SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Quality Account
2014/15
An integrated care organisation
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
A précis version of this account will be produced by the Trust
Communications Department in response to requests from members of
the Healthwatch groups. This will be available on request from 12th July
onwards from the Communications Department on 01704 704714
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
CONTENTS
PRESCRIBED REQUIREMENTS
PART 1
Achievements in Quality
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
Achievements in Quality
Statement from the Chief Executive and Chairman
Introduction to 2014/15 Quality Account
Director of Nursing and Medical Director’s Summary of Achievements
Care Closer to Home
Community Emergency Response Team
Paediatric Achievements
Safer Staffing Levels
Implementation of VitalPac
Scope or Change (LIA)
HQIP Award - Come Dine With Me
John’s views on being a dining companion
Work Placement Programme with West Lancashire College
End of Life Care
Pride Awards
North West Regional Spinal Unit Out Reach Team
Statement of Responsibilities from The Board of Directors
1
2
3
5
6
7
8
10
11
12
14
15
16
25
27
28
PART 2
Priorities for Improvement
2.1
2.2
2.3
2.4
2.5
Priorities for Improvement 2015-2016
Review of Services (Statements of Assurance from the Board (in regulations)
Participation in Clinical Audit
Regulated information
Participation in Clinical Research
Regulated information
Goals agreed with commissioners use of the CQUIN payment framework
29
30
30
31
33
2.6
2.7
What others say about us - statements from the CQC
Regulated information
Data quality: relevance of data quality and action to improve data quality
34
36
2.8
2.9
2.10
NHS number of general medical practice code validity
Information governance toolkit attainment level
Clinical coding error rate
PART 3
36
36
36
Regulated information
Regulated information
Regulated information
Regulated information
Regulated information
Review of Quality Performance
3.1
3.2
3.3
Targets as set out in the 2013 / 2014 quality account
DOMAIN Preventing People Dying Prematurely
Enhancing quality of life for people with long-term conditions
Hospital Standardised Mortality Rates
Summary Hospital level Mortality (SHIMI)
Prescribed information
The percentage of patient deaths with palliative care coded
Prescribed information
38
39
40
41
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12
3.13
3.14
3.15
3.16
3.17
3.18
3.19
3.20
3.21
3.22
App 1
App 2
App 3
App 4
4.1
4.2
4.3
4.4
4.5
4.6
Advancing Quality
DOMAIN Helping people recover from episodes of ill health following
injury
Patient Reported Outcome Measures PROMS
Prescribed information
Re Admissions
DOMAIN Ensuring people have a positive experience of care
41
Responsiveness to the Personal Needs of the Patient
Prescribed information
-National Inpatient Survey 2014
-Complaints
Staff Recommending Organisation as a place to work
Prescribed information
Friends and Family Test
Prescribed information
Improving Experiences and Support for Cancer patients
DOMAIN Treating and caring for people in a safe environment and
protecting them from avoidable harm
VTE Venous Thromboembolism Risk Assessment
Prescribed information
Infection Prevention and Control
Prescribed information
Never Events
Prescribed information
Reported Patient Safety Incidents
Prescribed information
Safety Thermometer
Pressure Ulcers (Hospital Acquired and Community)
Falls
Recognition of the Deteriorating Patient
Early Warning Score Audits
Fluid Balance Monitoring Audits
Cardiac Arrests
Eliminating preventable morbidity in maternity care
APPENDICES
Glossary
National Clinical Audits
National Confidential Enquiries
Local Clinical Audits
PART 4
ANNEX
STATEMENTS OF ASSURANCE
Sefton Healthwatch
Lancashire Healthwatch
Sefton Overview & Scrutiny Committee
South Sefton CCG and Southport and Formby CCG
Statement from Southport and Ormskirk on changes made after 30/4/15 Draft
Independent Auditors Limited Assurance Report to the Directors of Southport
and Ormskirk Hospitals NHS Trust on the Annual Quality Account
46
If you require this document in an alternative format,
please contact our Communications Team on 01704 704714
44
46
51
52
56
58
59
63
63
64
66
70
71
71
71
72
73
75
77
87
88
104
106
108
110
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.1
Achievements in Quality 2014 / 2015
Southport and Ormskirk Neonatal Unit won the Community Hero
Team Award voted for by parents in North West and sponsored by
Scottish power and Trinity Newspapers
95% of our patients have received harm free care against the four
key harm events, Venous Thrombosis , Pressure Ulcers, Catheter
related Urinary Tract Infection and Falls.
We have improved nurse recruitment resulting in a saving on
agency and temporary staffing spend.
Dr Karen Groves, Palliative care consultant awarded MBE for her
services to Palliative Care.
Trust wins Health Quality Improvement Partnership Quality
Improvement Awards for the introduction of the helping hands and
come dine with me initiative.
Chef Karl Watling was named North West Chef of the Year at the
Hospital Caterers Association Awards
The Paediatric Diabetes service scored best in the North West in a
peer review
One of the top 3 performing Trusts in England for vaccinating staff
against the flu with 81.4% of staff being vaccinated.
Among the best Trusts for the CQC Inpatient Survey 2014 with
positive responses to the question “Did the anaesthetist or another
member of staff explain how he or she would put you to sleep or
control your pain”?
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
PART 1
1.2 Statement from the Chief Executive and Chairman
We are pleased to present the Trust’s Quality Account for 2014/15 and we hope that
you find the array of different highlights interesting and informative.
As we have previously said, it is impossible to name check every initiative of which
we are proud, but given the increasing challenge of producing quality and efficiency
projects that reduce spend, meeting our performance and quality targets and working
on a number of cultural change projects, the biggest of which is the embedding of an
Integrated Care ethos throughout the Trust and the local health economy, the
following initiatives spring readily to mind:


Successfully implemented Vital PAC throughout the organisation, a
unique clinical software system that alerts clinicians to prioritise poorly
patients and reduces mortality, cardiac arrests and length of stay.
Dr Karen Groves one of the Trust’s Palliative care consultants has been
awarded MBE for her services to Palliative Care and collected her
award in summer 2014.
The Trust pride awards recognised the continuing excellent work of the
Trust staff and celebrated in June 2014.
We commend this Quality Account to you.
Sue Musson
Chairman
1|Page
Dr Jonathan Parry
Chief Executive
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.3
Introduction to 2014 /2015 Account
Southport and Ormskirk Hospital NHS Trust is pleased to present the Quality
Account for the period 1st April 2014 to 31st March 2015. This document provides an
overview of the progress made during the reporting period, the priorities for the
coming 1st April 2015 to 31st March 2016 and includes the regulated information
prescribed under the National Health Service (Quality Accounts Regulations 2010,
2011, 2012/13 update and 2013/14 updates).
During 2014/15 the Trust has continued to implement and monitor the Trust Quality
Strategy ‘Right First Time – Every Time’ (2012-2015) the resulting work plan has
been monitored through the Operational Trust Quality and Safety Committee. The
new Director of Nursing and Quality will be reviewing the Trust Quality strategy and
developing a new work plan the next three years.
The current Quality Strategy ‘Right first time, every time’ describes our approach to
reducing errors, preventing harm and ensuring a positive experience of care for our
patients and staff. This will be further developed in the new Quality strategy.
Put simply, quality care is the care you would want for you and your family.
“The Chief Executive’s Big 5” are drawn from what patients say is important to
them. They will help us deliver the care we would want for ourselves. The “Big 5” are:
1. Preventing patients dying prematurely
2. Reducing pressure sores by 25% each year
3. Achieving 100% in hand hygiene audits and results
4. Improving the use of expected date of discharge to at least 90%
5. Eliminating preventable morbidity in maternity care
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.4
Director of Nursing and Quality and the Medical
Director’s executive summary of achievements
This quality account details our achievements over the past year and our plan
for improvement in 2015 / 2016.
The Trust has seen a number of changes and key events during 2015/15.
During 2014/15 we saw of our Director of Nursing Mrs Liz Yates, retire after 8 years
in post, and we welcomed Mr Simon Featherstone who commenced with the Trust as
the new Director of Nursing and Quality in February 2015.
April 2014 saw the introduction of the VitalPAC system across adult inpatient areas.
VitalPAC is award winning technology designed for clinicians that increases the
speed and accuracy of recording patient observations and will be used to improve
the care we deliver to patients on the wards.
In November 2014 the Trust had a planned inspection by the Care Quality
Commission (CQC) the report of which was published in May 2015.The report
highlighted the ‘fantastic, caring and proud staff’ who work at the Trust and
commented on a number of areas of good practice within the organisation, such as
children and young people’s services; community services for children and young
families and the dignified care we give patients who are dying.
They also noted areas of outstanding practice including the Community Emergency
Response Team’s work with patients to reduce avoidable hospital admissions; the
excellent service of the mortuary team; and the work of the children’s diabetes and
respiratory teams.
The overall rating for the Trust was requires improvement, and the Trust has been
working hard since the report in those areas where the inspectors felt improvement
was needed. This work will continue through 2015/16 and will form the focus of our
work during the year.
In November 2014 the Trust was delighted to be awarded the gold award for the best
quality improvement project overall at the Heath Quality Improvement Partnership
Awards, for its work providing help and companionship for older people with
dementia at mealtimes. The ‘Come Dine With Me’ project was started in summer
2013 and currently has around 25 trained dining companions working across a
number of wards within the Trust. We also won the award for Local improvement
following national clinical audit.
The Trust views the safety of its patients as paramount, and 2014 saw significant
investment in the numbers of trained nursing staff working on the wards. Overall the
Trust invested £1.3 million on additional staffing to ensure that staffing levels were
safe and reliable.
We recognise, however, that there is always room for improvement. The key quality
targets we set ourselves in 2014/15 around reducing falls, infection control and
reducing harm in maternity were met, however additional work needs to be done,
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
particularly in reducing our overall mortality rates and eliminating pressure ulcers. To
this end we will embark on two major events which will focus on these two areas and
will see colleagues from across the whole Trust and beyond come together to
address the key issues of preventing unnecessary deterioration in patients and
preventing patients from developing pressure ulcers. The events will run from July for
a period of 9 months, with challenging targets agreed by the Trust Board and led by
the Trust’s Quality Improvement Team.
2015/16 will also see the Trust continue its improvements in its community services,
with a restructure which will provide a responsive and proactive service, built around
patients’ needs and tailored to the specific health requirements of local
neighbourhoods.
We pride ourselves on the care we give to our patients and the safety and quality of
the work we do. It is our pleasure to thank all the Trust staff who throughout the year
have provided our patients with the level of care and commitment we would all
expect to receive for ourselves and our families.
Thank you.
Mr Robert Gillies
Executive Medical Director
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Simon Featherstone
Director of Nursing and Quality
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.5
Care Closer to Home
The Care Closer to Home Programme is collaboration across West Lancashire and
Southport and Formby CCG, as well as other provider organisations which outlines
the strategic vision for urgent care in our health economies over the next three years.
It defines a vision for the integration of health, social and voluntary care service
provision at a local neighbourhood level, working to prevent ill health and support
local care delivery to those with urgent needs, to minimise the number of adults and
young people who need to go to hospital for their care. Following completion of
phase 1 of this programme, the Care Closer to Home Programme is now embarking
on phase 2 of its journey. Care Closer to Home is our approach to achieve the whole
system transformation required across our health economy, and is a true testament
to collaborative working amongst West Lancashire CCG and its partner
organisations, Southport and Formby CCG and the ICO.
To deliver our vision we will aim to establish services to deliver as much as possible
of peoples’ urgent care needs out of hospital if they do not need the expertise of
hospital clinicians. We will ensure that primary care services are accessible and of
high quality in order to reduce demand on hospital services. Our vision is of an
integrated model of care closer to home, that maximizes the potential for people
to be seen, assessed, signposted and treated by safe, high quality services
that are efficient and cost effective.
Health support in rural communities
We plan to continue to develop a neighbourhood team model approach to primary
care, bringing together GPs, social care, acute providers, third sector groups, families
and carers. This will enable us to deliver coordinated care, closer to home and
balance the health inequalities that exist for those living in rural communities. We are
committed that this will be more focused in 2015/16.
Repeat visits to hospital for long term conditions
Continue our vision for integrated care to ensure better coordination for those with
long term conditions. We plan to integrate services locally as part of our
neighbourhood model. GP practices will be at the centre of delivery, meaning we can
deliver care closer to home for these patients.
Hospital discharge process/hospital relationship
Continue to develop a discharge coordination service to improve discharge planning,
remove unnecessary delays and improve the experience for our patients.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.6
Community Emergency Response Team (CERT)
The Community Emergency Response Team (CERT) was formed fourteen months
ago as part of the Care Closer to Home Programme through the expansion of the
existing Intermediate Care and Rapid Response teams. The main aim of the team is
to prevent unnecessary hospital admissions by maintaining patients in their own
home, admitting patients to Commissioned nursing and residential homes and
facilitating timely discharges from hospital. The Team is made up of Nurses,
Therapists, Carers, Therapy Assistant, Social Workers and GP’s.
Rapid Response - multidisciplinary members of the team visit patients in their
homes who have been referred by a health care professional in order to keep the
individual care closer to home.
Bed Based Units - nursing and intermediate care therapy beds where the team in
reach on a daily basis. The GP provides a ward round three times a week and aims
to see all new patients admitted to the beds within 48hrs. The current length of stay
within the beds is between 15 and 19 days which according to figures gained from
the National Intermediate Care Audit last year is the fourth lowest length of stay in
the country.
Hospital In-Reach - in order to facilitate timely discharge of patients. CERT nurses
visit the wards including Observation and A&E and work with the Discharge Coordinators to identify and assess patients able to transfer out of hospital either to a
bed or home with CERT support.
Patient JH, fell in church and hurt her back
and arm. She went home and struggled all
week. Eventually went to A and E the
following week and was discharged home
again on Friday. Over the weekend went into
crisis and called her GP on Monday. Rapid
response attended and placed her in Nursing
Home. During assessment at home the lady
had a temperature and also high blood
pressure. She was sent for an X-Ray of right
wrist to discount any fractures to her wrist.
She was discharged home the following
week with CERT carers.
Mrs MW was admitted to the A&E department
on Sunday following a fall. After examination it
was determined that the lady had not
sustained any injuries but was finding it difficult
to cope at home. However being a Sunday
Social Services were not available to provide a
care package to enable her to go home again.
Therefore CERT were contacted and provided
two calls a day to “bridge the gap” until a more
permanent care package could be arranged.
This allowed the lady to return home in a
timely manner and avoided an unnecessary
hospital admission.
Mr C an 89 year old gentleman referred to the CERT by his GP had been suffering from a tooth
abscess for some time and had not sought help, the infection had spread and he now had mild
delirium and required a course of antibiotics. CERT nurses attended and carried out a full
assessment in the patient’s home. He was being cared for by his daughter who was happy to
continue. It was agreed that the team nurses would continue to monitor the situation over the
following few days and CERT therapists would carry out assessments for needs, in particular
OT aids for the home.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.7
Paediatric Achievements
Awards/ National Assessments
Southport
and
Ormskirk
Neonatal
Unit
won
the
Community Hero Team Award
voted for by parents in North
West and sponsored by
Scottish power and Trinity
Newspapers
The Paediatric Diabetes Team in Southport and Ormskirk was the top performer in
North West and ranked 4th in the country for the 2014 National Peer Review
Assessment Programme (National Diabetes Peer Review is a national quality
assurance programme for NHS diabetes services) and the unit was one of the first in
the North West to achieve best practice tariff in the north west region
The Paediatric Diabetes Team was recently shortlisted in the National British Medical
Journal Awards 2015 for the Diabetes category with our project “Digital Technology &
Diabetes” which encompassed Facebook communications with parents/patients,
implementing an electronic diabetes information management system (Twinkle.Net)
and undertaking routine uploading of glucometers and pumps (DIASEND®) with the
aim to improve paediatric diabetes care.
Paediatric Department
The Paediatric Unit has also been noted as an exemplar department for progress in
developing the successful Community Children’s Home Nursing Outreach Team
(CCNOT) scheme and nurse-led clinics. The CCNOT team initiative has been
presented at national conferences and published in the British Journal of Nursing
One of our consultants, Dr Ng is the Chair of the North West Paediatric Diabetes
Network with 28 paediatric diabetes units, and has led the North West Network to
achieve 100% submission to the National Paediatric Diabetes Audit since September
2013. In the National Diabetes Quality Awards 2014, the Network was commended
for developing a ‘National Care Plan for the Management of Diabetes in Schools’
which has been adopted nationally and endorsed by Diabetes UK.
The Department also successfully initiated training of Advanced Paediatric Nurse
Practitioners and Emergency Nurse Practitioners which has been highly successful in
contributing to an efficient workforce
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.8
Safer Staffing Levels
Hospital staff in Southport and Ormskirk helped develop the national Care Certificate
to support the training of healthcare assistants and support workers.
The Care Certificate meets concerns raised in the Cavendish Review following the
inquiry into the quality of care at the former Mid-Staffordshire NHS Foundation Trust.
The review found formal support and education for healthcare assistants and social
care support workers was inconsistent. A common qualification was needed to
assure the public that all those who provide care achieved a minimum standard of
training.
Southport and Ormskirk Hospital NHS Trust was one of 13 health and social care
organisations that piloted and reported on the effectiveness of the Care Certificate to
NHS England. Healthcare assistants found working towards the Care Certificate
hugely useful not least because it underpins the trust values as being a supportive
and caring organisation.
The Trust has been focusing on reducing bank and agency costs during 2014 – 2015
and has introduced a number of initiatives which have helped our spend decrease:



Forging closer relationships with the HEIs and working closely with them to
ensure that the student workforce is well supported and offered employment
opportunities once qualified.
Development of minimum standards for the training of all HCAs (incorporating
the fundamental care certificate) to provide clear standards for HCA training
based around the National Standards of Training for HCAs.
2014/15 has seen an overall reduction in the numbers of nurse vacancies,
however recruitment remains incredibly competitive in region and the Trust will
undertake additional overseas recruitment in 2015/16.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Recruitment from abroad has also improved our staffing levels and during 2014/15
we recruited 10 Romanian nurses and a very welcome contribution/addition to an
already diverse workforce
Nursing Student Quality Ambassadors (SQA)
SQAs act as ambassadors and champions of care both within NHS and non-NHS
placements. They are empowered to promote good practice by challenging
standards of care within the workplace and by suggesting areas for improvement.
SQAs work alongside and liaise between practice education facilitators (PEFs),
higher education institutes (HEIs), students, and service users/patients and carers,
as well as showcasing student innovation projects within trusts. They are also test
subjects for innovations such as trialling the use of the electronic practice
assessment record (PAR), the numeracy assessment project (SNAP) and the North
West Values and Behaviours tool.
The Trust is fully involved in this initiative and in January 2015 the held a Student
Quality Ambassador Focus Group. The aim of the focus group was to explore the
feelings of third year healthcare students who have had placements in Southport &
Ormskirk hospital and newly qualified nurses who have taken a staff nurse post and
completing preceptorship at Southport & Ormskirk Hospital. The event was led by
one of the Qualified Quality Ambassadors who currently works in Southport &
Ormskirk Hospital.
The feedback from this event, both positive and negative, has been used to support
the Trusts development of support for students, newly qualified staff and assist in
retention of staff.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.9
Implementation of VitalPac
In April 2014 Southport and Ormskirk NHS Trust were awarded £949.000 over 5
years to implement VitalPAC technology across adult inpatient areas. VitalPAC is
award winning technology designed for clinicians that increases the speed and
accuracy of recording patient observations and automates the calculation of Early
Warning Scores (EWS), prompting escalation and earlier intervention for the
deteriorating patient. This is enabled by the use of hand held devices (iPods and
iPads), co-ordination of data and accessibility of key clinical data outside of the ward
area. Other modules secured in the bid support Infection Prevention and other key
patient safety drivers within the Trust.
Current Position April 2015





19 Adult inpatient wards now live with VitalPAC Core/Ward/Clinical and Performance.
Dementia Module now live (from 1st April 2015) across all VitalPAC wards
730+ staff trained including ward based staff, AHPs, Pharmacy, Audit, Senior
Managers, Matrons etc.
On average 35,000 sets of patient observations are recorded on VitalPAC every
month
Suite of reports now available and circulated to Senior staff and ward managers
monthly. They combine not only VitalPAC data, but also bed occupancy, staffing
levels, DATIX incidents etc.
Staff have been involved at every stage of the VitalPAC project and the project team
were keen to receive feedback regarding the implementation so far.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.10
Scope for Change
Between June - September 2014 we held 75 sessions where we asked staff how we
could improve delivering excellent service, treatment or care. These were pulled
together into a list of main themes and staff were asked to vote on which project they
would like to see taken forward and developed into projects.
Some quick wins were identified:
You Said
Too few wheelchairs & what happened to
those bought for Outpatients?
You needed car park access out of hours
for safety. You wanted night staff to be
allowed use of car parks near hospital
entrances.
Update telephone directory and who's
who.
You wanted to know more about different
services and suggested Spotlight on
Services to raise profiles and celebrate
We Did
Order chased up and wheelchairs
delivered within 2 weeks of reporting – 15
more now available at SDGH
Access arrangements on the entrance
opposite CEC to be changed to allow
access out of hours & the area of car
park C can be accessed by staff out of
hours. Investigating the re-instatement of
an out of hours exclusion on car park C,
separate card access between possibly
hours of 20:00 & 08:00 We are
considering an appropriate arrangement
at ODGH
Who’s who done. Phonebook now
interactive so staff can update their own
details.
First spotlight will be on SDGH works
department in September in Team Brief.
The feature will appear monthly.
819 staff voted for their favourite project. The 5 projects which received the most
votes and will be taken forward during 2015 / 2016 are:





Project to review Mandatory Training against actual need and relevance to role
Project to determine what is needed to ensure staff feel valued and respected
Project to determine the time taken to recruit new staff
Project to establish car parking access for those who carry out home visits
Project to establish nursing career development and succession planning
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.11
Health Quality Improvement Partnership Awards (HQIP)
In November 2014 the Trust won 2 awards at the HQIP Quality Improvement
Awards 2014. The Trust won the award for local improvement following a national
clinical audit project with the introduction of helping hands and dining companions,
following the national audit of dementia. The Trust also won the conference gold
award for the best quality improvement project overall.
The Trust embarked on a volunteer programme in the summer of 2013 to find Dining
Companions who are volunteers who would sit with patients who need additional
help at mealtimes. This project was called ‘COME DINE WITH ME’. As well as
assisting with eating, the Dining Companions can chat and support vulnerable
patients such as those with dementia or any other additional need. The Dining
Companions we have recruited range in age from 18 to 84 and have decided to give
their services for a variety of reasons. Some because they want to experience
working in a hospital setting to decide if they want a career in the National Health
Service and others who want to help because they or their family have had care in
the Trust and they want to give something back. Currently we have 25 trained Dining
Companions who are able to work on Wards 14A, 9B and 7A at Southport Hospital
and on H Ward at Ormskirk Hospital.
Following on from this success we asked staff in clinical areas if they would want the
help of volunteers and a number of roles were created. We now have 22 volunteers
who are able to work in administration roles in the Corporate Management Office at
Southport Hospital, on hospital wards assisting the Ward Clerks, helping in A&E at
Southport, the Treatment Centre at Ormskirk and in the community in the Southport
Centre for Health and Wellbeing.
The feedback we have received from staff has been positive with comments such as
‘a very valuable part of the team’, 'they are great and always happy to help’, ‘I don’t’
know what we‘d do without them’.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.12
John’s views on being a dining companion
“I find the whole process extremely rewarding. As a Dining Companion volunteer, I support
patients on Ward 9B which is a mixed ward of patients with varying degrees of Dementia.
Due to their illness, many of the patients are unable or indeed incapable of feeding
themselves. Cleanliness, hygiene, infection control and good housekeeping are an essential
part of any role within the NHS, therefore, clearing away and picking up items in order to
keep the unit safe and infection free are an essential part of my role.
Prior to taking up this role, I attended a number of courses. The Trust’s Induction course,
which included hand washing to a high standard. A course on Nutrition and some Dementia
awareness training, including how to feed patients having that illness, do’s and don’ts of my
role and the filling in of fluid and food charts.”
“My duty begins with me making
sure that my hands are clean
before entering the ward, and
preparing the tea trolley to do a
ward round of drinks.
Going
around the ward with the trolley is a
great way of talking to the patients,
a good icebreaker, getting to know
them and putting them at ease.
After the drinks round, the dinner
trolley arrives. With some 30
patients on the ward, this is an
extremely busy time. Once they
have been given out, I liaise with
the nursing staff as to which
patients require assistance to eat.
I am a people person. I love talking
to people and I always knew that
any volunteering work I undertook
would involve talking to people. I
would recommend anyone with a
few hours to spare to give it some
serious thought. You will be
pleasantly surprised”
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
1.13
College
Work Placement Programme with West Lancashire
Last year Southport and Ormskirk Hospital NHS Trust embarked on a work
placement programme for people with learning difficulties and disabilities with West
Lancashire College. This is the only college who the Trust has this arrangement
with, at this time.
In cooperation with the college, the Trust arranged for the students to be interviewed
at the college by Trust staff, arranged for DBS checks and Health Assessments to be
completed and then a specifically tailored Induction, delivered by senior hospital staff
was held at West Lancashire College.
Students and Support Workers were provided with a yellow polo shirt which is the
corporate uniform for volunteers working in the Trust. This was to give the students a
sense of identity and belonging.
The Trust took into account the students capabilities and choice of work and provided
placements in various departments at the hospital. The students were welcomed on
their first day by the Chief Executive of the Hospital and were introduced to hospital
staff that would support them through their placement.
The students were also supported by the Volunteer Coordinator, the Trust’s
Additional Care Needs Team and other Trust colleagues whilst they were on the
work placement programme. Hospital staff are in full agreement to support this
programme and offer the students an opportunity to come and work as part of their
teams.
The Trust is delighted with the success of this programme as it provides positive links
between the hospital and the community.
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1.14
End of Life Care
Dr Karen Groves, the Medical Director of Queenscourt Hospice in Southport, and
palliative care consultant with the Trust has been awarded an MBE for her services
to palliative care.
End of Life and Palliative Care are spearheaded by the End of Life Strategy Steering
Group within the Trust and the West Lancs, Southport & Formby Palliative & End of
Life Care Services Subgroup of Cheshire & Merseyside Palliative & End of Life Care
Network across the whole area. The Director of Nursing has always provided a
supportive Executive Lead for End of Life care and consequently during this year the
lead was Liz Yates until her retirement in September, then Angela Kelly, Interim
Acting Director of Nursing, and now is Simon Featherstone from February 2015. The
Trust has an End of Life Strategy. The Trust has appointed Lionel Johnson as a lay
member to represent the Board and he attends both the End of Life Strategy Group
and the Palliative & End of Life Care local subgroup of the Network.
Care of the Dying
UK media coverage of End of Life Care across the U.K. has continued this year with
the publication of ‘One Chance to get it Right’, by the Leadership Alliance for the
Care of Dying People, the coalition of government and national bodies. This set out
new Priorities for Care of the Dying on 29 June 2014. Following its publication, the
Trust in union with the local area, introduced a focused and robust training
programme for staff to update them about the new priorities for care and how to
develop an individual plan for the care of those thought likely to be dying, initially
particularly concentrating on ensuring that the terminology used across the whole
area was ‘euphemism free’ and left no room for misunderstandings. Staff have been
encouraged to undertake this training ‘because it matters’ and not ‘because it is
mandatory’ – a strategy which appears to be working, since over 1300 Trust staff
have been trained, mainly on a one to one basis, within the first eight months
following the changes. Posters, mouse mats, magnetic postcards, A4 handouts have
all supported staff in the changes.
Audits of all aspects of care of the dying have been undertaken in the Trust this year,
as in other years, to include communication, symptom control and anticipatory
prescribing, spiritual care, eating and drinking.
Although the Trust scored well above the national average for documentation of food
and fluids in the National Care of the Dying in Hospital Audit 2013 (NCDHA)
(documented assessment of ability to swallow 23%; need for clinically assisted
hydration 69% & nutrition 84%) following the introduction of the new priorities for care
of the dying in June 2014 the documentation, across all settings, improved
considerably (documented assessment of ability to eat & drink 91%; plan for food
and drink &/or mouthcare 80%).
Anticipatory prescribing was undertaken in hospital for 90% of all those thought likely
to be dying for analgesia, 90% for antiemetic, and 95% for anxiolytic and
antisecretory, thereby ensuring that nurses were able to give the medicines required
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for symptom control without delay. In terms of symptom control, reviewing all
expected deaths for 2014-15, 82% patients in hospital:86% at home were free from
pain in the last hours of life; 80%:78% free from respiratory tract secretions;
80%:85% free from agitation and 83%:96% free from nausea and vomiting.
Audits of conversations showed improved documentation of the conversation (to
include the word ‘dying’) from 41% to 65% of conversations; understanding of the
family from 47% to 56%; concerns from 38% to 65% and wishes of the patient from
13% to 32% (many were unconscious).
Education
Southport & Ormskirk Hospital NHS Trust (S&O), as an integrated care organisation
responsible for local community and hospital services, has always understood the
essential nature of the education of all staff in end of life care and communication
skills. The Trust’s continuing recognition of their responsibilities in this regard, despite
many other competing priorities, has helped in coping with this difficult period in end
of life care and enabled staff to ensure that the concerns of patients and families are
addressed wherever possible. The concentration on ensuring that senior nursing,
medical and therapy staff have the opportunity to undertake the Advanced
Communication Skills training has been particularly important.
Collaboration between S&O and Queenscourt, the integration of Specialist Palliative
Care Services across boundaries, close working between specialist and generalist
services and the fact that programmes such as the Transform Programme and the
Six Steps to Success for care homes, all intertwined and linked with already
existing programmes working out of the Terence Burgess Education Centre at
Queenscourt, ensures that staff, of all disciplines and in all settings, receive a
consistent educational message, and all services speak with one voice. Development
of simple, effective, workbook based programmes in communication, advance care
planning and spirituality, and the educator development programme, ensure that
these vital topics are easy to facilitate. The production of new presentations, ward /
neighbourhood folders, handouts, cue cards for each of the key enablers of end of
life care – Care Co-ordination (Gold Standards Framework), Future Care Planning
(Advance & Anticipatory care Planning), Dealing with Uncertainty (AMBER Care
Bundle), Respecting Patient Choices (Rapid End of Life Transfer) and Care of the
Dying (New Priorities for Care) has ensured consistent, repeated, memorable
education for all staff.
The End of Life Skillset Challenge, launched to coincide with the British Olympics,
continues and 213 staff signed up to work through this programme. 26 have already
achieved bronze level, 15 silver and 8 gold which includes completion of a case
study and an end of life audit.
S&O ICO staff have accessed free education at the Terence Burgess Education
Centre at Queenscourt, as well as in their wards and departments from the
Transform Programme. During 2014/15, 32 more staff have embarked on or
completed the six day palliative care education course for senior nurses (14 hospital
& 18 Community) making a total of 353 (120 hospital & 233 community) nurses who
have undertaken this course locally since it started some years ago. In 2014/15 the
number of hospital and community staff who undertook training in:- Advance Care
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Planning was 231 (171 in 2013/14) making a total to date of 974; Gold Standards
Framework – 211 (155 in 2013/14) - total 1293; Rapid End of Life Transfer 86 (151
in 2013/14) total 647; new priorities for care of the dying (2014) – 1604 ; Simple Skills
Secrets core communication skills 68 (59 in 2013/14) bringing the total to 515;
Advanced Communication Skills 21 (15 in 2013/14) bringing the total to 160 band 6 &
above nurses and senior doctors; Spiritual Care - ‘Opening the Spiritual Gate’ course
37 (total to date 119) and short session 42 (total to date 292).
Specialist & Generalist Services
S&O understands that the care given to those who are dying is a reflection of the
care given to all patients. Specialist & generalist services are equally vital in palliative
and end of life care, each dovetailing to provide the seamless service which patients
with complex needs and their families expect and require. Intertwined, integrated,
collaborative, cross boundary services are stronger together than they are
individually and good clinical relationships and communication, within and without the
Trust, instil confidence in patients, families and staff in all settings.
The specialist palliative care teams with their palliative care nurse specialists, led
by Cathy Brownley, and two consultants, Dr Karen Groves & Dr Clare Finnegan,
work in a cross boundary multiprofessional team, able to provide seven day a week,
advice, support, education and care wherever it is needed.
The district nursing and community services, especially including the out of hours
nursing services who have at last been repatriated to Southport & Formby, provide
round the clock advice and care for patients and their families, relieving symptoms
and anxieties with their confident competence. Frontline ward staff in the hospital
setting provide that crucial total person care and support families and those important
to the patient, often in busy ward settings, with calm reassurance and compassion. A
Community of Practice of band 6 nurses across the Trust, from wards and
community neighbourhoods, was developed, studied and met together over 2014 to
prepare for a role in which they would be responsible for end of life care across the
Trust.
The newly formed Transform Team, formed mainly by innovative use of existing end
of life care posts and working out of Queenscourt, into hospital led by Elaine
Deeming, and community settings led by Louise Charnock, have helped to support
patients approaching the end of life who do not have specialist needs, their families
and the staff looking after them – particularly focusing on supporting families,
ensuring excellent communication, offering choices and facilitating conversation and
operation of rapid end of life transfers.
Specialist Palliative Care Services
Local Specialist Palliative Care Services, have been integrated across hospital and
community, voluntary and NHS services, since their inception. Now fully established
after a period of staffing crisis, an internal weekly education programme has
continued this year to support staff not only to undertake their own advisory role but
also to educate others. With a full complement of consultant led, specialist services
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across the Palliative Care Team and Queenscourt Hospice, patients with specialist
palliative care needs can receive advice and care in a variety of ways and places.
During 2013/14 464 patients were referred to the hospital and 876 to the community
palliative care nurse specialists. 30% had non-malignant disease. 63% died in their
usual place of residence (home/care home) and 26% in hospital.(Community
palliative care nurse specialist – 71% usual place of residence and 17% hospital;
Hospital PCNS – 49% usual place of residence and 40% hospital)
Specialist Palliative Care Services MDT development (supported by Cheshire &
Merseyside Palliative & End of Life Network) which started in 2013/14 with six
workgroups (presentation skills; caseload management; education; non-medical
prescribing; debriefing; research & publication) has continued into 2014/15 and
members of the local Specialist Palliative Care Services Groups and the CCGs are
represented on the Network Steering Group and its sub groups, and also relate to all
the Greater Manchester, Lancashire & South Cumbria Network groups as well.
In line with Network guidance all SPCS updated their MDT Peer Review
documentation, Annual Report, Operational Policy and Annual Workplan in 2014/15
despite the fact that the SPCS Peer Review standards have not been updated and
Specialist Palliative Care Peer Review has not been undertaken since 2012.
Place of Death
Within the local area of West Lancashire, Southport and Formby (WL,S&F), with a
population of about 235,000 inhabitants, an increasing number, now nearly 2,700
(almost 1.15% of the population compared with the UK average of 1%) people die
each year. Approximately 205 will be sudden unexpected deaths or deaths following
a short illness; 40% are known to specialist palliative care services and in 40%
although end of life may be approaching, it is not always recognised. National figures
suggest that two thirds of people would prefer to be cared for and to die in their own
homes. Office of National Statistics annual place of death figures for WL,S&F 2013
(2014 figures are not yet available until June 2015) show that, deaths from ALL
causes in the usual place of residence (home and care home) (48%) have exceeded
deaths in hospital (45%) for the third year running and this year by 3%. Although this
appears to be a great improvement, approximately a quarter of people still do not
achieve their preferred place of care.
In 2013 the proportion of West Lancs, Southport & Formby residents dying with
cancer related illnesses who manage to stay in their usual place of residence was
55% (52% 2012) compared with the number who died in hospital which had dropped
to 29% (28% in 2012).
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WL, S&F ALL Hospital & Usual Place of Residence Deaths
100%
90%
80%
70%
60%
54% 53%
56%
49%
50%
40%
30%
39% 40% 38%
51%
47% 49% 48% 49% 49%
43% 44% 42% 45% 44% 42% 43%
47% 47%48%
46% 46%
45%
Hospital
UPR
20%
10%
0%
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Office for National Statistics Place of Death figures for 2013 (2014 figures available June 2015)
WLS&F CANCER Deaths in Hospital & Usual Place of Residence
100%
90%
80%
70%
60%
50%
40%
30%
41%
39%
42%
46%
50%
48%
50%
56%
52%
55%
Hospital
UPR
32%
44%
35%
20%
34%
32%
33%
29%
26%
33%
30%
28%
29%
10%
0%
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Office for National Statistics Place of Death figures for 2013 (2014 figures available June 2015)
We are delighted that 2013 figures, released in summer 2014, demonstrated that the
hard work of hospital and community services has maintained the trend for people
being cared for and dying in their usual place of residence, which is where most
people want to be.
WL, S&F has more than 3,400 people in registered care homes, more than twice the
national average for the size of population, and not surprisingly, almost 28% of all
those who die are now able to be cared for in care homes until their death. 1 This
makes it imperative that we identify and consider this population specifically with
regard to communication, education and clinical support of their employed carers,
1
Office of National Statistics 2013
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regarding end of life care. This is supported by the Six Steps to Success Care
Homes Programme now undertaken by the TRANSFORM Team.
Transform Programme
The Transform Programme, ensures that systems are in place to maximize the care
and co-ordination of those towards the end of their lives by use of five key enablers:1) Recognition and co-ordination of the care of this group of people using the
Gold Standards Framework (GSF) and Electronic Palliative Care Coordinating System (EPaCCS) the latter of which is not yet in place across the
area, despite a national drive to do so by Dec 2013. Being recognised as GSF
and holding a ‘gold card’ helps patients to navigate healthcare systems and staff
to be aware of their needs. (853 WL,S&F people have been recognised as
approaching the end of their lives and GSF registered to help co-ordinate their
care in 2014-15, 180 of these (25%) were recognised whilst in hospital and the
rest by their GP practice). Two District Nursing (DN) teams led by Gill Sperrin and
Martha Finch, piloted a Community Gold Standards Framework Care Plan and a
Carer’s Care Plan and the resulting differences in care documented has been
audited for the third time, is being presented as a poster at the European
Palliative Care Congress in May 2015, and is now being rolled out across all DN
teams. There have been 641 admissions of known GSF registered patients into
S&O hospital during 2014/15 and each of these has been seen and followed up
by the Transform Team.
2) Encouraging expression of wishes and preferences by implementing a
system of Future Care Planning, encouraging staff to facilitate conversations
about personal wishes (Advance Care Planning (ACP)) and being proactive in
planning for expected clinical situations (Anticipatory Clinical Planning). Having
wishes and preferences documented means that subsequent conversations are
easier and patient’s wishes can be met even when there is loss of capacity to
make decisions. In addition to the training given to 100 local GPs in 2013/14 and
the education for our own staff, a pilot of documentation of future care planning
conversations has been undertaken with the Formby DN team, by Emma Pringle
PCNS. This has shown acceptance of the method of documentation and an
increase in confidence following the educational programme. At least 312
WL,S&F people who are known to be GSF registered are known to have had an
ACP conversation, some have then gone on to make an Advance Care Plan, an
Advance Decision to Refuse Treatment, or appoint a recognised Lasting Power of
Attorney to act on their behalf in making health decisions if they are unable. In
2014/15 the number of people who were GSF registered with a recorded
preferred place of care (PPC) was 862, over two thirds of whom of whom chose
‘home’. 92% of the 935 who died had expressed a PPC, and 85% achieved it.
3) Recognising and discussing uncertainty of recovery of those who are
seriously ill, develop an acute illness and where treatment may or may not show
benefit (AMBER Care Bundle (ACB)). This involves the documentation of
appropriate care plans, ceilings of treatment, conversations with patients and
families and other health professionals. Early audits demonstrate that the
elements of ACB are increasingly being incorporated into post take ward round
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documentation and helping to inform decision making. The most important
element of this is, of course, the conversations about uncertainty of recovery that
are undertaken between clinical staff and patients and their families.
4) Respecting patient choices particularly of those who recognise that they are in
the last days and hours of life but are not in their preferred place of care, and
having systems in place to undertake a Rapid End of Life Transfer safely,
efficiently and effectively for them, their families and their health professionals.
This is unlikely to happen if the conversation explaining the possibility does not
happen. In 2014-15, 224 people, who were close to the end of their lives, had a
conversation about the possibility of a rapid end of life transfer and 83 people
were transferred as they requested (58 in 2013/14). Where necessary a private
ambulance has been used, on occasion, to enable a REoLT to take place if the
timeliness of the NWAS ambulance transport was the limiting element.
5) Care for those who are dying and the ‘families’ (relatives, friends, colleagues,
informal carers) who keep vigil with them is crucial, along with the important
conversations with senior health professionals who can deal with the concerns,
questions and emotions expressed. 379 (47%) (384 (42%) in 2013/14) patients
thought likely to be dying in hospital had an individual plan for the care developed
with them and their family as did 323 (334 in 2013/14) in the community (including
residential homes).
Families (and those important to the patient)
Continued effort has been made to visit, on the wards, families of those who are
thought to be dying, to enquire about their concerns and try to address them
immediately. Feedback from patients and families has generally been very positive,
and also grateful for the extraordinary lengths to which staff on wards go, to help
them to cope at this difficult time. Information regarding incidents, concerns and
compliments received by any method has been documented, investigated and fed
back through various routes to ensure awareness of any issues that transpire.
Families, who may feel completely isolated, at a loss and out of place in the hospital
environment, feel even more so when they also have to deal with the impending
death of a loved one. The ‘Oasis’ Room, for those who are keeping vigil with
someone who is likely to be dying, has been well used, sometimes by several
families at a time. This consists of sitting and sleeping areas, and gives families an
opportunity for rest & refreshment whilst staying close by. This has been much
appreciated by families who in the heightened emotions of this important time for
them, rate highly the care and concern offered to them, and leave comments and
suggestions in a book left in the room for the purpose and also donated a fridge for
the use of other families. Support from the Transform Team and Specialist Palliative
Care, as well as ward and neighbourhood teams, snack boxes and access to the
restaurant overnight, a free car parking trial, use of shower facilities in the spinal
injuries gym, and carer’s comfort packs of donated toiletries, use of the carer’s care
plan and including the carer on the district nurse’s caseload so that they receive the
support they need during the period of illness and into bereavement, have been
additional supports at a difficult time.
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Pharmacy
The Deputy Pharmacy Manager and Specialist Palliative Care Pharmacist, has been
actively involved in the complicated business of working with the CCGs to
successfully reinstate the service level agreements with community pharmacies to
hold a small stock of those drugs which might be required out of hours to control
symptoms patients reaching the end of life. Ensuring availability of medications which
may be needed at the end of life, is vital if good care is to take place and avoid the
distress caused to families when they are chasing around local pharmacies with a
prescription they cannot fill, whilst a loved one is seriously ill at home. Guidance in
line with NICE guidance has been produced for those taking prescription opioids and
further extended to address the new laws on driving whilst taking medication. New
inpatient prescription charts now include guidance for anticipatory prescribing for
those thought likely to be dying.
Spiritual Care
Spiritual distress may be particularly evident as life draws to a close when a search
for meaning, peace, reconciliation of relationships, enjoyment of nature or beauty and
perhaps religious expression become particularly poignant. At no time in life may
spiritual care be more important for patient or family. The Trust Chaplain, the clergy
team and chaplaincy volunteers, work to meet expressed spiritual and religious
needs at this time.
The Trust now has a Spiritual Care Policy and a Spiritual Care Plan both of which
support staff in recognising and addressing spiritual needs of patients and families.
However they cannot meet needs which are unrecognised and currently the ‘Opening
the Spiritual Gate’ programme is ongoing to assist staff to be aware of and discuss
spiritual needs with patients and families, so that chaplaincy or other spiritual
services can be enlisted where patients and families would welcome this support.
During 2014-15 at least one member of staff from most wards and neighbourhoods
have undertaken this programme with only 5 areas still to complete.
The Prayer/Quiet Room/Chapel are available at both Ormskirk and Southport sites
with multi faith areas. There are plans to ensure that the needs of those who require
ablution facilities prior to prayer can be met as these are as yet unavailable.
Care for the bereaved
The mortuary and bereavement team have continued to provide continuity of care
after death for the patient and for the bereaved family, with sensitive individual
touches - improved quality property bags for patients’ effects; ‘last thoughts, words
and wishes’ cards; ‘forget me not’ seeded cards; keepsake pebbles; ribbon ties and
muslin bags for hair locks and free parking for those collecting certificates.
Coding
The Trust coding for Specialist Palliative Care (Z51.5) has been regularly audited
again this year and continues to be accurate as a result of work between the
Specialist Palliative Care Service and the coding department.
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Audit
Audit of end of life and palliative care is important and two strong audit strands exist.
The cross boundary Specialist Palliative Care Audit programme has been ongoing for
16 years and at four meetings throughout the year a selection of audits undertaken
by members of the integrated specialist palliative care services are presented. These
have included for example:- Advance Care Planning; AMBER Care Bundle; cross
boundary Specialist Palliative Care Services co-ordination; coding; eating and
drinking at end of life; spiritual care; Famcare II (national bereavement audit);
recording of next of kin details; opioid prescribing against NICE guidelines; oral
assessment; patient experience; preferred place of care and rapid end of life
transfers.
The end of life audits are presented at a mini conference the third of which occurred
this year ‘Celebrating Success: Building Bridges’, chaired by Dr Gerard Corcoran,
previously Consultant in Palliative medicine at Aintree University Hospital. At this,
many of the ward/department End of Life Audits were presented. Topics such as
religious needs, named senior clinicians, mouthcare, genograms, quality of life
feeding, community GSF care, wheelchairs at end of life, dying pre & post July 2014,
organ & tissue donation, small changes, big difference, analgesia administration,
transform, spiritual care of the dying, information for pregnancy loss, conversations
about dying and spinal spirituality have all been presented.
This year two new awards were made at this mini conference:–
 The inaugural Liz Yates Legacy Award for the audit most likely to change practice
was awarded jointly to Gill Sperrin and Martha Finch for their excellent work in
auditing care in the last months of life and beyond and the development of the
GSF and carer’s care plans.
 The inaugural Rabbi Sidney Kay Award for the clinician’s audit most likely to
improve spiritual care, was awarded to Lucy Gough, Spinal Injuries Unit for her
audit of spiritual care and the development of the Trust Spiritual Care Plan.
Looking forward to 2015 / 16
Thanks to support from Southport & Formby Clinical Commissioning Group and West
Lancashire Clinical Commissioning Group alongside the positive Trust commitment
to end of life care, at every level from board to ward, it will be possible to continue to
develop the very important good work being undertaken around specialist and
general, palliative and end of life care in all health care settings into 2015/16. We
have only one opportunity to get it right for each individual and their family – there is
no rehearsal and no opportunity for complacency.
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1.15
Pride Awards
The Trust held its annual Pride Awards in June at the Floral Hall in
Southport. Nearly 400 staff and guests attended the awards dinner and
ceremony at which the 13 awards recognise the dedication and skill of
staff were presented.
The winners were (clockwise from top left): Adults at Risk Liaison Team
(Patient Safety Award); Bert Ball (Chairman’s Award); Karl Watling
(Support Worker of the Year); Hayley Nothard (Administrate/Clerical
Worker of the Year); Victoria Finney (Doctor of the Year); Sickness
Absence Team (Safely Reducing Costs Award); Spinal Injuries Unit
Outreach Team (Team of the Year); Mark Bennett (Patients’ Award); Sally
Nichol (Chief Executive’s Award); Wendy Benson (Nurse/Midwife of the
Year); Dominic Bray (Health Professional of the Year); Debbie Curran
(Leadership Award); Ann Whitfield (Healthcare Assistant of the Year).
We were also grateful to our sponsors for helping make the event
possible. They were Hill Dickinson; Allocate Software; CRG Software; Edge
Hill University; The Learning Clinic; and, System C.
Category
Chairman’s Award (for volunteers):
Patients’ Award:
Safely Reducing Costs:
Patient Safety Awards:
Doctor of the Year:
Nurse/Midwife of the Year:
Healthcare Assistant of the Year:
Health Professional of the Year:
Support Worker of the Year:
Administrative/ Clerical Worker of the Year:
Leadership award:
Chief Executive’s Award
Team of the year:
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Winners
Bert Ball, chaplaincy team
Mark Bennett, Nurse Consultant
Sickness Absence Team
Adults at Risk Liaison Team
Victoria Finney
Wendy Benson
Ann Whitfield
Dominic Bray, Clinical Psychologist
Karl Watling, Chef
Hayley Nothard
Debbie Curran, CERT Team Manager
Sally Nicol, Occupational Therapist
Spinal Injuries Unit Outreach Team
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
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1.16
North West Regional Spinal Unit Out Reach Team
The service has enabled an improvement in patient flow throughout the unit. The
team enable patients to be discharged to their home environment quicker and
receive care at home rather than in a hospital setting.
Average LoS (all levels of injury)
150
100
Grand Total
50
0
Linear (Grand Total)
Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2 Qtr3 Qtr4 Qtr1 Qtr2
2012
2013
2014
The outreach service is delivered through:
 8 contracted community beds
 Spot purchase of beds
 Support patients in the community as an alternative to hospital admissions
(currently 16 pts supported in this way) – these are for specialist rehabilitation
issues such as bladder, bowels, skin/pressure sores which develop as a result of
spinal cord injury
 Top up of patient education and rehabilitation in their home environment
 Basic spinal care rehabilitation that can be done in the home environment rather
than be admitted
 Supporting referrals that can be offered an alternative to admission and can be
supported at home with outpatient/outreach work.
 The spinal outreach team supporting and educating clinicians in the local trauma
centres in the management of spinal injury patients so that they are admitted with
less complications which has an impact on the time that they can commence
rehab. This is known to improve the potential for rehabilitation and will decrease
the time they are in an acute bed.
 Spinal specialist nurse developing the skills and knowledge in the local trauma
centres.
Active Rehab in Community Beds
April
May
June
July
August
September
October
November
TOTAL
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118
120
127
157
130
102
140
139
1033
Community Support - Alternative
to Hospital Admission (bed days)
201
325
427
440
314
244
244
204
2399
Specialist SCI Hospital Bed Days
Saved
319
445
554
597
444
346
384
343
3432
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
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PART 2
2.1
Priorities for Improvement 2015- March 2016
The CQC inspection reported in May 2015 will form the basis of our improvement
priorities for the coming year and are detailed below. We will also focusing on the
deteriorating patient and patient falls during the coming year.
Southport & Formby DGH MUST:-
Ensure adequate nurse staffing levels and an appropriate skill mix in all areas, but
notably the Emergency Department
Ensure equipment used in the theatres is fit for purpose and older equipment is
replaced under a planned replacement schedule.
Ensure medicines management meets national standards in the critical care unit and
in the emergency department
Improve infection prevention and control processes within the medical directorate
Ensure that there are suitably qualified, skilled and experienced staff to meet the
needs of the patients in the North West Spinal Injuries Centre
The trust must ensure adequate senior nursing management is afforded to the North
West Regional Spinal Injuries Centre
Ensure the equipment used is fit for purpose and older equipment is replaced under
a planned replacement schedule
Ormskirk DGH MUST:-
Ensure adequate medical and nursing staffing levels and an appropriate skill mix in
all areas notably Maternity
Ensure medical and senior nurse cover out of hours is safe and fit for purpose
Ensure consent for obstetric procedures is recorded appropriately
Ensure all staff working in obstetric theatres are appropriately trained and
experienced to provide safe care
Review the incidence of peripartum hysterectomies and the use of forceps delivery
are appropriate and safe
Ensure all newly qualified midwives receive support and supervision as per their
perceptorship guidance, taking into account the number of experienced midwives
working with them on any shift
Ensure the leadership of the maternity services encourage and enables an open and
transparent culture
Ensure the equipment used in the theatres is fit for purpose and older equipment is
replaced under a planned replacement schedule
Community Adult Services MUST:-
Complete the staffing review for district nursing and establish a clear plan for the
management of increasing workloads
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2.2
Review of Services
Statements of Assurance from the Board (in regulations)
Between April 2014 and March 2015 the Trust provided acute hospital and
community NHS services made up of the following regulated activities, for which
the Trust became registered with the Care Quality Commission (CQC) without
conditions from April 2010;
-Treatment of diseases, disorder or injury
-Surgical procedures
-Diagnostic and screening procedures
-Management of supply of blood and blood derived products
-Maternity and Midwifery services
-Termination of pregnancies
-Assessment or medical treatment for persons detained under 1983 Mental
Health Act
-Family planning
 Southport and Ormskirk Hospital NHS Trust has reviewed all the data
available to them on the quality of care in all of these NHS Services
 The income generated by the NHS services reviewed in the period April 2014March 2015 represents 92.67% of the total income generated from the
provision of NHS services by the Trust for April 2014-March 2015.
2.3
Participation in Clinical Audit
 During April 2014-March 2015 30 National Clinical Audits and 4 National
Confidential Enquires covered services that the Trust provides
 During that period the Trust participated in 100% of the National Clinical
Audits and 100% of the National Confidential Enquiries which it was eligible to
participate in
 The National Clinical Audits and National Confidential Enquiries that the Trust
was eligible to participate in during April 2014-March 2015 can be found in
Appendix 2 & 3
 The National Clinical Audits and National Confidential Enquiries that the Trust
participated in and for which data collection was completed during April 2014March 2015 are listed in Appendix 2 & 3 alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or enquiry
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
The reports of 30 national clinical audits were reviewed by the Trust in the
period April 2014-March 2015 and the Trust intends to take the actions
described in Appendix 2 to improve the quality of healthcare provided

The reports of 250 local clinical audits were reviewed by the provider in the
period April 2014-March 2015 and the Trust intends to take the actions
outlined in Appendix 4 to improve the quality of healthcare provided
Southport & Ormskirk hospital NHS Trust Trauma Audit and Research Network
(TARN) Data Accreditation
Data 2012
Data 2013
Data 2014
91.6%
97.7%
97.9%
There is a website for the project www.tarn.ac.uk
2.4
Participation in Clinical Research
The Trust were actively involved in conducting 141 clinical research studies during
2014/15 – including actively recruiting studies and those in the follow up phase, with
a total of 552 Southport & Ormskirk patients consenting to be part of a research
project.
Southport & Ormskirk NHS Trust is committed to encouraging participation in high
quality national and multi-national research studies, recognising that research is vital
in providing the new knowledge needed to improve health outcomes
A study entitled Research Activity and the Associations with Mortality, published in
February 2015, showed that patients cared for in research-active acute NHS Trusts
have better outcomes. The results demonstrated a direct association between higher
levels of research activity and lower rates of patient mortality following emergency
admissions.
According to Cancer Research UK, over the last 40 years, cancer survival rates in
the UK have doubled. In the 1970s just a quarter of people survived. Today that
figure is 50%. This is directly as a result of clinical research and with the
development of targeted therapies and studies involving predictive biomarkers, this
figure will undoubtedly increase dramatically over the next few decades. There are
currently 4000 scientists in the UK working to detect and fight cancer and nearly
3,000 patients per month involved in Cancer trials. The Trust currently has 15
actively recruiting Cancer trials and 23 trials that have closed to recruitment, although
many of these patients will be followed up by the research team for life.
Currently, there is substantial research investment into the causes, symptoms and
treatments of diabetes, but despite this, a new report published in the journal
‘Diabetic Medicine’ has projected that the NHS’s annual spending on diabetes in the
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UK will increase from £9.8 billion to £16.9 billion over the next 25 years, a rise that
means the NHS would be spending 17% of its entire budget on the condition.
Southport & Ormskirk NHS Trust are actively recruiting to research studies in
paediatric, adult, Types 1 and 2, commercial and non-commercial diabetes research.
The Research & Innovation team at Southport & Ormskirk NHS Trust also guide and
support would be researchers who work within the Trust, through the complex
research application system and the many regulatory authorities approval processes
they will encounter, to enable them to carry out their own research ideas and
proposals.
Fracture Free Study - The Fracture Free study was set-up by the University of
Oxford and in May 2014 Southport and Ormskirk NHS trust became a recruiting site.
The aim of the study is to improve the understanding of the causes and
consequences of fractures, and provide a fracture free future for patients.
To date we have recruited 104 patients, which is a great achievement.
Patients are recruited from the Fracture clinic; both at Southport and Ormskirk, from
surgical wards, Minor Injuries at Ormskirk and also by patients phoning up the
Research department having viewed an advertisement within the trust.
We are collaborating with the Orthopaedic Consultants, and clinic staff, who are all
very proactive and have helped us achieve successful recruitment figures.
Mr Suraliwala is a very dedicated Principal Investigator, and was recently awarded
‘Investigator of the year’ due to his enthusiasm for research.
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2.5
Goals agreed with commissioners use of the CQUIN
payment framework
A proportion of Trust income in the period April 2014-March 2015 (2.5%) was
conditional in achieving quality improvement and innovation goals agreed between
the Trust and its commissioners, through Commissioning for Quality and Innovation
payment framework (CQUIN).
Target has been achieved
Work is still ongoing to achieve target
CQUIN Scheme
Value
Friends and Family Test
250,831
Safety Thermometer
£179,165
Dementia
£286,664
Advancing Quality (excludes West Lancashire)
£157,665
All Discharges to be sent electronically
£978,607
All Discharges to be sent within 24 hours to GP
£919,413
Audit Quality of e-discharges
£228,960
Outpatient letters sent to GP within 24 hours
£224,960
Reduce number of hospital cancelled outpatient
appointments
Audit the usage of the Nutritional Assessment Screening
Tool
Stroke - Assistive devices, All suitable admitted patients
that have had a stroke to be assessed for the Functional
electrical stimulation treatment (FES)
All patients to receive FES therapy that have been
assessed as suitable for this type of therapy
Stroke - Assistive devices. All suitable admitted patients
that have had a stroke to be assessed for SALT computer
therapy
All patients to receive SALT computer therapy in hospital
that have been assessed as suitable for this type of
therapy
All patients to receive SALT computer therapy after
discharge from hospital that have been assessed as
suitable for a period of 6 months.
Implement a programme for the use of Microsoft's Stroke
Recovery with Kinect.
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£224,999
£164,905
£56,214
£56,214
£56,214
£56,214
£56,214
£56,214
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
2.6
What others say about us - statements from the CQC
On 11th November 2015, the Trust underwent a 4 day long inspection by the Care
Quality Commission Chief Inspector of Hospitals (CIH) Team using the new
inspection model. The inspection utilised intelligent monitoring from multiple sources
to form the basis of their key lines of enquiry during the inspection. The inspection
was supported by a Lead Inspector, Inspection Manager and 60 inspectors
comprising of clinical experts, service users and analysts who used their professional
judgement, supported by objective measures and evidence, to assess the Trust
against five key domains.
The aim of the new inspections is to get to the heart of people's experiences through
examination of the quality and safety of the care we provide based on the things that
matter to people and concentrated upon evidence to show whether the services we
provide are:
• Safe
• Effective
• Caring
• Responsive to people’s needs
• Well-led
The announced inspection was reinforced by two public meetings and a number of
individually structured focus groups along with an unannounced visit out of hours
during the evening of 20th November 2015. The inspection will provide an overall
rating for the Organisation based on a scale of outstanding, good, requires
improvement or inadequate. This is still awaited at time of report.
The inspection was Organisational wide and provides a baseline for continual
improvement. All areas of the organisation were included within the inspection and as
an Integrated care Organisation (ICO), the Trust was one of the first inspections to
actively include community services alongside acute services. All employees and
stakeholders were involved and embraced the opportunity to become involved in the
preparation for the inspection, showing how proud they were of the services that they
help to deliver. The recommendations will be instrumental in driving the quality
agenda within the Trust in the coming months.
The final report was published on the 13th May 2015 given the Trust as a whole a
rating of requiring improvement.
The inspectors also gave good ratings for the dignified care we give patients who are
dying; many services at Ormskirk hospital including children and young people’s
services, and outpatients diagnostics and imaging; and, community services for
children and young families.
They noted areas of outstanding practice including the Community Emergency
Response Team’s work with patients to reduce avoidable hospital admissions; the
excellent service of the mortuary team; and the work of the children’s diabetes and
respiratory teams. A breakdown of the CQC ratings are provided over the page.
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2.7
Data quality: relevance of data quality and action to improve
data quality
Southport and Ormskirk NHS Hospital Trust has a programme of work aimed at
improving data quality and for the financial year 2015/16 is focussed at reviewing and
improving data captured within the Trusts new Electronic Patient Records (EPR)
including A&E and Maternity.
2.8
NHS number of general medical practice code validity
The following information is taken from the latest Data Quality dashboard published
by the Health and Social Care Information Centre (HSCIC). This information shows
the percentage of valid NHS Numbers and General Medical Practice codes
submitted by the Trust to the Secondary Uses Services (SUS) at December
reconciliation point covering Admitted Patient Care (APC), Outpatients and A&E
attendance activity during April to December 2014.
Which included the patient’s valid NHS number was:
o 98.9% for admitted patient care
o 99.6% for outpatient care
o 97.6% for accident & emergency care
Which included the patient’s valid general medical practice code was:
o 100% for admitted patient care
o 100 % for outpatient care
o 99.8 % for accident and emergency care

A Payment by Results audit was deemed by the Audit Commission to be not
necessary in 2014/15.
2.9
Information governance toolkit attainment level
Southport and Ormskirk Hospital NHS Trust Information Governance Toolkit
Assessment Report overall score for 2014/ 2015 was fully compliant at 71% rated
Satisfactory.
2.10
Clinical coding error rate
Southport and Ormskirk NHS Hospital Trust was not subject to the Payment by
Results clinical coding audit during 2014/15 by the Audit Commission as part of this
year’s assurance framework. However, the Trust commissioned its own internal
audit, which supports the Trusts Information Governance toolkit submission,
requirement 505. The primary purpose of this audit is to assess compliance of clinical
coding with national clinical coding standards. The audit was based on requirements
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and standards set out within the HSCIC’s Clinical Coding Audit Methodology 20142015 Version 8.0 and undertaken by an HSCIC approved clinical auditor. The audit
found the general standard of clinical coding of at Southport & Ormskirk NHS
Hospital Trust as good, the accuracy of clinical coding is shown below:
Coding Field
PERCENTAGE CORRECT
REQUIREMENT
2014/2015
2013/2014
505 LEVEL 2
505 LEVEL 3
Primary Diagnosis
91.0%
91.0%
>=90%
>=95%
Secondary Diagnosis
89.2%
94.2%
>=80%
>=90%
Primary Procedure
93.6%
95.2%
>=90%
>=95%
Secondary Procedure
94.6%
88.9%
>=80%
>=90%
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
PART 3
Our targets as set out in the 2013 / 2014 quality account were:
1. Review mortality process and reduce mortality rate to 85% in next 12 months
as measured by HSMR
2. We will reduce the hospital-acquired pressure sores by 25% each year
3. We will improve undertaking of hand hygiene audits to 100% within 12
months and results of the hand hygiene audits to 100% within 24 months
4. We will reduce the number of inpatient falls
5. Eliminate preventable morbidity in maternity care over the next 3 years
6. We will decrease the number of Clostridium Difficile infections
7. Maintaining an Embedding Mandatory Professional Standards
Target has been achieved
Work is still ongoing to achieve target
Target
Review mortality process and reduce mortality rate to 85% in
next 12 months as measured by HSMR
(Section 3.1 and 3.2 of quality account)
We will reduce the hospital-acquired pressure sores by 25%
each year
(Section 3.16 of quality account)
We will improve undertaking of hand hygiene audits to 100%
within 12 months and results of the hand hygiene audits to 100%
within 24 months
We will reduce the number of inpatient falls
(Section 3.17 of quality account)
Eliminate preventable morbidity in maternity care over the next 3
years
(Section 3.22 of quality account)
We will decrease the number of Clostridium Difficile infections
(Section 3.12 of quality account)
Maintaining an Embedding Mandatory Professional Standards
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Progress
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
DOMAIN:
Preventing people dying prematurely
Enhancing quality of life for people with long-term conditions
3.1
Hospital Standardised Mortality Rates (HSMR)
The hospital standardized mortality ratio (HSMR) is an important measurement tool
that compares a hospital's mortality rate with the overall average rate. Used widely in
the United Kingdom and the United States, the ratio provides a starting point to
assess mortality rates and identify areas for performance improvement. When
tracked over time, the HSMR indicates how successful hospitals have been in
reducing inpatient deaths and improving care.
The HSMR only reflects deaths which occur in hospital. A monthly update of the
HSMR is published on the Trust Quality dashboard highlighting any diagnosis or
procedure where we are falling outside the expected mortality rate (based on national
benchmarks). The Trust aims to be below 100.
HSMR by Year
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3.2
Summary Hospital Level Mortality (SHIMI)
Summary Hospital Level Mortality (SHIMI) includes those patients dying within 30
days after discharge from hospital and includes all deaths. If a patient dies while in
hospital or within 30 days of discharge, their death is attributed to the Trust providing
care. This is also being monitored monthly on the Quality dashboard and Trust
progress can be seen below.
Prescribed information: Southport and Ormskirk Hospital NHS Trust considers that this
data is as described for the following reasons: All activity data is submitted by the Trust to
Secondary Users Service (SUS) in line with national mandated requirements complying with
data definitions as per the Data Dictionary.
Apr 13 - Mar 14
Jul 13 - Jun 14
114.2
114.3
Banding
1
1
England
100
100
Highest Trust
53.9
54.1
119.7
119.8
Southport & Ormskirk NHS Trust
Lowest Trust
Data from the Information Centre
Southport and Ormskirk Hospital NHS Trust has taken the following actions to improve this
score and so the quality of its services, by the following :
-The executive medical director has established a mortality review group which
meets monthly to focus on improving the Trusts mortality levels.
-An action plan has been developed and this is monitored by the Trust board.
-We have in place a mortality policy and process to standardise our reviews and
learning.
-The SHIMI makes no adjustments for palliative care. The table below gives a
measure of the palliative care provided by the Trust reported in the SHIMI.
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3.3
The Percentage of patient deaths with palliative care coded
Prescribed Information (Data from the Information Centre)
April 13
- March
14
July 13 - June 14
Southport & Ormskirk NHS Trust
21.8%
21.5%
England
23.6%
24.6%
Highest Performing Trust
48.5%
49.0%
Lowest Performing Trust
0.0%
0.0%
The percentage of patient deaths with palliative care coded
at either diagnosis or specialty level:
3.4
Advancing Quality
The Advancing Quality (AQ) programme commenced in 2008 and is facilitated by
AQuA, Advancing Quality Alliance, and aims to give patients a better experience of
the NHS by ensuring the highest standards of care are consistently delivered. The
main principle of the programme is to ensure, based on pathways agreed by upon by
experts in each specialty, the best outcome for patients suffering from these
conditions. This is monitored in respect of providing the correct care at the correct
time within their respective clinical pathway.
For this Trust, during the period of 2014/15, overall performance was assessed using
a ‘Composite Process Score’ for each of the following focus areas.
 Acute Myocardial Infarction (Heart Attack)
 Heart failure
 Hip & Knee Replacement
 Community Acquired Pneumonia
 Stroke
 COPD
 Sepsis
A Composite Process Score (CPS) is an aggregated delivery of several clinical
processes
An Appropriate Care Score (ACS) is all measures passed for an individual patient
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Based upon validated available data provided by AQUA, the table below
demonstrates the performance of the Trust:
Actual Care Score
Stroke
AMI
Heart Failure
Pneumonia
Hip & Knee
COPD
SEPSIS
11/12
Actual Target
50.1%
12/13
Actual Target
47.7%
13/14
14/15 YTD*
Actual Target Actual
Target
42.7% 53.6%
35.5% 53.6%
86.5%
93.8%
Composite Score
Actual Care Score
90.1%
97.8%
85.0%
88.7%
100.0%
85.0%
Composite Score
Actual Care Score
98.9%
75.0%
95.0% 100.0%
74.8%
95.0%
Composite Score
Actual Care Score
88.7%
65.1%
89.0%
88.6%
67.4%
95.0%
Composite Score
Actual Care Score
90.1%
91.4%
95.0%
89.5%
93.7%
95.0%
Composite Score
Actual Care Score
97.7%
95.0%
98.3%
95.0%
96.4%
70.9%
85.4%
75.8%
91.3%
69.7%
95.0%
83.7%
94.5%
95.0%
71.0%
97.1%
71.3%
71.0%
65.4%
85.1%
70.5%
65.4%
82.1%
88.8%
84.2%
82.1%
91.1%
96.3%
0.0%
Composite Score
Actual Care Score
29.7%
39.7%
Composite Score
64.5%
*Discharges to end January 201
Within the organisation the Executive Medical Director has established working
groups to focus on improvements in key areas and to review our current pathways.
The focus groups are led by consultants who are focusing on Stroke, Sepsis and
Pneumonia.
Advancing Quality - Overall Performance based on Composite Process
Score
Stroke
AMI
Heart Failure
Pneumonia
Hip & Knee
100%
95%
90%
85%
80%
75%
11/12
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12/13
13/14
14/15 YTD
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Advancing Quality - Overall Performance based on Actual Care Score
Stroke
AMI
Heart Failure
Pneumonia
Hip & Knee
100%
90%
80%
70%
60%
50%
40%
30%
20%
11/12
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12/13
13/14
14/15 YTD
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
DOMAIN
Helping people recover from episodes of ill health following injury
3.5
Patient Reported Outcome Measures-PROMS
Patient Reported Outcome Measures (PROMs) are a means of collecting information
on the effectiveness of care delivered to NHS patients as perceived by the patients
themselves.
PROMs comprise of a pair of questionnaires completed by the patient, one before
and one after surgery (at least three months after for groin hernia and varicose vein
operations, or at least six months after for hip and knee replacements). Patients’ selfreported health status (sometimes referred to as health-related quality of life) is
assessed through a mixture of generic and disease or condition-specific questions.
EQ-5D-3L: Comprises of 5 qualitative dimensions: mobility, self-care, usual activities,
pain/discomfort and anxiety/depression. Each dimension has 3 levels: no
problems, some problems, extreme problems
The respondent is asked to indicate his/her health state by ticking (or
placing a cross) in the box against the most appropriate statement in each
of the 5 dimensions.
EQ VAS: The EQ VAS records the respondent’s self-rated health on a vertical,
visual analogue scale which can be used as a quantitative measure of
health outcome as judged by the individual patient - ‘Best imaginable
health state’ and ‘worst imaginable health state’.
Using source data available through the NHS Information Centre the following
reports show performance based on four common elective surgical procedures: groin
hernia operations, hip replacements, knee replacements and varicose vein
operations.
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The data below shows the position of the Trust.
EQ-5D-3L (April 2014 – September 2014)
Southport and
Ormskirk NHS
Trust
Groin Hernia
Varicose Vein
Hip replacement
Knee Replacement
England
Number of
Returned
Responses
31
19
10
9
Number of
Returned
Responses
No.
Reporting
% Reporting
Improvement Improvement
12
38.7%
7
36.8%
8
80.0%
7
77.8%
No.
Reporting % Reporting
Improvement Improvement
No.
Reporting
Same
15
6
0
1
No.
Reporting
Same
%
Reporting
Same
48.4%
31.6%
0.0%
11.1%
%
Reporting
Same
No.
Reporting
Worse
%
Reporting
Worse
4
12.9%
6
31.6%
2
20.0%
1
11.1%
No.
%
Reporting Reporting
Worse
Worse
Groin Hernia
6047
3037
50.2%
1955
32.3%
1055
17.4%
Varicose Vein
1475
794
53.8%
468
31.7%
213
14.4%
Hip replacement
3199
2897
90.6%
163
5.1%
139
4.3%
Knee Replacement
3898
3205
82.2%
369
9.5%
324
8.3%
No.
Reporting
% Reporting
Improvement Improvement
11
34.4%
5
27.8%
6
60.0%
3
50.0%
No.
Reporting % Reporting
Improvement Improvement
No.
Reporting
Same
6
4
2
0
No.
Reporting
Same
EQ-5D VAS (April 2014 – September 2014)
Southport and
Ormskirk NHS
Trust
Groin Hernia
Varicose Vein
Hip replacement
Knee Replacement
England
Number of
Returned
Responses
32
18
10
6
Number of
Returned
Responses
%
Reporting
Same
18.8%
No.
Reporting
Worse
%
Reporting
Worse
46.9%
%
Reporting
Same
15
9
2
3
No.
Reporting
Worse
%
Reporting
Worse
22.2%
20.0%
0.0%
50.0%
20.0%
50.0%
Groin Hernia
6273
2397
38.2%
1294
20.6%
2582
41.2%
Varicose Vein
1453
594
40.9%
266
18.3%
593
40.8%
Hip replacement
3074
2049
66.7%
334
10.9%
691
22.5%
Knee Replacement
3688
2083
56.5%
505
13.7%
1100
29.8%
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3.6
Readmissions
Unfortunately the publication for emergency readmissions to hospital within 28 days
of discharge indicators has been delayed this year. The information centre are
currently reviewing the methodology and specifications which will have an impact on
when they will actually be published. However, it is highly unlikely that they will be
published this year.
Prescribed information: Southport and Ormskirk Hospital NHS Trust considers that
this data is as described for the following reasons all activity data is submitted by the
Trust to Secondary Users Service (SUS) in line with national mandated requirements
complying with data definitions as per the Data Dictionary.
Information centre provides only data on 0-15 and 16+ for re admissions
0-15
16 +
Southport & Ormskirk NHS
Trust
England
Highest Performing Trust*
Lowest Performing Trust*
Southport & Ormskirk NHS
Trust
England
Highest Performing Trust*
Lowest Performing Trust*
2009/10 2010/11 2011/12
10.80%
10.01%
6.33%
14.20%
12.41%
10.01%
5.87%
13.78%
11.31%
10.01%
5.10%
13.58%
11.06%
11.18%
7.34%
13.30%
11.17%
11.43%
7.68%
13.00%
11.05%
11.45%
8.96%
13.50%
*Medium Acute Trusts only
Please note the latest figures from the NHS Information Centre are for 2011/12
DOMAIN
Ensuring people have a positive experience of care
3.7
Responsiveness to the Personal Needs of the Patient
The data below was as a result of the 5 questions below asked through the
National Inpatient Survey and one formed the basis for one of the national
CQUINs.
Q32 Were you involved as much as you wanted to be in decisions about your care and
treatment?
Q34 Did you find someone on the hospital staff to talk to about your worries and fears?
Q36 Were you given enough privacy when discussing your condition or treatment?
Q56 Did a member of staff tell you about medication side effects to watch for when you went
home?
Q62 Did hospital staff tell you who to contact if you were worried about your condition or
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treatment after you left hospital?
Southport and Ormskirk’s results from the National Patient Survey are as
below:
Southport & Ormskirk
NHS Trust
England Average
Highest Performing Trust
Lowest Performing Trust
2009/10
66
2010/11
63.9
66.7
81.8
58.3
67.3
82.6
56.7
2011/12 2012/13
63.7
62.2
67.4
85
56.5
68.1
84.36
57.43
2013/14
74.8
2014/15
74.4
76.9
87.1
67.1
76.6
87.4
67.4
Obtained from the Information Centre
Prescribed information: Southport and Ormskirk Hospital NHS Trust considers
that this data is as described for the following reasons: It is co-ordinated centrally
for all trusts by an External source.
Southport and Ormskirk Hospital NHS Trust has taken the following actions to
improve this score and so the quality of its services, by the following actions :



The Patient Experience Group monitors the results of all the patient
experience questionnaires undertaken with the Trust and monitors actions
taken to make improvements.
The pharmacy team have held an “In Your Shoes” patient experience event
solely focusing on medication and how we can improve the information
provided on medicines.
The pharmacy team have established a regular patient focus group to discuss
medication issues on an on-going basis.
National Inpatients Survey 2015
Between September 2014 and January 2015, a questionnaire was sent to 850 recent
inpatients at each trust. Responses were received from 388 patients. People were
asked to answer questions about different aspects of their care and treatment. Based
on their responses the CQC gave each NHS trust a score out of 10 for each question
(the higher the score the better). Each trust also received a rating of ‘Better’, ‘About
the same’ or ‘Worse’.
Better: the trust is better for that particular question compared to most other trusts
that took part in the survey.
 About the same: the trust is performing about the same for that particular question
as most other trusts that took part in the survey.
 Worse: the trust did not perform as well for that particular question compared to
most other trusts that took part in the survey.

The emergency/A&E department
Waiting lists and planned admissions
47 | P a g e
8.2/10
About the same
8.7/10
About the same
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Waiting to get to a bed on a ward
7.2/10
About the same
The hospital and ward
8.1/10
About the same
Doctors
8.4/10
About the same
8.1/10
About the same
7.5/10
About the same
8.3/10
About the same
Nurses
Care and treatment
Operations and procedures (answered by patients who had an operation or
procedure)
Leaving hospital
6.9/10
About the same
5.3/10
About the same
7.9/10
About the same
Overall views of care and services
Overall experience
Areas scoring worse than other Trusts
Before you left hospital, were you given any written or printed information about
what you should or should not do after leaving hospital?
Being told who to contact if worried about condition or treatment after leaving
hospital
During hospital stay, being asked to give their views about the quality of care
6.0/10
Worse
7.0/10
Worse
1.3/10
Worse
Complaints and Compliments
Complaint Numbers
600
520
500
421
400
300
369
285
279
200
100
0
10/11
11/12
12/13
13/14
14/15
The Trust received 520 formal complaints in 2014/15. This is an increase of 41% on
the numbers reported in 2013/14. This increase however can be attributed to a
change in the way complaints were categorised, which took place with effect from
September 2014. As per the NHS Complaints Guidance, any complaint which
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
cannot be responded to within 1 working day, must be treated as a formal complaint.
Prior to this, we had treated many of these as informal concerns.
If we look at the combined numbers of both concerns and complaints, year on year,
there has actually been a reduction of 9.4%, which suggests that we are learning
from our complaints and implementing actions to improve things for our patients.
The table below provides some context to the complaint numbers received into the
Trust. The process for collection of compliments changed in 2014/15, whereby staff
are encouraged to log the compliments received electronically to enable themes to
be drawn and fed back to the relevant areas. As a result we have noticed a
reduction in the numbers reported as demonstrated below.
1/1/1031/12/10
Total Outpatients
1/4/1131/3/12
1/4/1231/3/13
1/4/1331/3/14
1/4/1431/3/15
254,836
253,320
249,415
266,167
273,086
59,511
61,049
60,589
61,416
61,390
Community Contacts
205,957
230,220
272,095
284,164
Outpatients Appointments-Community
108,425
117,025
130,727
133,960
314,347
614,066
637,949
730,405
752,600
2775
6708
13,432
5,665
2,191
287
279
421
369
520
0.88%
1.09%
2.10%
0.78%
0.29%
0.09%
0.04%
0.07%
0.05%
0.07%
Total Inpatients
Total Patient Contacts
Compliments
Complaints
Compliments as a % of Total Patient Contacts
Complaints as a % of Total Patient Contacts
Reasons for Complaint
The pie chart demonstrates the subjects identified as the primary reason for the
complaint. Unsurprisingly, complaints are dominated by issues pertaining to clinical
care, with patients specifically citing poor co-ordination of treatment, issues with
nursing care, medication/pain management and diagnosis issues.
Oral
communication has remained consistently in the top three reasons for complaint in
2014/15, with patients complaining about not receiving clear explanations. There has
been an increase this year in complaints around appointment dates, with patients
complaining of unacceptable waits for appointments or cancellation of appointments.
49 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
What are we doing?
Work is ongoing to improve our communication with both patients and relatives.
Customer Care training has been implemented and is currently being extended to all
staff groups. A new standard operating procedure has been introduced in A&E to
reduce the potential for missed diagnoses of fractures. The Trust has also
introduced a new system for triage in A&E following repeated complaints around lack
of privacy and confusion about the process.
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.8
Percentage of staff who would recommend the provider to
friends or family needing care
The 2014 NHS Staff Survey involved 287 NHS organisations in England and over
624,000 staff were invited to participate. Nationally, 255,000 responses were
received, a response rate of 42% (49% in 2013) with 419 staff from the Trust
responding to the survey.
The trust saw an improvement in the overall staff engagement measure to 3.66,
however this remains below the national average of 3.7. The Trust also achieved
levels above the national average in areas such as:
Staff motivation
Satisfaction with the quality of work and patient care staff are able to deliver
Staff receiving appraisals and the structure of appraisals
Staff receiving health & safety plus equality & diversity training in the last 12
months
Provision of equal opportunity for career progression and promotion
% of staff agreeing / strongly agreeing with the
following statements:
Trust
2014
Average
Acute
Trusts 2014
Trust
2013
"I would recommend my organisation as a place to
work"
55%
58%
50%
3.50%
3.67%
3.46%
Staff recommendation of the trust as a place to
work or receive treatment
"If a friend or relative needed treatment,
I would be happy with the standard of
care provided by this organisation"
Trust
2014
Trust
2013
53%
51%
Best Worst Acute Trusts
Average
2014
93% 35%
67%
A Trust action plan has been developed and will be monitored through the workforce
committee. Divisional reports will also be developed for local action plans to gain
further improvements in how it feels to work at the Trust.
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The results of the survey are primarily intended for use by NHS organisations to help
them review and improve staff experience so that staff can provide better patient
care. The Care Quality Commission will also use the results from the survey to
monitor ongoing compliance with essential standards of quality.
3.9
The National Friends and Family Test
Inpatient feedback is now obtained through the implementation of the Hospedia
system via the bedside screens. This system has been implemented for inpatient
areas. The Friends and Family Test was a Department of Health initiative that was
introduced in April 2013. The Trust was required to ask all patients the following
question:
Would you recommend the hospital wards or accident and emergency unit to a
friend or relative based on your treatment?’
The Net Promoter Score Definition
Net Promoter Score = (% of Promoters) - (% of Detractors)
The equation is therefore capable of delivering a numeric output anywhere in the
range -100 (all detractors) to +100 (all promoters). The nearer to +100 the better!
The data below is the most recent information available.
Acute Inpatients
Apr14
May14
Jun14
Jul14
Aug14
Sep14
Oct14
Nov14
Dec14
Jan-15
S&O
37.9%
36.0%
42.2%
37.1%
32.3%
28.7%
19.9%
27.0%
22.7%
19.5%
England*
34.8%
35.3%
37.3%
38.0%
36.3%
36.2%
37.1%
36.8%
33.5%
35.8%
Highest Performing Trust*
74.0%
80.5%
72.2%
77.9%
72.0%
71.9%
70.1%
79.9%
74.7%
77.6%
Lowest Performing Trust*
13.6%
14.0%
12.7%
16.5%
13.5%
15.7%
18.3%
3.6%
16.6%
18.9%
Apr-14
May14
Jun14
Jul14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
S&O
85.2%
91.5%
92.9%
88.0%
89.8%
83.1%
88.0%
89.2%
85.7%
85.1%
England*
93.9%
94.2%
94.1%
94.2%
93.8%
93.5%
93.7%
94.7%
94.5%
94.2%
Highest Performing Trust*
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
Lowest Performing Trust*
76.5%
75.9%
78.8%
75.2%
70.3%
74.7%
77.2%
80.3%
77.9%
51.5%
Response Rate
% Would Recommend
*Without Independent Sector Providers
52 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Inpatients - Friends & Family Test
% Would Recommend
94%
45%
Response Rate
40%
35%
90%
30%
88%
25%
86%
20%
84%
15%
82%
10%
80%
5%
78%
0%
Response Rate
% Would Recommend
92%
Accident and Emergency
Response Rate
S&O
England
Highest Performing Trust
Lowest Performing Trust
Apr- MayJunJulAugSepOct- NovDec14
14
14
14
14
14
14
14
14
6.7% 5.1% 5.8% 8.4% 9.1% 8.1% 12.1% 11.9% 11.6%
18.6% 19.1% 20.8% 20.3% 20.0% 19.5% 19.6% 18.7% 18.1%
49.2% 49.5% 43.5% 47.7% 44.6% 63.8% 54.4% 45.5% 41.9%
3.2% 0.0% 2.3% 0.8% 4.2% 2.4% 3.1% 1.3% 2.2%
Jan-15
12.1%
20.1%
53.9%
3.2%
% Would Recommend
S&O
England
Highest Performing Trust
Lowest Performing Trust
Apr14
75.9%
86.5%
99.5%
42.8%
Jan-15
81.6%
88.1%
98.1%
55.2%
53 | P a g e
May14
81.6%
86.1%
98.7%
50.8%
Jun14
76.2%
86.1%
98.0%
58.3%
Jul14
76.9%
86.3%
98.7%
61.2%
Aug14
80.1%
87.5%
99.3%
66.8%
Sep14
68.6%
86.4%
99.0%
64.5%
Oct14
82.9%
86.8%
99.4%
58.5%
Nov14
87.3%
87.4%
99.3%
63.5%
Dec14
70.3%
86.2%
99.8%
53.5%
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
A&E - Friends
& Family Test
% Would Recommend
Response Rate
14%
85%
12%
80%
10%
75%
8%
70%
6%
65%
4%
60%
55%
2%
50%
0%
Maternity
Maternity - Friends & Family Test
Antenatal
110%
% Would Recommend
100%
90%
80%
70%
60%
50%
54 | P a g e
Birth
Postnatal Ward
Postnatal Community
Response Rate
% Would Recommend
90%
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Apr14
May14
Jun14
Jul14
Aug14
Sep14
Oct14
Nov14
Dec-14
Jan-15
100.0%
92.1%
93.8%
100.0%
100.0%
100.0%
98.3%
84.2%
96.7%
100.0%
93.8%
94.2%
94.1%
93.8%
94.5%
94.7%
94.6%
95.5%
96.0%
94.8%
Highest Performing Trust*
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
Lowest Performing Trust*
40.0%
51.2%
44.9%
55.6%
57.1%
61.5%
52.4%
53.9%
61.1%
41.4%
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
S&O
88.6%
87.0%
92.8%
78.6%
92.9%
78.7%
97.7%
90.3%
92.9%
86.1%
England*
95.1%
95.2%
95.6%
95.2%
95.3%
95.2%
94.8%
96.8%
96.6%
96.8%
Highest Performing Trust*
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
Lowest Performing Trust*
50.0%
65.1%
62.4%
58.8%
65.8%
55.6%
71.8%
80.7%
79.7%
82.6%
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
S&O
87.5%
87.5%
93.4%
89.6%
94.6%
88.2%
98.7%
86.5%
93.7%
83.9%
England*
92.0%
91.8%
92.6%
91.8%
91.4%
90.9%
91.5%
93.0%
92.9%
93.0%
Highest Performing Trust*
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
Lowest Performing Trust*
56.8%
55.1%
57.1%
51.0%
43.8%
60.0%
63.1%
72.9%
71.4%
64.4%
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
S&O
90.9%
94.1%
100.0%
100.0%
100.0%
97.5%
100.0%
100.0%
100.0%
97.8%
England*
96.0%
96.1%
96.2%
96.2%
96.7%
95.7%
96.2%
97.0%
98.0%
97.1%
Highest Performing Trust*
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
Lowest Performing Trust*
50.0%
61.1%
58.9%
56.8%
60.0%
60.0%
60.6%
83.3%
76.5%
76.5%
Antenatal
S&O
England*
Birth
Postnatal Ward
Postnatal Community
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.10
Improving Experiences and Support for Cancer patients
More than one in three people in the UK develop cancer and half will now live for at
least ten years – forty years ago the average survival was just one year. Work
continues on a national and local level to improve prevention; ensure swifter
diagnosis; and better treatment, care and aftercare for all those diagnosed with
cancer.
Ensuring cancer is diagnosed as early as possible and starting treatment quickly is
key to improving survival for many cancers. Meeting National target targets can
present a challenge, for many reasons and although we have had an increase in the
number of patients referred diagnosed with cancer and receiving their first cancer
treatment within 62 days of referral. The Trust continues to work hard to ensure that
we continue to improve performance.
The Trust has seen an increase of 49% in the number of patients referred with
suspected cancer over the last 5 years. This year we have seen a further 1.4%
increase. These figures mirror the national picture and demonstrate how pressured
cancer services are becoming. Despite this steady increase in numbers of patients
being referred by their GP with suspected the Trust has met the all of the cancer
targets for all 4 quarters, excluding bowel screening. (figures below)
The Trust continues to work hard to ensure that we continue to improve this
performance.
The Trust received 7741 suspected cancer referrals from GP’s and from this
753 patients were diagnosed with cancer.
The total number of patients
diagnosed from referrals by GP and emergency presentations was 1460.
National Standard
14 Day GP referral to Appointment
31 Day Decision to Treatment
31 Day Subsequent Treatment Surgery
31 Day Subsequent Treatment Drug Therapy
62 Day GP Referral to Treatment
(Classic): National
62 Day Screening Referral to
Treatment
56 | P a g e
Q1
Q2
93%
96%
97.2%
100.0%
95.5%
99.1%
95.3% 94.5%
100.0% 100.0%
Year
end
95.7%
99.5%
94%
97.3%
100.0% 100.0% 100.0%
95.5%
98%
100.0%
100.0% 100.0% 100.0% 100.0%
85%
85.4%
85.8%
85.5%
87.1%
85.4%
90%
100.0%
50.0%
77.8%
40.0%
66.9%
Target
Q3
Q4
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
The Trust has been working with clinical teams to review patient pathways and make
improvement to ensure timely diagnostics and treatment. Some of the improvements
made this year have been:
LUNG
Straight to CT scan - The lung team are alerted to abnormal
chest x-rays requested by GP’s and requesting CT scan
immediately rather than waiting for GP’s to refer back in. This
has resulted in patients having a diagnosis sooner or being
referred back to the GP earlier with reassurance.
HAEMATOLOGY Code alert for Haematology - The haematology and radiology
team have set up a code alert system to ensure that any patients
suspected lymphoma detected through their imaging. The
person who referred the patient and haematology team are
alerted immediately by radiology to inform timely management
UROLOGY
Improvements in timely processing of urology referrals through
dedicated support worker working with the clinical teams.
DERMATOLOGY Increased specialist nurse support for dermatology – increasing
numbers of minor operation lists and nurse led clinics.
Cancer Patient Experience
The Trust continues to use patient feedback to let us know how we are doing. The
National Survey 2013 results stated that overall 89% of patients who responded
rated their care and treatment very good/excellent. There are always areas to
improve and we have a detailed plan in place to address these some key areas are:
-Review of the specialist nursing support available to patients
-Increasing patient engagement in services development and feedback
-Improving support and Information
A successful patient feedback event was held in February 2015 – the “In your shoes
event” brought over 30 patients and carers to tell our staff about their
experiences. A follow up action group is being arranged and will involve patients.
The Trust commenced a Macmillan project to test electronic structured holistic needs
assessment and care planning. The e-HNA (electronic holistic needs assessment)
involves meeting patients to discuss care/emotional needs at key points in the cancer
pathway. The pilot is underway in Urology and Lung and is proving supportive to
patients. From this treatment summaries given to patient and GP at the start and
end of treatment. This work supports the concept of the Recovery Package which
was developed and tested by the National Cancer Survivorship Initiative| (NCSI) - a
partnership of Macmillan Cancer Support, Department of Health and NHS England to assist people living with a diagnosis of cancer to prepare for the future, and identify
their individual concerns and support needs. This enables people to return to as near
a normal lifestyle as possible, including returning to work.
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DOMAIN
Treating and caring for people in a safe environment and protecting
them from avoidable harm
3.11
Venous Thrombo-Embolism (VTE) Risk Assessment.
Prescribed information: Southport and Ormskirk Hospital NHS Trust considers
that this data is as described for the following reasons : The Trust carries out
local audits to check validity of this data.
% of Patients Risk
Assessed
Southport & Ormskirk
Hospital NHS Trust
2013/2014
Q1
Q2
Q3
Q4
95.53%
95.45%
96.65%
95.74%
96.00%
95.80%
95.57%
96.00%
Highest Performing
Trust
100.00%
100.00%
100.00%
100.00%
Lowest Performing
Trust
78.78%
81.70%
77.00%
78.86%
England
% of Patients Risk
Assessed
Southport & Ormskirk
Hospital NHS Trust
Q1
Q2
2014/2015
Q3
96.67%
96.16%
96.45%
96.19%
96.80%
95.96%
Highest Performing
Trust
100.00%
100.00%
100.00%
Lowest Performing
Trust
87.20%
86.40%
81.19%
England
Information Centre data
Q4
Data not
published
yet
Southport and Ormskirk Hospital NHS Trust is pleased with the slight increase
noted in 2014 / 2015 and consistently being above the average. The Trust has
taken the following actions to improve this percentage and thus the quality of its
services:



Annual training for medical staff
Review of process and introduction of root cause analysis
Assessment processes and audits of compliance.
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3.12
Infection Prevention and Control
MRSA Bacteraemias
The graph below illustrates that the Trust has had 2 cases of MRSA during 2014 /
2015.
Hospital Acquired MRSA Cases
6
5
5
4
3
2
2
2
1
0
10/11
0
12/13
11/12
0
13/14
14/15
Hospital Acquired MRSA Cases
The Trust has reviewed both cases in detail with representatives from the Clinical
Commissioning Group as part of the RCA/PIR (root cause analysis/post infection
review) process.
Both patients were frail and had numerous comorbidities and were therefore difficult
complex cases, however in hindsight clinical actions could have been improved, i.e.
clinicians could of identified the increase in C-reactive protein (CRP) a little earlier
and investigated the cause which may have led to treatment being administered a
couple of days earlier. In the second case there was the opportunity, but only of a
couple of days, to of treated the patient with a more appropriate antibiotic.
Actions and improvements include:
Cases being highlighted as part of mandatory training; in addition to a discussion
regarding screening there is also a discussion regarding monitoring results, acting
appropriately on findings and the appropriate use of antibiotics. These topics have
also been addressed in the Operational Infection Prevention and Control Meetings
and Medical Meetings.
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On a weekly basis the Infection Prevention Control team monitors new admission
MRSA screens and if not found will request an urgent screen. There is also the
consideration of additional MRSA screens on patients who have tested negative on
admission, but who are still in the hospital a month later; this is to be discussed
further in the Trust Infection Prevention & Control Committee Meeting.
Another improvement is the inclusion in the Trust Antimicrobial Guidelines the need
for considering adding IV Vancomycin for MRSA colonised patients who present with
signs and symptoms of infection – this will be introduced and highlighted by the
Microbiologists in the Medical Meetings as the guidelines are introduced this year.
Clostridium Difficile Infections
Prescribed information: Southport and Ormskirk Hospital NHS Trust considers
that this data is as described due to the following reasons: All data is collected
and verified by the Infection Prevention and Control Team who fully investigate
each case.
Southport and Ormskirk Hospital NHS Trust has taken the actions described in
the next few pages to improve this rate, and so the quality of its services.
C.diff - rate per 100,000 bed
days
Southport & Ormskirk NHS
Trust
England
Highest Trust
Lowest Trust
Information Centre data
14/15
2010/11
2011/12
2012/13
2013/14
33
22.5
15.6
22.7
29.7
0
71.8
22.2
0
51.6
17.4
0
30.8
14.7
0
37.1
Southport & Ormskirk internal data-C. diff Infection by 100,000 bed days
24.4
Internal data source
The Trust’s target for 2014/15 was 27 cases, actual figure was 35. However 16 of
these cases were successfully appealed therefore our true figure, post appeal, is 19
cases and therefore under trajectory.
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All cases of C. difficile infection continue to have a root cause analysis carried out to
ensure that lessons learned are disseminated throughout the Trust to prevent reoccurrence.
Since October 2014, the Trust was performing below trajectory on a monthly basis,
not taking into account appeals, however in March there were 4 cases which put us
over the monthly trajectory - reviews have been completed on these cases and a
proportion may be considered for the appeals process.
It is evident with some of these cases that we are dealing with chronically ill patients
who have received multiple episodes of care and antimicrobial treatment in both the
acute and community settings and despite our best efforts succumb to C diff
infection.
Our focus continues to be appropriate antimicrobial prescribing, early identification of
symptomatic patients including their isolation, sample acquisition and treatment, and
the maintenance of the Bristol Stool Chart; including recording the Bristol Stool
number on sample request forms.
Hand Hygiene Audit Compliance
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
61 | P a g e
Hand Hygiene
Compliance
99%
97%
98%
97%
95%
97%
96%
98%
Completion of Hand
Hygiene Audits
88%
93%
92%
92%
97%
78%
92%
95%
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Dec-14
Jan-15
Feb-15
Mar-15
14/15 Average:
Change on 13/14
99%
98%
99%
98%
79%
78%
92%
87%
98%
2%
89%
2%
Hand hygiene audits involve staff being watched while they wash their hands to
ensure they are following the correct procedure.
62 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.13
Never Events
Never Events are serious incidents that are wholly preventable as guidance or safety
recommendations that provide strong systemic protective barriers are available at a
national level and should have been implemented by all healthcare providers. Each
Never Event type has the potential to cause serious patient harm or death. However,
serious harm or death is not required to have happened as a result of a specific
incident occurrence for that incident to be categorised as a Never Event.
This year the Trust has reported one Never Event, which was linked to incorrect
administration of potassium.
The incident highlighted the need for the Trust to review its systems and processes in
relation to the prescribing and administration of potassium to ensure safe systems
are in place. This has included more stringent checking of the drug, similar to that of
a controlled drug, changes to policy and observational audit and communication to
both substantive and locum nursing and medical staff of the changes. The incident
remains under review.
3.14
Reported Patient Safety Incidents
Prescribed information: Southport and Ormskirk Hospital NHS Trust considers
that this data is as described for the following reasons : Trust staff now enter
data directly onto a web based system which all staff in the Trust have access to.
This data is automatically uploaded onto the NRLS.(National Reporting and
Learning System) from this database Local audits take place.
Organisational incident data, April 2014 – September 2014
April 2014 – September 2014
Degree of harm
Severe
Death
Number of
incidents
occurring
Southport &
Ormskirk NHS
Trust
England *
Highest Trust *
Lowest Trust *
Information Centre data
63 | P a g e
Rate per
100
admissions
1989
27.16
587483
12020
35
N/A
74.96
0.24
Number
9
%
Number
%
0.45%
2 0.10%
2168 0.37%
74 74.29%
0 0.00%
683 0.12%
27 8.57%
0 0.00%
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
The national data has been obtained from the National Reporting and Learning
System (NRLS) as detailed above.
All deaths are reviewed by a within a new mortality process and any unexpected
deaths are being reviewed during this process. This will enable accurate reporting
onto the system.
Southport and Ormskirk Hospital NHS Trust has taken the following actions to
improve this rate, and so the quality of its services, by :






Revision of the mortality audit process as described earlier
Implementation of web based incident reporting system allowing more timely
investigation of incidents by Risk Management Department with appropriate
actions.
Strengthened Serious Untoward Incident Investigation process and monitoring
of action plans for completion.
Implementation of web based complaints, concerns and claims to allow better
triangulation of data.
Lessons learnt Bulletins across the Trust
Revised more detailed Serious Untoward Incident reporting..
3.15
Safety Thermometer / Harm Free Care
The NHS Safety Thermometer has been developed for the NHS by the NHS as a point of
care survey instrument. The NHS Safety Thermometer allows teams to measure harm
and the proportion of patients that are ‘harm free’ during their working day. Harms that
are measured are Falls, Pressure ulcers (Pressure ulcers are an injury that breaks
down the skin and underlying tissue. They are caused when an area of skin is placed
under pressure. Pressure ulcers can range in severity from patches of discoloured
skin to open wounds that expose the underlying bone or muscle); Catheter related
urinary tract Infections and Venous Thrombo-Embolism (VTE). 94.59% of patients
during 2014 / 2015 experience harm free care.
64 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Harm Free:
100%patients with Harm Free Care - 14/15
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Mar14 Apr14 May14 Jun14
Jul14
Aug14 Sep14 Oct14 Nov14 Dec14 Jan15 Feb15 Mar15
Harm Free
97.49
95.81
96.06
93.87
93.46
95.65
94.09
94.9
94.21
96.36
93.48
95.45
94.59
One Harm
2.51
4.19
3.6
6.13
6.32
4.35
5.77
5.1
5.79
3.53
6.31
4.43
5.09
Two Harms
0
0
0.34
0
0.22
0
0.13
0
0
0.11
0.21
0.12
0.32
Three Harms
0
0
0
0
0
0
0
0
0
0
0
0
0
Four Harms
0
0
0
0
0
0
0
0
0
0
0
0
0
876
907
889
832
902
942
762
922
864
906
966
813
943
Patients
The graph below indicates the type of harm which occurred on the 5.41% of patients
who did experience a harm.
Types of Harm: patients with each type of Harm - 14/15
5%
4%
3%
2%
1%
0%
Mar1
4
Apr14
May1
4
Jun14
Jul14
Aug1
4
Pressure Ulcers
1.83
2.32
3.04
4.69
4.43
3.08
4.59
Falls
0.11
0.33
0.22
0
0.22
0.42
0.52
0
0.88
0.45
0.72
1.11
0.42
New VTE
0.57
0.66
0.56
0.72
1
Patients
876
907
889
832
902
Catheter & UTI
65 | P a g e
Nov1
4
Dec1
4
Jan15 Feb15
Mar1
5
4.01
4.63
2.76
4.76
3.81
3.61
0.11
0.12
0.44
0.21
0.12
0.74
0.66
0.76
0.23
0
0.72
0.62
0.85
0.42
0.26
0.22
0.81
0.55
1.04
0.12
0.53
942
762
922
864
906
966
813
943
Sep14 Oct14
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.16
Pressure Ulcers
All pressure ulcers are reported via the DATIX risk management system and are
defined as non hospital or non community acquired and hospital or community
acquired.
Pressure ulcers of grades three and above are classed as serious untoward incidents
and are reportable via Strategic Executive Information system (StEIS). (This is a
serious untoward incident which is reportable to the commissioners and triggers an
investigation). They are also considered to be a safeguarding issue and are reported
through to social services for investigation.
Healthcare professionals use several grading systems to describe the severity of
pressure ulcers. The most common is the European Pressure Ulcer Advisory Panel
(EPUAP) grading system. The higher the grade, the more severe the injury to the
skin and underlying tissue.
A grade one pressure ulcer is the most superficial type of ulcer. The affected area of
skin appears discoloured. Grade one pressure ulcers do not turn white when
pressure is placed on them. The skin remains intact, but it may hurt or itch. It may
also feel either warm and spongy, or hard.
In grade two pressure ulcers, some of the outer surface of the skin (the epidermis)
or the deeper layer of skin (the dermis) is damaged, leading to skin loss. The ulcer
looks like an open wound or a blister.
In grade three pressure ulcers, skin loss occurs throughout the entire thickness of
the skin. The underlying tissue is also damaged, although the underlying muscle and
bone are not. The ulcer appears as a deep, cavity-like wound.
A grade four pressure ulcer is the most severe type of pressure ulcer. The skin is
severely damaged and the surrounding tissue begins to die (tissue necrosis). The
underlying muscles or bone may also be damaged.
During 2014 / 15 there was some ambiguity of agreeing responsibility of pressure
ulcers discovered in the community. This resulted in a delay for some pressure ulcers
being reported to StEIS as required. There has been ongoing training for staff on the
reporting of pressure ulcers and the Trust are confident that all StEIS reportable
incidents are now reported in a timely manner.
66 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Pressure Ulcers
90
81
80
70
60
58
50
41
40
38
34
31
30
20
10
0
9/10
10/11
11/12
12/13
13/14
14/15
In 2014 / 2015 there has been a slight increase in the number of pressure ulcers
reported from 31 to 34.
All hospital acquired pressure ulcers of grade 2 or above are subject to root cause
analysis review. The reviews are led by the Deputy Director of Nursing and the Lead
Tissue Viability Nurse.
Hospital Acquired Pressure Ulcers (Grade 2- 4)
Total Hospital Acquired Pressure Ulcers
Grade 2
Grade 3
90
80
70
60
50
40
30
20
10
0
09/10
67 | P a g e
10/11
11/12
12/13
13/14
14/15
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Community acquired pressure ulcers
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Total
Monthly No of Community
Pressure Ulcers 14/15
14
4
11
13
16
6
17
15
11
24
15
21
167
Grade 2
13
4
10
8
12
5
11
10
9
18
13
18
131
Grade 3
1
0
1
5
4
1
5
4
2
5
2
3
33
Grade 4
0
0
0
0
0
0
1
1
0
1
0
0
3
Pressure ulcers are reported by all nursing teams with a heightened awareness and
request to report all pressure ulcers being made at monthly Head of Nursing
meetings . Also , any pressure ulcers developed in the podiatry service have been
requested to be reported on the Trust incident reporting system. (datix) .
All teams complete an RCA for grade 2 to 4 inclusive with Strategic Executive
Information System (STEIS) meetings taking place for grade 3 ulcers and above .
There has been a change in process for the review and monitoring of pressure ulcers
which are supported by community staff attending STEIS meetings , chaired by
Integrated Governance colleagues with this process being in place from July 2014.
Pressure ulcers are reported for those that develop whilst on a community team’s
caseload and also for a new patient referred with a pressure ulcer . Reporting and
prevalence of pressure ulcers is greater in Hants lane and Burscough team in West
Lancs and also in Churchtown and Curzon Rd who have the greater elderly
population and number of residential care homes. CERT in West Lancs and
68 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Southport and Formby have greater reported number of pressure ulcers which are
identified on first contact with the patient at the time of the first assessment when
referred to the service
The datix reporting categories has been reviewed in the last month to enable
pressure ulcers to be reported as those developed whilst receiving care from a
community team and also those developed externally which will give a greater
understanding on those being attributable to the Trust and in the Community CBU.
Community & Continued Care are also reviewing sickness and absence rates in the
team establishing via triangulation if this is impacting on continuity of care giving by
team members
69 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.17
Falls
The Trust is committed to providing a safe service for all patients and collects
information on patients who fall in the community and in hospital. We have made
some changes to our falls process:



The Trust Falls Committee has been re-established as two separate groups.
One for acute and one for community. This will enable each group to focus
on issues within each area.
The Trust is participating in the ‘Transparency’ Project in conjunction with
NHS England North. As part of this, the Root Cause Analysis process for falls
has been re-evaluated to enable more precise information to be collated.
The Trust has reviewed its falls risk assessment document.
14/15
Falls (Acute only)
Falls (including
Community)
Apr May
13/14
Falls (Acute only)
Falls (including
Community)
70 | P a g e
Jun
Jul
Aug
Dec
Jan
Feb
Mar
Total
45
59
48
54
53
Sep Oct Nov
46
59
60
61
60
43
47
635
49
60
50
56
57
54
63
61
64
66
44
53
677
Apr May
Jun
Jul
Aug
Sep Oct Nov
Dec
Jan
Feb
Mar
Total
46
52
53
56
46
56
56
64
44
61
36
67
637
49
53
54
57
46
56
58
64
44
63
36
67
647
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.18
Recognition of the Deteriorating Patient
The Trust continues to monitor clinical staff compliance to the policies for recognition
and treatment of deteriorating patients. The monthly audits carried out in each area
of the Trust by the Critical Care Outreach Team are illustrated by the early warning
score audits and the fluid balance monitoring audits.
3.19
13/14
14/15
Early Warning Score Audits
Apr
99.1%
97.7%
May
Jun
97.6% 99.0%
97.7% 96.4%
EARLY WARNING SCORES
Jul
Aug
Sep
Oct
Nov
Dec
98.2% 98.9% 99.0% 99.1% 98.0% 99.0%
98.7% 99.7% 93.8% 99.0% 96.1% 98.8%
Jan
Feb
98.0% 98.0%
N/A
N/A
Mar
98.0%
N/A
Early Warning Scores Performance 13/14 - 14/15
Target 13/14
102%
Target 14/15
13/14
14/15
97%
92%
87%
Apr
May
3.20
13/14
14/15
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Fluid Balance Monitoring Audits
Apr
May
95.7%
92.0%
90.3%
94.4%
FLUID BALANCE MONITORING
Jul
Aug
Sep
Oct
Nov
Jun
91.4% 96.0%
97.2% 96.8%
91.8% 95.1%
95.0% 95.4%
Dec
Jan
Feb
Mar
89.1% 84.0% 90.0% 92.0% 92.0% 88.0%
95.0% 96.7% 99.0% 96.1% 92.4% 95.2%
Fluid Balance Performance 13/14 - 14/15
Target 13/14
Target 14/15
13/14
14/15
100%
95%
90%
85%
80%
75%
70%
Apr
71 | P a g e
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.21
Cardiac Arrests
The Trust collects information on cardiac arrests and reviews every
cardiac arrest to ensure lessons are learned and changes to practice can be made.
Cardiac Arrests
140
133
120
99
100
92
87
80
71
60
40
20
0
10/11
Apr
13
May
13
Jun
13
11/12
Jul
13
Aug
13
12/13
Sep
13
Oct
13
13/14
Nov
13
Dec
13
14/15
Jan
14
Feb
14
Mar
14
9
8
12
8
10
4
8
7
9
7
13
4
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Mar15
4
6
8
3
8
6
13
7
13
11
8
5
As you can see from the graph there was a massive trend downwards year
2011/2012 this was attributed to the introduction of Early Warning Scores,
appropriate Do Not Attempt to Resuscitate (DNACPR) and the vigil pathway. We
achieved a reduction of 46%.
In reality this figure was probably not sustainable and currently a rate of 7/ 8 arrests a
month are average for the trust. There have been certain changes in external policies
that influenced the trends. The change in the vigil pathway to individualised care has
possibly influenced these figures as has the ruling by the courts around the
Cambridge case. We still have a 30% decrease from the original figures which is
good. From looking at the root cause analysis (RCA) there are some cases that
perhaps should have been considered not for resuscitation on admission or at an
earlier date. There are times when things are missed, such as correct escalation,
observation frequency and fluid balance. All these issues are fed back to ensure
learning. Issues are dealt with either at ward level, lessons to be learned and at F1
tutorials. There does not appear to be any seasonal trends and in the National
Cardiac Arrest Audit we are within the 95% confidence interval.
72 | P a g e
Total
99
92
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
3.22
Eliminating preventable morbidity in maternity care
Reducing Unplanned Admissions of Full Term Babies to Neonatal Unit
All unplanned or unexpected admissions to the Neonatal Unit of full term babies are
reviewed as part of the Maternity Services clinical incident review meeting. Where
there are concerns about the management and/or care of a baby further investigation
is undertaken such as a case review to consider any lessons learnt. These findings
are presented to the Governance committees and changes to practice made as
required.
In 2012/2013 Full term babies transferred to NNU was 221
In 2014/2015 Full term babies transferred to NNU was 215
Reducing Elective Inductions Prior to Term + 12
To reduce our induction rate women attending for antenatal care at 38 weeks are
offered information about the risks and benefits associated with pregnancies to
ensure they are fully informed especially if requesting induction of labour
In addition to this
 We have introduced membrane sweeps at clinics for women at term and 41
weeks of pregnancy. Additional sweeps are offered if labour does not start
spontaneously. This gives women the opportunity for labour to start naturally
 Offer of induction of labour between 40 and 41 weeks and not before term
unless there is a clinical reason to do so
In 2012/2013 The induction of labour rate was 34.3%
In 2014/2015 The Induction of labour rate was 30.4%
Paired Cord Blood Samples Undertaken at Delivery
Umbilical cord blood sampling is the most objective method of determining a baby’s
condition at birth .This is in place for all babies but in particular those babies who
have:
 Been born by emergency caesarean section
 Been delivered by instrumental delivery (Forceps or ventouse)
 Had their blood gases checked in labour
 Have been born in poor condition
This enables those babies who need closer monitoring to be identified earlier and
treated accordingly. This ensures their condition doesn’t deteriorate which could
result in further intervention and transfer to the Neonatal Unit
Reduction in the Number of Unnecessary Caesarean Sections
Increased neonatal morbidity is a risk associated with caesarean sections. The
following has been introduced to reduce our caesarean section rates :
73 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST








Review of clinical guidelines to ensure best practice and compliance with
NICE Guidelines
Development of local dashboard to identify C/Sections performed outside of
current guidelines. This enables identification for areas of audit
Changed practice in response to audit include
- Development of checklist proforma for maternal request and for women
to be seen by the Consultant Obstetrician to discuss her options on no
less than two occasions
- Developed Supervisor of Midwife referral letters for those
Women requesting a C/section to enable further support and discussion
for women
Monthly Multidisciplinary Caesarean Section meeting are held to discuss audit
and monitor progress
Joint Vaginal Birth After Caesarean (VBAC) clinic led by Consultant Midwife
and Consultant Obstetrician
New CTG Monitors have been purchased which have improved ability for
monitoring the foetal heart in particular in women where there have been
difficulties for example raised body mass index
Achieved a reduction in Induction of labour rates
Trialled an introduction of a midwifery case loading team to support women
(Evidence demonstrates that continuity of care/carer increase normality and
reduces intervention)
Work in progress includes:
 Ongoing audit and disseminating lessons learnt
 Submitted bid for funding to develop designated midwife led beds on delivery
suite and develop triage area
 Training to support midwives and clinicians in managing more challenging
women requesting delivery by elective c/section
2012/2013 Overall Caesarean section rate 27.9%
2014/2015 Overall Caesarean Section Rate 25.2%
Development of the New-born Early Warning Scores
The new-born early warning scores were developed by the multidisciplinary team and
introduced in 2013. This provides quality of care for babies in our care by ensuring
early recognition of those babies who are becoming ill. Every baby who is an
inpatient has early warning scores performed.
This has enabled babies who are becoming unwell to be treated sooner by early
review by the paediatrician and a management plan implemented. This also means
that babies do not always need to be transferred to the neonatal unit and can often
remain with their mother
74 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
GLOSSARY
A&E
ACS
Appendix 1
Accident and Emergency Department
Appropriate Care Score - All measures passed for an individual
patient
AQ
Advancing Quality
CBU
Clinical Business Unit
CCU
Coronary Care Unit
C.diff
Clostridium difficile
CQC
Care Quality Commission
CQS / CPS Composite quality Score - Aggregated delivery of several clinical
processes
CQUIN
Commissioning for Quality and Innovation
DAHNO
Data for Head and Neck Oncology
DON
Director of Nursing
DDON
Deputy Director of Nursing
DIPC
Director of Infection Prevention and Control
DNACPR
Do Not Attempt to Resuscitate
DSSA
EoL
EPaCCS
GSFAH
HAPS
HCAI
HCC
HES
HONS
Delivering Same Sex Accommodation
End of Life
Electronic Palliative Co-ordination System
Gold Standard Framework Acute Hospitals
Hospital Acquired Pressure Sores
Health Care Acquired Infections
Health Care Commission
Hospital Episode Statistics
Heads of Nursing
HRG
HSMR
HQIP
IBD
ICT
IV
LD
MDT
MINAP
MRSA
MSA
Healthcare Related Groups
Hospital Standardised Mortality Ratio
Healthcare Quality Improvement Partnership
Irritable Bowel Disease
Integrated Care Teams
Intravenous
Learning Difficulties
Multi Disciplinary Team
Myocardial Infarction National Audit Project
Methicillin Resistant StaphlococcusAureus
Mixed Sex Accommodation
75 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
NCEPOD
NCISH
NICE
NICOR
NIHR
NNAP
OSA
OSC
PDR
PLACE
National Confidential Enquiry into Patient Outcome and Death
National Confidential Enquiry into Suicide and Homicide
National Institute of Clinical Excellence
National Institute for Clinical Outcome Research
National Institute for Health Research
National Neonatal Audit Programme
Obstructive Sleep Apnoea
Overview and Scrutiny Committee
Personal Development Review
Patient Lead Assessments of the Care Environment
PREMIER
PPC
PROMS
RAG
RAM
RCOG
RCPH
REoLT
SHMI
SIRRS
STEIS
SUI
SUS
TARN
UTI
VAP
VTE
WRVS
American Advancing Quality lead company
Preferred Place of Care
Patient Reported Outcome Measures
Red, Amber, Green
Risk Adjusted Mortality
Royal College of Obstetricians and Gynaecologists
Royal College of Paediatric and Child Health
Rapid End of Life Transfer
Standardised Hospital Mortality Indicator
Serious Illness Recognition and Response Committee
Strategic Executive Information System
Serious Untoward Incident
Secondary Users Services
Trauma Audit and Research Network
Urinary Tract Infection
Ventilator Acquired Pneumonia
Venous Thrombo-Embolism
Women’s Royal Voluntary Service
76 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Appendix 2
The National Clinical Audits that Southport and Ormskirk Hospital NHS Trust participated in during April 2014 – March
2015 are as follows:
Eligible – 30
Participated/participating – 30
Not eligible/no audit information available – 12
Not starting until 2015-16 but listed on QA list for 2014-15 – 2
Removed from QA - 1
No.
1
2
3
4
5
National Clinical Audits
Acute coronary syndrome or
Acute myocardial infarction
(MINAP)
Adherence to British Society
for Clinical Neurophysiology
(BSCN) and Association of
Neurophysiological Scientists
(ANS) Standards for Ulnar
Neuropathy at Elbow (UNE)
testing
Adult bronchiectasis
Adult cardiac surgery audit
Adult community acquired
pneumonia
77 | P a g e
Eligible
Participated
No
No
Yes
No
No
Yes
Yes
Yes – currently
participating
Submitted
166
Required
All cases
Percentage
100%
Changes in Practice
No report
Not due to finish until May 15
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
No.
National Clinical Audits
Eligible
Participated
Yes
Submitted
495
Required
All cases
7
Bowel cancer (NBOCAP)
Yes
Yes
145
N/A
8
9
No
Cardiac arrhythmia (HRM)
No
Chronic kidney disease in
primary care
Chronic Obstructive Pulmonary Yes
Disease (COPD)
Yes
79
All cases
6
10
11
12
13
Adult critical care (Case Mix
Programme – ICNARC CMP)
Congenital heart disease
(Paediatric cardiac surgery)
(CHD)
Coronary angioplasty
Diabetes (Adult) ND(A),
includes National Diabetes
Inpatient Audit (NADIA)
78 | P a g e
Yes
No
No
No
No
Percentage
100%
Changes in Practice
Results taken from the ICNARC
data on delayed admissions and
discharges. Will be discussed at
Critical Care Delivery Group
regularly and an action plan
compiled within the group for
regular discussion
Ongoing – no report until
Autumn 2015
100%
The report released in February
2015 has been circulated around
the Trust for information and an
action plan will be compiled.
Unfortunately the respiratory
team is under extreme clinical
pressure at present and time for
non-clinical duties is not always
available
No NADIA audit in 2014 and
did not participate in National
Diabetes Audit as not applicable
to the Trust.
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
No.
National Clinical Audits
Eligible
Participated
Yes
Submitted
124
Required
All cases
Percentage
100%
15
Elective surgery (National
PROMs Programme)
Epilepsy 12 audit (Childhood
Epilepsy)
Falls and Fragility Fractures
Audit Programme (FFFAP)
Yes
Yes
747
All cases
100%
Yes
Yes
17
All cases
100%
14
16
17
18
19
20
21
Diabetes (Paediatric) (NPDA)
Familial hypercholesterolaemia
(National Clinical Audit of Mgt
of FH)
Fitting child (care in
emergency departments)
Head and neck oncology
(DAHNO)
Mental health (care in
emergency departments)
79 | P a g e
Yes
Only due
to start
2015-16
Changes in Practice
Business case for psychology
input submitted in response to
National Audit and National
Peer Review Assessment
No changes in practice
Removed from Quality
Accounts 2014
Yes
Yes
30
30
Yes
Yes
7
N/A
Yes
Yes
19
25
100%
76%
No report – only 30 cases fitted
the criterion in A & E although
the CEM recommends 50
These patients are referred on to
another service
No report – only 25 cases fitted
the criterion in A & E although
the CEM recommends 50. We
could not locate the CAS cards
for the missing 6
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
No.
National Clinical Audits
Eligible
Participated
Submitted
1
Required
1
Percentage
100%
Changes in Practice
An action plan has been
compiled on the back of the
organisational and clinical audit
reports and several changes have
been put forward as follows:
 IBD MDT now takes
place so that the IBD
team can discuss cases
effectively
 Business case put
forward for further IBD
Nurse support
 Frequent Local audit
undertaken by IBD
specialist nurse to check
our IBD care in line with
standards
 Policy written for
transitional care for IBD
from Paediatric to Adult
services
 Database kept that lists
all IBD patients
23
National Heart Failure Audit
Yes
Yes
272
All cases
100%
No report received
22
National Inflammatory Bowel
Disease audit - Organisational
and clinical
80 | P a g e
Yes
Yes in
organisational
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
No.
National Clinical Audits
Eligible
Participated
Yes
Submitted
9
Required
N/A
Percentage
25
26
Pulmonary Hypertension
BSR Rheumatoid & early
inflammatory arthritis
Sentinal Stroke Audit
No
Yes
No
Yes
Changes in Practice
 The Trust have
introduced personal
growth charts for
pregnant women over the
past year with
appropriate guidance and
management of reduced
growth, including
induction of labour and
delivery were indicated
 Women who present
with reduced movement
are managed differently
depending on gestation
and induction of labour
and delivery if indicated.
10
N/A
N/A
Yes
Yes
284
N/A
N/A
No changes as yet as audit
ongoing until 2016
Quarterly reports released and
actioned asap. Any outstanding
actions are added to Trust Stroke
action plan and monitored
through the Stroke Strategy
Group.
24
27
Maternal, newborn and infant
clinical outcome programme
(MBRACE)
81 | P a g e
Yes
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
No.
28
National Clinical Audits
Trauma Audit & Research
Network
82 | P a g e
Eligible
Yes
Participated
Yes
Submitted
144
Required
200+
Percentage
At present
49% approx
Changes in Practice
Figures required are unclear
until HES data submitted. The
submission end date for TARN
is M/E June 15. As at
16/04/2015 there are still 100
case notes to be looked at by the
TARN team.
Changes in practise due to
TARN include:
 New Rib Fracture
Pathway now being used
in A & E
 Major Trauma
Coordinator Nurse now
in post in A & E to
streamline the trauma
process and help to
collect TARN data
 Addition of in-situ
trauma training as from
Jan 2015
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
No.
29
National Clinical Audits
National Hip Fracture
Database
Eligible
Yes
Participated
Yes
Submitted
296
Required
N/A
Percentage
Changes in Practice
•All results have improved since
previous year
•For most indicators we are
doing better than the national
and north west averages.
We are not performing better
than the National average in:
•Time to orthopaedic ward
(S&O 16.3 compared with 9.5
hours nationally)
•Time to theatre (S&O 31.2 &
30.6 hours nationally)
•Infection rates continue to be
excellent.
30
31
Mental health clinical outcome
review programme: National
Confidential Inquiry into
Suicide and Homicide for
people with Mental Illness
(NCISH)
National Audit of Intermediate
Care
No
No
Yes
Yes
354
N/A
No actions from report as yet.
The report is with the Rehab &
Social Integration Service
Manager for Community and
Continued care for presentation
and dissemination.
Action plan to follow May 15
83 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
No.
32
33
National Clinical Audits
National Cardiac Arrest Audit
(NCAA)
National Comparative Audit of
Blood Transfusion programme
Eligible
Yes
Participated
Yes
Submitted
82
Required
All cases
Percentage
100%
Yes
Yes
193
193
100%
34
National emergency
laparotomy audit (NELA)
Yes
Yes
114
All cases
N/A – We
currently
have no
unlocked
cases on the
NELA
website for
year 1
35
National Joint Registry (NJR)
Yes
Yes
412
All cases
100%
Changes in Practice
More timely DNAR forms being
completed
All relevant transfusions
submitted – no changes in
practise as there was no actions
This audit is still ongoing so this
is just the figures as at M/E
March 15.
 Quarterly meeting takes
place with NELA team to
discuss the findings of
the audit and action
 Action plan in place that
is monitored regularly
 NELA added to the
agendas for Surgical and
Anaesthetic audit
meetings. Joint meeting
to be held twice yearly to
ensure group work on the
project
195 - Hips
206 – Knees
11 - Shoulders
No report until Oct 15
84 | P a g e
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
No.
National Clinical Audits
Eligible
Yes
Participated
Yes
Submitted
378
Required
All cases
37
Oesophago-gastric cancer
(NAOGC)
Older people (care in
emergency departments)
Paediatric intensive care
(PICANet)
Yes
Yes
103
N/A
Yes
Yes
100
50
36
38
39
Neonatal intensive and special
care (NNAP)
85 | P a g e
No
Percentage
100%
Changes in Practice
The report for this audit is not
released until Autumn 2015
however there have been
changes in practice introduced in
2014 that will improve the
results. These include:
 Since Feb 2014 all
patients are screened for
ROP on time so the
results in Autumn 2015
should show 100%
 A new alert was created
in Evolve in March 2014
to ensure that babies are
flagged for a 2 year
follow up appointment as
we have been 0% in
previous years. This
should improve the
results in coming years
but might not show in the
2015 data.
100% +
No report
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
No.
National Clinical Audits
41
Pleural procedures
42
Prescribing Observatory for
Mental Health (POMH)
Prostate Cancer
No
44
45
40
43
Participated
Submitted
Required
Percentage
Changes in Practice
Yes
4
All cases
100%
Minimal patient data so no
changes could be viable based
on the results – only 4 cases
fitted the audit criteria
Yes
Yes
164
N/A
National Care of the Dying
audit
Yes
Yes
77
All cases
Diabetic Foot care Audit
Yes
Yes
5 – Hospital
cases
Parkinson's disease (National
Parkinson's Audit)
Eligible
Only due
to start
2015-16
Yes
12 –
community
cases
86 | P a g e
100%
The Trust has not submitted a
full year of data yet
 Lay board member with
designated responsibility
for EOL now in place
 EOL care plan updated.
 Spiritual Gate
programme ongoing.
 TRANSFORM team and
Trust chaplain visit
wards on weekly basis.
 Continuing education.
Ongoing to July 15
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Appendix 3
The national confidential enquiries that Southport & Ormskirk Hospital NHS Trust participated in during April 2014 –
March 2015 are as follows:
Organisational Questionnaires 2014 - 2015
NCEPOD Project
NCEPOD - Tracheostomy Study
NCEPOD - Lower Limb Amputation
NCEPOD - Gastrointestinal Haemorrahge
NCEPOD – Sepsis
Date National Report Received
June 2014
November 2014
Awaiting Report
Awaiting Report
Clinical Data Collection Questionnaires 2014 - 2015
Confidential Enquiry Data Collection
NCEPOD – Gastrointestinal Haemorrhage
NCEPOD – Sepsis
NCEPOD – Lower Limb Amputation
NCEPOD – Gastrointestinal Haemorahge
87 | P a g e
Eligible
Yes
Yes
Yes
Yes
Participated
Yes
Yes
Yes
Yes
Submitted
3
Still Open
4
6
Percentage
100%
100%
100%
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
Appendix 4
Local Clinical Audit Projects Undertaken during April 2014 – March 2015 and a selection of changes:
Db ID
Audit Title
14-001
CG29 Pressure ulcer management
Audit the process for generation of follow up letters
in A&E for missed fractures
Audit HR policies for employment checks and
Professional Clinical Registration
14-003
14-005
14-006
Changes made as a result of audit project
Audit indicated good use of the skin bundles, but need to improve the use of
the body maps.
New SOP written in AED for missed fractures to ensure that the correct
protocol is followed
Business Unit
Integrated
Governance
Policy has been changed to reflect current process.
Process introduced to check mental health act papers prospectively as they
come into the organisation
Human Resources
Integrated
Governance
Agreed standards for Paediatric Radiology Reporting.
Planned Care
Integrated
Governance
Integrated
Governance
Integrated
Governance
Integrated
Governance
Women’s and
Children’s
14-016
Audit of The Mental Health Act
Audit of radiology reporting timescales for paediatric
patients
14-019
Re- Audit of Clinical Audit Policy
Audit indicated improvement in following the clinical audit policy.
14-020
Patient identification/wristband audit
14-021
Risk Register Assessments Re-Audit
Improvement noted with significant assurance for audit project.
Further improvement is still required as not all risks have an associated risk
assessment.
14-022
Audit of Transfer Policy (Hand over of care)
Policy currently being reviewed.
14-026
Audit of Ante-natal ward rounds
14-027
Audit of medicine trolley
14-033
Audit of mental health screening during pregnancy
Improvement noted and ward rounds taking place.
clear plastic bags to be used on wards for storage when patients have
multiple medicines; medicine management training days and readers now
incorporate information about appropriate storage and labelling of meds
New paperwork has been introduced to standardise the patient mental
health assessment.
88 | P a g e
Urgent Care
Service Improvement
& Support
Women’s and
Children’s
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
14-035
Do older women with breast cancer receive high
quality care?
14-038
Re-audit of adherence to NICE Policy
14-050
re-audit of NG Tube placement (carried over)
14-057
Audit of Nutrition Policy
14-058
Partner notification in the management of
Chlamydia
14-059
CG43 Obesity
14-066
Audit of Blue MDT Sheets
Intravenous Drug Administration point prevalence
audit
14-074
14-082
Random audits of casenotes to ensure that the
swab counts are being performed and being
counter signed
Audit to look at thrombolysis data re door to needle
time
14-083
Audit of patients discharged with AF re
Anticoagulation
14-075
89 | P a g e
The results show considerable variation in treatment by age that is not
explained by tumour characteristics or levels of recorded comorbidity. It is
likely that treatment decisions made on the basis of chronological age
rather than the patient fitness contribute to the age gradient, though other
factors such as patient preferences and levels of frailty may play a part.
Compliance to the policy was found with significant assurance.
Further training to clinicians re completion of request forms and to
radiographers around gold standard
Improvement still required in weighing patients. New nursing documentation
has been introduced and VitalPac for electronic recording.
The use of a prompt sheet. More use of Patient Information e.g. Leaflet and
documentation. Although PN rate met national standards it can improve
further. Repeat PN audit one year (national recommendation)…this is
particularly relevant as this audit was done on patients in GUM preintegration. We need another one in a years’ time to see whether we are
meeting standards at all venues within our service.
The audit indicated full compliance with the NICE guideline.
The form has now been incorporated into the discharge plan booklet which
has been introduced.
No changes to practice. Feedback to nurses to confirm positive results and
encouraging continued compliance to standards
Continue with the process of formal feedback to all staff groups regarding
swab count. Continue to include the subject in maternity mandatory training.
Increase the focus upon raising awareness via email and face to face
feedback to all members of the obstetric staff group regarding swab count
counter signature pre and post repair. Raise awareness to HCAs’ and
students via one to ones of the requirement to sign for checking the swab
count.
To be presented at the regional stroke meeting. April 15
Dr McDonald and Dr Koram are already looking at the data for 2014 and
have identified that the % of patients given NOACS has grown and there
seems to be more understanding across the Trust about their use. The
NICE guidance was only introduced in July 2014. This data is now
Planned Care
Integrated
Governance
Planned Care
Integrated
Governance
Urgent Care
Integrated
Governance
Integrated
Governance
Service Improvement
& Support
Women’s and
Children’s
Urgent Care
Urgent Care
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
14-084
Audit of Management of pre-term labour in ODGH
14-085
Audit of Management of pre-term pre-labour
rupture of membranes in ODGH
14-086
Brachial Plexus
14-088
Immediate Care of the Newborn (Meconium)
14-092
Care of women in Labour
14-093
Intermittent Auscultation
90 | P a g e
continually monitored via SSNAP and is more readily available for up to
date data analysis and Dr McDonald will look at this on a quarterly basis
and action accordingly.
Computer information system. Code for threatened pre-term labour.
Gestation added to triage logbook. Larger audit over a period of time. Cost
analysis of implementing Actim Partus. Email and training to all to all staff
who use these. Email and training to all staff around the guidelines of
threatened pre-term labour. Reaudit
Computer information system. Code for suspected prelabour premature
rupture of membranes (PPROM). Gestation added to triage logbook. Larger
audit over a period of time. Cost analysis of implementing Actim PROM.
Email and training to all to all staff who use these. Training to those who
have no achieved basic competencies in USS
100% compliance with audit standards therefore no specific actions apart
from dissemination of results
Optimise Proforma to highlight ‘Not Relevant’ options to ensure clearer
understanding. To review non-compliant notes with regards to prescribing
intra-partum antibiotics and make suggestions for improvement. Document
meconium grading in all cases. Share findings with maternity and paediatric
team. To reaudit in 6 months’ time
Disseminate results at maternity care forum and maternity mandatory
training. Delivery suite staff and Obstetricians to audit one case each of
care of women in labour. Continue to issue reminder cards. Feed back to
staff of good documentation and poor documentation.
Feedback will be given to individual midwives with a reminder card for
future documentation. Request non-compliant staff to audit 3 sets of notes
each to raise awareness of what documentation is required. The results of
the audit to be disseminated at maternity mandatory training and maternity
care forum. Results to be sent as a global email to all staff.
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
To present the findings in audit meeting and maternity forum. Carry out live
audits during CTG meetings. Encourage doctors to use FBS stickers. Live
audit of case notes in CTG meetings. FBS Guideline to be altered according
to current practice. Reminder card on the electronic foetal monitors for data
to be included on the tracing. Refresher training to be delivered to midwives
on Antenatal Ward and Delivery Suite on recording of data on the tracing.
14-094
Continuous electronic foetal monitoring/ Foetal
Blood Sampling/ Use of Oxytocin
14-097
Emergency Caesarean Section (All Grade 1's)
14-107
Shoulder dystocia
14-108
Postpartum Haemorrhage
14-112
Booking appointments
14-121
Non-Obstetric Emergency Care
14-123
Bladder Care (Docs = dysfunction Midwives other)
91 | P a g e
While reviewing the cases in CTG meetings, audit the cases simultaneously
to raise awareness among medical staff the minimum data required in foetal
heart monitoring.
The requirement need to be changed to ‘documentation of results in
paediatric notes’
To achieve 100% of all Grade 1 caesarean sections within 30 minutes and
correct classification of grade 1 caesarean sections. • Circulation of audit
report to Consultant Obstetricians, Shift Leaders and Delivery Suite for
dissemination
100% compliance with audit standards therefore no specific actions apart
from dissemination of results
Dissemination of report findings to multi-disciplinary team. Ongoing review
of all major PPH and implementation of feedback. Update of findings to
skills and drills training – forward results of the audit to all Consultants and
skills and drills trainers. Multidisciplinary review of all peripartum
hysterectomy. Visual prompts for estimated blood loss. Swabs to be
weighed for all deliveries to get a more accurate measure of blood loss.
Update of Postpartum haemorrhage guideline to included tranexamic acid
Dissemination of the results via the Maternity Care Forum. Reminder to
staff who are
arranging bookings of the
timescales within the guideline.
The audit confirms that the process for referral to Obstetricians is
operational when A&E doctors deal with pregnant women with non-obstetric
emergencies. Recommendation would be to continue with the current
practice.
Present findings at Maternity Care Forum and Maternity Mandatory training.
Feedback to individual staff non-compliant notes. Audit all confirmed
bladder dysfunction from 2014
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
14-164
14-167
14-168
clinician's conversations with families at the end of
life
Transfer of the Critically Ill
Patient
Critical Care Follow up
Clinic
Education to all staff around importance of having conversations with
patient and families around dying & documentation of these. Staff support
by TRANSFORM team. Laminated cards available as guidance around
terminology to be employed
Consultant anaesthetist in charge of ITU to feedback improvements made
and to speak about how to increase necessary monitoring and recording of
observations to anaesthetic staff at medical audit meeting. Inform nursing
staff of audit results at unit meeting and discuss at next Critical Care
Delivery Group meeting. Remind Nursing staff to time manage transfers so
that paperwork and charts can be organised and checklist can be followed.
Place equipment to ensure ease of monitoring during transfer.
No recommendations for improvements suggested
Definite improvement in the amount of areas that check their trolleys 100%
of the time.
Community &
Continued Care
Urgent Care
Urgent Care
14-171
Crash Trolley Audit
14-172
Spiritual/Religious Care needs assessment re-audit
14-177
Achieving preferred place of care (re-audit)
14-178
Efficiency of Quality of Life Feeding Summary (reaudit)
14-182
A & E Mortalities Audit
14-184
DC Cardioversion
Re-Audit of VTE Policy (CG92 Venous
thromboembolism - reducing the risk)
Marked improvement in training opportunities available for CMT/F2 grade
Urgent Care
Action plan currently being compiled
Urgent Care
CG95 Chest pain of recent origin
Audit of pathway for patients presenting with painful
and swollen testes
Action plan currently being compiled
Checklist is currently being developed for use. Re-audit planned for next
year when checklist has been finalised and put into practice.
Urgent Care
14-187
14-189
14-193
92 | P a g e
•Only two trolleys checked 75% of the time again a massive improvement.
Failed rapid EOL transfers to be reviewed weekly at TRANSFORM
meetings
QOL feeding decision summary form had been re-designed following cycle
1. Results from cycle 2 showed some improvement in documentation but
scope for further improvement remains
A & E to work with surgeons and anaesthetists on a pathway for patients
with abdominal pain, particularly elderly patients. A & E to create a pathway
with the surgeons and anaesthetists to ensure that abdominal pain is
monitored effectively and acted upon as appropriate
Urgent Care
Community &
Continued Care
Community &
Continued Care
Community &
Continued Care
Urgent Care
Planned Care
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
14-199
Emergency Contraception Audit
Development of pro forma to ensure that both EHC and IUD are discussed
with the patient. Development of pro forma to ensure that STI testing has
been offered and discussed with the patient.
14-200
Provision of contraception following termination of
pregnancy
The sexual health service now has regular clinical input into the TOP
service. Reaudit required as audit was done at time of tender
14-201
Child Protection Audit
14-202
Neonatal Hypoglycaemia
14-203
Audit on Diabetes retinopathy incidence
No changes to be made. Reaudit Dec 15
Organise teaching on the new guidelines. Send out email to nurse lead for
postnates and cascade it to all midwives. Send out email to all doctors
regarding proper documentation. To change the flow chart as per the
recommendations
Not applicable as regional audit resulting in poster. Also 2013 registered
audit
14-204
UK NSC National Hepatitis B in Pregnancy Audit
Awaiting National report
14-205
To assess the compliance and drop in Intraocular
pressure with Preservative free ganfort
14-206
Paediatric Cystic Fibrosis Service Evaluation Audit
As per email from Dr Gonzalez on the 17th September no actions or
requirement for reaudit
Maintain standards according to national guideline. Use of specific inpatient
short stay/long stay CF proforma. Now addressed as new
Dietician/Physiotherapist appointed. Monthly MDT meeting –Physiotherapist
and Dietician attendance to be maintained. Community Physiotherapy
/Dietetic support to be improved. Transition service to be developed
according to guidelines
14-207
An audit of timing of foetal anatomy scans within
Southport and Ormskirk NHS Trust
14-209
14-210
14-211
Re-audit DKA protocol - is it improving patient care
Audit to check compliancy with national IBD Audit
2014
ER & HER-2 positive rates in symptomatic breast
cancer cases 2008-13
93 | P a g e
Midwife to write down when patient is 20+6 for receptionist. Offer patients in
SDGH scans in ODGH
Poor results and circulated to the wider diabetes team as we need to collect
more patients and monitor their future treatment. Amy the new Diabetes
nurse is collecting a list of patients that we can use for the review. This audit
may be superseded by the AQ data and I am currently discussing this with
the Diabetes team
IBD MDT introduced into the Trust for a more integrated approach.
The audit results are satisfactory and no remedial actions are therefore
needed
Urgent Care
Urgent Care
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
Planned Care
Women’s and
Children’s
Women’s and
Children’s
Urgent Care
Urgent Care
Service Improvement
& Support
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
14-217
14-222
14-231
Parenteral Nutrition Audit
Reconciliation of Medicines (re-audit)
Omitted Doses of Medicines (carried over)
Start smart than focus antibiotic audit (carried over)
14-232
Doctor left the Trust but made several recommendations for improvement.
Waiting for response form Dr Butcher as sponsor to find out if any have
been implemented
Amendments to Medical management policy underpinning the new process
agreed for marking off completed medicines reconciliation
Changes made to Medicines management policy regarding dose omissions
and critical meds. Information on omission of meds and high risk meds
included in induction training. Guidance on critical drugs and
tackling/preventing omissions now included in nurse preceptorship training.
Review of night store list and people needing access to night store
SSF stewardship guidance incorporated in new edition of trust antimicrobial
guidance. E-readers for Nursing prescribers in place. Presentation to junior
doctors.
14-238
Management of Meningitis
14-240
TARN ISS>15 Audit
More education introduced
No changes as many patients are self-presenters at AED with unknown
head injuries, continue with current protocols for head injury
14-283
Onychomycoses
Improved documentation of usage of patient information leaflet. Now
consider pre-treatment cervical smear (where indicated) and pregnancy
test (where indicated in childbearing age). Recommend the use of EASI
where appropriate .Re-audit use of individual systemic drugs in five years.
14-289
Dependency Scoring and Staffing Levels on CCU
14-296
CG85 Glaucoma
14-300
Management of Medical Disorders in pregnancy
94 | P a g e
Analysis found that there are no issues with staff numbers so no report or
actions required functional. Carla to meet with Karen to discuss this
Dilated Disc Examination allows a clear fundal view of disc. Perform at least
annually. AC depth recording as a VH number. VF at least annually. Digital
Disc Recording at least once. 67% pts were overdue routine ppt
Presentation at audit meeting. Discuss at mat care forum. Finalise
guideline. Separate audit of general ANC patients to asses BMI v outcome.
New audit of outcome in patients with GDM using old v new diagnostic
criteria. Discuss at mat care forum
Electronic notes
Urgent Care
Service Improvement
& Support
Service Improvement
& Support
Service Improvement
& Support
Urgent Care
Urgent Care
Planned care
Urgent Care
Planned Care
Women’s and
Children’s
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
14-303
14-305
14-308
Current management of acute PID
Post-Menopausal Bleeding
Delays in Theatre
14-314
Cataract Surgery Outcomes
14-315
14-316
14-325
14-327
Produce a local guideline and pro forma. Agree antibiotic policy with med
micro particularly for actinomyces but may still need to be on patient to
patient basis. Refer patients for complex Gynae cases to MDT. Give patient
info – BASHH website. Keep contemporaneous patient list to ensure we
are capturing relevant cases. Reaudit when local guideline is available to
establish improvement in some areas
One stop clinic and more OP hysteroscopic procedures. Make local
guidelines available and update
First patient to be sent for prior to Team Brief and kept in Recovery/Forward
Wait until Team Brief complete; Urology patients - the all day list would be
morning and afternoon list and that patient would be staggered for
admission; Recovery staff to collect patients and get hand over from
theatre; ODP’s completing check in of patients in anaesthetic room and
completing WHO sign in;
Women’s and
Children’s
Women’s and
Children’s
Planned care
CG54 Urinary tract infection in children (carry over)
To reaudit with a prospective record of complications post op.
Nursing staff to be informed to do above documentation. Ward managers
informed and message circulated
Planned Care
Women’s and
Children’s
CG97 Lower urinary tract symptoms
Introduction of initial assessment proforma
Planned care
Audit of processes for check up and ensuring blood
gas analysers are safe and fit for purpose
Improvements made on Delivery suite. Audit again in 2015. Neonatal all
compliant
Women’s and
Children’s
To increase awareness of red flags in history and examination. To increase
awareness for immediate/close follow-up of children needing
disimpaction/rectal medication. To improve documentation. Provide specific
written information
Women’s and
Children’s
Analysis Underway
All Specialities
Where cause of infection is not known to consider sending urine sample
and discussing with senior member of team
Suggested named individual in each area responsible for checking Team
Brief for relevant updates to leaflets and to carry out regular review of ward
Service Improvement
& Support
Strategy, Commerce
& Communication
14-329
CG99 Constipation in children and young people
Local adherence to the Health Records Policy (this
will be changeable due to electronic records being
introduced)
14-331
Gram-negative bacteraemias (carried over)
14-332
patient information leaflets (carried over)
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SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
stocks.
14-333
14-334
14-339
14-341
14-343
14-346
re-audit Radiological request forms (carried over)
re-audit Review of laboratory confirmed RSV
infections in children (carried over)
Attempted retrieval of Temporary IVC filters (carried
over)
Storage of Medicines in Community Clinics (carried
over)
Transportation of samples and blood products
(carried over)
14-353
Storage of Pharmacy delivery notes (carried over)
Audit of prescribing of cephalexin for Obs & Gynae
patients and compliance with trust antibiotic policy
(carried over)
Audit to assess the number of drug charts which
stay on the ward and the number of drug charts
which leave the ward to come to Pharmacy (carried
over)
14-361
Management of suspected VTE in pregnancy
14-352
14-364
Screening project
14-365
Unanticipated Admissions to Neonatal Unit
14-367
Examination of the Newborn (hips, hearts, eyes and
testes)
14-368
Support for Parents
96 | P a g e
No changes made. Educational issues identified and acted upon.
Microbiology service now with STHK. Possible introduction of in-house
rapid antigen screening test o be discussed and led by Paediatrics
Reminder now circulated to clinician at agreed time prior to planned
removal of IVC filter. Typed letter/proforma in place
Purchase of thermometers for areas without. After cycle 1 expiry check to
be carried out on regular basis. Cycle 2 (Sefton clinics) - no expired items
found
Planned Care
Service Improvement
& Support
Planned Care
Training sheet amended to include driver's number to help identification
No changes requires as audit demonstrated that delivery notes were being
stored for the required amount of time
Service Improvement
& Support
Service Improvement
& Support
Service Improvement
& Support
No changes made. Educational issues identified and redressed through
dissemination of results and discussion at audit meeting
Service Improvement
& Support
Appointment of Band 7 pharmacist. Increasing number of discharge
pharmacist afternoon slots.
Protocol for management of VTE in pregnancy currently under review by
the Urgent Care Governance committee for introduction
Postnatal - Presentation of the audit findings to the Maternity Care Forum
and Paediatric Departmental Meeting. Dissemination of the findings of the
audit to the Maternity and Paediatric Teams. Antenatal - Review the
process for documentation of the discussion of NIPE at 28 weeks gestation
Liaison with the Neonatal Unit Clinical Lead to cross reference all term
babies admitted to Neonatal Unit from Delivery Suite.
Service Improvement
& Support
Appropriate training for new junior doctors during induction. Proforma not
designed to differentiate clinical significance of abnormalities…set out clear
outlines
Changed audit proforma – senior paediatrician review with 24 hours of
delivery. Added section on neonatal admission form about if parents have
been informed.
Urgent Care
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
14-369
14-375
Immediate Care of the Newborn (Strep B)
NICE guidance - Opioids in Palliative Care (carried
over)
14-378
Out of hours transfusion
14-379
CG89 When to suspect child maltreatment
14-382
14-391
Staff attendance at case conference
Audit of GSF information on Nursing admission
documentation
Regional RTC audit of the management of major
haemorrhage associated with trauma
14-394
MRSA pathway
14-395
Blood culture contaminations
14-396
Availability of hand gel
14-397
14-400
Hand hygiene compliance
Audit on the correct use of the WHO checklist
(within the peri-operative checklist) in theatres at S
& O Trust
14-402
Audit of referrals to falls team in community
14-390
97 | P a g e
To alter Proforma to clarify whether paediatrician was called and whether
they were present and also to note if reasons for non-attendance were
known. To provide feedback of good practice to Midwifery team – via
maternity care forum. Re-audit with optimization of audit tools e.g. evolve
and proforma. Regular review of guidelines for both medical and nursing
staff. Standardize documentation of maternal risk factors
educational issues, currently being redressed
Transfusion observations now to be documented on VitalPac and
transfusion sheets
To increase awareness through staff training and reaudit on 2015
Written to Sefton Social Care requesting a copy of all invites relevant to the
trust are sent to the named nurse child protection(NNCP) Requested
information from Community
Midwives and Paediatrics Consultants of attendance at conference.
Database recently developed to collated this information
Introduction of new GSF careplans supported by training
Transfusion practitioner now on Trauma bleep in Trust and an active
member of the Trauma Care Delivery Group
Results of audit fedback as part of monthly performance report which is
disseminated widely
Results of audit fedback as part of monthly performance report which is
disseminated widely
Results of audit fedback as part of monthly performance report which is
disseminated widely
Results of audit fedback as part of monthly performance report which is
disseminated widely
Monthly audit of the use of the WHO checklist. Audit has indicated
improvement in post list briefings.
Specific education plan for the identified ENP
Generic ENP teaching as most patients seen in minors stream therefore
more likely to be seen by ENP
Falls clinic referral to be included as part of the F2 teaching plan.
Women’s and
Children’s
Community &
Continued Care
Service Improvement
& Support
Women’s and
Children’s
Women’s and
Children’s
Community &
Continued Care
Urgent Care
Integrated
Governance
Integrated
Governance
Integrated
Governance
Integrated
Governance
Planned Care
Urgent Care
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
14-406
14-408
14-415
An audit of compliance with 62 days wait for newly
diagnosed haematology cancer patients
Genograms in specialist palliative care assessment
Administration of regularly prescribed analgesia in
palliative care patients
Dr Khine is going to present this at the next cancer meeting in Nov 14 as
there are some issues with indirect referrals being within the 62 day cancer
wait. Once presented she will compile an action plan and this will be
monitored regularly by the Haematology Team meeting 05/12/14 - emailed
DR Khine to see if discussed and to ask her to compile action plan. Jackie
Brunton is dealing with this and the action pan has been discussed at the
Cancer meetings regularly. Dr Toth is keen for the waiting time to improve
as is Jackie and she will feed back to me once all actions in place
Teaching pack produced. Teaching sessions to entire PCNS team. Aidememoire designed and disseminated to help implementation of assessment
tool
Education programme on pain & analgesia to be produced and rolled out to
hospital ward staff
To communicate the audit results to the Maternity Care Forum, Clinical
Lead Midwives and all midwives. • Responsive feeding and Relationship
building to be the focus of midwives 2015 mandatory training.• Staff to be
reminded of point 5.4 of the Infant Feeding Guideline-Responsive feeding
using read and sign. Neonatal nurses to have training as above. To remind
staff of point 5.6 of the Infant Feeding Guideline using read and sign
14-416
Breast Feeding mother
14-418
Bottle Feeding mother
To communicate the audit results to the Maternity Care Forum, Clinical
Lead Midwives and all midwives. • Responsive feeding and Relationship
building to be the focus of midwives 2015 mandatory training.• Staff to be
reminded of point 14.2 of the Infant Feeding Guideline-Responsive feeding
in a read and sign.• Staff to be reminded of section 14. Artificial Feeding of
the Infant feeding Guideline In a read and sign. • Staff to be reminded of
section 14. Artificial Feeding of the Infant feeding Guideline in a read and
sign
Supplementation
Effectiveness of a knitting and crochet group for
patients with long-term conditions
To communicate the audit results to the Maternity Care Forum, Clinical
Lead midwives and all midwives, HCA’s and MCP’s. • To remind postnatal
ward staff of Appendix 3 ‘The Effects of Top-up feeds’ and point 7.5 of the
Infant Feeding guideline in the form of a read and sign.
Group will now run under auspices of Living Well centre. Patients can still
be referred via Pain Clinic/Macmillan
14-420
14-423
98 | P a g e
Urgent Care
Community &
Continued Care
Community &
Continued Care
Women’s and
Children’s
Women’s and
Children’s
Women’s and
Children’s
Community &
Continued Care
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
14-425
Indications for hysteroscopy under GA
14-437
Recognition and referral for diagnosis of pre-school
aged children with suspected autistic spectrum
disorders
Use of Prothrombin Complex Concentrate
(Beriplex) to reverse the effects of Warfarin
Management of Community Acquired Pneumonia following on from AQ results 2013-14
14-438
NICE CG169 - Audit on the management of AKI
14-426
14-432
14-442
Review of TVT and TVTO over 2 years
14-443
Discharge rate on 1st referral patients to
Ophthalmology
14-444
14-448
14-451
Audit of quality of imaging for neonatal chest x-rays
Elective Caesarean section prior to 39 wks
gestation
Pulmonary/Cardio Rehab Education feedback form
99 | P a g e
Discussion of the results of the audit in Audit meeting and make aware
everyone the importance of performing hysteroscopy in outpatient clinics in
appropriate cases. Discussion of the results of the audit in Audit Meeting
and encourage good documentation.
Better communication with SCAT team lead – Hilary Cowan and updates
from their administrator to ensure reports available. Aim to improve waiting
time to be seen (dependant on staff numbers – Paeds & SCAT). Re-audit
with recommendations to make changes in 12 months. Ensure all patient
notes are available – both clinical letters/written notes and SCAT reports.
Paediatrician to be included in post-SCAT diagnosis correspondence to
help with monitoring progress of child
Lab SOP now in place
More and regular teaching on CAP diagnosis & management and CXR
interpretation
This audit has been superseded by the AQ measures for AKI. However if
the results for the AQ AKI audit are poor then an audit may be required to
look at our practice
Re-audit of notes between Feb 2015 and August 2015.Use of Kings
Questionnaire will be replaced with EPAQ. Will be included as standard in
the Re-audit.
To determine if Ophthalmologists are providing adequate feedback back to
the initial referrers. To determine any reasons for delayed discharge
Chart/book to be made available to ensure consistency of exposures.
Images to include exposure factors and time x-ray taken. Manual
collimation not to be applied post exposure. Use of paediatric aspect
markers and lead rubber (for top of incubator when using mobile machine)
To present the findings of the audit report at the Maternity Care Forum and
Managers / Consultants meeting. Reminder to obstetricians to book elective
CS from 39 weeks onwards and to confirm estimated date of delivery by
dating ultrasound scan. If unable to facilitate CS at 39 weeks to document in
the maternal records
Patients will be told at future educational sessions that hand-outs are
available for them to take away and that medication will be covered as a
separate topic
Women’s and
Children’s
Women’s and
Children’s
Service Improvement
& Support
Urgent Care
Urgent Care
Women’s and
Children’s
Planned Care
Planned Care
Women’s and
Children’s
Community &
continued care
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
14-454
Mitral Regurgitation: Are we adhering
14-455
On call medical team satisfaction with clinical
handover
14-456
14-462
Review of Cancer MDT meetings
Management of Diabetes and Insulin Administration
in hospital
No changes made due to the implications of making changes in such a
small Trust. The necessary patients will still continue to be followed up but
no changes will be made to current practice
ISBAR posters on all wards to advise of the importance of handover. A & E
aware of handover times so do not contact Doctors during this time to
ensure that handover is completely effectively
Improvements have been made to the chairing and organisation of Cancer
MDT meetings.
Diabetes specialist nurse input now available
14-463
Audit of Potassium Policy
14-467
Consultant referral letters priority codes
14-469
Renal Colic
A new potassium checklist has been introduced and will be re-audited in
2015 / 2016.
Audit has been presented to remind consultants of the process and codes
they should be using.
Re-audit in 2015-16 to close the audit loop working with the radiologists to
ensure the service is improved
14-470
Early pregnancy Referrals to AED
New Pathway in place
14-471
Documentation of Spiritual assessment and care on
SIU
Spiritual care plan developed and in place ("management of the spiritual
care needs of the patient").
14-473
Audit of women being offered a home birth
Audit indicated that where possible women are offered a home birth on
booking.
14-475
Rapid End of Life Transfers
Re-design of Rapid End of life documentation. Re-audit planned soon.
14-477
Audit of CAS alerts policy
14-479
Re-audit of wheelchair services for EOL patients
Audit indicated improvement in CAS alert recording system.
Information packs circulated giving criteria for priority 1 patients; where
variance in delivery times is not due to Wheelchair service this is now to be
documented.
14-493
Identification of named nurse and senior doctor on
patients name boards
Results of audit passed on to Acting Director of Nursing and cascaded
down to matrons and managers
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Urgent Care
Urgent Care
Planned Care
Urgent Care
Service Improvement
& Support
Planned Care
Urgent Care
Urgent Care
Community &
Continued Care
Women’s and
Children’s
Community &
Continued Care
Integrated
Governance
Community &
Continued Care
Community &
Continued Care
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
14-494
Audit of the Bed Rail Policy and compliance to the
recommendations within
14-499
Audit of Paediatric Fax Machine pre-programmed
numbers.
14-500
Real Time monitoring of van delivery system
Fax machine process is being reviewed.
Audit indicate the transport vans follow the new standard operating
procedures.
14-507
Audit of Time of death on ward and Time to
Mortuary
Audit requested as result of complaint and indicated significant assurance
with standards of good practice.
14-509
Trauma Fall down stairs audit
All fall down stairs patients get an automatic trauma team activation
14-511
Premature pre labour rupture of membranes for the
development of a regional guideline
Main action was around better documentation which they could look at as a
separate audit next year
14-488
Complaints Audits
14-524
“Comfortably Numb” An Audit of the Adherence to
Guidelines regarding Ketamine Sedation in Children
14-530
Network Time to CT audit
14-532
Eating and drinking at EOL
14-533
Comparison audit of Vigil care plan & individual
care plan of those thought likely to be dying
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New audit ideas highlighted from the results of this audit. Possible addition
to VitalPac to include Bed Rail eligibility
Audit provided evidence for developing complaint Key performance
indicators.
A patient identification sticker is used for full identification of the patient’s
attendance in all cases. The monitoring chart times to be completed by time
of observation which must be recorded and not as designated currently to a
3 minute predesignated slot. Time of monitoring checked Time of ketamine
administration.Et CO2 measurement must either be used or withdrawn from
the proforma. Time of discharge to be added to post procedure. Proforma
document to be photocopied or scanned and added to the ED record so
duplication of recording is minimised.
No changes as yet but discussions ongoing with radiology team to improve
time to CT
changes made to the process in collecting the ‘Individual Plans for Care for
Patient thought likely to be dying’
Amendments to audit database to aid data collection and allow more
detailed analysis eg is the patient conscious
Integrated
Governance
Women’s and
Children’s
Facilities
Integrated
Governance
Urgent Care
Women’s and
Children’s
Integrated
Governance
Urgent Care
Urgent Care
Community &
continued care
Community &
continued care
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
14-536
CT for pelvic/ hip fracture
14-528
Audit of TTO documentation
14-543
Major Haemmorhage
14-551
Renal Care Bundle
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Now carry out CT of the pelvis to look for occult fracture of the sacrum and
opposite hip.
Audit indicated that improvement in TTO documentation is still required.
Improvement in Obstetrics use of MHP but not in SDGH. Michelle to
complete work over next 12 months and re-audit this closer to the time
Patients with AKI now have Urine analysis and Renal ultrasound if
pylonephritis is suspected, patient is at risk for urinary tract obstruction or
the cause of renal failure is unknown
Planned Care
Service Improvement
& Support
Urgent Care
Urgent Care
SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST
PART 4
ANNEX
STATEMENTS OF ASSURANCE
The Draft Quality Account was circulated for comments to both CCGs, both
Healthwatches and to the Overview and Scrutiny Committee. On the following pages
are the responses received.
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4.1 Sefton Healthwatch received by email 16th June 2015
Healthwatch Sefton would like to thank Southport and Ormskirk Hospital NHS Trust
for the opportunity to review the Quality Account for 2014/2015. The account is a
comprehensive document and provides a great deal of information. It is good to see
that the “Chief Executives Big 5” are drawn from what patients say is important to
them and it’s also nice to see early in the document the achievements made over the
last year. We would also like to congratulate Dr Groves on receiving an MBE for her
services to Palliative care.
The work that the trust has undertaken in supporting the role of volunteer dining
companions is welcomed. During this period we asked for more information about
this role which the trust provided. We were assured that volunteers attend a number
of courses prior to starting this role including a full induction.
It is clear from the graph relating to safer staffing levels that the cost of agency staff
has been high over the last 3 years. The initiatives described to address this indicate
that greater efforts are to be made to address this situation and we look forward to
finding out how this situation improves over the coming year. In line with the scope
for change work it was good to see that staff had been included throughout the
process from identifying themes to voting on which projects were taken forward.
The section on ‘you said, we did’ is a good way to capture those quick wins identified.
The low response rates for the ‘Friends and Family test in Accident and Emergency
is noted and we would be keen to hear about how the Trust is learning from other
providers to look to improve this in the coming year.
In the draft version reviewed the list of priority improvements for April 2015 – March
2016 had not been included and we therefore are unaware of the priorities that have
been chosen moving forward. Similarly information provided on page 31 relating to
CQUINs doesn’t include how the Trust performed against them just the monitory
value. An update on how the trust performed against each CQUIN target would have
been useful.
The Trust has been operating as an Integrated Care Organisation for a number of
years now but we find many of the statements within the account to be aspirational. It
would have been good to hear about what has been achieved over the past year.
We are aware of the outcome from the CQC inspection and are aware of the
improvements which are required. There are a number of areas which require
improvement but we are aware that the regional spinal injuries centre and maternity
and gynaecology services have been assessed as being inadequate. There is no
information relating to the findings from the inspection within the account which we
have reviewed. We will be keen to monitor how action plans from this visit are
implemented over the coming year.
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The account is lengthy but it is good to see that the Trust will be producing a patient
facing summary of targets. This is a request we have made to the Trust over the last
few years and it is good to see that this will be available. There are still a large
number of acronyms used which are omitted from the glossary or simply stated within
being preceded by their full explanation. It would have been good to see the glossary
at the front of the account to help lay readers with acronyms. Similarly the use of
symbols, for example ‘> ’ need to removed or explained to the lay reader with a
number of the graphs within the account being difficult to read. Summaries for graphs
need to be included to explain what they show and titles for tables may help.
As an organisation we would like to have a conversation with the Trust about how
Healthwatch Sefton can work effectively with directors and other staff members at the
Trust to build up a positive working relationship. We have 2 members on the Trusts
patient experience group but would like to meet with Directors on a quarterly basis
and receive regular updates on quality and equality.
Healthwatch Sefton.
Company Ltd. by Guarantee Reg. No: 8453782
Healthwatch Sefton Registered Office: Sefton Council for Voluntary Service (CVS)
3rd Floor, Suite 3B, North Wing, Burlington House, Crosby Road North, Waterloo, L22 0LG
Tel: (0151) 920 0726 ext 240
www.healthwatchsefton.co.uk
info@healthwatchsefton.co.uk
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4.2 Lancashire Healthwatch
Comments received by email and telephone call on 3rd June 2015
Thank you for inviting Healthwatch Lancashire to feedback on Southport and
Ormskirk Hospital NHS Trust’s 2014/15 Quality Account.
Given that we received the report on 18th May 2015 it is disappointing that this report
does not include an overview / synopsis of the Care Quality Commission’s inspection
report in respect of the CQCs inspection in November 2014. It is also disappointing
that the report does not include information regarding the Trust’s Quality Priorities for
2015/16.
On a more positive note, the Trust’s quality achievements during 2014/15 are good to
see, in particular the ‘Care Closer to Home’ programme, Community Emergency
Response Team, Paediatric Services, Safer Staffing, Nursing Student Quality
Ambassadors, Implementation of VitalPac, Spinal Unit Out Reach Team and End of
Life Care. It is especially pleasing to note the Scope for Change sessions, HQIP
awards, Pride Awards, Dining Companions and Work Placement Programme as
these projects indicate that staff and the community are being consulted and involved
in the Trust’s quality improvement objectives. The Trust’s participation in clinical audit
and research is to be applauded too.
It would be helpful to have the CQUIN information (p 31) and 2014/15 quality targets
(page 35) RAG rated so we could clearly see where the Trust has achieved its
targets. It is disappointing to see that in 3 of the 4 areas for improvement identified
last year the target has not yet been reached, but it is reassuring to note the Trust
remains committed to achieving these quality goals.
Information regarding Hospital Standardised Mortality Rates (HSMR) and Summary
Hospital Level Mortality (SHIMI) would benefit from more explanation of the data as
would the Advancing Quality table (page 38) and associated graphs (page 39).The
results for Stroke services appear to indicate much work needs to be done to
improve these services and the deterioration of the service scores from 2001/12 to
date are of concern.
Results for Patient Recorded Outcome Measures (PROM) are variable but the low
numbers of responses do not facilitate an informed conclusion, but it would be good
to see the Trust improving the number of PROM responses in the future.
Results for the 2014 Staff Survey are all below the average acute trust scores which
again is a concern but it is reassuring to see an action plan is in place.
Deterioration in response rate in the Friends and Family Test for Acute Inpatients
and low rates of feedback for Accident and Emergency Services is very
disappointing because valuable information, which can help the Trust improve its
quality outcomes, can be gained from such patient feedback. It is a concern that the
percentage of patients that would recommend the Trust for Acute Inpatient and
Accident & Emergency services is consistently below other similar trusts in England.
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However it is pleasing to see the results for Antenatal and Postnatal Community
services, but again there appears to be improvement required in some maternity
services (Birth).
In respect of Infection Prevention and Control it is disappointing to see that the Trust
has had 2 Hospital acquired MRSA bacteraemias but reassuring to see an action
plan is being progressed. It is pleasing to note that hospital acquired C Difficile
infections are under trajectory for 2014/15 and that the Trust is focussing on
improvements in inappropriate antimicrobial prescribing.
The never event in respect of incorrect administration of potassium is a concern but
again reassuring that the Trust has reviewed its systems and processes for
prescribing and administration of this frequently used medication.
Data included in this report regarding pressure ulcers is inconsistent with that on the
Trust’s website (Open and Honest Reports April 2014- March 2015) and I would
request that this issue be addressed for the final version of this report. I would also
request a statement be included in this report which confirms that all StEIS
reportable incidents were reported to the Trust’s commissioners, and if that isn’t the
case, an explanation / action plan included.
The slight increase in falls is noted and it would be helpful to have the full dataset for
Early Warning Score Audits. The data for cardiac arrests is honest, but again it is
disappointing to see that the Trust sometimes misses important facets of care –
correct escalation, fluid balance and observation frequency.
Overall, the Quality Account appears to indicate the Southport and Ormskirk NHS
Trust is facing some significant clinical challenges. I hope that Healthwatch
Lancashire and the Trust can work collaboratively to raise the standard of care at
both hospitals and in the community we both serve.
Gill Brown
Chief Executive | Healthwatch Lancashire
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4.3 Sefton Overview and Scrutiny Committee
Ground Floor
Trinity Wing
Town Hall
Trinity Road
Bootle
L20 7AE
Mr. Jonathan Parry
Chief Executive
Southport & Ormskirk Hospital NHS Trust
Town Lane
SOUTHPORT
PR8 6PN
Date:
Our Ref:
Your Ref:
17 June 2015
DAC/O&S
Contact:
Debbie Campbell
Telephone Number: 0151 934 2254
Fax Number:
0151 934 2034
email: debbie.campbell@sefton.gov.uk
Dear Mr.Parry,
Southport & Ormskirk Hospital NHS Trust – Quality Account 2014/15
As Chair of Sefton Council’s Overview and Scrutiny Committee (Adult Social Care) I am
writing to submit a commentary on your Quality Account for 2014/15.
Members of the Committee met informally on 15th June 2015 to consider a small number of
Quality Accounts, together with representatives from Sefton Healthwatch who are co-opted
onto the Committee, and representatives of the Trust attended the meeting.
Committee Members welcomed the opportunity to comment on the Quality Account and a
brief outline of information received, together with comments made, is outlined below.
Members heard about a number of actions being taken by the Trust in response to the recent
CQC report. Members were concerned about the collaborative working with Morcambe Bay
and Blackpool Trusts regarding maternity services and considered that although there are
potentially “lessons to be learnt” from such Trusts, collaborative working with “outstanding”
Trusts in this particular area might prove to be more beneficial.
Members also heard details relating to “Responsiveness to the Personal Needs of the
Patient”, under the Domain of “Ensuring people have a positive experience of care”.
Information was provided on the prevention and control of C-difficile infections and Members
hoped to see a relatively significant reduction in this area next year.
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Members also heard details of recruitment measures being undertaken by the Trust to
address shortfalls in nursing staff.
Reference was made to the recent cessation of breast care services at the Trust and I
specifically requested that communication between the Trust and the Committee must be
improved in the event of a similar situation in the future.
We requested details of up-to-date data to be provided for submission to our Committee
meeting to be held on 5th January 2016, for consideration by Members and hopefully to see
evidence of improvements, particularly for the following areas:


Maternity services;
Infection control, including c-difficile
Safer staffing levels.
Please note that this information will need to be provided to the Clerk for our Committee
(details at the top of this letter) no later than 15th December 2015, in order for it to be
included with the agenda papers. Trust representatives do not necessarily need to attend, as
long as we receive the information requested.
I hope you find these comments, together with the discussion held at the informal meeting,
useful and I hope to see improvements within those areas of the Trust requiring improvement
very soon.
Would you please disregard the letter I submitted to the Trust dated 27th May 2015 and
accept this letter as the OSC’s formal response to your draft Quality Account.
Yours sincerely,
Councillor Catie Page
Chair, Overview and Scrutiny Committee (Adult Social Care)
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4.4 South Sefton CCG and Southport & Formby CCG
Southport and Formby CCG welcomes the opportunity to comment on Southport and
Ormskirk Hospital’s Quality Account 2014/15. As a Commissioner of health care
services and on behalf of our co-commissioning CCGs and the local population, we
believe this Quality Account demonstrates a commitment to quality improvement and
high quality services. The document provides an overview of the progress made
during 2014/15 and it is noted that the Trust continues to implement and monitor the
Trust Quality Strategy ‘Right First Time – Every Time (2012-15) which is monitored
through the Operational Trust Quality and Safety Committee.
This Quality Account provides an overview of priority areas and demonstrates the
provider’s achievement in terms of quality of service delivery against the backdrop of
a changing NHS. It is noted that delivering high quality care and treatment in an
organisation with such a wide range of services requires a high level of monitoring
and commitment to see through required changes. It is acknowledged, the past year
has been challenging year for the organisation and in particular the staff. The Care
Quality Commission / Chief Inspector of Hospital’s inspection reports identified a
number of areas requiring improvement. There has been a commitment by the Trust
to work with Commissioners to address all of the highlighted areas for improvement.
Southport and Formby CCG note the Trust is working to understand the increased
reporting of serious incidents particularly in the area of pressure ulcers and expect
any work carried out will support improvement in patient safety and the quality of
patient experience whilst receiving care. The development of specific work streams
to achieve improvements in patient care in an area that has been identified as
challenging is commended. However progress still needs to be made in the following
areas that the CCG has highlighted as emerging areas of concern:




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Staffing & Staff Experience
Patient Experience
Mortality
Safeguarding
A&E Performance / ambulance turnaround times.
It is felt that the priorities identified for the coming year are both challenging and
reflective of the current issues across the health economy. The CCG recognises that
the Trust acknowledges that improvements are required in certain areas and have
referenced these in the report. The CCG looks forward to the implementation of
these schemes to enhance the quality of services delivered. We therefore commend
the Trust in taking account of new opportunities to further improve the delivery of
longer healthier lives.
.
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4.5 CHANGES MADE TO THE QUALITY ACCOUNT AFTER 30TH APRIL 2014
-Included readmission data from previous year as suggested by KPMG
-Included FFT for staff highest and lowest percentage as suggested by KPMG
-Added information from the CQC visit as suggested by Healthwatch Lancashire
-Added CQUIN targets achieved as suggested by Healthwatch Lancashire
-Provided background information on HSMR and SHIMI as suggested by
Healthwatch Lancashire
-Reviewed the figures for pressures ulcers as suggested by Healthwatch Lancashire
and added a statement about the reporting to StEIS
-Amended graph for C-diff to include the number of cases after appeal
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4.6 Independent Auditors Limited Assurance Report to the Directors of
Southport and Ormskirk Hospitals NHS Trust on the Annual Quality Account
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