and that asking them to commit to completing a more detailed survey at this point
was unlikely to be successful.
In an attempt to elicit more comprehensive data, an option was added to the short form
survey asking if carers would be willing to participate in a more detailed extended survey.
Both surveys ask for feedback on how supported the carers felt and how we could improve
services. It also signposted carers to attend the Trust’s “Looking After Me” course.
Working with Herefordshire Council and Herefordshire Carers Support, we have been
making sure that information about our services, and those in the community are distributed
with the extended survey. This is to highlight support services available across the county for
carers.
The questionnaires were distributed around wards in the County Hospital and handed
directly to carers of patients with a confirmed diagnosis of Dementia/Alzheimer’s on
admission.
Questionnaires Returned
The number of short questionnaires returned during this time was 128. Out of the 44 longer
questionnaires handed out, the number returned was only 12 which equates to 27.2%.
The initial results were disappointing as carers appeared reluctant to complete the
questionnaires whilst patients are in the hospital setting. A revised approach to the
collection of the data which involves telephoning carers has improved the number of
responses the Trust has received and has also helped the Trust to initiate some important
changes.
Lessons Learned/Areas identified for further improvement
The following actions have been taken as a result of the feedback from carers:
 Development of a Dementia Working Group in May 2013
 Improved literature for carers.
 More joint working with local care homes.
 A carer has joined our Patient Involvement Group.
The development of a robust feedback process in relation to the support Wye Valley NHS
Trust provides to carers will formulate part of the national CQUIN targets for 2014/15.
21
2.1.10 Compliments
The Trust receives hundreds of compliments each month, mostly about staff and care
received. Each ward and department provides the number of compliments received each
month to the Patient Experience Team (PET), together with some examples of the type of
compliments received. This information is included in the Service Unit performance data.
Compliments are often sent directly to the PET or through the website ‘feedback’ page.
Compliments received through the Chief Executive’s office are also forwarded to the PET.
Compliments data is displayed in each ward as part of their quality dashboard.
Performance Data




From 1 April 2013 to 31 March 2014, the Trust has received 5026 compliments.
The vast majority of compliments relate to quality of care and helpfulness of staff.
The Wards and Departments receiving the most compliments during the year were:
- Teme Ward (364)
- Monnow Ward (321)
Ward Metric Posters
- Ross Community
Hospital (301)
Compliments data forms part
of the quality dashboard,
which is visible in all ward
areas.
Key Achievements
The number of compliments collected
has increased from the previous 12month period.
New ward posters have been introduced this
year to provide more detail to staff and the
public on ward metrics. These metrics include;
complaints, compliments, medication errors,
patient falls and pressure ulcers. In addition,
the posters include any action taken by the
ward to make improvements following incidents
and feedback from patients and the public. The
Trust is looking to further develop these
throughout 2014/15 and introduce the use of
‘huddle boards’.
Key messages from compliments are
used to identify good practice and
are regularly reported in the Trust’s
Team Brief, which is delivered to staff directly by the Chief Executive.
Lessons Learned/Areas identified for further improvement
Although the Trust records number of compliments received by area, there is little analysis of
the data. It is important that wards and departments learn from positive feedback as well as
negative and further work will be taken to share and learn from the data more widely across
the Trust.
An increased focus on collating this form of feedback from our community teams is planned.
2.1.11 Concerns
Patients and service users often wish to give feedback in an informal way or require advice
or assistance to help them. The PET provides on the spot assistance and advice and is
based at the main reception at the County Hospital, Hereford making the service very visible
and accessible.
22
Patients and the public can access PET through a variety of methods, including face-to-face,
telephone, letter and through the website address ‘Making Experiences Count’. The service
covers the whole of the Trust, including community hospitals and community services.



Often patients contact PET with concerns but do not wish to make a formal
complaint. They wish to feedback their experiences to those involved and ultimately
improve services for other patients or may require ‘real time’ assistance to improve
the situation they are in
The service is patient centred and the PET will work with the individual to agree an
outcome and timescale for resolution
The main difference between PET and formal complaints is the method used – all
formal complaints are in response to letters, which only account for 10% of PET
contacts.
Performance Data
Between 1 April 2013 and 31 March 2014, the PET has dealt with 796 concerns, and 319
comments about services.
The top 5 topics of concern are:
 Communication
 Information
 Quality and Safety of Care
 Access
 Relationships
The A&E Department received the highest number of concerns, mainly due to length of wait
and the effect of capacity issues on the department. Following the introduction of a Clinical
Assessment Unit in December, the number of concerns has steadily reduced.
Concerns with respect to communication and information, mainly around issues with
outpatient appointments accounted for 37% of all contacts received during the year. Issues
dealt with through the PET service with respect to Quality and Safety of Care accounted for
21% of contacts. Wherever possible, PET are involved at an early stage and provide support
to patients in order to resolve their concerns on the spot.
23
Key Achievements








During the year 30 concerns could not be resolved through the PET service and went
on to become formal complaints, this represents just 3.7% of all contacts.
Developing links with the Learning Disability Nurse has helped with inpatient care.
Following concerns from patients, we co-ordinated a review of all appointment letters
to ensure correct information was included.
Introduction of the Noise at Night Charter following concerns raised by patients.
Continued to develop good working relationships with staff.
Problems have been experienced where patients find it difficult to get through to
departments with questions about their appointments. Additional staff have been
recruited in peak flow areas to specifically answer telephones.
Following comments received about lack of wheelchairs in the main reception area,
further chairs have been provided.
Developed the interpreting provision service to accommodate increasing demand.
Lessons Learned/Areas identified for further improvement






Lean assessment of processes for dealing with concerns.
Greater visibility in the community.
Employment of specialist interpreters to support patients whose first language is not
English.
Development of e-learning package for customer care, in conjunction with the
Professional Development Team.
Patients being able to speak with staff about their areas of improvement.
The introduction of a Clinical Assessment Unit has resulted in a decrease in
concerns relating to waiting times in Accident and Emergency.
2.1.12 Complaints On the 1st May 2013 a revised complaints process was introduced within Wye Valley NHS
Trust. The revised process encourages more Service Unit ownership in relation to the
formulation of open and appropriate responses to a complaint.
When a complaint is received it is reviewed and assigned a grade (red, amber or green)
through a triage process concerning seriousness. The complaint is logged on an electronic
risk system called Datix and sent to the relevant Service Unit in accordance with agreed
timescales. The complainant receives a written acknowledgment with anticipated timescales
for a full response to their complaint. This is within 25 working days for red and amber
complaints and 10 days for green. If the complainant feels that the timeframe is not
acceptable, they are asked to contact the Complaints Team to discuss an alternative date.
The complainant receives a written response from the Chief Executive. All complainants are
provided with information on how to access the Independent Complaints Advocacy Services
(ICAS) and details of the Parliamentary Health Service Ombudsman (PHSO) who they can
contact for a review of their case should they be unhappy with the Trust’s response.
A complaint is defined as an expression of dissatisfaction that takes longer than 48 hours to
resolve or where the individual clearly states that they are making a complaint. A formal
complaint is an expression of dissatisfaction usually in writing to the Chief Executive and the
complaints wishes to receive a written response through the NHS complaints procedure.
General concerns are those that take longer than 48 hours to resolve or where the individual
clearly says that they do not wish to make a complaint. 24
Performance Data The Trust has received 242 complaints as compared to 266 in the period 2012/13.
Service Unit Comparison
The number of complaints received by other Trusts in the Arden, Herefordshire and
Worcestershire areas.
Trust
Complaints received 2012/13
Worcestershire Health and Care NHS Trust
295
South Warwickshire NHS Foundation Trust
214
George Eliot Hospital NHS Trust
293
Worcestershire Acute Hospitals NHS Trust
707
University Hospital Coventry and Warwickshire
483
18 complaints have been referred to the PHSO of which two have been upheld and three
have been partially upheld. The PHSO felt that there was not enough evidence to proceed
with an investigation with regard to one complaint and the Trust is currently awaiting the
outcome of twelve cases.
25
Top 5 Themes
The table below demonstrates the top five themes highlighting the highest number of
complaints received is with regard to the quality and safety of care.
Wards and departments that have received five or more complaints April 2013 to
March 2014
The Trust is working to address those areas which have been highlighted as areas of
concern, noting its values include:




People First
Passion for excellence
Personal responsibility
Pride in our team
Particular areas of concern include Accident and Emergency Department and Maternity.
The Trust also received a high number of complaints regarding Car Parking
The Trust has subsequently implemented the following initiatives:
26
 A new compassionate caring vision for nurses launched nationally, is being rolled out
across the Trust. The vision is based around six values – care, compassion,
courage, communication, competence and commitment. The vision aims to embed
these values, known as the Six C’s, in all nursing, midwifery and care-giving settings
throughout the NHS and social care to improve care for patients. This was launched
at the annual public meeting in July 2013.
 Accident and Emergency developments include:
- Improved feedback to patient waiting times
- Greater utilisation of television screens to provided up to date information to
patients
- Clinical Team providing records to patients as opposed to Reception staff.
 Opening of the new Clinical Assessment Unit to aid the flow of patients requiring
urgent assessment, diagnosis and treatment
 Delivery of the implementation plan following the National Maternity Engagement
Survey
Key Achievements
The Trust has worked hard to embed the new complaints process which has included the
appointment of a new Patient Experience Officer to manage the process. Training sessions
regarding the production of draft response letters has been offered to all staff who may
potentially be involved in providing complaint responses and meetings.
A patient-led forum held on the 20th November 2013 sought to identify what were the most
important factors to delivering a service that patients would wish to recommend to their
friends and family. The feedback from this session was considered in the delivery of the
Quality and Safety Strategy for 2014 -17.
Specific examples of learning from complaints include:
Ward/Department
Complaint
Accident & Emergency Poor attitude of receptionist
Accident & Emergency
Paediatrics
Surgical Admissions
Unit
Locum junior doctor had not
picked up the fracture to
neck when reviewing xrays.
Child’s operation cancelled
at the last moment due to
undetected allergy.
Concerns about
environment pre-operatively
in Surgical Admissions Unit
Actions Taken
All reception staff have been
reminded of correct procedures
whilst at the reception area and
additional training has been
provided to the team.
Introduction of a priority in-tray for
returning x-rays to ensure they are
processed in a timely manner.
A review of the Children’s ENT
pathway in regards to preoperative
assessments has taken place.
The patient literature is being
reviewed to ensure all information
is captured in advance to avoid
cancellations on the day of
surgery.
Pre-operative assessment team to
review and amend current
information provided to patients
and their families for admission,
including the environment and
purpose of the Surgical
Admissions Unit.
27
Maternity
Failure to identify urine
retention following birth of
baby
The postnatal management of the
bladder will be considered at staff
up-date sessions to raise the
awareness of this condition.
Lessons Learned/Areas identified for further improvement
Positive, open and honest steps have already been introduced to initiate the changes
required to provide a robust complaints process. This emphasises the requirement to learn
and respond. Prior to the implementation of the revised process all complaints were
formulated from telephone conversations, emails and letters sent to the Complaints Manager
from a number of sources which was often disjointed and defensive in nature.
The Trust must continue to encourage Service Units to take ownership of complaints to
include personal contact with complainants to discuss their concerns in a more patient
centred way. Assurance must be given to complainants that their complaint has made a
difference in preventing reoccurrence. The complaint process must strive to be as
independent as possible.
Car Parking
Car Parking charges at the County Hospital Site were increased January 2013.
The car parking charges at the County Hospital are set within the schedule of
rates (Schedule 10) as part of the PFI Contract that is managed by Mercia
Healthcare, sub-contracted to CP Plus.
These parking charges cover the cost of managing and running the car parks,
which includes parking attendants to prevent shoppers and commuters taking up
parking spaces intended for use by patients and visitors attending the hospital.
The Trust has urged the company to keep down the costs and has tried to
influence this by continuing to offer a range of concessions to help cover the
additional cost incurred to the patient attending the hospital for treatment. To
ensure the public are aware of the concessions available they are published on
the hospital web site and notices by all pay and display machines. Also the public
are informed to speak to staff on hospital receptions desks they have been fully
briefed on what concession is available and whether they are eligible to receive
them.
The Trust is also committed to sustainable travel and operates a travel plan which
ensures and encourages alternative methods of travel to the hospital.
2.1.13 Claims
Claims Background
Claims fall into four categories, which are as follows:



Clinical Negligence (patient claims)
Employers’ Liability (staff claims)
Public Liability (visitors, contractors etc.)
28

Property Expenses (anything related to Trust property)
NHSLA Risk Pooling Schemes
The Trust is a member of the following
National Health Service Litigation
Authority (NHSLA) Schemes:

Clinical Negligence Scheme for
Trusts (CNST)

Liabilities to Third Parties
Scheme (LTPS) and Property
Expenses Scheme (PES)
[known collectively as the Risk
Pooling Scheme for Trusts
(RPST)]
NHSLA
2013/14 saw the NHS LA change its
approach to the risk management standards
and assessment process and as a result of
this, undertook a limited assessment
programme during the period of 1st April
2013 to 31st March 2014.
However they have continued to work with
their members, to ensure that any revised
process is focused on helping organisations
reduce harm to patients and the number and
cost of claims they receive.
The costs of the scheme are met by
membership contributions. The
projected claim costs are assessed in
advance each year by professional actuaries. Contributions are then calculated to meet the
total forecast expenditure for that year. Individual member contribution levels are influenced
by a range of factors, including the type of Trust, the specialities it provides and the number
of “whole time equivalent” clinical staff it employs.
Performance Data
CNST Claims:
There has been a systematic increase year on year of NHSLA clinical negligence claims.
The table below shows the number of claims opened in the financial year (April 2013 to April
2014) with a breakdown by Service Unit.
This year we received 36 CNST clinical negligence claims compared to 17 in 2012/13.
Service Unit
Elective Care
Integrated Family Health Services
Urgent Care/ Care Closer to Home
Total for Wye Valley NHS Trust
Total
22
7
7
36
You can see from this table that the Elective Care Service Unit received the highest number
of Claims this year.
Of the Elective Care claims 6 had been classified as diagnosis failed or delayed, 15 had
concerns with their treatment/procedure and 1 involved treatment from a medical device.
29
Comparison of the Trust against the National Average Relating to Clinical Negligence
Claims
Key Achievements Within the Trust there has been improved triangulation of data between Claims, Complaints
and the Incidents. This eliminates some unnecessary duplication (for example clinician’s
comments) and the sharing of information between departments can lead to a more
thorough and timely investigation particularly relevant for Claims.
A bi annual report is produced and presented to the Quality Committee to provide assurance
in respect of the Trusts compliance with National Health Service Litigation Authority
(NHSLA) guidelines and Pre-Action Protocol for Resolution of Clinical Disputes.
Lessons Learned/Areas identified for further improvement 30
Clear and concise documentation in relation to the information written in medical records has
been identified as an area which needs to be improved to enable thorough investigations
into Claims.
2.1.14 National Cancer Patient Experience
Survey The National Cancer Patient Experience Survey (NCPES) is one of the largest cancer
survey programmes in the world.
The 2012/13 NCPES Survey follows on from the successful implementation of the 2010 and
2012 NCPES, designed to monitor national progress on cancer care. The 2013 survey is
congruent with the National Operating Framework (NOF) for the NHS 2012/13, which
measures performance against: safety, effectiveness and patient experience. The NCPES
provides information that can be used to drive service improvement, delivery and
commissioning and is consistent with the objectives of NHS policy.
The NCPES survey includes all adult patients (aged 16 and over) with a primary diagnosis of
cancer who had been admitted to an NHS hospital as an inpatient or as a day case patient,
and had been discharged between 1 September and 30th November 2012. The three-month
eligibility period for data capture purposes is identical to that for the 2010 and 2012 NCPES.
Postal surveys were sent to patients’ home addresses following their discharge. Up to two
reminders were sent to non-responders. A freepost envelope was included for their replies.
Patients could call a free telephone line to ask questions, complete the questionnaire
verbally, or to access an interpreting service.
We sent out surveys to 214 eligible patients and 135 questionnaires were returned. This
represents a response rate of 66%. The national response rate was 64% (68,737
respondents). In 2012 the national response rate was 68%.
Performance Data
 The Trust was ranked 35 of the 155 Trusts surveyed. In 2011/12 we were ranked 70
of the 160 Trusts surveyed
 The Trust was in the top 20% of Trusts in 20 areas
 The Trust was in the bottom 20% of Trusts on 11 out of 63 scored questions in the
survey
Key Achievements
Key areas of improvement against the 2011/2012 survey are:

Overall rating of care:
“excellent/very good” = 91% (5% lower than the highest ranking Trust
nationally and a 1% increase on the previous survey)

Clinical Nurse Specialist (CNS) definitely listened carefully last time spoken to:
97% which was a 6% increase on the previous survey and equalled the
highest score of any Trust nationally.

Patient’s family definitely had an opportunity to talk to the doctor:
An improvement from 64% to 81%.
31

Hospital and community staff always worked well together:
A significant improvement on the previous two surveys = 73% only 8% below
the highest-ranking Trust nationally.
Lessons Learned/Areas identified for further improvement
The key areas identified for improvement were:
 Information and communication: on tests, bringing a friend/family member with them,
information on side effects.
 Sensitively communicating the diagnosis.
 Information on free prescriptions.
 Involvement in cancer research.
 Respect and dignity.
 Information given on discharge.
 Availability of the correct information for review appointments in the Outpatient
Department.
 Communication and information about the patient’s condition and treatment pattern
for the patients GP.
 One of the most striking findings of the 2010, 2012, 2013 surveys is that those
patients with a CNS report significantly better overall patient experience (following a
recent review of CNS provision in the Trust, a business case has been developed to
address a shortfall in Urology).
Following receipt of the survey results, an action plan was developed and presented to the
cancer board and service user group
Due to the limited time between publication of the results of this survey and the dates from
which the sample of patients for the next survey are drawn it is possible that some of the
improvements put in place as a result of this survey will not be demonstrated until the
2014/2015 report is published.
2.2 Safety
2.2.1 WHO Checklist
The aim of the Surgical Safety Checklist is to ensure safe surgery for all patients and aid
communication between all members of the clinical team. It was launched by The World
Health Organisation (WHO) in response to an identified global risk of patient safety. The
checklist includes a number of safety checks, which have to be undertaken at the following
stages:



Before anaesthetic
Before the surgical operation begins
Before the patient leaves the operating room
The checklist requires all members of the team to be involved at each stage.
32
Performance Data
We monitor completion of a checklist on all surgical operations in all of our operating
theatres on a continuous basis. Results have shown high levels of completion at 99 -100%
throughout 2013/14. Results for each month are shown below:
Month
Checklists fully completed
April - 2013
May - 2013
June - 2013
July - 2013
August - 2013
September - 2013
October - 2013
November - 2013
December - 2013
January - 2014
99.18%
99.7%
99.5%
99.7%
99.4%
99.4%
99.5%
99.7%
100%
99.7%
Results are reported on a monthly basis to heads of relevant departments, clinical directors,
the Trust Board and to NHS Herefordshire Clinical Commissioning Group.
Key Achievements
Although levels of completion of the checklist have been high, the aim is to improve
wherever possible.
 A World Health Organisation (WHO) “WHO Shield”, showing the number of days with
fully completed checklists, is displayed within Theatres and is updated on a daily
basis.
 During 2013/14 the Trust developed and implemented a new policy on the use of the
WHO Safer Surgery Checklist. The policy requires that any failure to complete the
safety checks be reported as a serious incident. This is followed by a full
investigation by a senior member of theatre staff of the circumstances leading to the
failure, so that lessons can be learned and actions can be taken to prevent further
failures to complete the checklist appropriately.
 A Standard Operating Procedure was developed to provide further guidance to staff
on how to undertake the WHO checklist and appropriately report any instances
where checks have not been fully performed.
 If the WHO checks are not fully performed, the incident is escalated to the
appropriate senior manager through the Trust’s incident reporting system.
 A Practice Development Facilitator was appointed within Theatres in 2013/14.
Following a review of WHO Safer Surgery checklist training and competencies, she
has rolled out a robust training programme focused on the new policy and
procedures.
 Human factors training has been provided to staff. This is designed to help staff in
challenging other members of the team who may not be supporting the WHO
process.
Lessons Learned/Areas identified for further improvement

A review of the checklist document showed that it was being used to record
information that was not part of the safety checks.
33


Action: A new checklist, to be used solely for the safety checks, was developed and
implemented. This has made the checklist easier to follow and reduces the risk of
checks being missed.
Areas for Improvement – It has been identified that there is a need for further full
engagement in the WHO checks by some surgical and anaesthetic staff. Details of
any failure to engage are therefore provided to the Clinical Directors of Surgery and
Anaesthetics to take forward with individual members of staff.
2.2.2 VTE Risk Assessment
Venous thromboembolism (VTE) is a term that covers both deep vein thrombosis and its
possible consequence: pulmonary embolism (PE). A deep vein thrombosis (DVT) is a blood
clot that develops in the deep veins of the leg. If the blood clot becomes mobile in the blood
stream it can travel to the lungs and cause a blockage (PE) that could lead to death.
In 2005 the House of Commons Health Committee reported that an estimated 25,000 people
die from preventable hospital acquired VTE in the UK every year. The risk of hospitalacquired VTE can be greatly reduced by risk assessing patients and prescribing them
appropriate measures that prevent a VTE from occurring.
Since the 1June 2010, all NHS hospitals have been monitored nationally to ensure 95% of
patients have a VTE risk assessments undertake on admissions. The completion of risk
assessments also formulates part of NHS national CQUIN targets. In 2013/14 the Trust
successfully achieved over 95% compliance each month against the target.
Performance
As part of the VTE risk assessment the target achievement level is 95%. The Trust has met
this target each month this financial year.
Key Achievements
A number of measures are in place to ensure any non-compliance with completing the VTE
risk assessments is quickly identified and acted upon;
 Service Unit Managers and Service Unit Directors are notified on a weekly basis of
any areas that have been identified as non-compliant.
 The completion of VTE risk assessments is incorporated into Service Unit Key
Performance Indicator dashboards.
 Service Units are challenged on poor performance monthly to ensure robust plans
are in place to continue emphasising the need to have 100% compliance with
completion of VTE risk assessments.
 The Trust is currently trialling an electronic record system for capturing VTE data in
Orthopaedics and early indications are that this system is being successfully
implemented and VTE risk assessments appropriately completed.
Lessons Learned/Areas identified for further improvement
The Trust continues to strive to keep every patient free from harm and will endeavour to
continue to make improvements. The roll out of the electronic record system identified above
to other areas would assist the Trust in achieving this goal.
34
2.2.3 Theatres and Delivery Suite Ventilation
In October 2013, issues with the theatre and delivery suite systems came to light and
experts who were called in confirmed that not all the ventilation systems met required
standards. The ventilations systems are operated and maintained by the PFI company,
which provides the building and services in which the Trust delivers care and treatment.
We took immediate action, closing several of the theatres and diverting operations to ensure
procedures only took place in those with the right environment.
Remedial work, undertaken by the Trust’s PFI partners, has been externally verified as
working to required standards. To ensure the air quality and air pressures within our theatres
continue to meet requirements, we have introduced robust testing and monitoring
procedures. Throughout the process, exhaustive air quality tests have been carried out and
there is no evidence that these issues have affected patients.
2.2.4 Serious Incidents Requiring Investigation
(SIRIs) SIRIs are incidents that occur that have, or potentially may have, caused serious harm to
patients or the Trust. Although measures are in place to prevent these incidents, when
things do go wrong we ensure staff are open and honest about what has happened and
encourage speedy reporting of such incidents. This allows for a culture of learning, which in
turn will benefit patients by strengthening what we already do to ensure harm doesn’t come
to patients whilst in our care.
SIRIs have to be reported immediately through the Quality and Safety Team, who then notify
the relevant external organisations; a Root Cause Analysis (RCA) investigation is
commenced. These investigations are led by a clinician or nurse and follow the incident trail
to determine why the incident occurred and how it can be prevented in the future. In some
instances a Non-Executive Director is involved in the investigation to give a ‘fresh eyes’
perspective on the investigations and to ask the questions that a health professional may not
think to ask. Staff members are given training on how to complete these investigations
Speak Out Safely Campaign
This campaign was run in conjunction with the
Nursing Times to encourage NHS organisations to
develop cultures that are honest and transparent, and
to actively encourage staff to raise the alarm when
they see poor practice and to protect them when they
do so.
Before investigations are signed
off as complete they are subject
to rigorous review by Executive
Directors to ensure necessary
steps have been taken to
identify the root cause and put
in place mitigating actions to
prevent
incidents
from
reoccurring.
As an organisation, we have signed up to the Speak
Out Safely Campaign, making a public commitment to
supporting staff who raise concerns. We have done
this jointly with Herefordshire Clinical Commissioning
Group.
35
Performance Data
Any types of incident could potentially be reported as a SIRI depending on the consequence;
however there is national guidance available to ensure that the Trust reports accurately. The
graph below shows all the types of incidents reported as SIRIs in 2013/14.
Top 5 Themes
The top 5 incidents reported as SIRIs are





Category 3 pressure ulcer
Category 4 pressure ulcer
Patient fall resulting in a fracture or serious injury
Drug incident
Never Events
Pressure ulcers are the most reported SIRIs and as such are a priority for the Trust. A
significant amount of work has been undertaken by the Tissue Viability Team and nursing
staff to reduce pressure ulcers as detailed in section 2.2.7.
Half of the pressure ulcers were reported by the Neighbourhood teams and the other half
were reported by the acute and community hospitals.
Patient falls resulting in a fracture or serious injury is the next highest reported, with over half
reported by the community hospitals. The actions taken to reduce the number of falls are
detailed in section 2.2.14.
Key Achievements




Members of staff in the Maternity service can initiate a case review if they wish to
discuss a patient’s care.
Development of a WHO Surgical Safety Checklist Policy.
Following a SIRI, a round table discussion is held with everyone involved in the
incident to ensure a clear timeline is established.
Development of a procedure to investigate and learn from incidents, complaints and
claims.
36

Lessons learnt from serious incidents are shared Trust-wide through Trust Talk and
Team Brief.
Lessons Learned/Areas identified for further improvement



Accurate and timely documentation of any care intervention
Correct filing of notes to prevent potential incorrect treatment being given
Appropriate escalation of the deteriorating patient in a timely manner
2.2.5 Safety Alerts
The Central Alerting System (CAS)
CAS is a web-based cascading system for issuing patient safety alerts, important public
health messages and other safety critical information and guidance to the NHS and others,
including independent providers of health and social care.
CAS was established in 2008, replacing the previous Public Health Link (PHL) and Safety
Alert Broadcast System (SABS).
Issued alerts are available on the CAS website and include safety alerts, messages, drug
alerts, Dear Doctor letters and Medical Device Alerts issued on behalf of the Medicines and
Healthcare products Regulatory Agency, the National Patient Safety Agency, and the
Department of Health.
All alerts received by the Trust are assessed and sent out to relevant service units/managers
for action. All alerts including field safety notices are time bound and the Trust need to
action/close alert within specific time frame. Any alert which breaches deadline will be
escalated to the Chief Executive Officer via CAS and escalated internally by quality and
safety office to the Trust Board.
Performance Data
During 2013/14 there were a total of 232 alerts issued to the Trust.
All alerts were received, escalated and acted on as appropriate



191 alerts required no action by the Trust
40 were applicable to the Trust and acted on within time frames
1 assessing relevance (not breached)
There was one alert which did breach in 2013, but was issued in 2009 with a long deadline;
The alert should have been closed before 1/4/2013, (issued in 2009) but due to a delayed
communication from the supplying company informing the Trust that the purchase of new
pumps was required owing to the discontinuation in supply of the infusion lines due to noncompliance the Trust breached the stated deadline. The Health and Safety officer spoke
with the Medicines and Healthcare products Regulatory Agency (MHRA) before deadline
and explained problem. MHRA stated the Trust could close the alert with the proviso; Trust
should ensure that the alert is placed on risk register and is monitored through relevant
Governance group with associated action plan to close alert.
Quality and safety office closed the alert on the 16th April 2013, 15 days after deadline. Alert
was classed as breach but with no further actions from MHRA.
37
Key Achievements
All alerts that are sent out via quality and safety office are assigned to individuals/service
units with appropriate deadline attached. The alerts are monitored by the health & safety
officer/health & safety administrator for completion. Any alert that is close to breach date is
escalated to head of quality & safety for action.
Example of alerts which have benefitted
trust/patients;
Alert issued in 2013 for; Receptacle
suction canisters and liners.
Following the receipt of this alert the Trust
have replaced all receptacle canisters and
liners through supplies and Electrical
Biomedical Engineering Department
(EBME). Action was taken and completed
within the required time frame.
2.2.6 RIDDOR Reportable Incidents
Reportable Injuries Diseases Dangerous Occurrence Regulations 2013
RIDDOR is the law that requires employers, and other people in control of work premises, to
report and keep records of:




Work-related accidents which cause death
Work-related accidents which cause certain serious injuries (reportable injuries)
Diagnosed cases of certain industrial diseases
Certain ‘dangerous occurrences’ (incidents with the potential to cause harm)
Why report?
Reporting certain incidents is a legal requirement. The report informs the enforcing
authorities (Health and Safety Executive (HSE) and Local Authorities) about deaths, injuries,
occupational diseases and dangerous occurrences, so they can identify where and how risks
arise, and whether they need to be investigated. Allows the enforcing authorities to target
their work and provide advice about how to avoid work-related deaths, injuries, ill health and
accidental loss.
Non/late reporting
The Trust has a legal duty to report all RIDDOR incidents in a timely manner. Work related
accidents which lead to member of staff unable to work for more than 7 days needs to be
reported within 15 days of incident. More serious incidents, deaths, fractures, breaks need
to be reported within 48hrs.
Failure to report within deadline could lead to fines and inspections.
38
Performance Data
During 2013/14 there were a total of 13 RIDDOR incidents reported to the HSE.




Nine reports were related to; sprain, strain where individual was off work for more
than 7 days.
Two reports relate to patient falls/injuries.
One report relates to an electric shock (staff)
One report relates to dangerous occurrence/over exposure (Nitrous Oxide)
Key Achievements





During 2011 there were a total of 22 RIDDOR incidents reported by the Trust.
During 2012 there were a total of 18 RIDDOR incidents reported by the Trust.
During 2013/14 there were only 13 RIDDOR incidents reported by the Trust. This
decrease in reporting to the HSE has triggered action to raise awareness re:
RIDDOR incident regulations, responsibilities and reporting awareness of the Trusts
Managers.
During 2011/12 the Trust did not have full time health & safety officer in post and
RIDDOR incidents reports were made automatically without investigation into
incident which lead to over reporting.
Managers/health and safety representatives are now all trained by trust in terms of
incident reporting and RIDDOR incidents. RIDDOR incidents are also now included
on induction and annual refresher training for all staff.
Lessons Learned/Areas identified for further improvement
The Trusts Health and safety Officer will review each incident report and determine if
RIDDOR incidents are reportable. RIDDOR incidents can only be reported from the Quality
and Safety office. 2.2.7 Pressure Ulcers
Around 412,000 people in the UK are likely to develop a pressure ulcer (Bennett et al 2004)
including 4-10% of patients admitted to hospital (Royal College of Nursing 2005). Due to
this, and the associated costs, pressure ulcers are a core quality indicator for patient safety.
We have a zero tolerance approach to pressure ulcers and aim to eliminate all avoidable
category two, three and four pressure ulcers. The Harm Free Care initiative and the CQUIN
for 2014/15 relating to the use of the National Safety Thermometer all aim to reduce
pressure ulcers.
What is a pressure ulcer?
A pressure ulcer is a type of injury that affects the skin and underlying tissue caused when
an area of skin is placed under pressure. Pressure ulcers can occur after pressure has been
exerted for a short period of time or when less pressure is applied but over a longer period of
time. The wounds can vary from discolouration of the skin to an open wound that may
expose bone or muscle.
Why do we report them?
All category three and four pressure ulcers have to be reported as a Serious Incident
Requiring Investigation (SIRI) as they are a key quality indicator for the organisation. The
Trust is focussed on improving patient care and all actions that are identified as a result of
39
the Root Cause Analysis undertaken for each category three and four pressure ulcers are
shared with the wards and with the Service Units in their quality accounts.
Performance Data
NB* The Neighbourhood Teams contains data from September 2013. This was when the
new Neighbourhood Teams came into effect.
40
Key Achievements






The Tissue Viability Team has maintained regular teaching updates for all members
of the Healthcare team relating to
pressure ulcers.
6 C’s
A visual tool has been developed to
be use to identify patients who are at
The 6 C’s – Care, Compassion,
risk of pressure damage. This is
Competence, Communication, Courage
placed at the head of the bed so that
and Commitment reflect the values that
staff can see at a glance, which
healthcare professionals should all
patients are most at risk.
aspire to all day, every day. They are
The SSKIN bundle tool and booklet
the values that people said are
have been used widely across the
Trust and the booklet has helped
important to them when being cared
consistency of care once the patient
for. The 6 C’s, as they are referred to,
is transferred/discharged from
is a national initiative, and within Wye
hospital.
Valley NHS Trust we have adopted
Ward Managers have been
them and launched them at our annual
performing mini audits on
public meeting in July 2013. As part of
documentation to ensure that
our interview for our nursing workforce,
standards are maintained and that
preventative measures are taken
we test them out to see if they
quickly and appropriately.
demonstrate the 6 C’s. We also have
New nursing staff are asked to
pictorial statements around the
calculate a Waterlow assessment as
organisation telling us what the 6 C’s
part of their interview.
mean to us.
Purchasing new mattresses and
other pressure redistributing
equipment to ensure that patients
have access to the right preventative
equipment as soon as they are
admitted.
Lessons Learned/Areas identified for further improvement
Patient information has been identified as not being readily available. Staff have been
reminded of the need to give out a copy of the patient information sheet that is available on
the Trust’s Intranet, about the use of the SSKIN bundle booklet for patients who are going to
be transferred/discharged.
Spot checks are performed on the Patient Experience Walk Round to ascertain if this
information is being passed on.
Training programme to be more robust and accessible to staff which will include lessons
learned from recent events
All Pressure Ulcers should be photographed when identified. Staff have been reminded of
the importance of this. Wound Photography policy to be developed and ratified.
2.2.8 Incident Reporting
The Trust is an integrated care organisation, which includes both acute and community
services. Incidents that are reported cover a wide range of issues from lack of equipment
being delivered to a patient’s home to a patient fall in hospital. We are committed to
41
improving quality and safety in all of our work and by incident reporting we can both learn
and improve the quality of service that we deliver.
We have rolled out web based reporting. This is a secure system where any member of staff
can access an incident form online (the Trust’s intranet site) and enter the details of the
incident electronically. Once the incident form has been completed correctly it is then
submitted to the line manager to review and action. Depending on the nature of the incident
it may require further investigation.
The electronic reporting system provides a much more timely way of reporting and can
provide instant information on the number of incidents reported by one particular area or
department. Reporting, analysing and monitoring incidents enables us to take appropriate
actions and change services if necessary to improve both the quality and safety of care we
deliver.
Performance Data
Numbers of incidents reported April 2013 to March 2014
All Incidents Reported by the Trust in Both Acute and Community Areas
The latest available data comparing the Trust with other Trusts places us in the middle 50%
of reporters with a median of 7.4 per 100 admissions the Trusts median was 7.9.
42
KETTERING GENERAL HOSPITAL NHS FOUNDATION…
MILTON KEYNES HOSPITAL NHS FOUNDATION TRUST
DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST
EALING HOSPITAL NHS TRUST
BEDFORD HOSPITAL NHS TRUST
BARNSLEY HOSPITAL NHS FOUNDATION TRUST
HINCHINGBROOKE HEALTH CARE NHS TRUST
DARTFORD AND GRAVESHAM NHS TRUST
MID STAFFORDSHIRE NHS FOUNDATION TRUST
YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST
GEORGE ELIOT HOSPITAL NHS TRUST
HARROGATE AND DISTRICT NHS FOUNDATION TRUST
WESTON AREA HEALTH NHS TRUST
WEST SUFFOLK NHS FOUNDATION TRUST
SALISBURY NHS FOUNDATION TRUST
WYE VALLEY NHS TRUST
THE QUEEN ELIZABETH HOSPITAL KING'S LYNN NHS…
BURTON HOSPITALS NHS FOUNDATION TRUST
AIREDALE NHS FOUNDATION TRUST
TAMESIDE HOSPITAL NHS FOUNDATION TRUST
HOMERTON UNIVERSITY HOSPITAL NHS…
MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST
SOUTH WARWICKSHIRE GENERAL HOSPITALS NHS…
EAST CHESHIRE NHS TRUST
ISLE OF WIGHT NHS TRUST
SOUTH TYNESIDE NHS FOUNDATION TRUST
NORTHERN DEVON HEALTHCARE NHS TRUST
0.0
Wye Valley Trust
reporting rate 7.9 per 100 admissions
Median = 7.4 incidents reported per 100
admissions
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
20.0
Harm from Incidents Reported from April 2013 to March 2014
The degree of harm from incidents is measured by the Trust to improve the knowledge about
how these incidents occur and affect patients. This will help to concentrate efforts on those
incidents that cause a higher degree of harm but also understand multiple incidents of the
same nature which result in minor harm.
Top 5 Themes
The top 5 themes of incidents reported within the Trust are:
 Accident that may result in personal injury – these are mainly patient falls.
 Implementation of care or on-going monitoring/review – these are mainly pressure
ulcers both acquired and inherited.
 Infrastructure or resources - these incidents include staffing issues, difficulties with
obtaining general beds and concerns regarding the environment. There has been a
focus on staffing levels and a review of patient flows to address the infrastructure
incidents that have been reported. Measures such as the opening of the Clinical
Assessment Unit and uplift in staffing numbers have been put in place.
 Patient Information - the incidents reported in this category are connected with
patient records, documentation and filing of notes. Patient information and
43

particularly documentation in patient notes are a large issue due to the numbers that
are handled on a daily basis. Staff are continually reminded to make sure that the
documentation is up to date and filed correctly.
Medication – the types of incidents reported are prescription, administration and
preparation of medicines. A new policy has been introduced to manage medication
errors and ensure learning from these incidents.
Patient falls and acquired pressure ulcers are a high priority for the Trust and a number of
actions have been taken to reduce these numbers and these are detailed in separate
sections. The majority of these types of incidents are reported by nursing staff.
Key Achievements




Roll out of electronic incident reporting.
Embedding intentional rounding into practice.
Introduction of a more robust WHO checklist (this is a theatre checklist that is
complete pre anaesthetic, intra-operatively and post operatively to ensure the correct
person is receiving the correct operation).
Maternity and the laboratory have developed a blood form that integrates the family
origin questionnaire with the request form to reduce the incidents of screening
issues.
Lessons Learned/Areas identified for further improvement


Early escalation of the deteriorating patient using the national early warning score
(NEWS) to identify potential problems. The NEWS is used to standardise the
assessment of the acutely ill patient by record the patient’s clinical observations and
assigning a score to that observation. Incidents have shown that this scoring system
has not been used consistently and early escalation for a clinical review has not been
initiated or responded to. The Trust has provided eLearning to promote and
understand the scoring system and weekly audits are being undertaken to check
consistency of completion.
In community services there has been no standard approach to documenting when a
patient declines to comply with both pressure relieving advice and accepting the
appropriate equipment. Development of a form that is kept in the patient held records
entitled ‘decision against advice’ is to be shared with all District Nursing teams.
2.2.9 Infection Control
Infection prevention is a key priority for the Wye Valley NHS Trust. The Trust has a zero
tolerance approach to all avoidable healthcare associated infections. These include
Meticillin-Resistant Staphylococcus Aureus (MRSA), Clostridium difficile (C.diff) and any
bloodstream infections which occur more than 48hrs after admission to hospital.
Performance Data
Organism
MRSA Bacteraemia
C.diff
Externally set maximum
0
12
2013/14 Actual.
0
14
44
Themes and Trends
All cases are isolated and linked cases of C.diff are typed to identify the strain. There was no
evidence in 2013/14 of cross infection or outbreaks of C.diff.
Key Achievements




Reduced cases of MRSA bacteraemia to zero cases in 2013/14 from three in
2012/13.
Developed a Herefordshire wide C.diff prevention campaign, called C.diff ATTACK. Completion of infection prevention assurance audits across the Trust.
Introduction of new and innovative ways to manage C.diff including the new antibiotic
fidaxomicin and faecal transplants.
Lessons Learned/Areas identified for further improvement
Through surveillance we have identified the major focus for 2014/15 to be the prevention of
surgical site infections. Amongst other initiatives this will involve aseptic non-touch technique
external trainers refreshing knowledge and understanding through cascade training.
2.2.10 Medication Errors
The use of medication is the most common intervention used by the NHS and requires
robust management to minimise the potential significant clinical risk. Staff are encouraged to
report all medication related incidents via the Incident Reporting System. Incidents included
are prescribing, dispensing, administration, handling and side effects/adverse drug
reactions.
During 2013, we implemented a Management of Medication Errors Policy to minimise
reoccurrence and maximise learning from medication errors.
If a medication error involves a patient directly, action is taken swiftly to ensure on-going
safety of the patient. In line with local policy, a report of events that took place, remedial
action and, for those of a serious nature, a full investigation including root cause analysis
takes place. All actions are monitored to completion at Executive level.
Performance Data


From 1 April 2013 to 31 January 2014, the Trust has reported 328 medication related
incidents.
11% of incidents reported by the Trust relate to medications. This compares to 10%
for other small NHS Trusts for the same period (National Reporting and Learning
System (NRLS) Report).
The top reporting areas are:
 Pharmacy Department: 53 reported incidents. This includes dispensing errors, which
are fully investigated. The Pharmacy Department has a dispensing reliability level of
99.97% for this period. The pharmacy also has a full clinical support service to all
ward areas.
 Day Case Unit: 24 reported incidents. A significant number of these reports related to
medical outliers. The use of this area for medical outliers has now stopped.
 Admissions Ward: 34 reported incidents. The prevalence of incidents is not
unexpected due to the high volume and complex nature of patients admitted to this
45


area. The Service Unit Pharmacist for Urgent Care reviews incidents reported each
month and provides feedback and advice to the Service Unit.
The most common incident type reported is administration of medication with 158
incidents.
The most common specific cause of incident reported is missed doses where 42
incidents were reported. The second most common was wrong dose or strength at
36 incidents.
Key Achievements



Strengthening of the Medicines Safety Committee to include all Service Units, NHS
Herefordshire Clinical Commissioning Group, Quality and Safety, and Education and
Training representation. Attendance has been robust for each of the bimonthly
meetings.
Implementation of the Management of Medication Errors Policy. This policy is
specifically aimed at maximising learning by analysing system and human factor
failures.
Implementation of weekly monitoring of missed doses at ward level to raise
awareness and reduce likelihood in the future.
Lessons Learned/Areas identified for further improvement





The majority of incidents reported have a low impact on patient care. However there
have been trends and a single Never Event which have led to alterations to practice
to improve patient safety locally. These include:
Introduction of double checking systems for the administration of insulin and oral
methotrexate.
The strengthening of the local policy relating to injectable medicines to include all
intravenously administered medicines are administered via a double check at the
bedside to confirm patient identity.
Review and implementation of new inpatient medication charts in line with national
best practice standards for adult, paediatric and critical care areas and also the
recently created Virtual Wards.
Review of professional management structure for bank/agency staff to ensure there
is appropriate feedback relating to medication errors and to maximise learning.
The Trust recognises that learning from medication errors is a long-term commitment and,
although led by the Pharmacy Department, its success relies on multidisciplinary
involvement. The Clinical Director of Pharmacy (Chair), Medical Director and Director of
Nursing are all members of the Medicines Safety Committee.
2.2.11 Mortality and Care Bundles
The Trust continues to monitor and proactively review the monthly and annual mortality rates
with monthly reports from Dr Foster.
We have been concerned over the past two years about higher than average recorded death
rates and Hospital Standardised Mortality Ratio (HSMR) compared to national and regional
rates.
Over the last nine months there has been several initiatives introduced to target high risk
diagnostic groups and escalation of care in the acutely unwell patient. The responsibility of
reduction in avoidable harm and reduced hospital mortality rates also lies jointly across the
46
whole healthcare community including primary care, secondary care and the NHS
Herefordshire Clinical Commissioning Group. There is no one factor, which will reduce
avoidable deaths in a health community. The approach has to be a broad one to make sure
that inappropriate admissions are avoided; that emergency care in hospital is led by senior
clinicians and is not prone to variability in delivery; that the deteriorating patient is assessed
and treated promptly and correctly; that staffing numbers are right; patient moves are
minimised; bed occupancy rates are optimal; safe transfer and discharge arrangements
provided and best care after discharge is given.
The Hospital Standardised Mortality Ratio (HSMR)
The HSMR is the ratio of observed deaths to expected deaths for a collection of 56
diagnosis groups which represent approximately 80% of in hospital deaths. It is a subset of
all and represents about 35% of admitted patient activity. HSMR is quoted as a percentage
and is equal to 100; this means the number of observed deaths equals that of expected
deaths. If higher than 100, then there is a higher reported mortality ratio.
Standardised Hospital Mortality Indices (SHMI)
The SHMI is like the HSMR, a ratio of the observed number of deaths to the expected
number of deaths. However, this is only applied to non-specialist acute providers. The
calculation is the total number of patient admissions to the hospital that resulted in a death
either in‐hospital or within 30 days post discharge. Like all mortality indicators, the SHMI
shows whether the number of deaths linked to a particular hospital is more or less than
expected, and whether that difference is statistically significant.
Care Bundles
Care bundles were introduced in July 2013 and then re-launched with additional bundles in
September 2013. The diagnosis groups included currently are community acquired
pneumonia, acute kidney injury, sepsis, hyperglycaemia, gastrointestinal bleeding, stroke,
hip fracture and Chronic Obstructive Pulmonary Disease. There is published evidence that
shows that completion and implementation of care bundles leads to improved standardised
care, reduction in delays in treatment and reduced mortality rates.
Performance Data





Rolling timeframe of February 13 to January 14.
Most recent HSMR is 106.85 for February 13 to January 14
January‘s HSMR is 101.76 (2012/13 Benchmark) and is also within ‘expected’
range.
Most recent SHMI (July 12 to June 13) is 115.16 and significantly higher than the
benchmark. The published SHMI banding (95% confidence limits with over
dispersion) is also ‘above expected’ banding.
There was one HSMR basket diagnosis group classified as a statistically significant
negative outlier, Acute and unspecified renal failure.
47
HSMR 1 year Trend April 2013 to January 2014
Urgent Care Pathway Redesign
Emergency Physician of the Day (EPOD)
EPOD extended physician of the day 0800-2000 onsite consultant physician Seven days a
week provides senior clinician input for patients requiring urgent assessment, facilitating
early senior clinical decision making, this has been evidenced to improve outcomes for
patients.
Hospital at Home
A Hospital at Home pilot started in December 2013, facilitating early supported discharge of
patients safely into their own homes with senior nursing support including ongoing
intravenous therapy. Early indications are that the scheme is extremely successful in
supporting patients in their own homes with positive outcomes for patients and their families.
Clinical Assessment Unit (CAU)
On 23 December 2013 the Trust launched its CAU adjacent to A&E and at the front door of
the hospital. The development of this unit increases our ability to provide ambulatory care for
selected patients. This is another key area to improving the outcomes for all patients, and
thereby reducing mortality. This alleviates some of the pressure in A&E and allows
ambulatory patients to have a rapid assessment by a senior doctor, treatment started and
outpatient investigations arranged as appropriate. The CAU has been running for 2 months
and seen over 280 people with approximately 70% being discharged. The target discharge
rate is 80% to meet National figures.
See & Treat in A&E
Under the guidance of a visiting Nurse Consultant from Heartlands Hospital, A&E has
introduced ‘see and treat’ in minors since November 2013, and is now introducing ‘see and
treat’ for majors A&E patients. This will ensure that unwell patients are assessed
immediately by a senior clinician, which bypasses the triage stage. A treatment plan is then
initiated. This will reduce any delays in care or treatment, for example antibiotic
administration in severe infection. In addition, we are hoping to recruit an additional A&E
consultant to a vacant post and this will also facilitate improved patient care and increased
senior clinical time at the front door.
Lessons Learned/Areas identified for further improvement
48
Areas for improvement have been identified in combination with all the above initiatives to
improve patient care and reduce avoidable harm. These include:










Hydration and fluid balance vigilance.
‘See and Treat’ in A&E.
Identification and escalation of
Virtual Wards
unwell patients.
Intravenous cannulation team.
Introduced in Hereford city in September
Antibiotic administration.
2013 the Virtual Wards provides highly
Reduced use of agency nursing
skilled hospital standard health care to
and medical staff.
people in their own home , outcomes
Care Bundles.
include a reduction in A&E attendances,
Standarised pathway for hip
reductions in emergency admissions,
fracture care including hydration,
reduction in length of stay, reduction in
anaesthetics, mobilisation.
primary care attendance/ home visits
Admission and Discharge
and high patient satisfaction
processes.
Specialty bed allocation.
All of these areas are already currently
being addressed with excellent engagement from senior clinical staff and the senior
management structure.
2.2.12 Never Events
Introduction
Never Events are a sub-set of Serious Incidents and are defined as ‘serious, largely
preventable patient safety incidents that should not occur if the available preventative
measures have been implemented by healthcare providers’.
Some types of Never Events hold high potential for significant harm, and are designated
Never Events regardless of the actual degree of harm that occurred. Some types of incidents
are designated never events only if death or severe harm results. These must be reported to
the Quality and Safety Department as soon as possible.
Performance Data
We have had three Never Events reported in the period 1st April 2013 – March 2014, there
have been:
 2 Retained foreign object post operation.
 1 Inappropriate administration of daily oral methotrexate (cytotoxic, a drug that can
have harmful effects on cells).
Numbers of Never Events reported in the period 1st April 2013 – 30th September 2013
from NHS England
49
Total number of organisations reporting Never Events
Total Number of Never Events
Total Number of organisations reporting over 2 Never
Events
Wye Valley Trust
111
165
36
2
Lessons Learned/Areas identified for further improvement
There have been a number of lessons learned from the Never Events:
 There should be a clear, audible and uninterrupted count of the swabs by 2
people and the swab safe tray must be utilised to secure the swabs following
use.
 Staffing levels need to be adequate both numerically and in terms of experience
to ensure a safe working environment for both patients and staff. Staff feels
empowered to challenge if they feel that either the staffing levels or skill mix is
not satisfactory.
 Clear information should be provided regarding cytotoxic drugs to all inpatient
areas.
 All staff working within the Trust should have access to the policies and
guidance.
 There should be clear line management for all staff including bank and agency.
 Staff should be made aware of their responsibilities in both prescription and
administration of medications.
 The Trust shares the learning from these Events through ‘Trust Talk’ a weekly
newsletter and ‘Team Brief’ the monthly Trust-wide communication.
2.2.13 National Early Warning Scores (NEWS)
All patients have vital signs monitoring and, over the past ten years, a series of scoring
systems have been developed and used to identify patients who are at risk of clinical
deterioration.
In 2012 a working party hosted by the Royal College of Physicians (RCP) was formed to pull
together all the existing work on Early Warning Systems (EWS) with a focus on everyone
using the same system. This included producing a system and chart to be used in all
inpatient areas. The benefit of standardising the approach for all is to enable the system to
be linked to clearly defined parameters such as urgency of response, competency of
responder and organisational infrastructure required to deliver the effective clinical response
to acute illness.
Performance Data



NEWS was implemented across all inpatient areas in the Trust including community
hospitals.
Audit has been completed with regular programme in place for repeat.
71 patients sampled with observations reviewed for first 48 hours with a total 515
sets of observations. Initial results show 97% were correct.
Key Achievements
50


NEW was implemented across on implemented across all adult inpatient areas,
County Hospital, Leominster Community Hospital, Bromyard Community Hospital,
Ross on Wye Community Hospital and Hillside from September 2013
New vital sign charts introduced into all areas in accordance with national guidance.
Training sessions for all registered and non-registered staff.
Lessons Learned/Areas identified for further improvement







The review has shown need for continued education and increased knowledge of the
use of a tool known as SBAR – Situation, Background, Assessment and
Recommendation for escalation.
Redesign of the chart will occur to improve use of SBAR following finer details from
audit.
Acutely Ill Management (AIM) Course began in January 2014 with a further five
courses running through 2014. Priority is given to ward-based staff.
Utilise data to understand failure to escalate-review of critical care admissions,
Emergency call data and Critical Care Outreach data. Review and amendments to
weekly nursing documentation review to capture SBAR use and response to
escalation.
The Medical Director and Service Unit Directors ensure medical teams respond
appropriately to escalation according to NEWS scores.
Local training sessions cascaded across clinical areas.
New NEWS campaign was launched in Trust Talk in December 2013.
Any Other Information


Change of early warning score chart has initiated review of fluid balance charts and
escalation when urine output is poor. This is currently in progress.
Links with Care Bundles as NEWS is a key indicator in a number of Care Bundles.
2.2.14 Patient Falls Patient falls are one of the highest numbers of incidents reported in the Trust and occur in
the inpatient areas - approximately half on the acute wards and half in the community
hospitals.
It is important to record patient falls as it could indicate an underlying health issue or simple
issue with mobility that requires a review. Falls increase the risk of injury –related morbidity
or loss of independence and can increase the length of stay of a patient. Reporting patient
falls also enables the Trust to analyse areas that may be experiencing an increase in the
numbers and therefore target actions to reduce the risk.
When a patient falls they are immediately checked for any injuries that may have occurred
and their clinical observations are taken and monitored post fall. This is as a precaution as
some injuries can manifest some hours after the initial fall. The patient’s doctor is informed of
the fall and asked to review, looking at the nature and potential cause of the fall and any
injuries apparent.
Patient falls that result in serious harm, for example a fracture, are investigated as a serious
incident requiring investigation (SIRI) and a root cause analysis is completed. Patient falls
are also captured as part of the Safety Thermometer.
51
Performance Data
Number of falls and harm per 1000 bed days
Comparison of the number of reported patient falls in the Trust compared with other
‘small acute trusts’ information supplied from the NRLS.
Comparison of patient falls in Wye Valley Trust compared to other 'small
EALING HOSPITAL NHS TRUST
HINCHINGBROOKE HEALTH CARE NHS TRUST
BEDFORD HOSPITAL NHS TRUST
KETTERING GENERAL HOSPITAL NHS…
WESTON AREA HEALTH NHS TRUST
MILTON KEYNES HOSPITAL NHS…
ISLE OF WIGHT NHS TRUST
MID STAFFORDSHIRE NHS FOUNDATION…
DORSET COUNTY HOSPITAL NHS…
HOMERTON UNIVERSITY HOSPITAL NHS…
WEST MIDDLESEX UNIVERSITY HOSPITAL…
EAST CHESHIRE NHS TRUST
WEST SUFFOLK NHS FOUNDATION TRUST
THE QUEEN ELIZABETH HOSPITAL KING'S…
HARROGATE AND DISTRICT NHS…
BARNSLEY HOSPITAL NHS FOUNDATION…
MID CHESHIRE HOSPITALS NHS…
DARTFORD AND GRAVESHAM NHS TRUST
SALISBURY NHS FOUNDATION TRUST
TAMESIDE HOSPITAL NHS FOUNDATION…
YEOVIL DISTRICT HOSPITAL NHS…
WYE VALLEY NHS TRUST
BURTON HOSPITALS NHS FOUNDATION TRUST
SOUTH WARWICKSHIRE GENERAL…
SOUTH TYNESIDE NHS FOUNDATION TRUST
AIREDALE NHS FOUNDATION TRUST
NORTHERN DEVON HEALTHCARE NHS TRUST
0
200
400
600
800 1,000 1,200 1,400
52
The highest recorded areas where patients fall were reported are:
 Ross Community Hospital
 Lugg Ward
 Bromyard Community Hospital
 Leominster Community Hospital
 Frome Ward Acute Assessment Unit
/Short Stay Unit
Key Achievements
There have been a number of measures that are in place to reduce the risk of falling
however some falls cannot be prevented without restricting the patient’s liberty, privacy and
dignity. The measures that have been taken are:



The use of visual aids to prompt staff that the patient is at risk of falling and has had
a recent fall therefore needs extra vigilance.
Staff carry out intentional rounding, this entails the patient being checked on a
prescribed frequency to ensure they have everything they need and do not require
any assistance.
Trialling of alarms that are fitted to beds and chairs to alert staff that a patient is trying
to stand unassisted.
Herefordshire’s falls prevention team helped 385 people put their best feet forward safely
during Age UK’s national falls awareness week, 17 to 21 June 2013, by offering free advice
and tips on how to prevent falls in later life.
Lessons Learned/Areas identified for further improvement

The current falls policy is being reviewed to ensure it reflects the guidance by the
Royal College of Physicians.
2.2.15 Fire Compartmentalisation
In December 2012 the Trust and PFI partner received an Enforcement Notice from Hereford
and Worcester Fire and Rescue Service. This followed the identification of potential issues
with the integrity of the fire compartments between different areas which are critical in
providing separation to allow our procedures to work effectively (eg safe evacuation). Fire
risk assessments and procedures were immediately updated and a range of actions taken to
continue to ensure that the hospital could operate safely.
Lessons Learned/Areas identified for further improvement
A range of experts acting for each party assessed the deficiencies and Mercia Healthcare
Limited, which manages the PFI, undertook extensive remedial works. This included working
above the ceiling in most parts of the hospital and required extensive co-ordination with
departments to gain safe access.
Any Other Information
An application to lift the Enforcement Notice was successfully obtained from the Fire
Authority in December 2013.
53
2.3 Effectiveness
2.3.1 Readmission Rates
The Trust is monitored monthly on its emergency re-admission rates, re-admission rates are
a nationally set indicator and monitoring provides information to help the NHS monitor
success in avoiding (or reducing to a minimum) readmission following discharge from
hospital.
Not all emergency readmissions are likely to be part of the originally planned treatment and
some may be potentially avoidable.
It is important to ensure that safe and effective discharge practices are in place and that
good outcomes for patients are maximised. The demographic profile of the population that
the Trust serves requires us to provide services for high numbers of older patients, many
with multiple conditions and often requiring support with their social needs. This means that
we need to develop a multi-agency approach to supporting patient discharge.
Performance Data
In the last 18 months the senior clinicians from the Trust and NHS Herefordshire’s Clinical
Commissioning Group (HCCG) have undertaken two clinical audits of patients who have
been readmitted back to the County Hospital within 30 days of a discharge. The purpose of
the audit has been to determine if the readmission could have been avoided and if so, who
or which agency, could have prevented it.
The audit results were very positive in that there were very few instances where the
readmission could have been avoided. Whilst the Trust does not wish to see patients
readmitted, the purpose of the audit was to test for readmission clinical reasonableness and
for a potential failed original discharge.
Any lessons learnt, for those patients whose readmission could have been avoided, are
being reviewed as part of a multi-agency response including new service provision such as
Virtual Wards the primary aim of which is to maintain care in the community for patients
where it is clinically safe to do so.
Source: CHKS – readmissions within 30 days Trust
Peer
National
2012/13
6.4%
7.4%
6.7%
April to October 2013
6.5%
7.4%
6.7%
Key Achievements
The Trust has, along with its partner organisations, focused on safe and effective discharge
in 2013/14 which has resulted in the following pilot schemes:

Virtual Ward – Hospital at Home: Patients are identified for early supported discharge
and remain under the care of secondary care physicians. A graduated withdrawal of
54

care and support helps to ensure that discharges do not fail and result in readmissions.
Rapid Access to Care and Assessment – this provides an opportunity to ensure that
patients have an appropriate level health and/or social care assessment in an
appropriate alternative setting (either residential or nursing home) or in their own
homes with temporary domiciliary support when they become medically fit for
discharge but require additional support on discharge.
Lessons Learned/Areas identified for further improvement


Early successes with the Hospital at Home scheme have led NHS Herefordshire
Clinical Commissioning Group to consider expanding the scheme prior to the end of
the pilot period.
Working closely with Adult Social Care, the Voluntary Sector and NHS Herefordshire
Clinical Commissioning Group are essential to sustaining and improving
performance.
2.3.2 Clinical Audit
Clinical audit is a process designed to improve quality in healthcare and is therefore
important to staff, patients and the wider public. It includes:



Measuring processes and outcomes of patient care against agreed and proven
standards for high quality.
Where results show that practice is not in line with the standards, changes are
implemented by clinicians, teams or services to improve the quality of care and health
outcomes.
A further check is then performed to make sure that the changes have led to the criteria
being met. This further check is referred to as re-audit.
Performance Data
The Trust has an annual programme of clinical audit projects covering all clinical areas. The
projects are prioritised, with priority one being the highest priority.
 Priority one – for example mandatory national audits, audits undertaken in response to
serious untoward incidents.
 Priority two – for example audit of Trust policies which do not have regulatory
requirements.
 Priority three – Projects for which no specific prompt has been identified but which may
demonstrate good practice or help uncover weaknesses.
Priority of Project
One
Two
Three
Total Projects at
24/02/2014
No of Projects
On Planned
Added to
programme at April
Programme after
2013
April 2013
139
10
91
10
20
11
250
31
Total No of
projects
(percentage of
programme)
149 (53%)
101 (36%)
31 (11%)
281
55
Clinical Audit Programme 2013/14
All projects are registered on the Trust’s Clinical Audit database which is used to record
updates on projects. Monthly and quarterly reports on progress with programme are
generated from the database. Action is taken to progress any projects which are failing to
progress in accordance with agreed timescales.
Achievements in 2013/14
During 2013/14 the Trust reintroduced its Clinical Effectiveness and Audit Committee. The
role of the committee is to ensure that we have an effective strategy for delivering clinically
effective care and for measuring and improving clinical care through the practice of clinical
audit. Although the committee has only been in existence since September 2013 it has
already:
 Discussed and agreed the way forward for clinical effectiveness and audit activity within
the Trust. This will be incorporated into the Trust’s Quality Strategy.
 Focused resources available from the Clinical Effectiveness and Audit Department on
priority one projects.
 Drafted, for consultation, a new job description for clinicians who take on the role of
Clinical Audit Lead within their specialties.
 Reviewed participation in all national audits within the Trust.
Lessons Learned/Areas identified for further improvement
Involving patients and the wider public within clinical audit activity has been identified as an
area where the Trust needs to take further action. The Clinical Effectiveness and Audit
Committee will take this forward within the strategy.
Any Other Information
Details of the Trust’s participation in national clinical audit projects in 2013/14 as well as
actions taken from national and local clinical audit projects are given in Section 3 of the
Quality Accounts.
2.3.3 Commissioning for Quality and
Innovation (CQUIN)
This year, the Trust was set 13 CQUIN targets. Every NHS Trust is set CQUINs, some of
which are set nationally, others locally, depending upon the priorities across the health
economy.
CQUINs drive improvements within the organisation and the targets and milestones set
within each CQUIN have a financial incentive attached to them. This year the Trust
achieved all of its targets.
56
Performance Data
CQUIN
Achievement
Friends and Family Test - Phased
expansion
Roll out of Maternity Services October
2013
Roll
out of national programme March 2014
> 15% response rate increasing to 20%
by March 2014. Internally set target of
20% from October 2013.
Improvement in the score from the
2013/14 survey compared with 2012/13
survey
100%
Friends and Family Test Increased response rate
Friends and Family Test Improved performance on the staff
friends and family test
NHS Safety Thermometer - Data
Collection
Dementia - Find,
Dementia Assess
Dementia Refer
Dementia - Clinical Leadership
Dementia - Supporting Carers of
People with Dementia
VTE Risk Assessment
VTE Root Cause Analysis
Neighbourhood/Community Teams
- Personalised Care Plans
Neighbourhood/Community Teams
- Place of death preference
Neighbourhood/Community Teams
- Community delivery of IV
antibiotics
Neighbourhood/Community Teams
- Primary care survey
Status at
Year End




>90% (3 consecutive months)

Wye Valley NHS Trust must submit its
planned training programme in April
2013 and report at the end of year on
the progress against these plans
Wye Valley NHS Trust must undertake
a monthly survey of carers of people
with dementia and report the findings to
their board at least twice a year.
>95%
>95%
Increase in numbers from baseline
Increase in numbers from baseline






Increase in numbers from baseline

Complete survey in Q2, take action and
then resurvey in Q4

Key Achievements







Successful implementation of the Friends and Family Test within maternity services
and community hospitals.
Response rate for A&E increased from 16.28% in April 2013 to 25.8% in March
2014.
Volunteers are involved in promoting and collecting Friends and Family data from
patients.
Improved data validation for the Safety Thermometer data collected by ward staff.
Began roll out of electronic Safety Thermometer data collection.
Implementation of dementia training plan across the County Hospital.
Implemented weekly monitoring and alerts for non-completion of VTE risk
assessments.
57
Lessons Learned/Areas identified for further improvement



Consideration of roll out of dementia training for community staff.
The Safety Thermometer data will be further utilised in 2014/15 to monitor reduction
in harm free care.
Friends and Family Test will be rolled out to outpatient departments.
2.4 Staff Engagement
2.4.1 Staff Survey
Introduction
The annual NHS staff survey is completed by every NHS trust and compares performance
against other NHS Trusts and the previous year’s performance.
Performance Data
-
-
82% of staff either agreed or strongly agreed that they feel satisfied with the
quality of work and patient care they are able to deliver
54% of staff either agreed or strongly agreed that would be happy with the
standard of care at their trust is friends and family needed treatment
74% staff appraised
72% staff receiving job relevant training, learning and development
49% staff able to contribute to improvements at work
Key Achievements
There has been an increase in the number of staff who had an appraisal and a decrease in
the number of staff who felt they had suffered discrimination
Lessons Learned/Areas identified for further improvement
Staff reported a decrease in the amount job related training and also equality and diversity
training. We will be addressing these issues through the Trust’s Engagement Strategy and
Organisational Development Strategy.
2.4.2 Recruitment in Maternity, Health Visitors
and Nursing
The National Quality Dashboard issued guidance in relation to staffing capacity and
capability in November 2013. We have been working hard to ensure we have the
appropriate Midwifery, Health Visiting and Nursing workforce in place within the Trust so that
we can provide the best possible care to our patients.
58
Performance Data



Midwife to Birth ratio 1:30.
Health Visiting on target to meet the nation Health Visitor number for Hereford of 40.9
by March 2015.
Increased numbers of qualified staff in inpatient areas.
Key Achievements



Successful recruitment from overseas for nurses, 20 in place by the end of March
2014.
The Trust is now fully recruited to established midwifery levels which has been
positively impacted by the introduction of a midwifery academy.
Increased staffing levels in some community hospitals and medical and surgical
wards.
Lessons Learned/Areas identified for further improvement
Further work is underway to increase nursing members on wards and we are looking at
creative ways to recruit District Nurses. Six monthly reports on staffing levels are presented
to the Board.
2.5 External Reviews
2.5.1 West Midlands Quality Review Service
(WMQRS) Acquired Brain Injury team (ABI)
This review was initiated by Herefordshire Clinical Commissioning Group (HCCG) with the
Trust to clearly understand the service and give clear guidelines for improving the service
moving into 2014/15. The WMQRS team reviewed the community ABI team at Belmont on
5/12/13 but were unable to meet 2Gether trust regarding the Mental Health aspect of the
service. HCCG met the reviewers and gaps in service specification were identified.
Key Achievement


An excellent community based service was identified.
The ‘Return to Real Life’ programme was praised for being clear and restructured.
Lessons Learned/Areas identified for further improvement







Clear pathways of referral to the team were missing.
Out of county placements often have poor review processes in place.
Clear outcomes and goals for patients receiving individual rehabilitation programmes
were hard to identify.
Limited Mental Health services have been commissioned.
No Neurological Rehabilitation consultant hours are commissioned.
Clear service specification is needed for aspects of the ABI pathway.
Close working with NHS Herefordshire Clinical Commissioning Group is paramount.
59
2.5.2 Rapid Responsive Review and Care
Quality Commission Visit
On October 10 and 11 2013 the Trust was subject to a Rapid Response Review (RRR) and
Care Quality Commission (CQC) Visit. The key areas covered by these visits were:




Patient Experience
Workforce and Safety
Governance and Leadership
Clinical and Operational Effectiveness
As a result of these visits the findings have been collated and used to develop the Patient
Care Improvement Programme.
The Patient Care Improvement Plan is a comprehensive plan of action that is being
delivered across the Trust’s operational and corporate directorates. The plan has been
formulated to address essential service improvements to ensure that we deliver high quality,
safe care to the patients and carers who use our services. The plan coordinates the actions
that we are putting in place, following recent inspections. All of these actions aim to make
specific service improvements.
Lessons Learned/Areas identified for further improvement
A number of areas were identified where the Trust need to make further improvements.
These included:






The use of the Day Case Unit for inpatients
Mixed sex breaches within the Day Case Unit
Medical cover arrangements within community hospitals
Monitoring of governance and leadership arrangements
Process for recording and reporting complaints data
Awareness of Friends and Family Test amongst front line staff members
Key Achievements
Since the visit, the Patient Care Improvement Programme has been developed and actions
are underway to make the necessary improvements. To date we have:













Developed the Safety culture Survey and rolled it out to frontline staff.
Ensured annual monitoring of governance and leadership arrangements are in place.
Developed an enhanced training programme in relation to governance and
leadership.
Improved Executive and Non-Executive Director visibility throughout the organisation.
Opened the Clinical Assessment Unit (CAU) which is now operational seven days a
week.
Enhanced the phlebotomy service.
Increased medical input to community hospitals.
Implemented the mortality reduction plan.
Presented patient stories at the Trust Board.
Improved complaints data provided from Ward to Board and vice versa.
Rolled out Friends and Family data to community hospitals.
Undertaken a review of Nursing and midwifery establishments.
Provision of pressure area prevention materials reviewed and re-launched.
60



Strengthened the Standard Operating Procedures for Day Surgery Unit.
Developed a long term plan to improve the Day Surgery Unit layout.
Reviewed and updated the processes in relation to maximising privacy and dignity
within Day Surgery Unit.
2.5.3 Royal College of Obstetricians and
Gynaecologists (RCOG) Review
On the 23 and 24 October 2013 the Royal College of Gynaecologists attended Hereford
Hospital to conduct a review into our Maternity Services. The visit was undertaken at the
request of the Medical Director in response to a Serious Incident Requiring Investigation
(SIRI).
Lessons Learned/Areas identified for further improvement
The report identified that a number of areas in the maternity service that required further
improvement. To this end, an Extraordinary Plan (EOP) was put in place to address
concerns pertaining to sustainability of the current model of care.
Key Achievements
The review noted that all staff are ‘dedicated and committed to providing safe and
sustainable maternity care for the women they serve. The review supported the governance
and risk strategy/agenda and recognised the significant improvements that had taken place
in recent weeks.
Through management of this EOP 20 actions have been completed. The outstanding actions
have a scheduled completion date by 1 April 2014.
The improvements undertaken have seen positive quality and safety outcomes and, with
additional allocation of resources made available for 2014/15, we are confident that
improvements will be sustained.
Any Other Information The Trust has been supportive of the improvements needed to meet the safety standards
required, this included agreement for a 6th consultant.
61
Section 3: Mandatory Statements
Relating to Quality of NHS
Services Provided
Introduction
This section includes all the mandatory section that are required as part of the Department of
Health Quality Accounts Toolkit. It provides details of key quality aspects relevant to the
Trust.
3.1 Review of Services
During 2013/14 we provided and/or sub-contracted 54 NHS services. Wye Valley NHS Trust
has reviewed all the data available to them on the quality of care in 54 of these NHS
services.
The income generated by the NHS services reviewed in 2013/14 represents 100 per cent of
the total income generated from the provision of NHS services by Wye Valley NHS Trust for
2013/14.
3.2 Participation in Clinical Audit
During 2013/14, 29 national clinical audits and 3 national confidential enquiries covered NHS
services that Wye Valley NHS Trust provides.
During that period Wye Valley NHS Trust participated in 27 (93%) national clinical audits and
3 (100%) national confidential enquiries of the national clinical audits and national
confidential enquiries which it was eligible to participate in. Decisions were made not to
participate in the remaining two national audits, as follows:


The decision not to participate in the National Cardiac Arrest Audit was taken after
review by Resuscitation Committee showed that the national audit would not provide
anything over and above that already provided by the Trust’s well established audit of
all cardiac arrests.
The Trust did not participate in the current round of the Paediatric Asthma Audit as
results from previous rounds showed that the Trust performed well. The clinical
team involved wished to focus their 2013/14 audit activity on areas where
improvements may be required.
The table below lists the national clinical audits and national confidential enquiries that Wye
Valley NHS Trust was eligible to participate in during 2013/14 and indicates whether or not
participation took place. The table also shows the number of cases submitted to each audit
or enquiry as a percentage of registered cases required by the terms of that audit or enquiry
for those where data collection was completed during the period April 2013-March 2014.
62
Comments
WVT
participated
Percentage of
required cases
submitted
Acute coronary syndrome or Acute
myocardial infarction

Data submission
ongoing
Adult critical care (Case Mix
Programme)

Data submission
ongoing
National Bowel Cancer Audit

Data submission
ongoing
Eligible National Audits
Cardiac Rhythm Management National
Audit

Data submission
ongoing
Chronic Obstructive Pulmonary
Disease National Audit

Data submission
ongoing
Data for calendar
year 2013 –
submission rate
estimated at
100%.
Adult Diabetes Audit Programme,
includes:
100%
Retrospective
data submission
for 2012/13 of all
patients seen in
diabetes
outpatient clinics
100%
All eligible
inpatients at the
time of the audit
100%
Relates to eligible
women who
consented to take
part in the audit
100%
Retrospective
data submission
of all patients
seen in diabetes
outpatient clinics
between January
2012 and March
2013.




Adult Diabetes Audit
National Diabetes Inpatient Audit
Pregnancy in Diabetes Audit
National Paediatric Diabetes Audit



63
Comments
WVT
participated
Percentage of
required cases
submitted
Elective surgery (National Patient
Reported Outcomes Measures
Programme)

Data submission
ongoing
National Emergency Laparotomy Audit

Data submission
ongoing
Epilepsy 12 National Audit (Childhood
Epilepsy)

Data submission
ongoing
Falls and Fragility Fractures Audit
Programme includes National Hip
Fracture Database

Data submission
ongoing
National Head and Neck Cancer Audit

Data submission
ongoing
National Heart Failure Audit

Data submission
ongoing
Eligible National Audits
Inflammatory Bowel Disease National
Audit
National Lung Cancer Audit

100%

Data submission
ongoing
National Audit of Moderate or Severe
Asthma in Children (Care provided in
Emergency Departments)

100%
National Audit of Seizure Management

100%
National Cardiac Arrest Audit

.
National Comparative Audit of Blood
Transfusion Programme

Data submission
ongoing
National Joint Registry

Data submission
ongoing
Neonatal Intensive and Special Care
National Audit (National Neonatal Audit
Programme)
Round Two
Eligible ulcerative
colitis cases and
organisational
data
Maximum of 50
cases required
Data period by
calendar year.

100%
All babies
admitted to
Special Care
64
Comments
Eligible National Audits
WVT
participated
Percentage of
required cases
submitted
Baby Unit.
National Oesophago-Gastric Cancer
Audit

Paediatric Asthma Audit (British
Thoracic Society)
.
Paediatric Bronchiectasis Audit (British
Thoracic Society)
Paracetamol Overdose National Audit
(Care provided in Emergency
Departments)


Sentinel Stroke National Audit
Programme
Data submission
ongoing
Participated but the number of cases
eligible for inclusion in the audit (3)
was below the minimum number set
(5) for analysis and reporting.
100%

Data submission
ongoing
Severe Sepsis & Septic Shock National
Audit

100%
Severe Trauma (Trauma Audit &
Research Network)

Data submission
ongoing
Rheumatoid and Early Inflammatory
Arthritis National Audit

Data submission
ongoing

N/A

Data submission
ongoing
Maximum of 50
cases required
In latest national
interim report the
Trust is reported
as 80-89%
submission rate
Maximum of 50
cases required
Eligible National Confidential Enquiries
Child Health Clinical Outcome Review
Programme
Maternal, Infant and Newborn Clinical
Outcome Review Programme
Reported by
national centre as
100% in
December 2013
Medical and Surgical Clinical Outcome Review
Programme: National Confidential Enquiry into Patient
Outcome and Death (NCEPOD).
Studies active in 2013/14:
65
Comments
Eligible National Audits
WVT
participated
Percentage of
required cases
submitted

Subarachnoid Haemorrhage Study

100%

Tracheostomy Study

100%

Lower Limb Amputation Study

100%

Gastrointestinal Bleeding Study

Data submission
ongoing
Review of Clinical Audit Reports
Within Wye Valley NHS Trust the reports of national and local clinical audits are reviewed by
the clinical teams involved in the audit. If the review indicates that improvements are
required action plans are devised and implemented. Reports and action plans of all audits
are reviewed by the Service Units Governance Groups. Reports and action plans from
national audits are reported to the Trust’s Quality Committee (sub-committee of the Trust
Board). This Quality Account gives details below of reports and action plans that reached
the stages of reporting to Quality Committee and/or Service Unit Governance Groups in
2013/14.
The reports of 13 national clinical audits were reviewed by Wye Valley NHS Trust in 2013/14
and the Trust intends to take the following actions to improve the quality of healthcare
provided:
Audit
National Diabetes Audit (Adult) 2011/12
The National Diabetes Audit is repeated on an annual basis and includes primary
and secondary care. For secondary care it includes data on all patients attending
diabetes outpatient clinics. The report published in 2013/14 covered patients seen
between January 2011 and March 2012.
Action
The results were reported in two parts:
Part One - Care Processes and Treatment Targets

The need for foot examination to be carried out in primary care as part of the
patients’ annual review is being clarified and agreed with the Clinical
Commissioning Group.
 Further data to be collected on the delivery of structured education.
Part Two – Complications and Mortality

No individual results given for regions or hospitals so no specific action can be
identified.
66
Audit
National Diabetes inpatient audit 2012 (reported 2013)
This audit is part of the wider national diabetes audit programme and is a snapshot
audit of inpatient care on one particular day. Results published in July 2013
showed areas of good performance but the following actions are being taken to
achieve further improvements.
Action
Audit

The national ‘Think Glucose’ campaign will continue to be publicised within the
Trust. This is to raise staff awareness of which patients, whilst in hospital, are
to be reviewed by a member of the diabetes team. ‘Think Glucose’ will also be
included in planned education sessions to clinical staff.
 The importance of foot examination for hospitalised patients with diabetes will
be highlighted to all members of the Department of Medicine at an education
session.
 To reduce the risk of any errors in insulin medications being made it will be
mandatory for all hospital prescribers, ward pharmacists and trained nurses
involved in administering insulin to complete the E-learning training on Safe
Use of Insulin.
National Paediatric Diabetes Audit
This national audit is repeated on an annual basis. During the year, three national
reports have been issued.
Actions Annual report of care processes (2011/12)
 Structured education and updates to continue, with events in 2014.
Complications report (2011/12)

The report has been reviewed but no hospital specific results are given. No
specific actions identified by the review.
Patient and Parent Reported Experience Measures (2012/13)

Audit
Business Plan has been submitted and approved for the appointment of a
second consultant paediatrician with an interest in diabetes and for dedicated
psychology support.
National audit of cardiac rhythm management
This national audit collects continuous data and reports annually. The most recent
report, the 7th annual report, describes cardiac device implantation performance in
each Cardiac Network in England and Wales for 2011.
Action



To increase access rates for cardiac pacing, particularly from Accident and
Emergency. A new Spacelab module is to be implemented, which will enable
digital archiving of Electrocardiograms (ECGs). The intention is for all
Accident and Emergency ECGs to be uploaded to the archive. This can then
be used to identify ECGs with relevant abnormalities.
To make the syncope clinic more accessible Protocols and pathways for
syncope clinic to be developed
To ensure correct interpretation in all healthcare settings of ECGs in patients
who have had a collapse an educational/long term strategy will be developed
for syncope and falls over the next 2-3 years, to include learning opportunities
for both primary and secondary care. Education on syncope will be included in
the annual cardiology education day.
67
Audit
British Thoracic Society National Paediatric Asthma Audit 2012/13
This national audit included children admitted with acute asthma during November
2012. Data were collected by the paediatric respiratory team and analysed by the
British Thoracic Society.
Action
Results indicated improvements had been achieved on those of the previous year
but further actions taken as follows:

Audit
Asthma pathway developed, to be used alongside normal clerking
documentation and Paediatric Asthma Warning tool
 Pre-printed drug chart developed to be used at admission of children with
asthma/wheeze
British Thoracic Society National Audit of Paediatric Pneumonia 2012/13
This national audit included children admitted with pneumonia over the three month
period November 2012 – January 2013. Data were collected by the paediatric
respiratory team and analysed by the British Thoracic Society.
Action

Results of audit and areas where improvements required presented at
Paediatric audit meeting, with handouts summarising BTS guidelines on
management of paediatric pneumonia
 Teaching sessions by paediatric respiratory team to include appropriate
indications for investigations, chest physiotherapy and follow-up appointments
and chest X-ray
 Review of the Wye Valley Trust antibiotic policy in the light of British Thoracic
Society guidelines
 Make British Thoracic Society guidelines on paediatric pneumonia available on
the Trust intranet
Audit
British Thoracic Society National Audit of Chronic Obstructive Pulmonary
Disease discharges. Data were collected from patients with a diagnosis of COPD
who were discharged from hospital during a two month period in 2012. Results
were reviewed by the Respiratory Medicine Team and actions developed:
Actions  COPD care bundle, based on the British Thoracic Society Care Bundle,
developed for use in the Trust.
 COPD Personalised Care Plan developed for use by Neighbourhood Teams for
patients being seen in their homes.
 Increase the checking and recording of inhaler techniques by group training on
inhaler technique to all existing trained staff on medical wards in the acute and
community hospitals; new trained staff to attend Respiratory Nurse-led study
day which includes inhaler technique; up to date inhaler technique file including
written instruction on inhaler technique to be kept on each medical ward.
 Liaise with ambulance service to make them aware of patients on the
respiratory database
Audit
British Thoracic Society, National Audit of Emergency Oxygen (2012/13)
The British Thoracic Society audit of emergency oxygen involved collecting data on
inpatients using oxygen at the time of the audit, to assess whether oxygen had
been prescribed in accordance with the Trust’s policy. Data were collected by the
Trust’s Respiratory Clinical Nurse Specialists, with analysis and reporting by the
British Thoracic Society.
68
Action
Audit

Feedback given to nursing and medical teams in all areas to highlight that
oxygen is to be prescribed, signed for and reassessed in keeping with past
medical history.
 All ward sisters asked to nominate a staff nurse to be oxygen link nurse for the
ward. Role of link nurse is to help with training to ward staff on the use of
oxygen and to keep staff updated.
 Staff nominated as “Oxygen champions” to explore options for making oxygen
prescribing part of mandatory training.
Acute coronary syndrome or acute myocardial infarction national audit
(MINAP)
Action
The twelfth MINAP annual report, published in October 2013, contained analyses
from all hospitals and ambulance services in England, Wales and Belfast that
provided care for patients with suspected heart attacks between April 2012 and
March 2013.
Review of the results did not identify the need for any specific action to be taken.
Audit
National Bowel Cancer Audit
Results of this continuous national audit are published annually. The report
published in August 2013 included the results of data collected on patients
diagnosed with bowel cancer in 2011/12.
Action
Audit

To improve the completion and accuracy of electronic data uploaded to the
national system, an application has been made to appoint a General
Surgery/Colerectal coder.
 To reduce the average length of stay in hospital for patients with bowel cancer
and reduce unnecessary readmissions, an application has been submitted for a
treatment room to allow rapid assessment of patients discharged after major
surgery.
 Increasing the average yield of lymph nodes has been discussed with site
specific pathologist.
Trauma Audit & Research Network (TARN)
This on-going national audit looks at aspects of the care given to patients with
severe trauma, including before arrival in hospital, and measures survival rates
according to severity of trauma.
Action
Audit

The Trust’s Trauma Sub-group reviews each 4-monthly report to assess
whether any improvement actions are required.
 Results on time to CT scanning led to the review of outliers to check on data
accuracy
 The reports are used to inform the content of multi-disciplinary trauma
meetings.
National Heart Failure Audit
This audit was established in 2007 to monitor and improve the care and treatment
of patients with an unscheduled admission to hospital in England and Wales with
acute heart failure. The sixth annual report included patients discharged from
hospital between April 2012 and March 2013.
69
Actions Following a review of the report by the Heart Failure Team, actions have been
taken to ensure that relevant patients with heart failure are admitted to the
appropriate clinical area and are under the care of Cardiologists where required:

Audit
Heart Failure Nurses can now directly refer patients under the care of other
specialties to the cardiologists
 Heart Failure Nurses can now initiate a patient move to the Cardiology Ward
 Heart Failure Multidisciplinary Group established, to improve the triage of
patients to the appropriate area of care
 A trial of regular meetings held in order to help enhance the transfer of patients
to the appropriate areas of care and to be seen by the right teams during their
stay in hospital.
Intensive Care National Audit
This national audit has been running since 1994 and now collects data from 90% of
adult critical care units in England, Wales and Northern Ireland. Data on patient
activity and outcomes of all patients admitted to critical care are submitted to
ICNARC for analysis and reporting. Intensive Care and National Audit Research
Centre (CMP) Case Mix Programme Annual Quality Report 2012/13 was published
December 2013
Actions 

Multi-disciplinary meetings established on monthly basis
Every death that appears on the ICNARC registry is reviewed at the monthly
multi-disciplinary meeting. All deaths were reviewed for 2012-13 and raised no
specific concerns.
The reports of 40 local clinical audits were reviewed by Wye Valley NHS Trust in 2013/14
and Wye Valley intends to take the following actions to improve the quality of healthcare
provided. .
Local Clinical Audits where actions are required:
Audit
Cardiac Arrests and Emergency Calls
A continuous audit of all cardiac arrests and other emergency calls made to the
Resuscitation Team is performed in the Trust. Results are reported quarterly and
reviewed by the Trust’s Resuscitation Committee for identification of action, before
being reported to the Trust’s Quality Committee.
Action
Audit

The patient booklet ‘Your guide to decisions about cardiopulmonary
resuscitation’ has been sent to all local General Practices and Community
hospitals, as well as being made available on relevant wards at the acute
hospital
 To prevent duplication of calls to maternity, staff have been reminded of the
indications for calls to be made to the obstetric team and those to the neonatal
team.
Audit of ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR)
documentation within the acute and community settings
The audit assessed whether the Trust’s policy on DNACPR was being followed in
respect to staff knowing the DNACPR status of patients; appropriate completion
70
and location of DNACPR documentation.
Action
Audit

Any DNACPR forms to be filed at the front of the patient’s notes so that it is
clearly visible to staff caring for the patient.
 The nurse in charge of the ward at the time of a DNACPR decision being made
is to document the decision in the nursing notes.
 All DNACPR forms completed by doctors below Consultant level to be
countersigned by a Consultant-level doctor within 24 hours
Audit of Care Bundles
Care bundles specify evidence-based interventions to be performed for patients
with specific conditions. Each bundle has between three and five specified
interventions. Six new care bundles were introduced in the Trust in 2013/14. Use
of these new care bundles, and an existing bundle, are audited on a regular basis
to assess whether they are being used and completed.
Action
Audit


Awareness of care bundles raised through medical and surgical meetings
Care bundle for Chronic Pulmonary Disease and Community Acquired
Pneumonia redesigned
 Audit to continue with monthly data collection
Audit of National Early Warning Score
The National Early Warning Score (NEWS) is a standardised track-and-trigger
system for acute illness in people presenting to, or within hospitals. Audit was
carried out following implementation of the system in the Trust in 2013.
Action
Audit

Present results of the NEWS audit at Senior Nurse meetings and Medical staff
meetings
 Roll out audit results and recommendations to all Trust staff through Team
Brief
 Explore the potential for incorporating NEWS into the electronic data system
used in Accident and Emergency
 Develop competency-based training packages for qualified nursing staff,
healthcare assistances and junior medical staff
 Weekly review of the use of NEWS to be carried out on a sample of ward
based patients
 Feedback to be provided to any individuals who fail to use the NEWS tool
appropriately
 Any instances where an escalation request has not resulted in an appropriate
response will be reported through the Trust’s incident reporting system and
used to provide monthly feedback of generic issues
 Weekly review by consultants on ward rounds in relation to documentation of
NEWS and medical management plans
Use of the SSKIN bundle in District Nursing - SSKIN (Skin, Surface, Keep
moving, Incontinence and Nutrition) Bundle - audit was carried out to specifically
look at the use of the SSKIN Bundle and the implementation of care plans. This
was also to inform the review of current district nursing documentation.
71
Action
Areas of good practice were identified but further work is underway to identify why
some assessments and care plans are not completed in a timely manner.
 Review of working and communication relationships with Care Agencies
 Training for Care Agencies by Tissue Viability Nurse service, including use
of SSKIN bundle and pressure area care
 Review current District Nursing documentation
 Develop and issue clear guidelines for District Nurse teams
 Develop Core Care plans.
 Provide educational sessions
 Hold one to one meetings with all relevant staff to review Wye Valley Trust
processes and procedures
Audit
Resuscitation Trolley Audit - The resuscitation trolleys have historically been
audited on a regular basis to ensure that the equipment is intact and also to identify
any failure in the regular checks that are required.
Action
Audit
Action
Audit
Action
Audit
Action
Audit
Action

Feedback on the results is given to each clinical area, to raise awareness of
and immediately rectify any issues
 Trolley in Radiology moved to more appropriate location
Review of effectiveness of paediatric aminoglycoside drug monitoring chart
– This audit was undertaken to assess the use of a checklist developed to aid
nursing staff in the administering of these drugs.
 Revise checklist to show amendments that have been identified
 Reminder and education to staff about the checklist and its importance
 Reminder to staff about importance of recording the drug levels
Robson Group 1 Audit - This audit was a review of Labour Ward practice in a
specific category of obstetric patients (Robson Group 1 )


Case review discussions to be carried out daily in Delivery Suite
Up to date training on cardiotocography to be completed by all relevant staff
Audit of Symptom Control in Dying Patients with Renal Failure – This Audit
was undertaken to compare current practice on symptom control in dying patients
with significant renal failure with hospital guidelines

Increase the use of renal specific symptom control guidelines by ward
doctors
 Information about the renal specific guidelines have been Incorporated into
education programme for hospital doctors
Bacterial meningitis and meningococcal septicaemia - To review admissions of
children and young people with suspected bacterial meningitis or meningococcal
disease, using National Institute Clinical Excellence (NICE) guidance
Re-education programme for medical staff covering:


The importance of monitoring all vital signs, including temperature and
neurological assessment hourly until the patient is stable.
The NICE guidance and recommended antibiotics, especially in babies less
than 3 months of age.
72

The importance of patients receiving antibiotics within 1 hour of admission,
and to document the reason for any delay.
Doctors to document:


Audit
Action
Audit
Action
Audit
Action
Audit
Action
Audit
Action
Audit
Action
Audit
Who transferred the child within hospital
Information given at discharge after a diagnosis of meningitis or
meningococcal disease, regarding long term effects and accessing future
care.
 Audiology test to be booked within 4 weeks and consultant follow up
booked within 6 weeks of discharge.
Quality of child protection medical reports produced by doctors in the
paediatric department - The main reason for conducting this audit is to establish
the overall quality of child protection medical reports which are then shared with
other relevant Safeguarding Agencies.
 Report always to be countersigned by relevant Consultant
 Printed version of the report to be in agreed layout
Re-audit of Appropriate Use of Platelets - To re-audit compliance with the British
Committee Standards in Haematology Guidelines for the Use of Platelet
Transfusions, on which the Trust Guidelines are based. Also to audit the
appropriate use of platelets.


Include Clopidogrel as an acceptable indication in policy
The Hospital Transfusion Committee is to specify the minimum platelet
count required for invasive procedures
Audit of positive Gonorrhoea cases against The British Association Sexual
Health and HIV (BASHH) auditable outcome measures – The aim of this audit
was to measure compliance with guidelines


Provider referral to be the default method of contact tracing
In-house leaflet issued at time of treatment stating date for Test of Cure and
need to contact trace sexual contacts
 When disclosure of clinic location of where contacts attended is requested,
clinician to clinician verification to be made via phone call
Anaphylaxis audit – Audit of compliance with NICE guidelines

Anaphylaxis pathway for adults and children now published and available
online
 Advice leaflet available for adults and children admitted with anaphylaxis
 Agreement from Biochemistry to perform Mast Cell Tryptase for
anaphylaxis
Audit of antenatally detected renal pelvis dilatation – Audit to measure
compliance with local guidelines

Introduce new structured sheet to help with the recording of birth
information
Audit of fetal scalp lactate 
Further staff training to improve the immediate fetal paired cord gas blood
pH analysis and documentation of the results.
Audit of Difficult Airway Equipment - This audit seeks to compare practice in
73
Wye Valley NHS Trust to a published national standard
Action
Audit
Action
Audit
Action
Audit
Action
Audit

Standardise the equipment for trolleys and devise a checklist of equipment
Audit of availability of alternative means of ventilation in all areas where
anaesthesia is provided - The purpose of audit was to check compliance with
guidelines regarding alternative means to ventilate patient

Place paediatrics self-inflating bags in Accident and Emergency
resuscitation area
 Place new checklist in all theatres for daily equipment check
Audit of adherence to 'Stop Before You Block' guidelines – This audit was to
measure adherence to guidelines following an alert published via the National
Reporting and Learning Service (NRLS)

Laminated poster displayed in anaesthetic room to raise awareness of the
‘Stop Before You Block’ campaign
Audit of major Haemorrhage Protocol - The aim of the audit was to review each
haemorrhage call in line with Trust guidelines to determine the appropriateness of
the call, wastage, communication, and laboratory response time.



Update switchboard’s haemorrhage protocol and log sheet
Devise & trial a haemorrhage proforma
Plan & undertake haemorrhage drills in Accident and Emergency,
Endoscopy and Theatres
Re-audit of the time to emergency surgery.
This was a second audit comparing local practice with Royal College of Surgeons
2011 guidelines on standards for unscheduled surgical care.
Action
Audit

The second audit showed that actions taken following the first audit had
achieved improvements. The second audit led to the code of urgency
being further defined.
Supplementation to breast-fed babies of formula feeds
This audit assessed local practice with the UNICEF Baby friendly Initiative (2010)
standard that - Food or drink, other than breast milk should only be given to
breastfed babies in cases of acceptable clinical indication, fully informed parental
choice or other reasons beyond the control of the hospital.
All eligible babies over a 6 month period were included in the audit
Action


Breastfeeding to be promoted by:
o Posters and leaflets in relevant areas.
o ‘Handy Hints’ laminated cards that all breastfeeding mums can access
for information on the maternity ward to be developed.
o Educating staff on risks and benefits of supplements of formula feed on
health and milk supply within feeding update sessions
The need to improve documentation to be addressed through discussions
within education updates/midwifery academy on informed consent.
Record keeping/documentation audits
74
The Trust carries out audits of clinical record keeping to ensure that the quality of the clinical
record facilitates high quality patient care and that subsequently the health record can justify
any clinical decision if required. Where results showed improvements were needed the
following actions are being taken:
Audit
Action
Audit
Action
Audit
Action
Audit
Action
Medical Inpatient Case-note Audit 
Written information on the standards of record keeping provided in the
induction packs for new doctors starting with the Trust.
General Surgery Record Keeping  Devise a typed surgical proforma for the recording of operation notes
 Update record keeping policy document
Accident & Emergency Department Record Keeping Audit 
Change to be made to the electronic system to enable the paediatric
assessment tool to appear if triage is not completed
 Improve process of completing information for patients discharged to the
ward.
Obstetric Record Keeping 
Introduction of ink stamps to improve the identity and legibility of signatures
Audit
Anaesthetic Record Keeping -
Action
 Procedure-specific leaflets to be handed to patients in both the wards and
pre-operative assessment clinic - Addition of a box on the chart to confirm
the patient received the leaflet
 Addition of “induction” and “knife to skin” boxes to the chart where the
corresponding times can be documented.
 Addition of “airway pressures” box to the chart
 Space on chart to document specific post-op instructions
 Addition of a box to the chart which can be ticked if there are no specific
further instructions e.g. “Routine post-operative care”
 Regular reminders for trainees and consultants at departmental
meetings/teaching
Physiotherapy Record Keeping -
Audit
Action
Audit
Action
 Include the Physiotherapy assistants in the audit process
 Derive a list of common contraindications for each inpatient team to assist
completion of assessment sheets - Discuss with all staff across inpatient
teams & Produce a word document that can be used in ward files
Occupational Therapy Record Keeping
 Team to receive feedback on current practices within record keeping
compared with guidelines (will highlight problem areas) with In-service
training on areas for improvement and national guidelines update
3.3 Participation in Clinical Research
75
The number of patients receiving NHS services provided or sub-contracted by Wye Valley
NHS Trust in 2013/14 that were recruited during that period to participate in research
approved by a research ethics committee was 159.
3.4 Use of the CQUIN payment framework
A proportion of Wye Valley NHS Trusts income in 2013/14 was conditional on achieving
quality improvement and innovation goals agreed between Wye Valley NHS Trust and any
person or body they entered into a contract, agreement or arrangement with for the provision
of NHS services, through the Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for 2013/14 are included in Section 2.3.3 and the
following 12-month period is available electronically on the Trust website.
3.5 Statements from the CQC
The Trust is required to register with the Care Quality Commission and its current status is
registered without conditions.
The Care Quality Commission has taken enforcement action against the Trust during
2013/14.
The Trust has made the following progress by 31 March 2014 in taking such action;
 All staff have been reminded of the importance of providing patients with information
about how to prevent pressure damage to their skin.
 The availability of patient information has been checked within all wards across the
Trust.
 Spot checks have been initiated during Patient Experience Walk Rounds to check
patients receive and understand the information they have received.
 Ward Sisters conduct periodic reviews of all documentation to ensure the provision of
patient information is being documented.
 A Trust wide audit of the use of the SSKIN bundle will be undertaken in July 2014.
 Training for staff will include the need to provide patient information booklets for
patients
 A project group has been set up to formulate a plan of additional long term works
required to maximise privacy and dignity within the DSU.
 Female surgical patients have been rerouted to ensure they do not pass through a
male occupied area following surgery.
 Temporary privacy screens were put in place immediately following the inspection
visit to eliminate the line of site between male and female bays.
 Permanent medical privacy screens have been purchased to eliminate direct line of
site between male and female bays.
 Mixed sex breaches are monitored on a daily basis and reported to NHS
Herefordshire Clinical Commissioning Group (CCG) weekly.
 All incidents in relation to mixed sex breaches are reported and investigated via the
Trust’s incident reporting processes.
 Small storage lockers used for DSU patients made available to inpatients for their
belongings.
 DSU department is looking to purchase slim mobile units as a more permanent
solution to storage issues.
 Clinical Assessment Unit opened in October 2013 to reduce the need to use outlier
areas for inpatients. This was extended in size and scope from January 2014.
 The use of DSU is on the risk register and reviewed monthly by the Service Unit and
Trust Executive Committee to ensure privacy and dignity is optimised.
 All inpatient admissions are recorded on Datix. A daily report is provided to
Executives and a monthly report to Quality Committee.
76



























From 10 January 2014 surgical cases only may be located in the Day Surgery Unit.
The Trust’s plan (assuming full use of the CAU) is to cease to use the Day Surgery
Unit for inpatients during February 2014.
All staff have been reminded of the importance of completing the SSKIN bundle and
following the SSKIN bundle guidance.
Ward Sisters conduct periodic reviews of all documentation to ensure this is been
completed accurately.
The Trust’s Training plan for the prevention and management of pressure area care
is being reviewed to ensure staff receive robust and regular training.
A full route cause analysis was undertaken in relation to the patient identified during
the inspection visit whose NEWS chart was not followed.
The DSU SOP provides clear guidance to staff about the use of the DSU for inpatient
beds. Within this it is made clear that one of the exclusions for admission to the DSU
are patients with a single NEWS score of 3 or combined score of 5.
NEWS audit was conducted during December 2013. The results will be reported to
the Quality Committee in February 2014.
Unexpected admissions to ITU /HDU and suboptimal care of the deteriorating patient
are now reported as separate fields within DATIX.
A NEWS campaign was conducted across the Trust to raise awareness.
Additional training in relation to the use of NEWS has been conducted across the
Trust by the Practice Development Team.
A revised training programme for 2014 has been developed by the Practice
Development Team (PDT) and Tissue Viability Nurses.
The Link Nurse training programme is being re-established across the Trust.
The Tissue Viability Action Plan has been updated and monitored by the Director of
Nursing & Quality.
A revised TNA has been developed for implementation across the Trust.
An action plan has been developed to ensure training is delivered in accordance with
the TNA.
Alternative training is routinely offered if training is cancelled due to operational
pressures.
A revised Induction Programme has been developed by the PDT.
ESR is being updated to allow for training data to be provided in a more user-friendly
format for reporting and monitoring both locally and by the Trust.
Learning lessons from incidents, complaints, claims and audit are included within
Trust Talk and Team brief
The Director of Nursing & Quality holds meetings monthly with the Heads of Nursing
and Ward Sisters upon which learning lessons is a standing agenda item.
Formalised documentation of learning for incidents, complaints and claims is taken to
Service Unit meetings by the Quality and Safety team on a monthly basis.
A six monthly report will be provided to the Quality Committee on “learning from
incidents, complaints and claims”
Nursing metrics including Friends and Family (FFT), complaints, compliments,
pressure ulcers, patient falls, medication errors and ‘You said… We did…’ are
provided monthly to wards. This ensures staff and patients have access to relevant
ward/department information on a monthly basis
Weekly FFT data is sent to ward managers.
Staff knowledge regarding never events and other issues that have occurred within
their area are included within the Patient Experience Walk rounds.
Generic PowerPoint presentation slides are included within each Trust training
session. These will highlight learning across the organisation from incidents,
complaints, claims and audits
77















Staff listening events were undertaken during November 2013 and reported to the
Trust Executive Meeting in February 2014.
A rolling programme of on-going listening events is planned for 2014 to enhance the
dialogue between senior management and the workforce.
The Trust has commenced an annual programme to capture staff feedback through
the Safety Culture Survey.
A global email was sent by CEO to all staff emphasising the importance of reporting
incidents and taking positive steps to maintain quality care for patients Each Service
Unit reviews its risk register (in accordance with the Risk Management Strategy) at
their monthly Service Unit Governance Group. The risks are discussed, prioritised
and any risks requiring escalation are identified.
The Service Unit Directors (SUDs) or representative attend the Trust wide Service
Unit Performance Committee at which they are expected to raise issues pertaining to
the risk register. The Service Unit Directors are also invited and encouraged to
attend the Quality Committee where clinical commitments allow. If the Service Unit
Director is unable to attend a representative from the Service Unit is expected to
attend in their place.
The risk register and any significant Service Unit risks are discussed at both the Trust
wide Service Unit Performance Committee, Trust Executive Committee and any
significant issues are escalated to the Trust Board (via the Trust Executive
Committee) so that appropriate actions can be taken.
Quality and safety issues are reported to the Quality Committee where additional
actions are discussed, recommended and agreed. In addition, all minutes of the Trust
Executive Committee are sent to the Non Executive Directors.
The Quality Committee also examines the Board Assurance Framework (which
contains both strategic and operational risks) on a monthly basis.
The effectiveness of the governance arrangements within the Trust will be audited
annually.
The Trust has initiated systems and processes to ensure mixed sex breaches are
being reported in accordance with national definitions.
These arrangements include SOPs for the use of the DSU. This provides clear
guidance to staff regarding what constitutes a breach and what actions should be
taken if this occurs.
The SOP also identifies exclusion criteria for patients who are not suitable for
admission to the DSU
The Trust monitors this process throughout the day at its bed meetings and also
provides assurance updates to NHS Herefordshire Clinical Commissioning Group on
a weekly basis.
The DSU has been reviewed jointly with NHS Herefordshire Clinical Commissioning
Group on two separate occasions, since the RRR visit, to ensure no breaches are
occurring.
Any deficiencies are reported via the incident reporting process and are included in
the monthly Quality and Safety Overview Report to Quality Committee. This includes
an explanation of action taken and the appropriate investigations that are being
undertaken should a breach occur.
3.6 Statement on relevance of Data Quality and your actions to
improve your Quality
Wye Valley NHS Trust will be taking the following actions to improve data quality;

Ensure continuous development and monitoring of all Data Quality action plans
through the Information and Information Technology Management Group.
78



Maintain the regular monthly audit activities to ensure accuracy of data within the
Patient Administration System for both Inpatient and Outpatient activity.
Regularly action and update the Trust’s overall Data Quality action plan.
Provide Data Quality Team support for the Trust wide Service Line Management
project.
3.7 NHS Number and General Medical Practice Code Validity
Wye Valley NHS 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 which included
the patient’s valid NHS number is:
99.8% for admitted patient care;
99.8% for out-patient care; and
99.9% for accident and emergency care which included the patient’s valid General Medical
Practice
Code was:
100% for admitted patient care
100% for out-patient care
96.1% for accident and emergency care
3.8 Information Governance Toolkit attainment levels
Wye Valley Trust Information Governance Assessment Report score overall score for 13/14
was 79% and was graded satisfactory.
3.9 Clinical coding error rate
The Trust was not subject to the Payment by Results clinical coding audit during 2013/14 by
the Audit Commission.
79
Prescribed Information
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—
(a) the value and banding
of the summary hospitallevel mortality indicator
(“SHMI”) for the trust for
the reporting period; and
(b) The percentage of
patient deaths with
palliative care coded at
either diagnosis or
specialty level for the trust
for the reporting period.
*The palliative care
indicator is a contextual
indicator.
Related NHS
Outcomes
Framework
Domain & who
will report on
them
1: Preventing
People from
dying prematurely
2: Enhancing
quality of life for
people with longterm conditions
Acute trusts
2013/14
2012/13
Supporting Statement
(a) The SHMI for
Wye Valley NHS
Trust for the
period July 2012
to June 2013
was 1.1516. This
gave the Trust a
banding of 1
(higher than
expected).
(b) Wye Valley NHS
Trust scored
18% for this
indicator.
(a) The SHMI for Wye
Valley NHS Trust
for the period of
April 2012 to March
2013 was 1.1257.
This gave the Trust
a banding of 2 (as
expected).
(b) Wye Valley NHS
Trust scored 17%
for this indicator.
Wye Valley NHS Trust considers that
this data is as described for the
following reasons;
Please see section 2.2.11
Wye Valley NHS Trust has taken the
following actions to improve this rate and
so the quality of its services, by
Please see section 2.2.11
Prescribed Information
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 trust’s
patient reported outcome
measures scores for—
(i) groin hernia surgery,
(ii) varicose vein surgery,
(iii) hip replacement
surgery, and
(iv) knee replacement
surgery,
during the reporting
period.
Related NHS
Outcomes
Framework
Domain & who
will report on
them
3: Helping people
to recover from
episodes of ill
health or
following injury
All acute trusts
2013/14
2012/13
Supporting Statement
Wye Valley NHS
Trust scored 01.28
for groin hernia
surgery for the time
period September
2013 to February
2014 compared to
0.086 nationally.
Wye Valley NHS Trust
scored the below;
Groin hernia – 0.115
Varicose vein – No
data available.
Hip replacement –
0.484
Knee replace – 0.328
For 2012/13 compared
to national scores of;
Groin hernia – 0.085
Varicose vein – 0.093
Hip replacement –
0.438
Knee replace – 0.319
Wye Valley NHS Trust considers that
this data is as described for the
following reasons:
There was no data
available for this
time period for
varicose vein
surgery, hip
replacement surgery
and knee
replacement surgery
on the Health and
Social Care
Information Centre
Indicator Portal

For the vast majority of measures
levels of improvement for the Trust
are above the national averages.
However, the Health & Social Care
Information Centre results shown
are based on provisional data only
and are subject to change until the
publication of finalised data,
expected later in 2014. All finalised
data was reviewed when published.
No concerns have been raised.

The data shown are only for
procedures where the Health &
Social Care Information Centre is in
receipt of a pair of linked preoperative and post-operative
questionnaires containing valid
entries on specific key items within
the questionnaire. Thus numbers
available for analysis may be lower
than overall numbers of procedures
or questionnaires.
Wye Valley NHS Trust has taken the
81
Prescribed Information
Related NHS
Outcomes
Framework
Domain & who
will report on
them
2013/14
2012/13
Supporting Statement
following actions:





The data made available
to the National Health
Service trust or NHS
foundation trust by the
3: Helping people
to recover from
episodes of ill
health or
Not available on
Health and Social
Care Information
Centre Indicator
(i)
10.14 for
2011/12
compared to
10.65 for the
Robust processes are in place to ensure
that all eligible patients are given the
opportunity to participate in the national
PROMs programme. Participation rates
for the Trust are very good and have
continuously been above national
averages.
If any eligible patients are not invited to
participate, reasons are explored and
relevant actions taken to reduce the risk
of this happening again.
Routinely monitors and reports national
and locally calculated participation rates
to ensure that we continue to achieve the
very good participation rates.
Outcome scores are sent to the Clinical
Directors in Surgery and Trauma &
Orthopaedics, and feedback requested.
Participation rates and outcome scores
are routinely reported to the Trust’s
Clinical Effectiveness & Audit Committee
and the Quality Committee.
Wye Valley NHS Trust considers that
this data is as described for the
following reasons;
82
Prescribed Information
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 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 trust’s
responsiveness to the
personal needs of its
patients during the
reporting period.
The data made available
to the National Health
Service trust or NHS
foundation trust by the
Health and Social Care
Related NHS
Outcomes
Framework
Domain & who
will report on
them
following injury
All trusts
2013/14
2012/13
Portal
(ii)
West Midlands
8.8.1for
2011/12
compared to
11.45 for the
West Midlands.
Supporting Statement
Please see section 2.3.1
Wye Valley NHS Trust has taken the
following actions to improve this rate and
so the quality of its services, by
Please see section 2.3.1
4: Ensuring that
people have a
positive
experience of
care
All acute trusts
Not available on
Health and Social
Care Information
Centre Indicator
Portal
Wye Valley NHS Trusts
score against this
indicator was 67.9 for
2012/13 compared to
68.1 for England.
Wye Valley NHS Trust considers that
this data is as described for the
following the inpatient survey.
Wye Valley NHS Trust has taken the
following actions to improve this score, and
so the quality of its services, by;
Please see sections 2.1.6 and 2.1.7
5: Treating and
caring for people
in a safe
environment and
protecting them
Wye Valley NHS
Trust achieved
95.2% for quarter 3
of 2013/14 against
this indicator
Wye Valley NHS Trust
achieved 92.5% for
quarter 4 of 2012/13
compared to 94.2% for
England.
Wye Valley NHS Trust considers that
this data is as described for the
following reasons;
The Trust improved its compliance with
83
Prescribed Information
Information Centre with
regard to the percentage
of patients who were
admitted to hospital and
who were risk assessed
for venous
thromboembolism during
the reporting period.
Related NHS
Outcomes
Framework
Domain & who
will report on
them
from avoidable
harm
All acute trusts
2013/14
compared to 95.8%
for England.
2012/13
Supporting Statement
completion of VTE risk assessments in
2013/14
Wye Valley NHS Trust has taken the
following actions to improve this
percentage and so the quality of its
services, by;


Service Unit Managers and Service Unit
Directors are notified on a weekly basis
of any areas that have been identified as
non-compliant. This enables the relevant
managers to make a targeted approach
in reinforcing the need for VTE risk
assessments to be completed in a timely
manner. This has been in place for a
number of months and has proved
positive in reacting to any areas of noncompliance.
The completion of VTE risk assessments
continues to be incorporated into Service
Unit
KPI
dashboards.
These
dashboards and the relevant supporting
information, i.e. details of areas of noncompliance
against
VTE
risk
assessment, are reported through
Service Unit Governance meetings and
Service Unit Performance meetings to
ensure robust plans are in place to
84
Prescribed Information
Related NHS
Outcomes
Framework
Domain & who
will report on
them
2013/14
2012/13
Supporting Statement
continue emphasising the need to have
100% compliance with completion of
VTE risk assessments.
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 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.
5: Treating and
caring for people
in a safe
environment and
protecting them
from avoidable
harm
All acute trusts
Not available on
Health and Social
Care Information
Centre Indicator
Portal
Wye Valley NHS Trust
had a rate of 15.5 for
2012/13 compared to
17.3 for England.
Wye Valley NHS Trust considers that
this data is as described for the
following reasons;
The Trust has a robust programme of
C. difficile prevention. This includes use
of the most sensitive PCR test for
primary diagnosis.
Wye Valley NHS Trust has taken the
following actions to improve this rate, and
so the quality of its services, by;
Wye Valley NHS Trust has purchased
hydrogen peroxide fogging technology and is
the process of implementing it use. For
2014/15 it is introducing a new root cause
analysis approach which will involve the lead
nurse in infection prevention and control
from Herefordshire CCG being an active
participant in all toxin positive case RCAs.
85
Prescribed Information
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 number
and percentage of such
patient safety incidents
that resulted in severe
harm or death
Friends and Family Test Question Number 12d –
Staff – The data made
available by National
Health Service Trust or
NHS Foundation Trust by
the Health and Social
Care Information Centre
‘If a friend or relative
needed treatment I would
be happy with the
standard of care provided
Related NHS
Outcomes
Framework
Domain & who
will report on
them
5: Treating and
caring for people
in a safe
environment and
protecting them
from avoidable
harm
All trusts
4: Ensuring that
people have a
positive
experience of
care
All acute trusts
2013/14
2012/13
Supporting Statement
Not available on
Health and Social
Care Information
Centre Indicator
Portal
Wye Valley NHS Trust
scored 7.9 for the rate
of patient safety
incidents reported for
October 2012 to March
2013. There was no
national comparable
data.
Wye Valley NHS Trust considers that
this data is as described for the
following reasons
Wye Valley NHS
Trust scored 54% in
relation this indicator
for 2013 Staff
Survey compared to
67% for all acute
organisations.
Wye Valley NHS Trust
scored 0 for the in
relation to the rate of
patient safety incidents
that resulted in severe
harm or death for
October 2012 to March
2013.
Wye Valley NHS Trust
scored 53% in relation
this indicator compared
to 65% for the Staff
Survey 2012 for all
acute organisations.

The Trust encourages open and
honest reporting of any incidents or
near misses.
Wye Valley NHS Trust has taken the
following actions to improve this rate and
so the quality of its services, by the
completion of the roll out of electronic web
based incident recording to ensure real
time reporting.
Wye Valley NHS Trust considers that
this data is as described following the
staff survey results.
Wye Valley NHS Trust intends to take the
following actions to improve this
percentage, and so the quality of its
services, by;
The NHS friends and family test came into
force on 1st April 2014 and requires the
Trust to ask all staff proportionally in
86
Prescribed Information
Related NHS
Outcomes
Framework
Domain & who
will report on
them
2013/14
2012/13
quarters 1,2 and 4 (quarter 3 is covered by
the staff survey). The questions are pre-set.
In March 2014 the staff Friends and Family
Test was discussed at staff partnership, i.e.
how to collect the information and this will be
rolled out will be rolled out May and June
2014 across the Trust.
by this organisation' for
each acute & acute
specialist trust who took
part in the staff survey.
Friends and Family Test –
Patient. The data made
available by National
Health Service Trust or
NHS Foundation Trust by
the Health and Social
Care Information Centre
for all acute providers of
adult NHS funded care,
covering services for
inpatients and patients
discharged from Accident
and Emergency (types 1
and 2)
Supporting Statement
4: Ensuring that
people have a
positive
experience of
care
This indicator is
not a statutory
requirement.
All acute trusts
Wye Valley NHS
Trust scored 25.8%
for this indicator in
March 2014
compared to 23.7%
nationally.
Friends and Family
data was reported
nationally from April
2013.
Wye Valley NHS Trust considers that
this data is as described for the
following reasons;
The Trust has actively promoted
responses to Friends and Family Test
throughout 2013/14.
Wye Valley NHS Trust has taken the
following actions to improve this
percentage and so the quality of its
services, by;
Please see section 2.1.7
87
Appendix 1:
Thank you for allowing Healthwatch Herefordshire the opportunity to comment on the
Wye Valley NHS Trust Quality Accounts.
After consideration Healthwatch Herefordshire would like to give the following feedback:
1) Priorities (Page 5)
HWH noted that the improvement plans only have three objectives, one of which
implies that it will be acceptable for WVT to harm 6 out of every 100 adult inpatients. We would recommend 100%, as the key performance indicator.
2) Patient Safety (Page 6)
In the subsequent Rationale section on patient safety, the proposed action plans seem
to address only some of the four bullet points. We would recommend addressing all
points.
3) Maternity Services
Healthwatch Herefordshire Board Member Sheila Marsh is currently the Lead for
Maternity Services. Sheila is supporting the implementation of a midwifery led service
in Herefordshire and acting as a critical friend to Maternity Services in engaging their
users in service development. A key area of the work is focused on reducing caesarean
section rates in the County.
a) In the Accounts it fails to mention the above average caesarean section rates
within the County. We are aware that the maternity department is working on this
area aiming to reduce numbers via a special audit. This is a big patient safety issue
that should be addressed in the document, in addition to the implementation of
key performance indicators.
b) The section on recruitment of staff refers to maternity but doesn't mention a
very positive step that has really transformed midwife recruitment which is the
establishment of a 'maternity academy' offering training and support to newly
qualified Midwifes. This is not only great for turning unconfident new Midwifes into
skilled practitioners it seems, but is also a real draw in getting applicants to apply previously a real problem for Hereford.
Complaints that have been received through Healthwatch Herefordshire enquiry line
during the past year, with respect to WVT include; communication from the Hospital to
the GP, lack of discharge planning, blood test results and thyroid issues.
Healthwatch Herefordshire Board Member, Allan Lloyd has established key working
relationships with Wye Valley NHS Trust. Allan regularly reviews and acts as a critical
friend to help improve the WVT and improve the Action Plan from the patient perspective
and will continue to feed in themes arising within the County. There is a shared
understanding between the Chief Executive of Wye Valley Trust and Healthwatch
Herefordshire, and ‘Working Protocols’ have been established and agreed by both
organisations.
In terms of future action planning Healthwatch Herefordshire would like to see next year
the endorsement of the dignity challenge by the WVT. If adopted, an ideal would be that
every patient gets the ten point list in hospital and is asked if they received that standard
of experience when they leave.
We look forward to working with you and continue to be a ‘critical friend’.
Once again thank you for allowing us to comment.
Kind Regards
Healthwatch Herefordshire
89
Herefordshire Clinical Commissioning Group (CCG) is pleased to receive Wye Valley NHS
Trust quality account for 2013/14 which provides an overview of the quality of services
during the year, and sets out work plans for the forthcoming year.
Following a review of the data presented, coupled with commissioner led reviews of quality
across all providers, the CCG is satisfied with the accuracy of the report. The CCG
particularly welcomes the 2014/15 objectives established by Wye Valley NHS Trust relating
to improved mortality performance and patient experience, which specifically reflect
imperative local priorities which must be pursued with pace. It is clear that 2013/14 has
been a challenging year for Wye Valley NHS Trust, with increasing scrutiny of quality across
health care highlighted by a series of national reviews, alongside the Rapid Response
Review. A good deal of progress has been made in response to this focus, and the CCG is
keen to support the Trust with yet further improvement work in 2014/15.
Herefordshire CCG has set out a quality framework which includes assurance visits and
regular quality review meetings between provider and commissioners to scrutinise and
challenge quality. We look forward to continuing this work during the coming year to ensure
the delivery of high quality, high performing and safe services for the residents of
Herefordshire.
Yours sincerely,
David Farnsworth
Executive Lead Nurse
Herefordshire CCG
90