Quality Account
2014-2015
2
Contents
Quality Account 2014-2015
Contents
Introduction............................................................5
Statutory declarations
What we do.............................................................7
• Review of services.................................................... 28
• Participation in clinical audit................................ 28
• Participation in clinical research......................... 32
• Goals agreed with commissioners...................36
• Care Quality Commission registration
and inspection............................................................36
• Data quality.................................................................38
• NHS Number and GP practice Code Validity....38
• Information governance........................................38
• Clinical coding............................................................ 39
• Summary of hospital-led mortality indicator
(SHMI) and the percentage of deaths with
palliative care coding............................................... 39
• Patient reported outcome
measures (PROMS)..................................................40
• Percentage of patients readmitted within
28 days of discharge............................................... 41
• Responsiveness to inpatients’
personal needs............................................................ 41
• P ercentage of patients admitted who were
at risk of VTE................................................................ 42
• Patient safety indicators......................................... 42
• C.difficile infections................................................. 42
• Patients’ recommendation of the Trust as
a place to be treated............................................... 42
• Staff recommendation of the Trust as a
place to be treated................................................... 43
Vision and values.............................................8
Culture champions....................................... 10
How we look at the safety and
quality of our services............................ 13
Our safety and quality priorities... 14
Patient experience
• Eliminate clinically inappropriate mixed
sex accommodation................................................ 14
• Cleanliness................................................................... 14
• End of life care........................................................... 14
• Nutrition........................................................................ 15
• Patient experience.................................................... 15
Safety
• Falls.................................................................................. 16
• Pressure demage....................................................... 16
• Safety thermometer................................................ 17
• Dementia...................................................................... 17
• Healthcare acquired infection............................. 18
• Venous thromboembolism (VTE)...................... 19
• World Health Organisation (WHO) safer
surgery checklist........................................................ 19
• Fractured neck of femur (hip)............................. 19
• Patients admitted with stroke............................. 20
• Access to services..................................................... 21
• Incident reporting..................................................... 21
• Amber Care Bundle.................................. 22
• Safe and appropriate
discharge arrangements ............................ 22
• Mental health........................................... 22
• COPD Bundle............................................ 23
• Safeguarding............................................ 23
Produced and published by:
Communications,
Surrey and Sussex Healthcare NHS Trust
For additional copies please contact:
01737 768511 x 6199
Clinical effectiveness
• Mortality....................................................................... 24
• Readmission to hospital......................................... 24
• Reducing need for admission............................. 24
• Enhancing quality...................................... 25
• Enhanced recovery................................................... 26
• National Institute for Health and Clinical
Excellence (NICE) technology appraisals (TAs)...27
Staff awards and recognition.......44
Our priorities for 2014-15....................48
Glossary.....................................................................50
Appendices............................................................ 52
• Statement of our directors’ responsibilities.......52
• What our partners say........................................... 53
• How to contact us.................................................... 57
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4
Introduction
Quality Account 2014-2015
Introduction
Quality accounts are an
important way for local NHS
services to report on quality
and show improvements
in the services they deliver
to local communities and
stakeholders.
The quality of the services
is measured by looking
at patient safety, the
effectiveness of treatments
that patients receive and
patient feedback about the
care provided.
NHS Choices
Thank you for
taking an interest
in our quality
account, which is
designed to give you
information about how
we assure our patients and
their carers, our partners and
commissioners and ourselves on
the quality, safety and effectiveness
of the services we offer.
It has been another year where we are proud
to have maintained standards set nationally for
access to services in the emergency department
and to in-patient and operative care, despite
the challenges of more people than ever
needing unplanned care.
It has been another year where we have met
the standards set for us on patients suffering
from healthcare acquired infection and the
first year in our history where, although we
reported a single MRSA contaminant at blood
culture, we did not have a single MRSA blood
stream infection. Every patient who contracts
an infection related to hospital treatment
has a story that is used to drive learning and
improvement and this year the challenge is to
reduce infections where there is a failing of care
to an absolute minimum; a challenge we very
much want to meet.
I reported in our last quality account that we
had received a very useful and reassuring
‘mock’ CQC inspection provided by
colleagues from many departments at Frimley
Park NHS Foundation Trust. This was followed
in May 2014 by a three day inspection of all
our services by the Care Quality Commission
(CQC) themselves. This was a planned
inspection and as well as reviewing much of
the data related to our clinical performance
and outcomes, it also met with patients,
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6
What we do
Quality Account 2014-2015
carers and members of staff to gain an
overall picture of the care we provide.
I was delighted that as a direct result of our
strong clinical leadership and the commitment
of staff across the Trust we were rated as
’good’ across all five inspection domains:
• safety
• effectiveness
• patient experience
• access and responsiveness
• well led
In addition, our end of life services were
awarded ‘outstanding’.
This rating was a tremendous achievement
and one we are very proud of - nonetheless
we were told we could do more for patients
attending our out-patient services, improve the
availability of our medical notes and in relation
to our medical secretary and PA workforce. In
all of these areas we are advanced in delivering
the improvements we are grateful to the CQC
for raising.
We have had our best ever year for recruiting
patients into clinical trials. The ability for
patients to participate in research studies is
a less widely publicised marker of quality of
service - with many of the studies receiving
national and local attention.
Studies suggest that as many as nine out of ten
patients would be willing to take part and the
challenge we face is identifying studies which
are appropriate for us to take part in and asking
patients whether they are willing to take part.
Both of these aspects require an effective and
hardworking research and development team
and a willing and informed clinical workforce.
We plan to build on last year’s success by
working ever more closely with the Local
Clinical Research Network, which covers Kent
Surrey and Sussex, so that we are thought of
early when trials are looking for recruitment
centres. We will also ensure that we support
our research active staff to enable them to have
time to spend with patients explaining studies.
We continue to be an associated university
hospital of Brighton and Sussex Medical School
and, in addition, this year we have become a
member of Surrey Health partners. This initiative
links clinicians and academics around central
clinical themes and clinical academic groups
promoting research ideas, design and delivery
to ensure the best care is available to patients.
We have continued to be a member of the
Kent Surrey Sussex Academic Health Science
Network (AHSN) and, as reported in this
account, we have continued to perform well
within their enhancing quality and enhancing
recovery programmes. These programmes
look at the frequency with which patients with
certain clinical diagnoses receive specific quality
interventions and drive safety and effectiveness
of care. Looking forward, this year we will
work with the AHSN to further strengthen our
capacity to define quality for patient pathways
and design and evaluate even more effectively
the care we give.
Our journey towards Foundation Trust
status continues. At the time of writing this
introduction we have been referred by the
NHS Trust Development Authority to Monitor,
the Foundation Trust assessor and regulator.
We are part of a final assessment undertaken
by Monitor and we are pleased that at this
stage we have recruited more than 10,000
members who have chosen to be involved
in the future plans of our organisation. In
many ways, the most important advantage
of being a Foundation Trust is having this
proactive membership of people who
have signed up as being interested in how
we deliver our services for them and the
communities we serve. I am very grateful
that so many people have taken this step
and look forward to working with them this
year to further improve the care we give.
Michael Wilson
Chief Executive
What we do
Surrey and Sussex Healthcare NHS
Trust provides extensive acute and
complex services at East Surrey
Hospital in Redhill alongside a range
of outpatient, diagnostic, day case
and planned care at, The Earlswood
Centre, Caterham Dene Hospital and
Oxted Health Centre in Surrey and
at Crawley and Horsham Hospitals
in West Sussex.
Serving a population of over 535,000 we care
for people living, working and visiting east
Surrey, north-east West Sussex, and south
Croydon, including the towns of Crawley;
Horsham; Reigate and Redhill.
East Surrey Hospital is the designated hospital
for Gatwick Airport and sections of the M25
and M23 motorways. It has a trauma unit,
which cares for seriously injured patients in
partnership with the major trauma centres at St
George’s University Hospitals NHS Foundation
Trust and Royal Sussex County Hospital
Brighton. East Surrey Hospital has 666 beds
and ten operating theatres – along with four
more theatres at Crawley Hospital in our day
surgery unit.
We are a major local employer, with a diverse
workforce of around 3,700 providing healthcare
services to the community we serve.
The Trust is an associated university hospital of
Brighton and Sussex Medical School.
In 2014-15 we had an income of £244m and
we have delivered an increase in activity across
the services we provide and in the number of
people we have cared for:
In 2014-15 we saw more than
87,000
patients at our
emergency department
There were
We also saw
32,172 35,300
4,463 320,000
patients
elective patients
births
required
emergency
admission
were admitted
patients
at our
out-patient
clinics
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8
Our values
Quality Account 2014-2015
I couldn't have had better treatment.
All the staff were courteous and helpful.
Really impressed with East Surrey Hospital.
1 mile
Our vision
Safe, high
quality
healthcare
that puts our
community
first.
GREATER LONDON
CROYDON
SURREY
KENT
Caterham Dene
Hospital
REIGATE &
BANSTEAD
Oxted Health Centre
MOLE
VALLEY
Crawley Hospital
• Dignity and respect: we value each person as
an individual and will challenge disrespectful and
inappropriate behaviour
•Compassion: we respond with humanity and
kindness and search for things we can do, however
small; we do not wait to be asked, because we care
• Safety and quality: we take responsibility for our
actions, decisions and behaviours in delivering safe,
high quality care
TANDRIDGE
The Earlswood Centre
Our values
• One team: we work together and have a ‘can do’
approach to all that we do recognising that we all
add value with equal worth
East Surrey Hospital
Horsham Hospital
CRAWLEY
MID SUSSEX
WEST
SUSSEX
HORSHAM
EAST
SUSSEX
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Our culture champions
10 Quality Account 2014-2015
Our culture champions
Colin Pink, corporate
governance manager,
updates us on the role
of culture champions
at Surrey and Sussex
Healthcare NHS Trust…
Putting our patients first and at the centre of what we do is
key to enabling us to achieve our goal of moving from a ‘good’
organisation to an ‘outstanding’ one - making sure that everyone
has quality, safety, productivity and patient experience as the
cornerstones of their decision making.
In partnership with our staff, we have outlined the behaviours
and expectations that explain what our organisational values look
like in everyday practice. Now we must strive to make sure they
become part of the way we work, day in and day out.
To that end we have set up a network of culture champions who
will help give us focus and visibility and help the organisation
embed our culture in everything we do.
Chosen by the executive team and clinical chiefs our core group
of culture champions are a mix of people - all bands, all divisions,
all occupations - who are already role models for our values and
behaviours. Their role is to help us to embed our values and
behaviours by supporting our teams and staff: • At an individual level to help colleagues understand our
values and what it means for them, for our Trust and, most
importantly, for our patients
Culture
champions
- living the
values
• At a team level working with leaders to propose different ways
in which our values can be communicated and integrated
• At a Trust level to create awareness and focus and support
initiatives to integrate values and behaviours in our systems
and processes - recruitment; induction, recognition
In collaboration with members of staff from across the
organisation, we have developed a framework of ‘behavioural
anchors’ that support our four key values:
• Dignity
• One Team
• Compassion
• Safety and Quality
The anchors provide all staff with a fair
and transparent interpretation of what
our values mean in day-to-day situations
and will be become a powerful tool
in challenging behaviours and setting
appropriate expectations.
Our new achievement review process
is different; it signifies a change in how
contribution is reviewed by considering
the extent to which people achieve their
objectives in a way that reflects our values
and behaviours.
Changing the way we assess individual
achievement and contributions to our
organisation is one of the ways that we are
creating focus to accelerate our journey to
‘outstanding’. A new style achievement review
was developed during 2014/15, which replaces
our existing appraisal system, that has been
designed to help us feedback and reflect each
person’s contribution to our success.
To date this is making very positive changes to
the Trust which, for example in our theatre team,
can be seen in their development of team goals
and beliefs and the use of behavioural questions
in interviews for new staff.
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How we look at the safety and quality of our services
12 Quality Account 2014-2015
How we look at the safety and
quality of our services
Katharine Horner,
patient safety and
risk lead, explains the
background to how
we look at the safety
and quality of our
services…
The hospital was
clean and tidy and
the staff have all been
wonderful, extremely
kind and caring.
As we continue to grow and expand services we remain
committed to improving and providing high quality safe
and effective care to our patients and their families.
On a daily basis, teams across all wards and departments come
together to discuss patient safety issues such as the number
of patients who have a high risk of falling, the dependency of
patients on the ward and any staffing issues. Each clinical division
holds a monthly governance meeting to which safety concerns
and risks are escalated.
The information contained within the scorecard covers a wide
range of performance indicators for safety, clinical effectiveness,
patient experience, performance and productivity and covers
all services provided. This means that the sub-committees of
our Board can focus on the right quality and safety priorities
for patients.
The patient safety sub-committee provides an important
interchange of information and experience for the teams
responsible for ensuring that patients are safe. We recognise
that incident reporting is only effective if the organisation
learns lessons from the incidents that have occurred. We
have continued to see incident reporting rates at a level
that is consistent with a healthy incident and reporting
awareness culture.
We were pleased to see an improvement in the 2014 National
Staff Survey indicators: • percentage of staff reporting errors, near misses or incidents
witnessed in the last month (KF13)
• percentage of staff agreeing that they would feel secure
raising concerns about unsafe clinical practice (KF15)
Both indicators are better than the national average. In addition
for indicator, ‘Fairness and effectiveness of incident reporting
procedures’ (KF14) the improved picture for 2014 placed us in
the best 20% of Trusts in the country.
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Our safety and quality priorities
Quality Account 2014-2015
Our safety and quality priorities
Patient experience
Eliminate clinically inappropriate
mixed sex accommodation
Improvement sought for 2014-15:
We said we would continue to ensure there are
no mixed sex breaches and enhance the privacy
and dignity experience for all our patients.
• 2014-15 Performance rating ➜ Met
In 2014-15 we had no mixed sex breaches.
Improvements sought for 2015-16:
To continue to ensure there are no mixed sex
breaches and enhance the privacy and dignity
experience for all our patients.
Cleanliness
Improvements sought for 2014-15:
Investment in new equipment to assist in a
more streamlined cleaning regime and cleaning
during the day rather than during the night to
alleviate unnecessary noise for our patients.
• 2014-15 Performance rating ➜ Met
New equipment has allowed us to provide
a more streamlined cleaning routine. Our
scheduled regular cleaning programme takes
place during the daytime - we do not routinely
clean during the night to ensure that our
patients are not disturbed unnecessarily.
Improvements sought for 2015-16:
To continue to maintain high standards of
cleanliness and to ensure patients are not
disturbed unnecessarily.
End of life care
Nutrition
Improvements sought for 2014-15:
The Trust’s end of life care strategy (2011-2014)
is due for renewal this year. This work will be
taken forward via the end of life care steering
group. We will continue to promote the use
of, and audit, the newly introduced end of life
care plan. We will introduce a palliative care
weekend service by expanding the nursing
team by two whole time equivalent clinical
nurse specialists.
Improvements sought for 2014-15:
We said we would continue to focus on
implementing protected mealtimes and have
an on-going audit to monitor progress and
adherence to this initiative. We also said that
we will introduce a new two week menu cycle
and the dieticians and catering department
have been working very closely to ensure this
menu offers variety and continues to meet the
nutritional standards for hospital catering. The
new breakfast menu will include prunes and
yoghurts at breakfast time following feedback
from patients.
• 2014-15 Performance rating ➜ Met
Our end of life care strategy has been renewed
for 2014-2017. The strategy has been reviewed
and agreed by the End of Life care steering
group and at board level by the clinical
effectiveness group and implementation is
monitored via an action plan.
We have expanded the service provision from
five days a week to include Saturdays and Bank
Holidays since September 2014 and are working
towards expanding this to a seven day service.
We have launched a two year pilot discharge
liaison partnership project with Marie Curie to
aid hospital discharge for patients, at the end
of life, to their preferred place of care.
Improvements sought for 2015-16:
We will continue to audit end of life care
through participation in the 5th National Audit
of Care of the Dying Patient and internal audit
of end of life care documentation. We will
develop, introduce and embed the second
version of our end of life care plan.
• 2014-15 Performance rating ➜ Met
Our audits confirm good progress and that
the two week menu cycle is proving popular
with patients.
Improvements sought for 2015-16:
We will continue to make improvements
to protected mealtimes. The nutrition and
hydration steering group and the oral nutrition
and hydration group will continue to monitor
progress and we will continue to monitor
feedback and make adjustments as necessary.
Patient experience
Improvement sought for 2014-15:
We said we would encourage more senior
frontline staff to respond directly to comments
on Patient Opinion and that we would roll out
the Your Care Matters programme to cover all
patient pathways, build upon using it as a way
to track performance and consistently respond
to the comments we receive and strive to make
improvements. We also said that we would
communicate the changes that we make to staff
and our patients and their families and improve
both admission and discharge patient literature.
• 2014-15 Performance rating ➜ Met
Your Care Matters: Our bespoke patient
feedback programme now covers the full
range of different patient pathways and
includes the Friends and Family Test as the
first question. Patients are asked to take part
in a short survey once they have experienced
an episode of care. The programme is widely
promoted across the Trust to both patients
and staff and text reminders are also used
to encourage participation. The survey gives
patients the opportunity to commend staff for
a job well done and also asks for any comments
or suggestions on how the service might be
improved. These staff commendations and
additional comments are automatically emailed
to key staff within the service. They are able to
share positive comments and review additional
comments alongside other sources of patient
feedback such as PALS contacts, Patient
Opinion and face to face interactions and make
improvements where possible.
Changes that are made as a consequence
of listening to our patients’ views are widely
communicated using ward boards and digital
screens across the hospital.
Improvements sought for 2015-16:
We will continue to promote both staff
and patient engagement with the Friends
and Family Test and Your Care Matters and
will make changes based on the feedback
we receive. We will further broaden the way
we seek feedback from the wider community
through increased use of focus groups and
wider consultation with stakeholder groups.
We will continue to train our staff in customer
care skills.
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16
Our safety and quality priorities
Quality Account 2014-2015
Safety
•2014-15 Performance rating ➜ Met
Also, in 2014-15:
Falls
Improvement sought for 2014-15:
We said we would improve data collection.
The falls prevention team would start monthly
falls clinics and develop routine monthly falls
ward rounds to continue to reduce the overall
number of falls and promoting good reporting
and management processes. There is a goal
to reduce the total number of falls by 25%. A
25% reduction is pragmatic for an organisation
that is not an outlier for falls and considered
by the majority of staff as a stretch target.
If delivered, this will result in a meaningful
improvement in the safety of our patients.
T he total number of patients who
suffered no harm due to a fall
has increased by
5.2%
compared to 2013-14
T he number of patients who
suffered major harms has
decreased by
21%
50%
•2014-15 Performance rating
➜ Partially met
There was a
We have started monthly falls clinics and
weekly falls ward rounds. In addition, we
also reconvened our falls prevention group in
March 2014 to monitor trends and themes on
falls. Patients are referred to our specialist falls
nurse consultant, who joined us in year, and
we have started ward staff teaching on falls
prevention; conducted an audit on the use of
falls care bundles for high risk areas; updated our
Trust falls strategy and appointed falls champions.
We have also, working with our colleagues at
the Kent, Surrey and Sussex Falls Collaborative
and also with NHS England at a national
level, assessed our current falls prevention
practices and strategies as per NICE guidance
and participated in the first national inpatient falls audit by the Royal College of
Physicians and the Falls and Fragility Fractures
Audit Programme (FFFAP). We will also be
participating in the largest research of its kind
in the UK with regards to preventing injuries
to older people through the provision of
shock-absorbing flooring led by the University
of Portsmouth.
Total falls
Falls with harm
2013/14
2014-15
1049
1195
298
315
reduction in the number of patients
who suffered an extreme harm
T he total number of serious
incidents due to a fall has also
decreased by
29%
Improvements sought for 2015-16:
We will continue to seek to achieve a 25%
reduction in total falls and in harms caused.
Pressure damage
Improvement sought for 2014-15:
The number of patients affected by pressure
damage is reported to the Trust Board at every
meeting. We will reduce hospital acquired
minor damage by 25% and have no hospital
acquired major pressure damage.
We have continued to reduce hospital acquired
minor damage by over 50% and we had no
hospital acquired major pressure damage.
Improvements sought for 2015-16:
Maintain our achievement of no hospital
acquired major pressure damage and
continue to strive to reduce hospital acquired
minor damage.
Improvements sought for 2015-16:
To maintain 95% average compliance with
safety thermometer new harm metrics
and increase average compliance to 97%
throughout January to March 2016.
Dementia
Safety thermometer
Improvement sought for 2014-15:
We said that a specific maternity safety
thermometer that was being piloted would be
introduced and that the Trust would continue
to engage with community services and clinical
commissioning group chief nurses to ensure a
joined up approach. The ‘new harms’ score is
between 94.19% - 96.5% and the Trust has
interrogated this data to allow it to identify
areas for improvement.
•2014-15 Performance rating ➜ Met
The maternity safety thermometer has not yet
been published and so we have been unable to
introduce and implement.
Harm free
(all harms) %
Harm free
(new harm) %
April 2014
90.5
95.4
May 2014
92.8
97
June 2014
93.4
97.6
July 2014
90.8
95.3
August 2014
92.5
96.1
September 2014
92
94.5
October 2014
95
98
November 2014
93
96
December 2014
93
97
January 2015
93
96
February 2015
92
95
March 2015
92
96
Improvement sought for 2014-15:
We said that in order to ensure the most
effective and significant engagement with local
commissioning and care quality improvement
initiatives, we would engage and commit to
local commissioning intentions and care quality
improvements. We also said that we would
demonstrate a community facing mind-set
and approach to dementia care, ensuring
that the organisation is involved at the heart
of efforts to minimise avoidable admissions,
whilst maintaining a commitment to providing
the highest standards of care for those who
require inpatient admission. And that we would
actively seek feedback from carers of people
with dementia about the care each individual
receives and how well, as an organisation,
we support the carer. We also said that we
will disseminate and utilise this feedback in
developing care delivery and where appropriate
provide feedback and evidence to the carer
demonstrating how their input has been
successfully employed to make alterations and
improve service provision.
•2014-15 Performance rating ➜ Met
We have been successful in ensuring that we
have adopted a strong community facing
approach to dementia care and are a key
partner in local commissioning efforts to
develop high quality dementia care. We have
been central in efforts to develop high quality
services which support a reduction in avoidable
admissions and we continue to support the
development of these services. We have also
sought to solicit the views and opinions of
carers of people with dementia to improve how
we support them and this will continue to be a
key feature of our aims going into 2015-16.
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18
Our safety and quality priorities
Quality Account 2014-2015
Improvements sought for 2015-16:
We will continue to develop and build new
pathways for both dementia and delirium
which will be linked to the East Surrey
Integrated Dementia Action Plan (ESIDAP)
and to primary care and community pathways.
Close involvement and support of the
implementation of the ESIDAP will help in
continuing to develop a community facing mind
set, collaborative approaches to care and the
avoidance of unnecessary admissions. We are
committed to holding a number of carers’ focus
groups to benchmark how well we support
carers currently and at how we can improve.
In-line with our commitment to the national
Sign up for Safety pledge we will audit and
benchmark our performance in the assessment
and management of pain in dementia and
undertaking an assessment of the knowledge
and skills of staff to identify any training needs
that can be met.
Healthcare acquired infection
Improvements sought for 2014-2015:
We said that we will meet the Department
of Health targets of no more than 29 patients
who are affected by Clostridium difficile, and
will have no preventable MRSA blood stream
infections. We also said that we would continue
to analyse all cases and disseminate learning
and that the focus in the coming year would be
to ensure that we identify patients with MRSA
promptly with our screening programme and
that we would prescribe and administer the
MRSA suppression treatment in a timely way.
•2014-15 Performance rating ➜ Met
• Clostridium difficile* - 24 cases**
• MRSA blood stream infections - 0
(with 1 contaminant)
*The national maximum for all Trusts reporting cases of
patients aged two years old or over during the reporting
period was 121minimum was 0
**This equates to 11.3 cases per 100,000 bed days
For the prevention of Clostridium difficile, there
has been a continuing emphasis on antibiotic
prescribing and improved timely risk assessment
of all patients with symptoms of diarrhoea.
There has been a continued focus on prompt
isolation of affected patients. All cases of
Clostridium difficile had full root cause
analysis performed and the clinical teams
fed these investigations findings back at
divisional governance and taskforce
meetings, so that learning could be spread
throughout the organisation.
MRSA infections are more likely if a patient has
intravenous lines, a urinary catheter, wounds,
or if it is not known that they are a carrier.
Over recent years there has been an overall
reduction in MRSA blood stream infection,
due to an enhanced focus on screening and
the care of patients with intravenous lines and
urinary catheters.
Learning: Each Clostridium difficile case
was subject to a comprehensive investigation
undertaken by a clinical team in conjunction
with the infection prevention and control team.
In 2014-15 there were 24 Trust apportioned
episodes of Clostridium difficile - 16 cases arose
within the medical division and 8 in the surgical
division; 19 patients had received an antibiotic
post admission, all prescriptions being clinically
justified. In four of these cases, although
antibiotics were required, prescribing was not
in line with Trust antibiotic policy (for choice,
dose or duration). There were three episodes
of probable cross-infection and there were
no deaths directly attributed to Clostridium
difficile infection.
Tackling Norovirus: Keeping the virus that
causes vomiting and diarrhoea away from
the hospital is a challenge every year. The
virus spreads easily and causes huge disruption
in all hospitals and schools, particularly over the
winter. The whole health economy is working
more effectively on Norovirus control, with
planning meetings taking place in September
of each year.
In October 2014, we organised a conference on
Norovirus and invited our community partners
to join us to decide the best way to prevent and
control the spread of the virus. Representatives
from nursing and care homes, the ambulance
service, Public Health England and other local
NHS trusts all attended to discuss working
together with us in seeking a common goal.
We looked at ways of avoiding admitting
people with Norovirus symptoms, patient
transport and the control of the illness in
care and nursing homes. The Trust has seen
a slightly higher level of activity compared to
last year, in common with community settings.
There were seven episodes of ward closures
due to confirmed Norovirus throughout winter
and spring. The focus of the coming year will
be on cleaning standards, hand hygiene and
the continued presence in wards of infection
prevention and control nurses, to support the
clinical assessment of patients with diarrhoea.
Improvements sought for 2015-16:
We will meet the Department of Health
objectives of no more than 15 patients who
are affected by Clostridium difficile and will
have zero preventable MRSA blood stream
infections. We will continue to analyse all
cases and disseminate learning.
For MRSA, the focus in the coming year will
be to ensure that we continue excellent practice
in the care of intravenous lines and urinary
catheters. For the prevention of Clostridium
difficile we will continue the high focus on
antibiotic prescribing and ensure that hand
hygiene and glove use is high on the agenda.
There will also be a continued presence in
wards by infection prevention and control
nurses to support the clinical assessment of
patients with diarrhoea.
Venous thromboembolism (VTE)
Improvement sought for 2014-15:
We said that the risk assessment will continue
to be carried out on more than 95% of patients
on admission and that the reassessment of risk
will be highlighted through staff education,
in line with NICE guidance. Also, that patient
information leaflets will be available to all
admitted patients within the Trust, highlighting
the risk of VTE and on-going preventative
advice on discharge. We also said that a
multi-disciplinary team would review any
cases where a patient develops a venous
thrombosis either whilst an inpatient, or within
90 days of discharge and that the numbers
of such cases and whether care was substandard will be published within our Board
performance papers.
•2014-15 Performance rating ➜ Met
Over the last year, 95% of patients looked after
by us had a formal VTE assessment carried out
on admission and recorded in the notes.
Improvements sought for 2015-16:
To continue to develop the improvements
achieved by the multi-disciplinary review of
venous thrombosis.
World Health Organisation (WHO)
safer surgery checklist
Improvement sought for 2014-15: We said that
we would continue to audit the quality of our
safer surgery processes.
•2014-15 Performance rating ➜ Met
Improvements sought for 2015-16:
We will continue to audit the quality of our
safer surgery processes.
Fractured neck of femur (hip)
Improvement sought for 2014-15:
We said that we will maintain and further
improve our best practice performance for
hip fracture care and that we will aim to
improve performance for time of admission
to the hip fracture unit. We also said that we
will look to improve our length of stay through
collaborative multi-disciplinary working across
the Trust and the community and that we
hope to be able improve our follow-up data
collection and reporting to achieve greater
19
20
21
Our safety and quality priorities
Quality Account 2014-2015
understanding of longer term outcomes for
our hip fracture patients.
The Sentinel Stroke National Audit Programme
(SSNAP) aims to improve the quality of stroke
care by auditing stroke services against evidence
based standards, and national and local
benchmarks. SSNAP audit has five metrics:
•2014-15 Performance rating
➜ Partially met
We have maintained very good access to
theatres and to pre-op local anaesthetic blocks
for pain relief. Tracking longer term outcomes
beyond discharge was not routinely performed
this year.
Fractured neck of femur: average length of stay
2010-11
2011-12
2012-13
2013-14
2014-15
19.2
19.7
21.3
20.5
19.6
Fractured neck of femur: % to ward within four hours
2010-11
2011-12
19.2
19.7
Improvements sought for 2015-16:
Further improvements in pre-operative pain
management and improved follow up for
treated patients, in addition to an increased
number of patients admitted to the ward within
four hours; in-line with best practice standards.
Patients admitted with stroke
Improvement sought for 2014-15:
We said that we will continue to ensure quality
by improving the performance in general
and further improvement on scanning time
although the target was met and to review
stroke coding and mortalities for 2013-14. And
that we would focus particularly on reinforcing
ring-fencing to admit acute stroke patients to
the acute stroke unit within four hours from
presentation to hospital.
We also said that we would focus on
improving clinical outcomes for patients who
have had a stroke within 72 hours, follow-up
assessment between four and eight months
after initial admission and discharged with a
joint health and social care plan.
•2014-15 Performance rating
➜ Met/Partially met
• Metric 1: Stroke patients scanned within
one hour of hospital arrivall ➜ Met
• Metric 2: Stroke patients scanned within
24 hours of hospital arrival ➜ Met
• Metric 3: Percentage of patients admitted
directly to an acute stroke unit within four
hours of arrival to hospital ➜ Not met
• Metric 4: Stroke - 90% or more time spent
on stroke unit ➜ Partially met
• Metric 5: Adjusted mortality for 2014-2015
➜ Met
1: Stroke Patients scanned within one hour of
hospital arrival
Jan – Mar 14 Apr – Jun 14 Jul – Sep 14 Oct – Dec 14
51.9%
53.1%
57.8%
41.7%
2: Stroke patients scanned within 12 hours of
hospital arrival
Jan – Mar 14 Apr – Jun 14 Jul – Sep 14 Oct – Dec 14
91.4%
92.7%
96.3%
96.4%
Access to services
Improvement sought for 2014-15:
We said that we wanted to deliver the national
standards for the emergency department (ED),
referral to treatment (RTT) and cancer and,
where possible, reduce waiting times for as
many patients as possible.
•2014-15 Performance rating ➜ Met
Last year we saw an increase in the numbers
of people treated by our emergency
department (ED) from 82,000 to around
87,000 and against the national four
hour access standard for the emergency
department, 95.1% were admitted or
discharged within four hours.
For the 18 week admitted pathway we
treated 20,667 patients – 18,513 (89.6%)
were treated within 18 weeks against the
NHS constitution standard of 90%. There
were 468 patients waiting more than 18
weeks for admitted treatment at the end of
the year compared to 165, 12 months earlier.
Cancer access standards were achieved:
3: Percentage of patients admitted directly to an acute
stroke unit within four hours of arrival to hospital
Jan – Mar 14 Apr – Jun 14 Jul – Sep 14 Oct – Dec 14
60.8%
52.1%
51.9%
33.3%
4: Stroke-90% or more time spent on stroke unit
Jan – Mar 14 Apr – Jun 14 Jul – Sep 14 Oct – Dec 14
84.9%
91.5%
90.1%
74.2%
5: Adjusted mortality for 2013-2014
2013-14
2014-15 (Apr – Dec)
108.46
88.23
Improvements sought for 2015-16:
To improve SSNAP audit performance to at
least a ‘B’ rating. To work with commissioners
on the community rehabilitation and
re-enablement pathway.
Surrey
and Sussex
Healthcare
NHS Trust
Nationally
set standard
93.15%
93%
Two week wait:
breast symptomatic
93.7%
93%
62 day*
86.5%
85%
62 day screening
94.3%
90%
99.3%
96%
100%
98%
100%
94%
Two week wait
31 day first
treatment
31 day subsequent
treatment: surgery
31 day subsequent
treatment: drugs
*Nationally this figure was not achieved
Improvements sought for 2015-16:
Our objective is to deliver the national
standards for the emergency department (ED),
referral to treatment (RTT) and cancer; being
above the medial for national performance in all
measurers and moving towards upper quartile
for as many as possible.
Incident reporting
Improvement sought for 2014-15:
We said we would continue to improve the use
of safety information at divisional governance
level by increasing incident reporting rates
whilst maintaining the percentage of harm,
increasing the numbers of audits recorded
that impact on patient safety and ensure that
patient safety data is made more transparent
for our patients and staff.
•2014-15 Performance rating
➜ Partially met
There is a steady increase in the numbers
being reported on a monthly basis (with some
fluctuations). The percentage of harm has
remained broadly static over the year. We
have robust processes in place to capture
incidents. We have provided training to staff
and there are various policies in place relating
to incident reporting. We have identified that
there is scope for improvement in our incident
report culture as we want to capture and learn
from every incident.
Level of harm
2012-13 2013-14 2014-15
None to moderate
3775
4717
5737
55
37
39
Total
3830
4754
5776
Percentage of severe harm
or death incidents
1.5%
0.8%
0.7%
Severe harm or death
How we compare nationally
Ratio of harm incidents*
Surrey and Sussex
Healthcare NHS Trust
All acute (non-specialist)
organisations
Severe
Death
0.8%
0.0%
0.4%
0.1%
22
Our safety and quality priorities
Quality Account 2014-2015
Improvements sought for 2015-16:
A key objective for the coming year is to
improve trust-wide communication on safety
issues to ensure that we improve dissemination
of learning from incidents. We will further
strengthen our incident investigation and
processes for addressing safety issues
throughout the organisation.
We will continue to improve the safety culture
within the Trust by encouraging the reporting
of low and no harm incidents. During 2015/16
we will be working with services to continue
to support the development of service specific
trigger lists. This will assist areas in accurately
reporting incidents.
Amber Care Bundle
We reviewed this priority following the trial at
Guy’s and St Thomas’ Hospital and believed
it was not appropriate to take forward at this
time. However, we have reviewed our end
of life care bundle internally and we received
an assessment of ‘outstanding' for end of life
care as part of the chief inspector of hospitals'
inspection in 2014.
Mental health
Dementia training: The training which is
currently provided has been established
based on and to comply with Health
Education England requirements for Tier 1
Foundation Level Dementia Awareness
training: for acute providers.
Chronic obstructive pulmonary
disease (COPD)
In addition, Health Education Kent Surrey and
Sussex (HEKSS) have agreed a local requirement
for Tier 1 Training which is also met by the
programme provided as mandatory for all Surrey
and Sussex Healthcare NHS Trust staff.
• Patient reviewed by respiratory consultant
before discharge
The training programme is a 45 minute
awareness raising session focussed at all
patient facing clinical and non-clinical staff. It
is currently provided exclusively as classroom
based, face to face teaching, however a
key objective for 2015/16 is to develop an
e-learning module which can support greater
numbers of non-clinical staff to undertake
the training.
The current taught module covers the following
key areas:
• The prevalence and consequences
of dementia
Safe and appropriate
discharge arrangements
We continue to focus on arrangements for safe
and appropriate discharge to:
• Understand the effectiveness of the current
integrated discharge processes/service and
assess compliance with National Standards
for Effective Discharge
• Determine any correlation between
compliance, non-compliance with standards
and identify delayed discharge challenges
attributed to us and the wider community
• Stretch on 14-15 safe and timely
discharge CQUIN
• Determine opportunities for the
development of a wider system
integrated discharge processes
• The nature of dementia as a condition
• Key signs and symptoms
• The difficulties faced by sufferers
• Sub-types and differences in sub-types and
distinction from other conditions
• Signposting to services
• Key clinical skills – such as empathy and
communication skills
Staff feedback has been collected as part of the
routine evaluation of all mandatory training.
We continue to implement the British Thoracic
Society chronic obstructive pulmonary disease
discharge bundle:
• Personalised self-management plan received
before discharge
• Referral for pulmonary rehabilitation and
point of contact for patient on discharge
• Advice on smoking cessation
• Assessment of depression by health and
wellbeing, assessed using the Hospital
Anxiety and Depression (HAD) Scale
Safeguarding
The Trust is committed to protecting the safety
and wellbeing of vulnerable children and adults.
Annual reports are provided to our Board
where key issues and statutory requirements
are discussed and demonstrated.
My visit was an
eye-opener. The
patience, kindness
and compassionate
treatment of the
bed-bound elderly
patients both day and
night staff, was truly
exceptional. A shining
example of the NHS from start to finish.
23
24
Our safety and quality priorities
Quality Account 2014-2015
Clinical effectiveness
Mortality
Improvement sought for 2014-15:
We said that we would continue to roll out our
enhanced review of all patient deaths to ensure
all divisions are using the electronic system for
reporting deaths. Themes will then be identified
by the mortality review group, which will
provide assurance that learning happens to the
clinical effectiveness committee. We also said
that we would seek to ensure that our mortality
rate, as reported through Dr Foster Intelligence
remains, ‘better than expected’ - investigating
any mortality outlier alerts.
•2014-15 Performance rating
➜ Partially met
This year, the work of the mortality group
has focussed on standardising reporting from
speciality morbidity and mortality meetings
and ensuring that discussions were taking
place at divisional level around the findings
at these meeting.
A template was rolled out at the end of last
year and divisions now have regular updates
on specialty morbidity and mortality meetings
and the Trust mortality review will now begin
to have divisional reports fed into it through
2015/16 where it will be able to look for any
emerging themes and trends and instigate
further reviews where applicable. The group
will also act as a forum for cascading learning
from the divisional reports as well.
The mortality rates for the Trust have continued
to improve this year with Dr Foster Intelligence
reporting that, as of the beginning of this year,
the Trust continued to have a ‘better than
expected’ mortality rate when compared with
the national average. The mortality rate, which
includes any death within 30 days of discharge
(Standardised Hospital Mortality Indicator) for
the Trust is improved and remains slightly better
than the national average and was classed as
‘as expected’.
No alerts on specific procedures or conditions
were identified by the Care Quality Commission
in their data on mortality as defined in the
Intelligent Monitoring Report.
Improvements sought for 2015-16:
The mortality group will increasingly look at
categories of death, rather than just individual
deaths and make recommendations through
the clinical effectiveness committee to
improve care.
Readmission to hospital
Improvement sought for 2014-15:
We said that we will continue to improve on
the changes made during 2013/14. There will
be a clinical review of one month’s clinical
readmission data and any lessons learnt will
be implemented. Readmission performance is
one of the main key performance Indicators
reported to the Trust Board, executive
committee board and divisional boards on
a monthly basis.
•2014-15 Performance rating ➜ Met
The Trust formally reported a readmission rate
of 7% which is less than half of the national
average and indicates excellent performance.
Readmission data for one month was
clinically validated jointly between hospital
consultants and GPs to evaluate any alternatives
to admission.
Improvements sought for 2015-16:
Working jointly with the Clinical Commissioning
Group’s (CCG) clinical teams we will audit
readmissions for one month in Quarter 1 and
act promptly on any agreed actions.
Reducing need for admission
Improvement sought for 2014/15: We said that
we would work with our health partners to
ensure 40 community and 20 virtual hospitalat-home places are commissioned for the
whole year. The newly established Urgent
Care Pathway Board are reviewing a number
of pathways to reduce emergency department
attendances and provide alternatives to hospital
admissions.
•2014-15 Performance rating ➜ Met
Improvements sought for 2015-16:
We will continue to develop additional
ambulatory care pathways. We will work
with commissioners to further reduce
acute length of stay and continue with
discharge to assess and introduce discharge
to assess in the emergency department.
Enhancing Quality Performance Report
Period: Jan 2014 - Oct 2015
Appropriate Care Score (ACS)
Composite Quality Score (CQS)
Graph 1 - Heart Failure
South East Coast (ACS)
South East Coast (CQS)
Trust J
Trust H
Trust D
Trust A
Enhancing Quality (EQ)
Improvements sought for 2014-15:
We said that we will continue to further
improve on our performance in the two
pathways of heart failure and pneumonia whilst
working with the Academic Health Science
Network in new clinical areas of
focus, including chronic obstructive pulmonary
disease and acute kidney injury.
Trust B
Trust E
Trust F
Trust K
Trust G
Trust I
•2014-15 Performance rating ➜ Met
For Heart Failure and community acquired
pneumonia, the teams have worked
collaboratively across the network to
make further improvements to the care of
patients with these conditions. The Trust also
began benchmarking data for acute kidney
injury patients working on improving the
identification and treatment of the condition.
Throughout 2014/15 the Trust has consistently
remained as the best performer in the region
for heart failure with over 90% getting all the
required interventions when being treated at
the Trust: (Graph 1)
For the pneumonia pathway, the whole region
has seen their results improve over the year and
there has been a significant reduction in the
variation of care across Kent, Surrey and Sussex.
The table shows the Trust around the average
for the region although the variation between
the top performing and bottom performing
Trusts is just 10%. (Graph 2)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Graph 2 - Pneumonia With CURB
South East Coast (ACS)
South East Coast (CQS)
Trust D
Trust K
Trust F
Trust A
Trust G
Trust B
Trust J
Trust I
Trust H
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
(Data period: January – December 2014. SASH = Trust J)
25
26
Our safety and quality priorities
Quality Account 2014-2015
For acute kidney Injury, the Trust is one
of only five Trusts contributing to the
benchmarking data and there remains
significant variation between all Trusts. But,
coupled with the increased focus through
this year’s commissioning for quality and
innovation (CQUIN) standard, the Trust is
refining its clinical pathways to improve on
2014-15 results through collaborative
working with the network.
Improvements sought for 2014-15:
The enhancing quality project remains within
the CQUIN for the coming year; the Trust will
continue to focus on further improvement for
the coming year as well as looking to work
with the Academic Health Science Network to
establish new pathways for chronic obstructive
pulmonary disease (COPD), fractured neck of
femur and emergency laparotomy.
Enhanced recovery
Improvement sought for 2014-15:
Having addressed our data collection
methodology, we said that we would now
seek to further increase the use of enhanced
recovery whilst maintaining high levels of
data completeness to demonstrate statistically
significant improvements by improving our
data collection methodology but also deliver
a genuine increase in enhanced recovery use
within the division of surgery.
•2014-15 Performance rating
➜ Partially met
The enhanced recovery project team continued
its focus on increasing the numbers of patients
going through each of the pathways. The group
was able to review the monthly reports on
progress and focus effort on the parts of the
pathway which were underachieving.
Enhanced recovery – orthopaedics
Clinical Area
Measures
Patient
information
on ERP
VTE_
Prophylaxis
Antibiotics
Prior
Epidural,
Regional or
Spinal Anaes
Early
Mobilisation
Discharge
advice
Numer- Denomiator
nator
2014 2015
2013 2014
222
225 98.67% 90.98%
215
225 95.56% 94.27%
195
225 86.67% 97.94%
190
225 84.44% 92.97%
197
225 87.56% 61.86%
205
225
91.11% 93.56%
CQS
1,224
1,350 90.67% 88.16%
ACS
141
225 62.67% 51.80%
Enhanced recovery – gynaecology
Clinical Area
Measures
Patient
information
on ERP
Antibiotics
Prior
Hypothemia
Prevention
Nausea and
Vomatting
control
Discharge
advice
Numer- Denomiator
nator
2014 2015
2013 2014
74
91 81.32%
73.11%
86
91 94.51% 97.48%
88
91 96.70% 74.79%
85
91 93.41% 99.16%
83
91 91.21% 94.96%
CQS
416
455 91.43% 87.90%
ACS
61
91 67.03% 52.94%
Enhanced recovery – colorectal
Clinical Area
Measures
Patient
information
on ERP
Carbothydrates
Given
Numer- Denomiator
nator
2014 2015
2013 2014
57
67 85.07% 81.98%
66
67 98.51% 89.19%
50
67 74.63% 83.78%
47
67 70.15% 78.38%
58
67 86.57% 72.07%
CQS
276
335 82.99% 81.08%
ACS
26
67 38.81% 36.94%
IOFM Usage
Post Op
Nutrition
Discharge
advice
For the three benchmarked pathways, we
improved performance in delivering the key
parts of each of the pathways with significant
improvements in the orthopaedic and
gynaecological enhanced recovery pathways.
The Trust also ensured it met the minimum data
completeness requirements.
Improvements sought for 2015-16:
We will maintain and improve performance
and commence pathways for breast surgery
and caesarean section.
National Institute for Health
and Clinical Excellence (NICE)
technology appraisals (TAs)
Improvement sought for 2014-15:
We said that we would continue to ensure that
we remain compliant with all published NICE
Technology Appraisals that are applicable to
the Trust. We also said that in order to gain
further assurance where we require audit
evidence to support Level 2 and 3 compliance,
the pharmacy team will priorities a number of
appraisals to be audited by the division this year.
•2014-15 Performance rating ➜ Met
We remain compliant for all TAs and this year
we identified five appraisals which we wanted
to focus our audits on, identified by the chief
pharmacist. The following were chosen based
on the following criteria:
TA 294: Aflibercept solution for injection for
treating wet age related macular degeneration now a choice of medicines, choice of locations,
and is a growing activity so the Trust needs to
ensure it is being used appropriately
TA 290: Mirabegron for treating symptoms
of overactive bladder - a new drug, where
the trust needs to ensure that the choice is
appropriate within NICE guidance
TA 261: Rivaroxaban for the treatment of
deep vein thrombosis and prevention of
recurrent deep vein thrombosis and pulmonary
embolism. Since its introduction there has been
a need for discussion on benefit and risks of
treatment options with the patients. The audit is
required to ensure this is properly recorded.
TA 265: Denosumab for the prevention of skeletalrelated events in adults with bone metastases
from solid tumours. A new high cost treatment,
so the trust need to review the choice of patients.
TA 243: Rituximab for the first-line treatment of
stage III-IV follicular lymphoma. Audit required
to ensure doctors are using and documenting
treatment criteria.
These were then added to the audit
programmes of the relevant specialities a
number were still ongoing at the time of
writing the report. For TA 243, (Rituximab) the
completed audit was used to assess whether
all haematology patients treated with rituximab
screened for hepatitis B surface antigen and
anti-hepatitis B core antibody. Through the use
of the audit tool, compliance was zimproved
from 66% to 100% in the re-audit which
completed in March 2015.
Improvements sought for 2015-16:
Audits against NICE TA will be undertaken
and be posted on audit intranet.
27
28
Statutory declarations
This section details
the information that
every NHS Trust
must include in their
quality account. We
have highlighted an
explanation of the key
terms at the start of
each topic.
29
Statutory declarations
Quality Account 2014-2015
Cases submitted
% of cases submitted
Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP)
133
72%
Bowel cancer (NBOCAP)
271
100%
During 2014/15, Surrey and Sussex Healthcare NHS Trust provided
38 different acute services and eight specialised services to NHS
patients (these numbers are based on the service specifications
included in the contracts with Clinical Commissioning Groups and
NHS England). We have reviewed all the data available to us on
the quality of care in all of these services. The income generated by
the NHS services reviewed in 2014/15 represents 100 per cent of
the total income generated from the provision of NHS services by
Surrey and Sussex Healthcare NHS Trust for 2014/15.
Cardiac Rhythm Management (CRM)
577
100%
Case Mix Programme (CMP) - ICNARC
417
98%
We have repeated the ‘deep dive’ programme which takes
a detailed look at services at speciality level, seeking assurance
and evidence that we are compliant with the five quality
domains defined by the Care Quality Commission (CQC).
The outcomes of these are reported to the safety and
quality committee.
Falls and Fragility Fractures Audit Programme (FFFAP)
Review of services
We continue to develop the quality programme to ensure inclusion
of all services within this review. Divisions receive information on a
monthly basis on patient safety, clinical effectiveness and patient
experience for their areas. They report on their services at monthly
governance meetings and to the executive committee for quality
and risk and at performance reviews.
Participation in clinical audit
Clinical audit involves improving the quality of
patient care by looking at current practice and
modifying it where necessary. We take part in
regional and national clinical audits. Sometimes
there are also national confidential enquiries that
investigate an area of healthcare and recommend
ways to improve that area of healthcare.
Coronary Angioplasty/National Audit of PCI
100%
Diabetes (Adult)
100%
Diabetes (Paediatric) (NPDA)
Epilepsy 12 audit (Childhood Epilepsy)
Head and neck oncology (DAHNO)
Inflammatory Bowel Disease (IBD) programme
N/A
Just commenced
Just commenced
N/A
26
168
98.20%
Lung cancer (NLCA)
74.9%
Major Trauma: The Trauma Audit & Research Network (TARN)
100%
Maternal, Newborn and Infant Clinical Outcome Review Programme
(MBRRACE-UK)
National Cardiac Arrest Audit (NCAA)
National Chronic Obstructive Pulmona
Began data collection March 2015
32
100%
National Comparative Audit of Blood Transfusion programme
National Emergency Laparotomy Audit (NELA)
191
National Heart Failure Audit
181
National Joint Registry (NJR)
409
National Prostate Cancer Audit
N/A
National Vascular Registry
Non-Invasive Ventilation - adults
The national clinical audits and national confidential enquiries
that Surrey and Sussex Healthcare NHS Trust was eligible to
participate during 2014-15 were:
Pulmonary Hypertension (Pulmonary Hypertension Audit)
Oesophago-gastric cancer (NAOGC)
100%
100%
All data submitted via network
100%
Neonatal Intensive and Special Care (NNAP)
During 2014-15, 30 national clinical audits and four national
confidential enquiries covered NHS services that Surrey and
Sussex Healthcare NHS Trust provides. During that period we
participated in 100% national clinical audits and 98% national
confidential enquiries of the national clinical audits and national
confidential enquiries in which it was eligible to participate.
100%
-
-
89
90%
Paediatric Intensive Care Audit Network (PICANet)
Renal replacement therapy (Renal Registry)
N/A
-
Rheumatoid and Early Inflammatory Arthritis
308
Sentinel Stroke National Audit Programme (SSNAP) (Organisational)
395
-
99%
30
Statutory declarations
Quality Account 2014-2015
The national clinical audits and national
confidential enquiries that Surrey and Sussex
Healthcare NHS Trust participated in, and for
which data collection was completed during
2013/14, are listed above 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.
Examples of improvements to care delivered by
the clinical audit programme:
Audit of elective caesarean section
bookings: women and children’s division.
In response to higher than average caesarean
section rates an audit of reasons for caesarean
sections showed that best practice was not
being followed when booking women for an
elective procedure.
The Trust set up a specialist birth choices clinic
(BCC) to counsel women who have had one
previous caesarean section and any other
reason which did not indicate a caesarean
section as best practice for the delivery.
Well done to
East Surrey hospital.
I could not have been
in better hands.
Thank you.
The birth choices clinic started in October
2012 and the audit showed a significant
impact with a fall of the elective caesarean
section rates from 17.8% in October 2012
to 6.9% in January 2013 and an average of
9.8% during 2013/14.
The audit demonstrated that the change in
service and the implementation of the vaginal
birth after caesarean (VBAC) pathway reduced
the elective caesarean section rates in the
largest group of women opting for a caesarean
section. This audit is now a rolling audit,
which monitors the elective caesarean section
requests against the clinical outcomes to
ensure compliance with the birth choices clinic
pathway and maintain the elective caesarean
section rate under the national rate of 10%.
Sepsis audit: medicine division.
The introduction of the sepsis six bundle has
been shown to reduce the relative risk of death
by 46.6%, so the audit looked at compliance
between April and June 2013.
To help build on the levels of compliance a
drive to improve awareness including simulation
training was implemented and a re-audit
followed in May - July 2014. Overall compliance
with the Sepsis Six improved between 2013
and 2014 - demonstrated by an increase in
all domains. Average mortality at 30 days
decreased between the two data sets from
38% to 18.9% with similar improvements for
the length of stay for patients.
A poster presentation of this audit at the recent
Kent Surrey Sussex Academic Health Science
(KSS AHSN) Awards ceremony saw this audit
awarded best poster prize in a competition
judged by Sir Bruce Keogh.
Mouth Care Matters audit: surgery division.
An original audit focussed on whether patients
who are hospitalised for more than 24 hours
had a mouth care assessment carried out and if
a mouth care assessment was carried out and
daily mouth care and mouth care supportive
measures were in place. The topic was picked
up from a complaint and also during the recent
Care Quality Commission (CQC) inspection and
was conducted in February, both looking at
case notes, and a survey of staff.
With poor compliance, training has been
rolled out across the organisation including
awareness campaigns around the importance
of maintaining mouth hygiene for patients.
The training package has now been successfully
introduced in the Trust and significantly has
now received regional funding by KSS to roll
out across the south-east. It was also a recent
topic at the Patient Safety Executive.
31
Statutory declarations
32 Quality Account 2014-2015
Participation in clinical research
Clinical Research involves gathering
information to help us understand
the best treatments, medication
or procedures for patients. It
also enables new treatments and
medications to be developed.
Research must be approved by an
ethics committee.
The key reason for our commitment to
research is to improve clinical treatments,
care and outcomes for our patients. We
want to offer our patients the opportunity to
be involved in research activities in order to
improve patient experience and enable them
to benefit from improved health outcomes.
Our performance in delivering research as
measured against the National Institute for
Health Research (NIHR) national performance
metrics is strong with increases in both the
number of different research studies for
patients to engage with and numbers of
patients recruited to studies.
Our strengthening relationship with the
pharmaceutical industry is enabling us to offer
our patients access to the newest treatments
within clinical trials. The Trust supported the
recruitment of patients to 45 different high
quality studies – ten of these studies were
pharmaceutical industry sponsored studies.
In 2014-15, we recruited 760 patients to
participate in research approved by a research
ethics committee.
Our key priorities are to:
• Increase the number of patients
participating in research studies
• Increase the number of high quality
National Institute for Health Research (NIHR)
Portfolio research studies open at our Trust.
• Maintain our high quality research
management processes and enhance
performance in project delivery
• Develop our infrastructure, staff and
facilities, to support research
• Become a preferred partner for the
pharmaceutical research industry and
increase our research income from
commercial contracts
We have highlighted research activity in
four different areas of the organisation:
• Anaesthetics
• Urology
• Dermatology
• Paediatrics
Anaesthetics
2012-13
2013-14
2014-15
Number of
studies open to
recruitment
Number of
pharmaceutical
industry studies*
Number of
research
participants
38
40
45
5
5
11
616
506
771
*Included within total number of studies open figure
Our clinicians are able to develop
their own research ideas into
research protocols bringing new
ideas and solutions into clinical
practice for the benefit of patients.
Designing research protocols which
enhance personal knowledge and
education in our clinical teams
allows us to provide higher quality
clinical care.
Dr Matthew Mackenzie, consultant
anaesthetist, successfully secured funding
from the Association of Anaesthetists of
Great Britain and Ireland (NIAA) for his
study: ‘Simulation Aided Assessment
of a Clinical Algorithm’ within the
anaesthetics department.
The study utilised the Newman Simulation
Suite, at East Surrey Hospital, and sought to
examine the use of emergency protocols of
relevance to anaesthetic practice by inviting
members of the anaesthetic department to
manage a simulated emergency situation on a
high-fidelity mannequin.
The benefit to staff participants was that
they were provided with personal updates in
the emergency management of anaesthetic
related complications listed as core continuing
professional development (CPD) topics by the
Royal College of Anaesthetists, which meant that
the research provided relevant clinician training.
The research will also provide an overall
contribution to the development of national
emergency protocols in the future.
Urology
Opening a new national trial has
allowed the urology team to offer
some of our intermediate risk
bladder cancer patients access to a
potentially advanced treatment.
The new study is exploring the benefits of
giving hyperthermic (heated) mitomycin
compared to current standard treatment,
mitomycin at room temperature. It is thought
that hyperthemic mitomycin will prove to
be a superior treatment due to increased
absorption by any remaining cancer cells at
a higher temperature and therefore improve
disease free survival.
Since the trial started, the urology team have
recruited nine patients to date and remain the
second highest recruiter nationally, the highest
being the lead site. Of these nine patients,
four have received hyperthermic mitomycin.
33
Statutory declarations
34 Quality Account 2014-2015
Paediatrics
Participation in clinical trials can
provide increased support for
families and young children at the
early stages of managing newly
diagnosed medical conditions.
A study for newly diagnosed diabetic children
aged seven months to 15 years began at
Surrey and Sussex Healthcare NHS Trust in
September 2012. Families recruited to the
study are randomised to receive either insulin
by continuous infusion via a pump or standard
intermittent injections, to see which is more
effective in the management of diabetes in
babies, children and young people.
The randomised treatment must be started
within 14 days of diagnosis and all patient
education, which ordinarily may normally
take up to three months to deliver must be
completed within that 14 day timeframe.
Families recruited to the study are then
supported during an intense 12 month
follow-up which tracks the course of their
normal diabetes management and logs all
interventions and clinical episodes. Quality
of life, control of blood glucose and costs
are all documented.
Whilst the treatment itself does not actually
change at all the study provides an opportunity
to acquire a pump very early from diagnosis
which can be a big asset. Initially, families can
find the thought of the randomisation quite
daunting but getting so much educational
input early on helps them to understand
the condition and to quickly develop skills to
support their child.
Dermatology research
One of the key ways of offering
new treatments to our patients
is through participation in clinical
trials. Incorporating clinical trial
research activities into clinical
practice can also encourage new
ways of working which lead to
improved models of patient care.
In 2011, the dermatology department
introduced a new way of working to help
accommodate a small Clinical Research
Network psoriasis study. This change has had
a significant, long-term impact on research
engagement and patient care. Dedicated
psoriasis clinics are run on a monthly basis
where patients can be reviewed in a 'one
stop shop'.
In addition to promoting research activity, the
changes have promoted more individualised,
holistic care for patients and streamlined
the review process for patients. Research
participation has been integrated into the
clinical pathway for patients with psoriasis
which has maximised recruitment potential for
studies and allowed the team to take on more
complex, clinical trials.
Running clinical trials allows us to offer
opportunities to have new treatments and
the reassurance of additional follow up visits
with a consultant dermatologist, specialist
nurse and research nurse which promotes a
positive patient experience. One of our research
participants, Jack Champ, 73, from West
Sussex, pictured with Nwando Onugha, lead
dermatology nurse, describes his experience:
Jack Champ and
Nwando Onugha
At all times I have
been treated with
respect, great
care and fully
informed. I am
pleased that I was
asked to take part
in the research.
Jack Champ
Dermatology patient
Lorna and
Lauren Davey
35
36
Statutory declarations
Quality Account 2014-2015
Goals agreed with
commissioners
Care Quality
Commission report
Clinical Commissioning Groups
(CCG) hold the NHS budget for their
area and decide how it is spent on
hospitals and other health services.
This is known as commissioning East Surrey, Surrey Downs, Crawley
and Horsham and Mid Sussex CCGs
are the four main commissioners
of our services. They set us targets
based on quality and innovation.
Everyone at Surrey and Sussex
Healthcare NHS Trust has a huge
commitment to safety, quality and
providing care and compassion
and this focus on excellence was
endorsed in 2014-15 by the Care
Quality Commission (CQC) team
of doctors, nurses and senior NHS
managers who completed an
inspection in May 2014.
A proportion of our income in 2014-15 was
conditional on achieving quality improvement
and innovation goals agreed between Surrey
and Sussex Healthcare NHS Trust and any
person or body we entered into a contract,
agreement or arrangement with for the
provision of NHS services, through the
Commissioning for Quality and Innovation
(CQUIN) payment framework.
Their report, published in August, by the chief
inspector of hospitals focused on five key
questions about the healthcare services we
provide, are they:
Further details of the agreed goals for
2014-15 and for the following 12 month
period are available on request from:
clinical.audit@sash.nhs.uk
• Well-led.
Care Quality Commission
registration and inspection
Last rrat
ated
ed
6 August 2014
Surr
Surrey
ey and
Sussex
Healthcar
Healthcare
NHS
The
Care
Quality
Commission
(CQC)eregulates
and
inspects health organisations across
Trust
England. Surrey and Sussex Healthcare NHS
Trust
to register
with
the Care
Overall is required
Inadequate
Requires
Good
Outstanding
rating
Quality
Commissionimprovement
and its current registration
status is ‘registered without conditions’.
The
Care
Quality Commission did not
Ar
Aree ser
servic
vices
es
taken enforcement action against the Trust
Good
Safe?
during 2014-15.
Effective?
Good
Well led?
Good
Surrey and Sussex Healthcare NHS Trust has not
Good or investigations
Caring?
participated
in any special reviews
by
the CQC during the reporting
period.
Good
Responsive?
• Safe
• Effective
• Caring
• Responsive to people’s needs
Thanks to the hard work of our staff, we
achieved a ‘Good’ rating across the board in all
five areas - to put this context nationally at the
time of the most recent (31) inspections only
four other Trusts achieved an overall ‘Good’
rating and only two of these were green in all
domains. This puts us amongst the best in the
country for the quality of services and the CQC
said that our staff should be extremely proud of
what they have achieved.
The report highlighted several areas of
outstanding and good practise, including:
• End of life care achieved an ‘Outstanding’ in
the responsiveness category
• The excellent care and facilities on the
midwife-led birthing unit and the neonatal
intensive care unit
• The pre-assessment clinic at Crawley Hospital,
which has been extended into the evening in
response to feedback and local demand
• Staff focus groups: best attended – more
staff than they had seen in any other Trust
• Clear ambition across the Trust to be the best
– from catering staff through to the chair
• Staff willingness to go the extra mile
and work together to meet individual
pastoral needs
• Strong desire to be clinically-led
• Large number of specialist nurses with a
strong focus on learning and development
The report recommended some areas where
improvements could be made – the majority
of which were in our out-patients areas.
These included a need to ensure adequate
capacity to meet demand and improvements
to the quality of service including waiting times
and cancellations.
We have made significant progress in
addressing these points - the refurbishment
of the out-patients department at East
Surrey Hospital and improvements to seating
and signage; the opening of the Earlswood
Community Diabetes and Endocrine Centre and
the involvement of our patients in focus groups
to help us to gather feedback and to co-design
and shape the service as we plan for the future,
are just some of the ways we have moved
forward and focused on putting people first.
We know that this will help us to improve the
experience we provide for our patients and also
for the teams involved.
The inspectors said our staff were the most
engaged out of all of the Trusts they had
visited and we know this makes a real
difference to patient experience and care. They
also said they would be very proud to work
here and would want their family and friends to
be cared for here which is a great endorsement
of everyone’s efforts and commitment.
Last rrat
ated
ed
6 August 2014
Surr
Surrey
ey and Sussex Healthcar
Healthcaree NHS
Trust
Overall
rating
Inadequate
Requires
improvement
Good
Outstanding
Ar
Aree ser
servic
vices
es
Safe?
Good
Effective?
Good
Caring?
Good
Responsive?
Good
Well led?
Good
The Care Quality Commission is the independent regulator of health and social care in England. You can read our
inspection report at www.cqc.org.uk/provider/RTP
We would like to hear about your experience of the care you have received, whether good or bad.
Call us on 03000 61 61 61, e-mail enquiries@cqc.org.uk, or go to www.cqc.org.uk/share-your-experience-finder
I am very proud of
our staff – this is
their story and I am
glad their talent,
hard work and
dedication has been
recognised. The
report also makes for
reassuring reading
for the communities
we serve and shows
our commitment to
safety and quality.
Michael Wilson
Chief executive
37
38
Statutory declarations
Quality Account 2014-2015
Data quality
Data quality measures whether
we record patients’ NHS and GP
numbers in their notes as well as
ethnicity and other equality data.
The chief operating officer has overall
accountability for the quality of data provided
to the Trust Board and executive committee.
The Trust has a data quality strategy which
describes the agreed strategic actions to
improve data quality.
The information team meets regularly to discuss
data quality and provides regular updates to the
information governance steering group on the
completeness and validity of data available to
the Trust.
We have a data quality team that is responsible
for the day to day management of data
quality. The team undertakes national data
quality checks, reviews the challenges from
the Clinical Commissioning Groups (CCGs)
and checks clinical coding daily. The data is
also checked externally by Indigo 4 Services
Limited, who provide services to a range of
NHS organisations.
The internal audit plan for 2014/15 – 2015/16
includes review of data quality and Information
governance. Internal audit also carries out
audits of systems that provide narrative
on elements of data quality, such as Board
assurance framework reviews and financial
feeder system audits. Internal Audit will make
recommendations to improve systems where
potential is identified, these recommendations
are developed into actions which are managed
locally and ultimately monitored by the audit
and assurance committee.
Clinical Coding
NHS number and GP
Practice Code validity
Surrey and Sussex Healthcare NHS Trust
submitted records during 2014-15 to the
Secondary Users Service for inclusion in
Hospital Episode Statistics, which are included
in the latest published data. The percentages
of records in the published data are:
NHS Number compliance
Valid
All
%
Emergency
In-patient Out-patient department
(ED)
105,337
445,64
85,969
105,848
99.5%
446,476
99.8%
87,276
98.5%
Total
636,954
639,600
99.6%
GP Practice Code
Valid
All
%
Emergency
In-patient Out-patient department
(ED)
105,537
444,297
86,385
105,848
99.7%
446,476
99.5%
87,276
99.0%
Total
636,219
639,600
99.5%
Information governance
Information governance means keeping
information about patients and staff safe.
Surrey and Sussex Healthcare NHS Trust’s
information governance assessment report
score for 2014-15 was 72% and was graded
‘satisfactory’. The report was finalised and
submitted on 31 March 2015. Of the 45
requirements within the assessment, 37 were
scored at level two; and eight at level three.
Action plans will be updated in order to sustain
and improve upon these scores during 201516. Our aim is to improve our compliance year
on year and a key element in achieving this is
ensuring that all staff receive annual training
and regular updates relating to information
governance. All information governance risks
are added to the Trust risk register and reported
in-line with the Trust risk management policy.
During 2014-15 no serious untoward
incidents were reported to the Information
Commission’s Office.
Clinical coding is the translation
of medical terminology as written
by the clinician, to describe a
patient’s complaint, problem,
diagnosis, treatment or reason
for seeking medical attention, into a
coded format which is nationally and
internally recognised. The process
is bound by National Standards
issued by the Health and Social Care
Information Centre (HSCIC). The
mechanism for receiving payment is
called Payment by Results (PbR).
The Information Governance clinical coding
Audit (IG Audit) in 2014-15 looked at 200
finished consultant episodes (FCEs) for accuracy
of both diagnosis and treatment:
IG clinical coding audit 2014-15
Primary diagnosis correct
91.50%
Secondary diagnoses correct
Primary procedure correct
Secondary procedures correct
94.80%
95.72%
96.24%
These accuracy levels mean the Trust achieved
Level 2 in the Information Governance
Assessment Requirement 11-505 for 2014-15.
Improvement aims for 2015-16:
We will continue to train two new trainee coders
using the clinical coding standards course and
help our experienced coders work towards
accreditation by supporting them to sit the
national clinical coding qualification (NCCQ). Our
aim is to continue to deliver 100% coded activity
at post-inclusion ensuring no loss of income to
the Trust due to uncoded or miscoded episodes.
The depth of coding is steadily increasing - 5.8
diagnosis codes per finished consultant episodes
(FCE) and we will continue to work with clinicians
to ensure coding accurately reflects clinical
diagnosis. On-going training programmes
for clinical coders are planned for continuous
professional development.
We are keen to have on-going clinical
engagement in all aspects of coding more so
in mortality coding as the data impacts the
trusts performance figures. The long-term plan
is to set up divisional coding leads to liaise with
the clinical leads of those particular divisions
which in turn will improve both mortality and
morbidity coding.
Summary of hospital-led
motality indicator (SHMI)
and the percentage of
deaths with palliative
care coding
SHMI is a hospital-level indicator,
which provides a summary
reporting of mortality (deaths)
at trust level across the NHS for
England. The SHMI is the ratio
between the actual number
of patients who die following
treatment at the trust and the
number that would be expected to
die on the basis of average England
figures, given the characteristics of
the patients treated here. It covers
all deaths reported of patients who
were admitted to non-specialist
acute trusts in England and either
die while in hospital or within 30
days of discharge.
SHMI values for each trust are made available
along with bandings indicating whether a
trust’s SHMI value is ‘as expected’ or otherwise.
The bandings are:
1 – where the Trust’s mortality rate is ‘higher
than expected’
2 – where the Trust’s mortality rate is
‘as expected’
3 – where the Trust’s mortality rate is ‘lower
than expected’
39
40
Statutory declarations
Quality Account 2014-2015
Our SHMI compares favourably to the
national average of 100% as it is lower at
93.07% (6.93% less than average) which was
an improvement on our position from the
previous year.
Improvement aims for 2015-16: We will
seek to continue to improve our mortality
through full participation in the Dr Foster
process of actions in response to alerts and
by working with external partners to ensure
seamless care between primary and community
and secondary care.
Summary of hospital-led mortality indicator 2014-15
Trust value
0.9307
Trust banding
Lowest (national)
Highest (national)
2
0.5966
1.1982
Patient reported outcome
measures (PROMS)
Percentage of deaths with palliative
(end of life) care coding
Trust
Lowest (national)
Highest (national)
Average (national)
Some patients are admitted to our care
and die while with us, or within a short
period of time after discharge. For some
of these patients their nearness to death is
recognised, either because of the terminal
nature of their illness or because all curative
and life prolonging treatment options have
been exhausted. In this case, end of life
care or palliative care can provide symptom
control. We recorded 34.3% of our deaths
as palliative, or end of life care, which is just
above the national average. This represents
an increase from last year which came from
the introduction of a palliative care weekend
service allowing us to more accurately
record patients requiring palliative care and
reflects a trend nationally for more accurate
identification of patients. The large range
also reflects the differing patient populations
of different hospitals in England.
As reported
in last year’s
Quality
Account
0.9307
October 2013
– September
2014
2
0.5966
1.1982
0
49.4
25.44
34.3
The percentage of elective admissions
resulting in a death occurring either in
hospital or within thirty days (inclusive)
of discharge for the period Oct 13 – Sept
14 was 0.2% (Range 0.2-7.8)
The percentage of non-elective admissions
resulting in a death occurring either in
hospital or within thirty days (inclusive) of
discharge for the period Oct 13 – Sept 14
was 3.7% (Range 1.2-5.9)
Patient Reported Outcome
Measures (PROMs) assess the
quality of care delivered to
NHS patients from the patient
perspective. Currently covering
four clinical procedures, PROMs
calculate the health gains after
surgical treatment using preand post-operative surveys.
PROMs measure a patient's health status or
health-related quality of life at a single point
in time, and are collected through short,
self-completed questionnaires. This health
status information is collected from patients
through PROMs questionnaires before and
after a procedure and provides an indication
of the outcomes or quality of care delivered
to NHS patients. The most recent data
available shows:
Groin hernia
2012/13
Eligible
episodes
*
432
Trust
average
health
gain
*
National average
0.087
0.085
Hip replacements
0.440
249
0.434
National average
0.416
0.436
Knee replacements
0.255
242
0.321
National average
0.302
0.323
Varicose veins
*
102
*
National average
0.095
0.093
*Data suppressed due to small numbers. No data = no
figures to report.
Single index measure which ranges from 0 to 1,
where 1 is the best possible state of health.
Responsiveness
to inpatients’
personal needs
This indicator is calculated as the
average of five survey questions
from the national inpatient survey
which is carried out each year.
Each question describes a different
element of the overarching theme
- responsiveness to patients’
personal needs.
The questions are:
Percentage of patients
readmitted within 28
days of discharge
• Were you involved as much as you wanted
to be in decisions about your care and
treatment?
There is a national expectation that patients
who are admitted for episodes of care
should not need to be readmitted soon
after they are discharged. The Trust uses the
Dr Foster quality monitoring tool as part of
its reviews of readmissions - this tool shows
a 28 day readmission rate based on latest
data published on the Health and Social Care
Information Centre: Compendium of Population
Health Indicators.
• Were you given enough privacy when
discussing your condition or treatment?
• Did you find someone on the hospital staff
to talk to about your worries and fears?
2010/11
2011/12
Under 16s
10.39
11.31
Average (national)
Adults and over 16s
Average (national)
N/A
9.83
11.04
N/A
11.47
11.08
• Did a member of staff tell you about
medication side effects to watch for when
you went home?
• Did hospital staff tell you who to contact if
you were worried about your condition or
treatment after you left hospital?
Responsiveness to
inpatients' personal needs
2012/13
Inpatient
survey
2013/14
Inpatient
survey
Trust value
74.2
74.3
Lowest (National)
Highest (National)
68
88.2
66.8
88.2
For the 2014 inpatient survey we were ranked
as 123rd among trusts in England in these
categories - we will continue to work to
improve our patients’ experience.
41
42
Statutory declarations
Quality Account 2014-2015
Percentage of patients
admitted who were at
risk of VTE
In 2014-15, we said that the risk assessment will
continue to be carried out on more than 95% of
patients on admission and that the reassessment
of risk will be highlighted through staff
education, in line with NICE guidance. Also, that
patient information leaflets will be available to all
admitted patients within the Trust, highlighting
the risk of VTE and on-going preventative advice
on discharge. We also said that a multi-disciplinary
team would review any cases where a patient
develops a venous thrombosis either whilst an
inpatient, or within 90 days of discharge and that
the numbers of such cases and whether care was
sub-standard will be published within SASH Board
performance papers.
•2014-15 Performance rating ➜ Met
Over the last year, 95% of patients looked after
by us had a formal VTE assessment carried out
on admission and recorded in the notes.
Improvement aims for 2015-16:
We will move to 95 of patients having their
ongoing VTE risk assessed at discharge
Patient safety incidents
These are incidents reported to the
National Reporting and Learning
System (NRLS) where the Trust has
failed to provide ‘harm free care’.
The Trust incident reporting system is webbased and available on every Trust computer
at each hospital site - this has increased our
ability to report and respond to safety incidents
at pace. It has also facilitated the ability to
track trends in safety incidents within the
organisation more readily so that we can target
our improvement work. Risk management
training is included in the mandatory training
programme. The risk management team
provide ad hoc bespoke training to clinical
teams on risk management which includes the
reporting of incidents.
C.difficile infections
Emergency department
We said we would have no avoidable Trust
acquired MRSA blood stream infections (zero
tolerance), and no more than 29 patients
affected by Clostridium difficile diarrhoea.
2014-15 Performance rating:
Clostridium difficile - 24 cases
•2014-15 Performance rating ➜ Met
2014-15 Performance rating:
MRSA blood stream infections- 0
(with 1 contaminant)
•2014-15 Performance rating ➜ Met
Patients’recommendation
of the Trust as a place to
be treated
The Friends and Family Test in our
inpatient wards and emergency
department is well established.
The most recent figures show the
percentage of respondents who
are ‘extremely likely’ or ‘likely’ to
recommend Surrey and Sussex
Healthcare NHS Trust as:
Inpatient wards
Date
April 2014
May 2014
June 2014
July 2014
August 2014
September 2014
October 2014
November 2014
December 2014
January 2015
February 2015
March 2015
Surrey and Sussex
Healthcare NHS
Trust
97.4%
National
average
97.1%
98.0%
98.1%
98.2%
86.7%
96.7%
97.0%
94.7%
95.7%
96.9%
94.2%
94.2%
94.1%
94.2%
93.8%
93.5%
93.7%
94.7%
94.5%
94.2%
94.5%
94.7%
93.9%
Date
April 2014
May 2014
June 2014
July 2014
August 2014
September 2014
October 2014
November 2014
December 2014
January 2015
February 2015
March 2015
Surrey and Sussex
Healthcare NHS
Trust
97.9%
National
average
97.7%
98.0%
98.7%
97.9%
97.5%
95.3%
96.4%
92.7%
95.8%
97.1%
94.7%
86.0%
86.1%
86.3%
87.5%
86.4%
86.8%
87.4%
86.2%
88.1%
87.9%
86.9%
86.5%
Our emergency department was in the top
10% of all Trusts for Q4 and we exceeded
the Commissioning for Quality and Innovation
(CQUIN) target response rate in both inpatients
and ED patients for Q4.
Staff recommendation
of the Trust as a place
to be treated
The Staff Friends and Family
Test is conducted in Q1, Q2 and
Q4 - the National NHS Staff Survey
takes place in Q3. Figures show
the percentage of respondents
who are ‘extremely likely’ or ‘likely’
to recommend Surrey and Sussex
Healthcare NHS Trust as:
Surrey
and Sussex
Healthcare
NHS Trust
Q1 – As a place
to work
Q2 – As a place
to work
Q4 – As a place
to work
Q1 – As a place
to receive care
Q2 – As a place
to receive care
Q4 – As a place
to receive care
National
Surrey
average and Sussex
Healthcare
NHS Trust
rank order
78%
62%
20th
76%
61%
27th
74%
62%
33rd
89%
76%
42nd
90%
77%
36th
88%
77%
41st
Response rates:
• Q1 response rate for Surrey and Sussex
Healthcare
NHS Trust was 22% against a national average
of 14%
• Q2 response rate for Surrey and Sussex
Healthcare
NHS Trust was 10% against a national average
of 12%
• Q4 response rate for Surrey and Sussex
Healthcare
NHS Trust was 14% against national average
of 13%
I was treated with total
dignity and professionalism.
43
44
Staff awards and recognition
Quality Account 2014-2015
Staff awards and recognition
I have to say that
I was overwhelmed
by the care provided
by the NHS at East
Surrey hospital. They
were so helpful, kind,
loving, compassionate
and professional.
They saved my wife's
life and I can't thank
them enough.
Comment posted
on Patient Opinion
Providing high quality patient
care and sustaining high levels
of service provisions would
not be possible without the
professionalism, dedication
and commitment of our staff.
Our patients and their relatives and friends
regularly let us know just what a difference
our staff have made to them through a range
of feedback options designed to meet the
needs of the people we care for.
Your Care Matters
We receive around 1,000 responses a month to
our Your Care Matters patient feedback survey.
Patients are encouraged to take part and can do
so on-line, by using a freephone number or, for
some services, completing a paper copy.
Patient Opinion
Patient Opinion is an an independent website
that provides an online option for patients to
tell their story about their experiences and
about the level of care they have received.
In the past 12 months 346 patients have told
their story and their comments were viewed
more than 67,100 times.
The nursing staff
were helpful and
kind and at each
stage introduced
themselves and
explained the tests
and procedures.
Comment posted
on Patient Opinion
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46
Staff awards and recognition
Quality Account 2014-2015
Annual staff awards
Every
day of the year our staff are responsible
for delivering high quality care to the
communities we serve and we know just how
much the people they care for appreciate their
compassion and commitment through the
feedback we receive. Each year we make sure
that we celebrate this hard work and dedication
at our annual Staff Awards of Excellence.
Over 100 staff were nominated in 11
categories for our 2014 awards along with
those recognised for long service. The winners
in each category were:
Innovation and Service Improvement:
Samantha Shale, senior
occupational therapist
As a result of her investigation
in to the sensory needs
of patients with dementia
Samantha introduced a
number of sensory items on to
her ward. Showing colleagues
how these could be used to
distract or stimulate patients resulting in a ward
that has a calmer, dementia friendly feel.
Frontline Employee of the Year
Sandhya (Sandy) Blakey, ward manager
Sandy was recognised for her
dedication and commitment
to putting patients first
and improving patient care
and also for looking after
relatives and staff. One of
her collegaues wrote: "She's
always ready to listen to each and every one
of us. The reason we work so well as a team is
due to her excellence in leadership." This was
also recognised in our recent CQC inspection.
Behind the Scenes Employee of the Year
Nalani Ruberoe, medical records clerk
Nalanie was recognised for
being hard working, kind and
helpful and for always going
the extra mile to ensure that
the patient is always having a
positive experience.
Compassion (individual ward)
Dr Jane Preston, dental officer
Frontline One Team
Michelle Cudjoe; Denise Newman; Adaline
Smith; Janice Blythman, maternity
matron team
This team was nominated for making a truly
inspirational difference in delivering a safe
service and developing our maternity services
into something that the Trust is really proud of.
They have worked exceptionally well as a team
and achieved many notable successes.
Jane was nominated for
the level of compassion
she shows patients and her
colleagues – making everyone
feel valued and special as
she not only listens to their
concerns but goes out of her
way to help them.
Compassion (team award)
Angela Main; Julie Anthony; Lisanne
Eagle; Caroline North; Sue Munn; Dr
Naomi Collins and Christina Probert,
palliative care team
The team was recognised as promoting
excellent patient care, dignity and compassion
to all in sometimes very difficult circumstances
and for providing support for healthcare
professionals at the trust, offering not
just education and advice but importantly
emotional support for those who need it.
They inspire others to care for those at the
end of their life, with dignity and respect.
Behind the Scenes One Team
Diane Mintrim; Hilda Williams; Lesley
Harmer, medical staffing team
The team were recognised for their sustained
commitment, dedication and organisation
in the smooth running of clinical staffing particularly the new intake of junior doctors
joining the Trust. This attention to detail was
noted by many of the junior doctors, who said
it was one of the most organised inductions
they had ever had.
feedback from patients.
One patient wrote: "She
was always so positive and
friendly. Always so patient
with everyone in our bay - she
showed an interest in each
and every one of us and was
reassuring, calm and confident in her care."
Dignity and Respect
Chatardharry Bissonauth (Krit),
nursing assistant
Krit was praised for his
exceptional manner in nursing
patients and for going out of
his way to ensure each and
every one of his patients is
looking their very best every
day. Most of his patients know
him by name and ask for him to attend to their
needs - a real testament to how they value the
care that he offers.
Safety and Quality
Debbie Cawston, senior radiographer
Debbie works remotely
and she was recognised for
bringing consistency to the
X-ray department at Horsham
and her ability to meet the
challenges of remote working
and her expert delivery of both
clinical and non-clinical aspects of her role means
that there are frequent health and safety audits,
exceptionally infrequent incidents, zero serious
incidents and low waiting times.
Volunteer of the Year
Gordon Thomson, volunteer
Your Care Matters – improving the
patient experience
Lynne McDowell, staff nurse
Lynne has received a number of SenSASHional
commendations through Your Care Matters
A veteran of the trust, Gordon
has volunteered with us for 22
years – he is loyal, supportive,
generous, diplomatic and
kind and greatly respected
and appreciated and was
recognised for his reliability,
dedication, commitment and
hard work.
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48
Our priorities for 2015-16
Quality Account 2014-2015
Our priorities for 2015-16
National Patient
Safety Collaborative
Likely to be based on five scoping events
In this account we have detailed
our areas of focus within the topics
of patient experience, safety and
clinical effectiveness and outlined
what we intend to achieve in
2015-16.
To enable us to define our priorities for the
coming year we have shared our account
with our:
• Board
• Clinical chiefs of service
• Lead clinicians
• Assistant directors of operations
• Senior nursing staff
SO2: Effective – Deliver effective and
sustainable clinical services within
the local health economy
SO4: Responsive – Become the secondary care
provider for the catchment population
Commissioning for quality and
innovation (CQUINS)
SO5: Well led – Become an employer
of choice and deliver financial and
clinical sustainability around a clinical
leadership model
• All national projects – sepsis, acute kidney
injury, dementia, urgent emergency care:
‘Reducing the proportion of avoidable
emergency admissions to hospital’ and
‘Improving diagnoses and re attendance rates
of patients with mental health needs at A&E’
Priorities for 2015-16
Our priorities for 2015-16 will include:
• Members
Five pledges in the sign up to safety plan;
put safety first, continually learn, honesty,
collaboration and support.
• Clinical Commissioning Groups
• West Sussex Health & Adult Social Care
Select Committee (HASC)
• Surrey Health Scrutiny Committee &
Surrey County Council Quality Account
Reference Group
Emerging priority areas:
All our quality improvement work will be based
on benchmarked quality performance through
locally generated metrics and those provided
through accepted agencies (Dr Foster, national
and regional data sets) based on the Trust’s five
strategic objectives:
SO1: S afe – Deliver safe services and be in the
top 20% against our peers
3. Culture and leadership
4. Medication errors
Sign Up to Safety
• Healthwatch (West Sussex & Surrey)
2. Safe discharge and transfer
SO3: Caring – Ensure patients are cared for and
feel cared about
• Divisional teams
We have also shared this account with:
1. Pressure ulcer
1. Identify, evaluate and implement patient
safety systems that look to enhance
the quality of our care by increasing the
chances of the initial signs of a deteriorating
patient being acted on appropriately.
2. Seek to improve the Trust’s systems for
identifying and managing pain specifically
with patients who have a diagnosis
of dementia.
3. E nsure that the Trust is compliant with
the statutory responsibility regarding
Duty of Candor.
4. Learn from COPD (chronic obstructive
pulmonary disease) pilot and seek to identify
and share learning across south east coast
area over the three year period of the pilot.
5. Help people understand why things go
wrong and how to put them right.
5. Sepsis
• All NHS England projects – not yet released
• Local CQUIN for Ward Accreditation
• Local CQUIN for discharge pathways
• Local CQUIN for participation in the
Academic Health Science Network Enhancing
Quality and Recovery programme
Mouth care for frail elderly
• Mouth Care Matters initiative, funded by
Health Education England, led by the Surrey
and Sussex Healthcare NHS Trust dental team
• four additional four dental nurse practitioners
who will work across the hospital to support
and provide extra training for our nursing
and ward teams as they care for our patients
• improving the oral health of the people we
care for, especially older patients will also
have a positive impact on their general health
and well-being too
Waiting times
• Reduce our waiting times for elective care to
achieve and maintain a position that is higher
than the National average
• Improve the process and timeliness of patient
discharge from ITU beds to wards
Outpatient services
Patient experience improvements defined in the
Care Quality Commission (CQC) action plan.
Virginia Mason Programme
and safety
• Review the possibility of starting the Trust
on a safety journey guided by the principals
established by the Virginia Mason Hospital (or
similar depending on position)
• Establish our patient safety executive
• Establish a series of anaesthetic standards to
be adopted by all anaesthetists
Nutrition
Review training on malnutrition universal
screening tool (MUST) with a focus on
improvement. Improve compliance for
protected meal times; provide more support for
patients who need help with eating and further
develop menus and food choices for patients
with specific needs.
Quality goals linked to
achievement reviews
Continue to embed the setting of personal
goals that effect quality of service for all staff.
2014-15 priorities to be retained
We will retain key priorities from the 14/15
Quality Account and continue to improve
all priorities.
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50
Glossary
Quality Account 2014-2015
Glossary
Community services
National patient surveys
Health services provided in the community, for
example health visiting and podiatry (footcare).
The National Patient Survey Programme,
coordinated by the Care Quality Commission,
gathers feedback from patients on different
aspects of their experience of recently received
care, across a variety of services/settings.
Visit: www.cqc.org.uk
Acute Trust
Clinical audit
Department of Health
A Trust is an NHS organisation responsible
for providing a group of healthcare services.
An acute Trust provides hospital services, for
example, Surrey and Sussex Healthcare NHS
Trust. But not mental health hospital services,
which are provided by a mental health Trust.
Clinical audit measures the quality of care and
services against agreed standards and suggests
or makes improvements where necessary.
The Department of Health is a department of
the UK government but with responsibility for
government policy for England alone on health,
social care and the NHS.
Audit Commission
The Audit Commission regulates the proper
control of public finances by local authorities
and the NHS in England. The Commission
audits NHS trusts to review the quality of their
financial systems. It also publishes independent
reports that highlight risks and good practice to
improve the quality of financial management in
the health service, and, working with the Care
Quality Commission, undertakes national valuefor-money studies.
Visit: www.auditcommission.gov.uk
Board (of Trust)
The role of the Trust’s Board is to take
corporate responsibility for the organisation’s
strategies and actions. The chair and nonexecutive directors are lay people drawn from
the local community. The chief executive is
responsible for ensuring that the Board is
empowered to govern the organisation and
to deliver its objectives.
Care Quality Commission
The Care Quality Commission (CQC) is the
independent regulator of health and social
care in England. It regulates health and adult
social care services, whether provided by the
NHS, local authorities, private companies or
voluntary organisations.
Visit: www.cqc.org.uk
Clinical Commissioning
Group
Clinical Commissioning Groups are
predominantly GP-led groups of local healthcare
professionals that commission the local health
services for their catchment population, based on
the needs of the patient population.
Commissioners
Commissioners are responsible for ensuring
adequate services are available for their local
population by assessing needs and purchasing
services. Clinical Commissioning Groups
are the key organisations responsible for
commissioning healthcare services for their
area. They commission services, including acute
care, primary care and mental healthcare, for
the whole of their population with a view to
improving the health of their population.
Commissioning for
Quality and Innovation
High Quality Care for All included a
commitment to make a proportion of providers’
income conditional on quality and innovation,
through the Commissioning for Quality and
Innovation(CQUIN) payment framework.
Foundation Trust
A type of NHS Trust in England that has been
created to devolve decision-making from central
government control to local organisations and
communities so they are more responsive to
the needs and wishes of their local people.
NHS Foundation Trusts provide and develop
healthcare according to core NHS principles
– free care, based on need and not on ability
to pay. NHS Foundation Trusts have members
drawn from patients, the public and staff
and are governed by a board of governors
comprising people elected from and by the
membership base.
Hospital Episode Statistics
Hospital Episode Statistics is the national
statistical data warehouse for England of the
care provided by NHS hospitals and for NHS
hospital patients treated elsewhere.
National Institute
for Health and
Clinical Excellence
The National Institute for Health and Clinical
Excellence is an independent organisation
responsible for providing national guidance on
promoting good health and preventing and
treating ill health. Visit: www.nice.org.uk
NHS Choices
The first port of call for the public for all
information on the NHS.
NHS Information Centre
The NHS Information Centre is England’s central,
authoritative source of health and social care
information. Acting as a ‘hub’ for high quality,
national, comparative data for all secondary
uses, they deliver information for local decision
makers to improve the quality and efficiency of
frontline care.
Visit: www.ic.nhs.uk
Providers
Providers are the organisations that provide
NHS services, for example Surrey and Sussex
Healthcare NHS Trust.
Registration
From April 2009, every NHS Trust that
provides healthcare directly to patients
must be registered with the Care Quality
Commission (CQC).
Research
Clinical research and clinical trials are an
everyday part of the NHS. The people who
do research are mostly the same doctors and
other health professionals who treat people.
A clinical trial is a particular type of research
that tests one treatment against another. It
might involve either patients or people in good
health, or both.
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52
Appendices
Quality Account 2014-2015
Appendices
Appendix A:
Statement of our
directors’ responsibilities
The content of this report was agreed with
the Trust’s executive team, senior clinical staff
(executive committee for quality & risk), the safety
and quality committee and the Trust Board. Our
priorities for quality improvement in 2014/15
are based on our quality strategy and follow
consultation through our clinical divisions with
staff, and with our other stakeholders, including
patients and their carers.
The report has been reviewed by:
• Crawley, Horsham, Mid Sussex Clinical
Commissioning Group
• East Surrey Clinical Commissioning Group
• Surrey Downs Clinical Commissioning Group
• Surrey Health Scrutiny Committee
• West Sussex Health and Adult Social Care
Select Committee
• Healthwatch Surrey
• Healthwatch West Sussex
They have been invited to review the report and their comments are included.
Statement of directors’
responsibilities in respect
of the quality account
The directors are required under the Health
Act 2009 to prepare a quality account for each
financial year. The Department of Health has
issued guidance on the form and content of
annual quality accounts (which incorporates the
legal requirements in the Health Act 2009 and
the National Health Service (quality accounts)
Regulations 2010 (as amended by the National
Health Service (quality accounts) Amendment
Regulations 2011).
Appendix B:
What our partners say
Crawley, Horsham
and Mid-Sussex,
East Surrey
and Surrey
Downs Clinical
Commissioning
Groups
In preparing the quality account, directors are
required to take steps to satisfy themselves that:
• the quality account present a balanced
picture of the trust’s performance over
the period covered
• the performance information reported in
the quality account is reliable and accurate;
• there are proper internal controls over the
collection and reporting of the measures of
performance included in the quality account,
and these controls are subject to review to
confirm that they are working effectively
in practice
• the data underpinning the measures of
performance reported in the quality account
is robust and reliable, conforms to specified
data quality standards and prescribed
definitions, and is subject to appropriate
scrutiny and review
• the quality account has been prepared
in accordance with Department of
Health guidance
The directors confirm to the best of their
knowledge and belief that they have complied
with the above requirements in preparing the
quality account.
By order of the Board
25 June 2015
Chair
25 June 2015
Chief Executive
Thank you for giving Crawley, Horsham
and Mid-Sussex, East Surrey and Surrey
Downs Clinical Commissioning Groups the
opportunity to comment on your Quality
Account for 2014/15.
The CCGs have reviewed the Surrey and
Sussex Healthcare NHS Trust Quality Account
and can confirm that the quality account
complies with the guidelines and demonstrates
progress against its priorities identified for
2014/15. The Quality.
Account provides information across the
three areas of quality: patient safety, patient
experience and clinical effectiveness and
highlights an on-going commitment to the
improvement of the quality of care.
Performance against
2014/15 priorities
The CCGs agree that the report is
comprehensive and although mainly reflecting
the good work that the Trust has done, it is in
fact balanced with areas where improvements
are required.
With regards to patient safety we are pleased
to note that the organisation has done well
to maintain reductions in Falls, Major hospital
acquire pressure damage and Healthcare
Acquired Infections. In particular, the section on
Healthcare Acquired Infections clearly highlights
how the processes put in place have enabled
the Trust to successfully reduce the number of
hospital acquired infections.
We have also considered that there were areas
of strength within the accounts, namely that
the accounts clearly show how the organisation
has set its future priorities for quality. We note
specific improvements made on environmental
cleanliness and nutrition. The investments in
the new cleaning equipment as well as the
introduction of the 2 week menu cycle and
dieticians show a real commitment to improved
patient experience.
Also noteworthy, is the Trusts performance
in the Friends & Family Test as evidenced by
high rating on a national level. We particularly
welcomed the inclusion of patient’s feedback
and staff recognition within the accounts.
The Trusts performance in reducing readmission
rates is also to be noted.
Priorities for 2015/16
Rather than selecting new priorities, the
organisation has sought improvements on
existing priorities from 2014/15. The CCGs
support the priorities for 2015/16 which appear
appropriate in this context, and it is encouraging
to note that the organisation acknowledges the
areas where further improvements are required.
However, a full evaluation of the priorities
for 2015/16 was limited as draft version was
incomplete and we have not been able to
evaluate the ones not included. The document
could be strengthened by consistently including
the improvements for all areas.
Conclusion
The Trust continues to make sustained
progress with its improvement priorities
within the context of continued whole system
challenges, in particular around demand and
workforce issues.
We believe that the Quality Account captures
the good work that the Trust is doing and
outlines the quality aspirations for 2015/16.
The CCGs consider the priorities outlined
for 2015/16 appropriate and look forward
to reviewing progress at the regular Quality
conversations throughout the year.
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54
Appendices
Quality Account 2014-2015
Healthwatch West Sussex
• Safety and hygiene - particularly in East Surrey
and Horsham hospitals
Introduction
• Staffing – poor attitude, inconsistency of
consultant and general staffing levels
As the independent
champion for health
and social care
for patients across West Sussex Healthwatch
(HWWSx) are pleased to be invited to comment
on Surrey and Sussex Healthcare NHS Trust (SaSH)
draft Quality Account (QA) for 2014-15.
We note that the Care Quality Commission (CQC)
has awarded a “Good” rating to the Trust with
some areas reported as “Outstanding”. The CQC
did identify a need to improve outpatient services
and communication with patients, therefore,
we are delighted to see a clear focus on patient
engagement embedded in the proposed
priorities for 2015/16. We await with interest
the report on Responsiveness to Patient
Personal Needs.
The Trust is commended for using a variety of
tools to elicit patients’ views and experience.
However evidence of actions taken as a result are
not included in the QA for 2014-15.
Our commentary not only reflects the content
of the Trust’s draft QA but is also drawn from
patient experience as recorded in our Client
Relationship Management (CRM) system.
HWWSx received both positive and negative
comments from patients.
In summary:
Positive
• Staff - A number of patients praised the
nursing and midwifery staff at Horsham,
Crawley and East Surrey Hospitals
Negative
• Delays in treatment - including not hearing
back about treatment/repeated cancellation
and postponement of appointments/
information lost or incorrect.
• Discharge - inadequate arrangement and lack
of follow up care.
• Treatment - condition not taken seriously or
condition not resolved
Further anonymised details can be supplied
if required.
Safety
Reported improvement 2014/15
• HWWSx welcome the reduction in hospital
acquired infections and pressure damage. An
improvement in access to services addresses
a number of issues reported to us. The use of
the WHO Safer Surgery checklist can only lead
to improvement in surgical practice.
Priorities for 2015/16
The Trust is to be commended in recruiting a falls
champion and working towards timely treatment
for fractured neck of femur using the research
based FNF care pathway.
Maternity services at the Trust are recognised as
offering high quality care which is supported by
the Maternity Safety Thermometer now rolled
out across Kent, Surrey and Sussex.
We have been made aware of national concern
around stroke, therefore, HWWSx is pleased to
see the Trust is introducing SSNAP standards.
Serious incidents and near misses are a source of
learning and we welcome the Trust’s renewed
focus on disseminating this to staff. We would
wish to see evidence of this included in the
Quality Account.
Effectiveness
Reported improvement 2014/15
HWWSx congratulate the Trust in reducing
the readmission rate and the need for
admission through partnership working with
community providers.
We would expect all Trusts to be compliant
with NICE guidance, to take part in the National
Clinical Audit Programme and Confidential
Enquires and hope to see evidence of improved
outcomes over time.
Priorities for 2015/16
Data quality and accuracy of coding are a major
issues for all healthcare providers. We are pleased
to note that the Trust is reviewing these areas.
We welcome the priority of a seamless care
pathway between primary/secondary care as it
will address some of the issues reported to us.
Patient experience
Reported improvement 2014/15
As the independent patient’s voice we commend
the Trust in its efforts to hear directly from
patients and carers and offer more information
on their services. We would wish to see
continued evidence of improvements made as a
result of patient feedback in the 2015-16 QA.
Priorities for 2015/16
HWWSx very much welcome the inclusion in
the QA of increased patient feedback through
focus groups and a Customer Care programme
to support the philosophy of patients at the heart
of care. The development of Cultural Champions
will assist staff and ensure that individuals with
protected characteristics receive equal access and
an improved experience of care from the Trust.
Conclusions from the service
user perspective
As an organisation representing patient
interests, viewing evidence of service
improvement is of primary importance to us.
HWWSx commends the Trust for their stated aim
of putting the patient at the heart of their care.
A commitment to high quality, safe care with a
view to continuous improvement is welcomed.
We congratulate the Trust on the improvements
achieved as identified in the QA 2014-15 report
but would wish to see a more outcomes focused
approach in the future with clear evidence
of actions taken as a result of meaningful
patient engagement.
A significant number of West Sussex residents’
access healthcare at various Trust sites. We
now welcome the recently introduced formal
opportunity for engaging with the Trust’s
Quality Nurse Lead and hope this continues
throughout 2015-16 and to work together on the
development of the Quality Account.
HWWSx looks forward to building an
open, transparent and mutually respectful
relationship with the Trust to support
continuous improvement in the delivery
of healthcare for all patients.
Surrey Health
Scrutiny Committee
The Committee
is grateful for the
opportunity to
comment on the Surrey
& Sussex Healthcare
NHS Trust (SASH)
Quality Account following regular meetings with
both the Medical Director and Director of Quality
& Nursing throughout the last year.
• Two Members of the Committee are
responsible for oversight of the Trust’s quality
and have scrutinised this year’s account and
wish to put on record the following comments:
• The Committee noted the high quality of care
provided by SASH and that it achieved a good
inspection outcome from the Care Quality
Commission.
• The Committee welcomed the fact that
SASH had met 70% of their targets, with the
remainder being partly met.
• The Committee welcomed the action that
the Trust was taking in relation to working
with partners to increase dementia and stroke
awareness and welcomed the fact that the
trust had a lead champion for the target areas.
However, the full data was not available for
stroke care – a partially met performance
which meant the committee could not fully
scrutinise performance in this area.
55
56
Appendices
Quality Account 2014-2015
• The Committee welcomed the actions being
taken to improve quality to an even greater
level to achieve a better result at its next
CQC inspection.
• The Committee welcomed the further focus
on screening and IV line/catheter hygiene
to achieve zero attributable cases of MRSA
and the emphasis on root cause analysis of
all incidents of C. difficile which, together
with appropriate antibiotic prescribing and
hygiene practices, has kept incidences below
the targeted maximum.
• The Committee welcomed the introduction
of mouth care assessments for in patients
• The Committee regrets that amongst the
items where the data was unavailable for
the draft were two important areas: firstly
safe and appropriate discharge and secondly
mental health as problems
with provision in both areas have occurred
across
Surrey. The Committee notes that SASH
had committed to a planned discharge
programme and would expect to assess
progress in implementation and analysis of
factors hindering progress such as difficulties
with patient transport services.
• The Committee noted that other NHS trusts
tend to include references to complaints and,
whilst noting that the SASH would be limited
by the regulator, advised that they would
welcome a section on complaints in
the quality account.
• The Committee noted this year’s objective
for improvement to encourage more
senior frontline staff to respond directly
to comments on Patient Opinion and roll
out the Your Care Matters programme to
cover all patient pathways, building upon
existing performance measurements and to
consistently respond to the comments they
receive and strive to make improvements.
West Sussex Health &
Adult Social Care Select
Committee (HASC)
Thank you for offering
the Health & Adult
Social Care Select
Committee (HASC)
the opportunity to
comment on Surrey
and Sussex Healthcare NHS Trust’s Quality
Account for 2014-15.
HASC is pleased that clinicians are now key
in managerial decision-making and that
external benchmarking is used to measure
all aspects of safety, clinical effectiveness
and patient experience.
The ‘Your Care Matters’ programme and the
Patient Opinion website are important and
have provided ways for patients to give vital
feedback to the Trust.
HASC welcomes the move towards more
transparency as a result of recommendations
in the Francis Report and also the
reconfiguration of staff ward ratios.
Finally, we look forward to hearing whether or
not the Trust achieves Foundation status.
How to contact us
Surrey and Sussex Healthcare NHS Trust
Surrey and Sussex Healthcare NHS Trust
provides emergency and non-emergency
services at:
East Surrey Hospital
Redhill
Surrey
RH1 5RH
Telephone: 01737 768511
Surrey and Sussex Healthcare NHS Trust
provides non-emergency services at Crawley
Hospital which is managed by NHS Property
Company.
Crawley Hospital
Crawley
West Sussex
RH11 7DH
Telephone: 01293 600300
We also provide a number of services at four
community sites:
Caterham Dene Hospital
Church Road
Caterham
Surrey
CR3 5RA
Telephone: 01883 837500
Oxted Health Centre
10 Gresham Road
Oxted
RH8 0BQ
Telephone: 01883 734000
The Earlswood Centre
Royal Earlswood Park
1 Anderson Court
Redhill
Surrey
RH1 6TP
01737 768511
x 1743
Surrey and Sussex Healthcare NHS Trust
Trust Headquarters
Canada Avenue
Redhill
Surrey
RH1 5RH
Telephone: 01737 768511
Email: enquiries@sash.nhs.uk
www.surreyandsussex.nhs.uk
twitter: @sashnhs
Horsham Hospital
Hurst Road
Horsham
West Sussex
RH12 2DR
Telephone: 01403 227000
• The Committee will continue to work
closely with the Trust and looks forward to
continued improvements in 2015/16.
www.surreyandsussex.nhs.uk
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Need help or advice?
The Patient Advice and Liaison Service (PALS)
focuses on improving services for NHS patients.
It aims to:
You can contact PALS by:
• advise and support patients, their families
and carers
• telephone: 01737 768511 x 6922 or 6831
(for all sites)
• provide information on NHS services
• e-mail: pals@sash.nhs.uk
• listen to your concerns, suggestions or
queries
• writing to: PALS, c/o East Surrey Hospital,
Redhill, Surrey RH1 5RH
• help sort out problems quickly on your
behalf
This information is available in other languages and formats including
audio tape, large print and Braille. For further information please
contact PALS (Patient Advisory Liaison Service) on 01737 231958 or
email: enquiries@sash.nhs.uk
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