2014/15
SAFE

A & E Attendances:
WCH: 32073 CIC: 47978
Operations, not number of procedures
WCH: 10034 CIC: 19742
Births, excluding
Home/Penrith:
WCH: 1253 CIC: 1696
Outpatient appointments
WCH = 79,786 CIC = 188,341
OUTREACH=33,700
2 | Quality Account 2014/15

PART 1: INTRODUCTION
PART 2: PRIORITIES FOR IMPROVEMENT
PART 3: REVIEW OF QUALITY PRIORITIES
36
7
www.ncuh.nhs.uk | 3

A Quality Account is an annual report to the public about the quality of the services our Trust delivers.
The aim of the Quality Account is to enhance the Trust’s accountability to the public and its commissioners (purchasers of healthcare) on both the achievements made to improving the quality of services for our local communities as well as being very clear about where further improvement is required.
Quality Accounts are both retrospective and forward looking.
A single definition of quality for the NHS was first set out in High
Quality Care for All. This definition sets out three dimensions to quality, all three of which must be present in order to provide a high quality service: l Clinical effectiveness - quality care is care which is delivered
according to the best evidence as to what is clinically effective
in improving an individual’s health outcomes l Safety - quality care is care which is delivered to avoid
all avoidable harm and risks to the individual’s safety l Patient experience - quality care is care which aims to give
patients as positive an experience as possible, including
being treated according to what that individual wants or
needs, and with compassion, dignity and respect
This Quality Account places the focus on the quality of the Trust’s services so that the public, patients and anyone with an interest in healthcare will be able to understand: l Where the Trust is doing well l Where improvements in service quality are needed and
how we have prioritised these l How the Trust Board has reviewed our challenges in
improving the quality of care during the year and what we
have prioritised for 2014/15
The Quality Account includes the following mandatory requirements:
Part 1 l A statement on quality from the Chief Executive
Part 2 l Priorities for improvement and statements relating to
quality of NHS services
Part 3 l Review of the quality performance for 2014/15 and
engagement with stakeholders l Statements from stakeholders and commissioners
This document complies with the Trust’s statutory duties under the Health Act 2009 and the guidance issued by the Department of Health for the development of Quality Accounts.
4 | Quality Account 2014/15

Welcome to the Quality Account for 2014/15.
This Quality Account is for our patients, families, staff, stakeholders and the general public to find out more about the quality of services provided at our hospitals.
I would firstly like to thank our staff for the commitment and compassion they continue to demonstrate. We have faced a number of difficulties over the past year and our staff have never failed to rise to the challenge. In our Chief Inspector of Hospitals report in 2014, our staff were given a rating of ‘good’ for caring across all of our services, something we should all be rightly proud of.
Our staff all work very hard to continually improve the safety and quality of patient care we provide and we have continued to make good progress over the past year. It was very reassuring to have this progress confirmed in a report by healthcare analysts Dr Foster in early 2015 which showed a consistent reduction in the Trust’s mortality rate since 2012 following a number of vital measures put in place by the Trust.
The Trust was re-inspected by the Chief Inspector of Hospitals in
March 2015 and I was delighted to be able to demonstrate all of the excellent progress we have made over the past 12 months.
However, we fully recognise that we still have a lot of improvements to make as we continue to work together to come out of Special Measures.
Our focus is on providing a safe, caring and responsive service to all of our patients, at all times and we have set out our key priorities for 2015/16 as follows:
Safe l Doing the right things in line with ‘best practice’ l Saving more lives and preventing harm l Guaranteeing safe levels of staff with the right skills l Sharing learning from errors and our experiences
Caring l Caring for our patients like we would for our families l Ensuring privacy and dignity l Listening and acting on concerns
Responsive l Providing the right care in the right place at the right time l Keeping patients and their carers well informed l Delivering care in a timely manner
The Trust published our clinical options in November 2014 after a team of our senior doctors and nurses got together to set out the areas where they felt further change was needed in order to improve the service for our patients. The four main areas highlighted were acute medicine, obstetric and midwifery care, paediatrics and planned care & outpatients.
A series of engagement events which were independently facilitated by Healthwatch Cumbria were held at the end of
2014 in order to gather the views of staff, patients and the wider public. I would like to thank everyone who took the time to share their thoughts with us and these are all being considered as we continue to work with the North Cumbria Programme Board and with all health and social care partners to determine the best possible future services.
We have a lot to look forward to this year with the new West
Cumberland Hospital set to open in autumn 2015 after suffering a setback in January 2015 due to a fire in the new Energy Centre.
The hospital has got back on track very quickly which is a real testament to all of the staff involved. The new hospital will see a modern and state of the art hospital environment for our staff and patients in West Cumbria.
The findings of an independent report, which the Trust commissioned to check fire safety compliance has identified a significant risk in relation to the fire stopping within the
Cumberland Infirmary. The Trust has taken active steps to put in place mitigation plans, including a fire safety group which meets weekly and includes representation from Cumbria Fire and Rescue
Service who are comfortable with all actions being taken at the present time. The Trust Board have requested a full survey of the hospital and is working with the PFI Company and their provider to actively put in place key programmes of work, which will include a designated decant facilities.
NHS England have announced that North Cumbria is one of three areas to be included in the Success Regime, a new national initiative to help the most challenged health economies. The Trust, together with our partner health and care organisations, welcome this announcement as it is further recognition of the long standing and systemic challenges across our health economy which are not easily fixed. These must be resolved if we are to make the necessary improvements to ensure that people living in North Cumbria receive the best possible health and care services going forward.
The Trust’s priority is to ensure we are providing safe, sustainable and high quality services to all of our patients for the long-term future.
I hope you find this Quality Account both an informative and interesting read about our achievements and plans to continuously improve the quality of care we give to our local population. To the best of my knowledge, the information contained in this Quality
Account is accurate.
www.ncuh.nhs.uk | 5

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6 | Quality Account 2014/15

As in previous years our clinical teams have shaped the development of our priorities for improvement and retained the focus of patient safety, reducing harm, delivering effective care and improving the experience of both our staff and patients. This includes the quality incentive schemes we have agreed with our commissioners under the Commissioning for Clinical Quality and Innovation
Payment Framework (CQUIN), which includes both national and locally driven priorities.
During 2014/15 the Trust developed a Quality Strategy, this sets out our aims for quality over the next three years: l To ensure that quality underpins every decision l To provide the safest health and care services to patients and service users l To be recognised as a caring organisation locally, regionally and nationally l To ensure quality and best use of resources are not considered in isolation, but together through the concept of value l Ensure our services are responsive to the needs of our patients and communities l Attract, retain, support and train the best staff
In November 2014, the Trust signed up to the national Sign up to Safety campaign and developed a Safety Improvement Plan to support the delivery of our safety pledges.
In setting our priorities for 2014/15 we have linked these directly to the delivery of our Safety Improvement Plan for 2014/15.
www.ncuh.nhs.uk | 7

PRIORITIES FOR IMPROVEMENT
Our clinical decision making aids and documentation will implement the requirements of our policy and standards.
Our handovers of care will be explicit about the sickest/deteriorating patient on the ward areas.
Our escalation of the deteriorating patient will be fail safe, every time.
Compliance with NEWS will be audited monthly throughout the organisation.
There will be a system in place to monitor compliance with training requirements for
NEWS; compliance with the training requirements will be monitored for all clinical staff.
A system of collating feedback from patients will be developed, this system will capture ‘how safe’ our patients feel and results will be fed back to the appropriate committee; feedback will be acted upon.
We will set out the minimum standards for handovers of care.
All specialties will have an agreed standard for medical and nursing handovers which is written as a Standard
Operating Procedure.
The methods for recording handover will be standardised as part of the SOPs for each specialties.
Handovers will be explicit about the sickest patients in accordance with NEWS.
An audit tool for best practice handover will be developed
We will undertake an audit of handover practice throughout the organisation.
A system of collating feedback from patients will be developed, this system will capture the experiences of our patients (including plans of care) and results will be fed back to the appropriate committee; feedback will be acted upon.
All staff will be aware of and understand how to deliver the
Sepsis Care Bundle.
We will have a targeted training programme for all staff which is focussed on the multi-disciplinary groups, for example what you would identify as a Health Care
Assistant or Medical Registrar.
Compliance with the sepsis bundle will be audited in both surgery and medicine
50% of all relevant staff will undergo sepsis training in 2015/16.
✓
✓
✓
✓
✓
✓
✓
✓
✓
* Progress against safety and quality priorities will be monitored via the Safety & Quality Committee and the Trust Board
8 | Quality Account 2014/15

In January 2015 the Trust Board approved the first Quality
Strategy for the Trust. This strategy builds on the work achieved during the last 2 years in responding to the findings of the Keogh
Review and the CQC CIH inspection. As part of this strategy the Board has identified that our fundamental priority as an organisation is to care that is safe, caring and responsive to the needs of our patients.
The Board has set out specific objectives for the next three years as part of this strategy: l Deliver a year on year reduction in mortality metrics across
our hospital sites l Ensure that level of preventable harm (Hogan methodology)
remains below the 5% national average as per the
Prism studies l Achieve and sustain the mandatory NHS Constitutional
Standards, including Care Quality Commission Regulations l Improve how we ensure we evidence delivery of care in
accordance with best practice and nationally recognised
outcomes across our services l Achieve and maintain and where possible exceed our top
decile position for patient and staff experience l Continue to improve our safety culture and develop a
learning organisation
Our Quality Goals
To support the delivery of the objectives set out in the Quality
Strategy, the specific quality goals we have approved for the next
2 years are:
SAFE l Safe levels of staff with the right skills l Zero tolerance to patient harm l Report all incidents and near misses l Act urgently on early warning scores l Measure consistency and effectiveness of care
CARING l Improve levels of staff satisfaction, engagement and support l Develop teams to ensure they deliver compassionate care l Listen to the views of patients and carers l Act on what matters most to patients l Prioritise care for frail older people with our partners
RESPONSIVE l Staff understand their contribution to the Trusts success l Patients will be treated within the national standards for:
- A&E - within 4 hours
- Cancer - within 62 days
- 18 weeks - 90% of inpatients l To be as good as the best in the NHS for meeting best
practice standard l Implement plans to achieve 7 day working for emergency care www.ncuh.nhs.uk | 9

PRIORITIES FOR IMPROVEMENT
Part of the Trust’s income for 2015/16 will be conditional upon making quality improvements and reaching innovation goals agreed with our clinical commissioners. This will be achieved and monitored through the National Commissioning for Quality and
Innovation Payment Framework (CQUIN).
CQUIN is based on national, regional and locally set goals and is fundamentally important in the Trust’s drive for continuous quality improvements. Progress towards targets will be monitored by the
Trust Board represent 2.5% of the Trust’s total contract income.
The Trust are currently in discussions with Cumbria Clinical
Commissioning Group (CCG) to agree CQUIN targets for 2015/16.
Once agreed, this information will be published on the
Trust’s website.
10 | Quality Account 2014/15

The Directors are required under the Health Act 2009 and the
National Health Service (Quality Accounts) Regulations 2010 to prepare Quality Accounts for each financial year.
The Department of Health has issued guidance to NHS Trust
Boards on the form and content of annual quality reports (in line with requirements set out in Quality Accounts legislation) and on the arrangements that NHS Trust Boards should put in place to support the data quality for the preparation of the
Quality Account.
In preparing the Quality Account, Directors are required to take steps to satisfy themselves that: l The content of this quality report meets the requirements
set out above l The Quality Account presents a balanced picture of the
Trust’s performance over the period covered l The performance information reported in the Quality
Account is reliable and accurate l There are proper internal controls regarding the collection
and the reporting of measures of performance included in
the Quality Account and these controls are subject
to review to confirm that they are working effectively
in practice l 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, is subject to appropriate scrutiny and review;
and the Quality Account has been prepared in accordance
with the annual reporting guidance (which incorporates the
Quality Account regulations) as well as the standards to
support data quality for the preparation of the
Quality Account
The content of this quality report is consistent with internal and external sources of information including: l Board minutes and papers for the period April 2014 to
June 2015 l Papers relating to quality and the performance dashboard
that is reported to the Board over the period April 2014
to June 2015 l Papers relating to quality and safety reported to the Safety
& Quality Committee (formally Governance & Quality
Committee) during the period April 2014 to June 2015 l Delivery of the Chief Inspector of Hospitals
Improvement Plan l The annual staff survey 2014 l Feedback from the Commissioners dated 3 June 2015 l Feedback from Local Healthwatch dated 29 May 2015 l The Trust’s complaints report published under regulation
18 of the Local Authority, Social Services and NHS
Complaints (England) Regulations 2009, dated June 2015 l Feedback from other named stakeholder involved in the
sign off of the Quality Account l The latest national patient survey dated 2014 l The Head of Internal Audit’s annual opinion over the trust’s
control environment dated 28 May 2015 l The annual governance statement dated 3 June 2015 l The Care Quality Commission’s Intelligent Monitoring
Report dated May 2015
The Directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account.
By order of the Board
Gina Tiller
Chairman
Date: 30 June 2015
Ann Farrar
Chief Executive
Date: 30 June 2015 www.ncuh.nhs.uk | 11

PRIORITIES FOR IMPROVEMENT
The mandatory quality indicators set by the Department of
Health that we are required to report in this Quality Account are detailed in the following pages. The data periods comply with the national required data sets for the production of this Quality Account. The performance column in the tables has been colour coded as follows to clarify our assessment of this quality standard:
Green - better than expected
Blue - as expected
Red - worse than expected
Summary Hospital Mortality Indicator (SHMI)
The preferred indicator for inclusion in the Quality Account is the SHMI.
North Cumbria University Hospitals NHS Trust considers that this data is as described for the following reasons: l As reported in previous versions of the Quality Account the
Trust had been an outlier for two consecutive years with
its Hospital Standardised Mortality Ratio (HSMR) in
2010/11 and 2011/12. The Trust has implemented a range
of improvements this includes the weekly system to review
of all deaths and is now within expected range for mortality. l The palliative care coding has not influenced the Trust’s
mortality rate.
Period
Published: April 2015
(Oct 2013 to Sept 2014)
Published: Jan 2015
(July 2013 to June 2014)
Indicator
SHMI
% of patient deaths with palliative care coded at either diagnosis or speciality level
SHMI
% of patient deaths with palliative care coded at either diagnosis or speciality level
North
Cumbria
Value
0.97
National
Average
National
Minimum
National
Maximum
Performance
1 0.59
1.2
As expected
19.70%
0.98
17.90%
25.32%
1
24.60%
0%
0.54
0%
49.4%
1.2
49%
As expected
As expected
As expected
12 | Quality Account 2014/15

Patient Reported Outcome Measures (PROMS)
PROMs calculate a measure of the health gains following surgical treatment using pre and post-operative surveys of the patients’ subjective impression of improvement. 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. The adjusted average health gain is a measure of the Trust’s score relative to other Trusts performing the same procedure. There are three methods of analysis employed that give slightly different results.
The procedures covered are hip and knee replacement, hernia and varicose vein surgery.
The PROMs results for North Cumbria have demonstrated that: l For one condition (varicose veins) the numbers were too
small for analysis l For all the other conditions the trust was very close to the
national mean l For all hips scores were slightly below average, for knee
replacement and hernia the Trust’s results varied between
just above and just below the national average, the results
differing according to the method of analysis employed
North Cumbria University Hospitals NHS Trust has reviewed this data and it does not give any immediate concern, nevertheless the trust will continue explore how to achieve continuous improvement in PROMS scores through the specialty review of outcome data and associated quality improvements.
Period
April 2014 -
Dec 2014
(Published 14
May 2015)
April 2013 -
March 2014
(Published 14
May 2015)
Indicator
EQ-5D index casemix adjusted health gain groin hernia surgery
EQ-5D index casemix adjusted health gain varicose vein surgery
EQ-5D index casemix adjusted health gain hip replacement primary
EQ-5D Index casemix adjusted health gain hip replacement revision
EQ-5D index casemix adjusted health gain knee replacement primary
EQ-5D index casemix adjusted health gain knee replacement revision
EQ-5D index casemix adjusted health gain groin hernia surgery
EQ-5D index casemix adjusted health gain varicose vein surgery
EQ-5D index casemix adjusted health gain hip replacement primary
EQ-5D index casemix adjusted health gain hip replacement revision
EQ-5D index casemix adjusted health gain; knee replacement primary
EQ-5D index casemix adjusted health gain; knee replacement revision
North
Cumbria
Value
0.072
National
Average
National
Minimum
0.084
0.009
National
Maximum
Performance
0.155
Better than expected
Low numbers*
0.432
0.102
0.449
0.009
0.335
0.158
0.548
*
As expected
Low numbers*
0.351
Low numbers*
0.102
Low numbers*
0.441
Low numbers*
0.311
Low numbers*
0.289
0.319
0.253
0.085
0.093
0.436
0.259
0.323
0.248
*
0.226
*
0.008
0.022
0.310
0.156
0.215
0.116
0.219
0.414
*
0.139
0.150
0.544
0.367
0.425
0.318
*
As expected
*
As expected
*
As expected
*
As expected
*
* Feedback from patients in the results of their surgery is not always received, resulting in low numbers for some producdures.
Where this is the case we cannot report performance
.
www.ncuh.nhs.uk | 13

PRIORITIES FOR IMPROVEMENT
Emergency Readmissions to Hospital within 28 Days
North Cumbria University Hospitals NHS Trust considers that this data is as described for the following reasons:
As the Trust has access to community hospital beds for step-down care, the length of stay is higher than average in some areas. This indirectly impacts on the readmission rate.
However, North Cumbria University Hospitals NHS Trust continues to maintain a favourable position against the national average performance.
North Cumbria University Hospitals NHS Trust has taken the following actions to improve this rate and so the quality of its services by: l Introducing an integrated discharge planning team.
A team of trained nurses from both the acute hospital and
community Trust who work together to support the ward
staff in developing discharge plans for those patients with
complex needs. Therefore improving the quality of
the discharge process for both patients and their
families and carers.
Period Indicator
Patients aged 0-15
North
Cumbria
Value
9.85%
National
Average
10.01%
National
Minimum
0.00%
National
Maximum
14.94%
Performance
Better than expected
2011/12
Patients aged 16 or over 10.49% 11.45% 0.00% 41.65% Better than expected
2010/11
Patients aged 0-15
Patients aged 16 or over
9.25%
9.84%
10.15%
11.42%
0.00%
0.00%
25.80%
22.93%
Better than expected
Better than expected
Responsiveness to the Personal Needs of Patients
North Cumbria University Hospitals NHS Trust considers that this data is as described for the following reasons:
The Trust has been below average in the following areas: l Poor discharge processes l Involving patients in care and discharge decisions l Confidence and trust in doctors (through improved
communication) l Cleanliness and hand washing l Information about purpose of medicines and medication
side-effects
North Cumbria University Hospitals NHS Trust has taken the following actions to improve this score and so the quality of its services, by: l Implementation of consultant-level patient experience feedback l Improvement of discharge information and process
including medication information l Delivery of the infection control improvement plan l Establishing the integrated discharge team
Period
2013/14
2012/13
Indicator
Responsiveness to inpatients’ personal needs
Responsiveness to inpatients’ personal needs
North
Cumbria
Value
66.1
National
Average
National
Minimum
68.7
54.4
National
Maximum
Performance
84.2
As expected
66.2
68.1
57.4
84.4
As expected
14 | Quality Account 2014/15

Staff who would recommend the Trust to Family or Friends
North Cumbria University Hospitals NHS Trust considers that this data is as described for the following reasons: l Staff morale has been consistently low for a number of
years challenged by the difficulty in recruiting to the area
and the pace of change ongoing throughout the Trust
North Cumbria University Hospitals NHS Trust has taken the following actions to improve this score and so the quality of its services by: l Creation and implementation of Quality Strategy l Creation and implementation of workforce strategy
- helping to identify recruitment and retention priorities l Ongoing work to support the delivery of the Organisational
Development action plan - continuing to provide blended
learning and development opportunities for all staff
throughout the Trust l Increased focus on employee engagement with increased
accessibility/visibility from senior managers and CEO drop
in sessions. Also medical engagement via MSC and time
out sessions for staff l Creation and delivery of focussed Business Unit staff survey
action plans
The results below demonstrate only a small improvement during this reporting period but with increasing challenges on the services throughout the Trust this is supportive of continued progress in this area. However the Trust remains in the worst
20% of acute trusts.
Period Indicator
North
Cumbria
Value
National
Average
National
Minimum
National
Maximum
Performance
2014
2013
Staff survey responses - if a friend or relative needed treatment,
I would be happy with the standard of care provided by this Trust
48%
40%
61%
64%
22%
38%
95%
94%
Worse than expected
Worse than expected
Patient Safety Incidents
North Cumbria University Hospitals NHS Trust considers that this data is as described for the following reasons: l The Trust submits all patient safety incidents to the
National Reporting and Learning System within the
required deadline l The Trust has continued to increase its reporting of
incidents including escalation of incidents as a
serious incident
North Cumbria University Hospitals NHS Trust has taken the following actions to improve this rate and so the quality of its services by: l The Trust has developed more robust reporting systems and
performance reports during 2014/15 l The staff have been encouraged to report incidents which
has resulted in improved staff survey results in key areas
Period Indicator
Apr 14 -
Sept 14
Reported by
30 Nov 14
Published
April 15
Number of Incidents
* Rate per 1000 bed days
Number of incidents resulting in severe harm or death
% of incidents resulting in severe harm or death
Oct 13 -
Mar 14
Number of Incidents
Reported by
31 May 14
* Rate per 1000 bed days
Number of incidents resulting in severe harm or death
Published
Sept 14
% of incidents resulting in severe harm or death
North
Cumbria
Value
National
Average
National
Minimum
National
Maximum
Performance
3,149 4,196 35 12,020 As expected
33.92
34
1.1
2,942
6.8
27
0.9
35.9
20
1.1
3,083
8.03
20
0.7
0.24
0
0.0
1,048
2.41
1
0
74.96
97
82.9
5,495
16.76
72
2.3
As expected
As expected
As expected
As expected
As expected
As expected
As expected www.ncuh.nhs.uk | 15

PRIORITIES FOR IMPROVEMENT
VTE Risk Assessment
North Cumbria University Hospitals NHS Trust considers that this data is as described for the following reasons: l The Trust had consistently achieved the 90% assessment
rate in accordance with the national target until
Q3 2013/14 l Improvement in the process in the Emergency Assessment
Unit (EAU) on both hospital sites has greatly enhanced
reaching the 95% compliance level for the Trust l Implementation of the Acute Consultant Physician (ACP) role l Monthly Clinical Indicator and Safety Express audits
consistently show the Trust achieving greater than 90%
compliance until Q3
North Cumbria University Hospitals NHS Trust intends to take the following actions to improve the risk assessment rate and so the quality of its services by: l In order to deal with exceptions earlier and reduce the
reliance on coded notes the Trust plans to implement
an electronic system in 2015
Period Indicator
North
Cumbria
Value *
National
Average
National
Minimum
National
Maximum
Performance
2014/15
Q4
Percentage of admitted patients risk assessed for VTE 96.3% 96.0% 79.0% 100.0% As expected
2014/15
Q3
Percentage of admitted patients risk assessed for VTE 97.4% 96.0% 81.2% 100.0% As expected
2014/15
Q2
Percentage of admitted patients risk assessed for VTE 94.5% 96.2%
2014/15
Q1
Percentage of admitted patients risk assessed for VTE 95.2% 96.1%
2013/14
Q4
Percentage of admitted patients risk assessed for VTE 78.9% 96.0%
2013/14
Q3
Percentage of admitted patients risk assessed for VTE 77.7% 95.8%
2013/14
Q2
Percentage of admitted patients risk assessed for VTE 92.1% 95.8%
2013/14
Q1
Percentage of admitted patients risk assessed for VTE 95.3% 95.5%
2012/13
Q4
Percentage of admitted patients risk assessed for VTE 90.2% 94.3%
86.4%
87.2%
75.0%
63.2%
44.4%
53.3%
81.3%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
As expected
As expected
Worse than expected
Worse than expected
As expected
As expected
As expected
* Values have been calculated on the basis of discharge data; this differs to the national approach of utilising admissions data to calculate the values.
16 | Quality Account 2014/15

C-Difficile
North Cumbria University Hospitals NHS Trust considers this data is as described for the following reasons: l Data is validated by the DIPC on a monthly basis reviewing
both laboratory and reported data, previous audits have
confirmed the accuracy of this method of data verification l All cases are assessed and undergo a post infection review
to identify contributory causes l All cases are discussed at weekly Healthcare Associated
Infection meetings to ensure lessons shared
North Cumbria University Hospitals NHS Trust has taken the following actions to improve this rate and so the quality of its services, by: l Work plan to improve cleaning and ensure all sites are
cleaning to BIS 2014 standards l Improve requesting to ensure samples are sent appropriately l Improve antimicrobial prescribing to reduce overuse l Verification of post infection review lessons by discussing
each case with Infection Prevention lead at CCG
Period Indicator
North
Cumbria
Value
National
Average
National
Minimum
National
Maximum
Performance
April -March
2014/15
Trust apportioned rate of C-Difficile infection for patients aged 2 years and over per 100,000 bed days
19.3
* * * *
April -March
2013/14
Trust apportioned rate of C-Difficile infection for patients aged 2 years and over per 100,000 bed days
24 31 0 144
Better than expected
April -March
2012/13
Trust apportioned rate of C-Difficile infection for patients aged 2 years and over
56 37 0 154
Worse than expected
* National data not yet available
Secondary Users Service (SUS)
North Cumbria University Hospitals NHS Trust submitted records during [reporting period] to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data:
Which included the patient’s valid NHS number was: l 98.2% for admitted patient care; l 98.6% for out patient care; and l 96.8% for accident and emergency care.
Which included the patient’s valid General Medical Practice
Code was: l l
100% for admitted patient care;
99.9% for out patient care; and l 99.7% for accident and emergency care.
www.ncuh.nhs.uk | 17

PRIORITIES FOR IMPROVEMENT
During 2014/15, North Cumbria University Hospitals NHS Trust provided and/or subcontracted 40 NHS services. The services or parts of the services subcontracted were: l Oral surgery l General surgery l Urology l Trauma and Orthopaedics l Cardiology l Dermatology l Ophthalmology l Gynaecology l Gastroenterology
The Trust has reviewed all the data available to them on the quality of care in two of these 40 NHS services, namely maternity and stroke care. This has been supported by external reviews into the services as part of the Trust’s clinical strategy.
The income generated by the NHS services reviewed in 2014/15 represents 6.1% of the total income generated from the provision of NHS services by North Cumbria University Hospitals
NHS Trust for 2014/15.
Quality Panels
The Trust had set out a clear aim to continue to develop quality panels in order to have a programme of service reviews.
However this has not progressed during the year due to the resources and focus being applied to delivering the Chief
Inspector of Hospitals Improvement Plan.
18 | Quality Account 2014/15

Clinical audit is one of the core foundations of clinical governance in healthcare and is integral to the fundamental business of the Trust.
All NHS organisations are required to have in place a comprehensive programme of quality improvement activities that include healthcare professionals participating in regular clinical audit to ensure they are delivering care to the best possible standard.
Our Clinical Audit Plan 2014/15
The Trust clinical audit plan for 2014/15 focussed on 3 core aspects:
Priority 1 - National Audits
The list of national clinical audits (52) for inclusion in the
2014/15 Quality Account is compiled on behalf of the
Department of Health by the Healthcare Quality
Improvement Partnership (HQIP). This also includes the specific National Confidential Enquiries (4) for 2014/15.
The National Audit requirements for healthcare providers also including the outcome data relating to ‘Everyone Counts’.
Further detail on performance in national audit is outlined in section 2.6.2.
Priority 2 - Trust Directed Audits
Our Trust priority audits (129) have focussed on a number of key improvement priorities which have included: l NICE guidance l Health Record keeping audits l Early Warning scores - National Early Warning Scores
(NEWS); Paediatric Early Warning Scores (PEWS);
Maternity Early Obstetric Warning Score(MEOWS) l Never Events l Serious Incidents l Care Quality Commission - Patient transfer, discharge
and consent l CNST Maternity audits
Priority 3 - Local Audits
The Business Unit priorities have predominantly focussed on compliance with NICE guidance, which we will continue to build on during 2014/15.
During the year the Trust Board and Safety and Quality
Committee have received quarterly reports on the delivery of the Clinical Audit plan and latterly monthly clinical effectiveness reports which has resulted in improved scrutiny of performance and delivery of the plan.
Our performance in National Clinical Audit for 2014/15
During 2014/2015 the Trust was eligible to participate in 32/52 national clinical audits and all 4 national confidential enquiries.
The Trust participated in 94% (30/32) of national clinical audits and 100% national confidential enquiries.
The Trust did not contribute to the national Heart Failure Audit and the Prostate Cancer Audit. The relevant Business Units are developing plans to address the non-submission of data in preparation for 2015/16. The number of cases submitted for each audit/enquiry is identified on the next page.
The National Clinical Audits and national confidential enquiries that North Cumbria University Hospitals NHS Trust participated in, and for which data collection was completed during 2014/15, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.
The reports of 13 national clinical audits and 1 Confidential enquiry were reviewed by North Cumbria University
Hospitals NHS Trust in 2014/15 and the Trust intends to take the following actions: l Continue to proactively support all business units to ensure
participation in national clinical audits and national
confidential enquiries where eligible.
l Encourage and promote learning from national clinical
audits and national confidential enquiries where they are
applicable to the services we offer.
l Share the outcome of national clinical audits and national
confidential enquiries to encourage staff engagement,
share the learning and ensure continuous quality
improvement of all our services.
www.ncuh.nhs.uk | 19

PRIORITIES FOR IMPROVEMENT
Title
Adult Community Acquired
Pneumonia
Eligible Participating
Yes Yes
% of cases submitted
Data collection in progress
Outcome and Priority for Improvement
Report not available
Adult critical care
(Case Mix Programme)
Yes Yes 100% Results with Business unit
National emergency laparotomy audit (NELA)
National Joint Registry
Yes
Yes
Pleural procedures
Severe trauma (Trauma Audit
& Research Network)
Yes
Yes
National comparative audit of
Blood Transfusion Programme
A) Audit of the use of Anti-D
B) Audit of patient information and consent
Yes
Bowel cancer (NBOCAP) Yes
Yes
Yes
Yes
Yes
Yes
Yes
84%
Actions to improve include:
1. Develop extra “urgent” lists in addition to CEPOD: the hot gallbladder list
2. Provision of 24-hour interventional service
- recruitment of adequate clinical staff
3. Formalise pathway for the care of unscheduled patients to facilitate the delivery of optimal emergency laparotomy surgery
Outliers - Revision Rate: Hip, Knee
- Green RAG rated on both sites
CIC - 87%
WCH - 95%
Outliers - 90 Day Mortality: Hips, Knees
- Green RAG rated on both sites
Ascertainment rate not available
Report not available
34% Report not available
0%
100%
Service description completed
Overall, the audit highlights the need for a more standardised and structured approach to the process of providing information and obtaining patient consent with emphasis on appropriate documentation
Actions to improve include:
1. Embed the documentation (in patient notes) of the following into medical and nursing education and training:
• The indication for transfusion
• Discussion with the patient of the risks, benefits and alternatives
• Gaining informed consent
2. Provide blood transfusion written information for patients with hard copy patient leaflets and electronic copy on hospital intranet/internet site
Ascertainment rate not available
Report not available
20 | Quality Account 2014/15

Title
Head and neck oncology
Lung cancer (NLCA)
Oesophago-gastric cancer
Prostate cancer
Acute coronary syndrome or
Acute myocardial infarction
Eligible Participating
Yes Yes
% of cases submitted
Ascertainment rate not available
Yes Yes
Ascertainment rate not available
Outcome and Priority for Improvement
Trust is compliant to the standards
Report with Business Unit
Yes Yes 100%
The Trust contributes demographic data. The 8 recommendations from the 2014 Report do not apply to NCUHT
Yes No
Yes Yes
0%
Ascertainment rate not available
Good results with the introduction of primary percutaneous coronary intervention for the treatment of acute myocardial infarction times
Actions to improve include:
1.Reduce the length of stay for NSTEMI patients
2. Improve the use of appropriate secondary prevention medication following MI
3. Improve access to Cardiac Rehabilitation in patients with NSTEMI
Cardiac Rhythm Management Yes Yes 100%
Cumbria rates of implantation of pacemakers,
ICDs and CRT devices are below average and national targets, despite an estimated
9% increased need compared with the national average
The bradycardia pacing service in NCUH is currently evolving with new processes for listing and scheduling and pre-assessment being introduced
Actions to improve include: Implementation of new heart failure bundle and additional heart failure nursing resource will contribute to identification of patients who can then be referred on to CRT and ICD devices
Risk: High
Coronary angioplasty (PCI)
National Cardiac Arrest Audit
(NCAA)
National Heart Failure Audit
Yes
Yes
Yes
Yes
Yes
No
Ascertainment rate not available
Report with Business Unit
100% Report with Business unit
0% www.ncuh.nhs.uk | 21

PRIORITIES FOR IMPROVEMENT
Title
National Vascular
Registry (NVR):
NVR Abdominal Aortic
Aneurysm AAA)
NVR Carotid Endarterectomy
Audit (CEA)
Diabetes (Paediatric) (NPDA)
Inflammatory bowel disease:
Biological therapy audit
IBD inpatient experience
IBD inpatient care
Eligible Participating
Yes
Yes
Yes
Yes
Yes
Yes
% of cases submitted
Outcome and Priority for Improvement
Ascertainment rate not available
100%
CIC - 13
WCH - 20
AAA: Actions to improve include:
1. Working on introducing a joint care pathway with our colleagues from the North East
2. An audit lead needs to be appointed for Vascular
3. Liaise with clinical coding regarding reviewing of coding and clinical audit data
4. An audit clerk is now in post to improve case ascertainment above 90%
CEA: NCUH performed very well in the domains of time from referral to surgery and symptom to surgery scoring well above national averages
Actions to improve include:
1. Meet with Stroke physicians to improve time from symptom to referral if possible
There was an improvement in median HbA1c and process indicators for 3rd consecutive year
Actions to improve include:
1. Pre-dates diabetes best practice tariff and diabetes MDT expansion
2. Increase in patient contacts to achieve best practice
3. Adoption of regional diabetes network high
HbA1c policy and implementation in practice
4.Six monthly review of local diabetes data and sharing with regional network
Actions to improve include:
1. Referral to IBD nurse specialist/ gastro team on admission document contact details
2. Liaison between IBD team and ward staff, build on current working relations to inform and support through offering workshops and teaching sessions
3. IBD template being developed for all staff to indicate appropriate care pathway including discharge information and CCUK information as patient information resource
4. Follow up appointments arranged for clinic prior to discharge
Actions to improve include:
1. IBD patients to be seen by an IBD nurse
2. Provide a robust system for patients receiving anti-TNF therapy increased IBD nurse provision as per IBD standards
3. Ward IBD template being developed to place in the IBD file the specialist
4. Registry for all IBD outpatients and inpatients within the Trust to standardise assessment and records
22 | Quality Account 2014/15

Title
National Chronic Obstructive
Pulmonary Disease (COPD)
Audit Programme
- Secondary care
Eligible Participating
Yes Yes
% of cases submitted
CIC – 40
WCH - 20
Outcome and Priority for Improvement
Report with Business Unit for review
Renal registry Yes Yes 100%
Actions to improve include:
1. Improve dialysis delivery through monthly
MDT meeting
2. Improve Hb in range for Haemodialysis patients through monthly MDT meeting
3. Improve bone metabolism parameters for HD patients through monthly meeting with dietitian
4. Improved access placement for HD patients through closer liaison with Vascular Surgeons
Rheumatoid and early inflammatory arthritis
Yes Yes
Data collection in progress
Falls and Fragility Fractures
Audit Programme):
National Hip Fracture
Database (NHFD)
Yes No
Yes
100%
90%+
The present data for this year is an improvement from last year’s results
Actions to improve include:
1. A full time orthogeriatrician is required to improve the 14% figure for reviews within 72hrs
2. Employ full time nurse practitioner for patients with neck of femur to improve the response to specialist assessment within 72hours
Report with Business Unit
Sentinel Stroke National Audit
Programme (SSNAP)
Elective surgery
(National PROMs Programme)
Fitting child (care in emergency departments)
Mental health (care in emergency departments)
Older people (care in emergency departments)
Epilepsy 12 audit
(Childhood Epilepsy)
Maternal, infant and Newborn clinical outcome review programme (MBRRACE-UK)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
94.7%
100%
100%
100%
0% Round 2
100%
Report not available
Report not available
Report not available
Service description complete
Report with Business Unit
Neonatal intensive and special care (NNAP)*
Yes Yes
Ascertainment rate not available
4 standards not met
Actions to improve include:
1.Needs improvement in entry and completion of data in BadgerNet system www.ncuh.nhs.uk | 23

PRIORITIES FOR IMPROVEMENT
National Confidential Enquiries
National Confidential Enquiry into Patient Outcome and
Death(NCEPOD)
Eligible Participate
Gastrointestinal Haemorrhage Yes
Sepsis Yes
Yes
Yes
Lower Limb Amputation Yes Yes
% of cases submitted
100%
In progress
82%
Outcome and Priority for Improvement
Report not available
Tracheostomy care Yes Yes 100%
Report with Business Unit
Result
25 recommendations received
- compliance with 13, implementation ongoing
Actions to improve include:
On line learning document to supplement the emergency tracheostomy algorithm
1. Scope of practice to be finalised and approved
2. No SLT or dietetic input out of hours or at weekends. KC & JS discussed investigating how much dedicated SLT time would be required to manage de- cannulation planning effectively in
ICU setting
3. Devise a de-cannulation checklist
4. Passport approval & regulation
Everyone Counts
For 2014/15 there were 12 specialities included in the national data. The Trust was eligible to participate in 7 of the audit areas.
The table below details the summary of the results.
Everyone Counts consultancy outcomes
Adult Cardiac Surgery
Bariatric Surgery
Colorectal Surgery / Bowel cancer
Head & Neck Surgery / Head and Neck oncology
Interventional Cardiology / Coronary angioplasty
Orthopaedic Surgery / National Joint Registry
Thyroid and Endocrine / Thyroid and endocrine surgery
(BAETS national audit)
Upper Gastro Intestinal Surgery /
Oesophago-gastric cancer
Urological surgery (BAUS Cancer Registry)
- Surgery relating to the urinary tracts
Vascular Surgery / National Vascular Registry
Lung cancer
Neurosurgery
Business Unit
N/A
Summary of results
N/A
Emergency Surgical & Elective Care Within expected levels
Emergency Surgical & Elective Care Within expected levels
Emergency Care & Medicine No outliers or concerns
Emergency Surgical & Elective Care Within expected limits
Emergency Surgical & Elective Care Within expected range
N/A
Emergency Surgical & Elective Care
Insufficient numbers for meaningful analysis
Emergency Surgical & Elective Care All within expected range
N/A
N/A
24 | Quality Account 2014/15

Other National Clinical Audits
The Trust also participated in a further 6 National Clinical Audits during 2014/15 that are not listed on the HQIP list for quality accounts for 2014/15. These include: Table 3:
Title of other
National Audits
National Audit of Cardiac
Rehabilitation (NACR)
- WCH - 2013/14
FFFAP - Pilot audit of inpatient falls
Improvement
Actions to improve include:
To network with other programmes. Possible changes to service provision and improve attendance at cardiac rehabilitation
Actions to improve include:
1. Ensure walking aids available 7 days a week
2. Ensure staff are aware of information available for fallers
3. New falls bundle and falls policy to be published to staff
4. Improve recording of BP lying and standing and vision of patients
Red cell usage NHSBT
National Comparative Audit
No areas of improvement identified for NCUHT, our usage in accordance with national figures
National Cancer Patient
Experience Survey 2014
National Chemotherapy
Patient Experience
Survey 2013
National Cancer Patient
Experience Survey 2013/14
Actions to improve include:
1. Better information regarding tests - What they are for and what to expect
2. Deciding on the best treatment - consider the patients view’s, involve them in decision making, explain side effects in a clear and understandable way using both written and verbal methods
3. Clinical nurse specialist - ensure all patients have one and know who they are
4. Support - ensure patients know about support groups, financial assistance, free prescription and the ongoing impact of having cancer
5. Operations - explain the outcome of operation in an understandable manner
6. Care and treatment - ensure privacy in all clinical areas and ensure patients are not left in pain
Chemotherapy service offered was found to be above national average
Actions to improve include:
1. Ensure letter inviting patient to attend appointment encouraged them to bring carer, relative or friend. Ensure all patients are offered a written record of the discussion regarding the need for treatment and a treatment plan
2. When options in location for receiving chemotherapy are not offered explain why not.
Offer both open plan and single room facilities where appropriate
3. Discuss clinical trials with patients. Explore and refer to other centres if appropriate
4. Ensure side effects/risks are discussed with patients and documented
5. Provide staff education to ensure a holistic assessment is performed pre and post chemotherapy, offering the patient the opportunity to discuss any concerns they may have. Education to improve symptom management of patients receiving chemotherapy
6. Improve information and forward planning for patients on completion of their chemotherapy
The Trust performed poorly in a number of areas specifically patient information and provision of
CNS information
Actions to improve include:
Upgraded patient correspondence and review of patient information. Centralisation of chemotherapy services are underway
Bi-monthly meetings introduced with patient representatives improving engagement and monitoring of actions
Implemented Cancer Operational Group to provide a forum for MDT engagement and pathway review
National Institute for Health and Care Excellence (NICE) guidelines
Compliance with NICE guidance continues to improve and since October 2014 significant progress has been made in identifying guidance which is applicable to each Business Unit within the Trust. At the end of Q4 2014/15 the Trust was demonstrating
79% compliance with guidance that had been through the Trust process, acknowledged and responded to by the relevant clinician.
Of this 79%, 20% have been audited to confirm compliance.
A risk assessment has been completed relating to non-compliant guidance and the Clinical Audit Plan for 2015/16 will incorporate a number of key NICE guidance for each Business Unit. This approach was approved by the Clinical Policy Group, March 2015.
www.ncuh.nhs.uk | 25

PRIORITIES FOR IMPROVEMENT
Our Trust continues to embrace clinical research as a means to contribute to progression of evidence-based medicine and surgery alike. On a national level there has been a far-reaching reorganisation of clinical research support. The National Institute for Health Research (NIHR) now operates 15 Clinical Research
Networks (CRNs). North Cumbria University Hospitals NHS
Trust is a Partner Organisation (PO) of the CRN North East &
North Cumbria. Further information on the remit of the CRN can be found on their website, http://www.crn.nihr.ac.uk/northeast-and-north-cumbria/.
Broadly speaking, research can be sub-divided into NIHR clinical research and home grown research. Funding for research support that our Trust receives originates from the NIHR, and therefore delivery of (inter)national clinical research studies is the core focus for the Research & Development Department. At present a team of around twenty staff - research nurses, research practitioners and administrators - supports delivery of trials that usually are multicentre studies organised by universities and large teaching hospitals. The exception is the HOPE Glaucoma study, which is a NIHR-recognised study developed and conducted by specialist ophthalmology nurse Marina Forbes.
Patient recruitment has been completed, and participants are now followed up for up to three years to collate data.
Research activity
Clinical research is thriving in numerous clinical specialties.
The number of patients under the care of North Cumbria
University Hospitals NHS Trust recruited during 2014/15 to participate in clinical research studies exceeds 4652 as of March
2015. Recruitment has gone up for the second year in succession; in the year 2013/14, a total of 1105 patients were enrolled and the year before the total reached 793 patients. To put this year’s recruitment figures in perspective, roughly 1 in 75 of the North
Cumbrian population has been enrolled in a research study this year. The figures reported here involve patients recruited to research studies recognised by the NIHR; all research studies have both national ethics and local Trust approval in place.
Figure 1 compares the research activity of our Trust with that of other member organisations of the CRN North East & North
Cumbria. On a national level, North Cumbria University
Hospitals NHS Trust is likely to be the 33rd highest recruiting
NHS Trust in the UK, out of a total of near 500 Trusts.
In 2014/15, a total of 59 different studies recruited patients, whereas this year (2013/14) the Trust reached 81 different studies. Studies range from observational (genetics or questionnaires) to interventional (new medical or surgical treatments and other novel interventions) research studies.
It is evident that a wide spectrum of clinical research trials is undertaken locally, as presented in Table 1. Sustained activity is achieved in oncology, cardiovascular disease, vascular surgery, gastroenterology, ENT, and obstetrics & gynaecology.
Emerging specialties include ophthalmology and rheumatology.
The Trust’s achievements in terms of research are recognised in a national league table, published annually by the NIHR and
Guardian newspaper (see http://www.theguardian.com/ healthcare-network-nihr-clinical-research-zone).
Figure 1,
Recruitment of patients into NIHR
National Portfolio research studies for 2014/15
26 | Quality Account 2014/15

Table 1, Patient recruitment per topic
Division
1
2
3
4
5
6
Speciality
Cancer
Cardiovascular Disease
Diabetes
Renal disorders
Stroke
Children
Haematology
Reprod Health & Childbirth
Dementias
Neurological Disorders
Ageing
Dermatology
Health Services
Musculoskeletal Disorders
Anaesthesia
Critical Care
Ear, Nose & Throat
Gastroenterology
Hepatology
Infectious diseases
Injuries & Emergencies
Ophthalmology
Respiratory Disorders
Surgery
TOTAL
2013/14
201
163
20
31
31
19
7
9
12
22
0
108
242
8
16
12
64
25
27
30
21
2
34
0
1105
2012/2013
192
105
5
26
47
1
15
4
11
09
9
0
0
3
134
144
6
0
18
31
8
0
0
0
783
2014/15
231
203
4
2
5
0
36
3862
14
4
12
8
40
1
43
14
2
0
10
23
14
68
33
23
4652 www.ncuh.nhs.uk | 27

PRIORITIES FOR IMPROVEMENT
Research studies
To illustrate what kind of research is being undertaken, a few examples are given below:
CATFISH
This University of Manchester-led study looks at the effect of systemic fluoride exposure in infancy and young children. North
Cumbria is in a unique situation because West Cumbria receives fluoridated mains water whereas in North-East Cumbria water does not contain fluoride. CATFISH is one of the largest studies ever conducted on the effect of fluoride on (dental) health.
A total of 2,000 mothers and their newborn child have been recruited into this study; they will be followed up for five years.
MCM5 urine study
At present, men are tested for PSA when they are suspected of having prostate cancer. MCM5 is a new biomarker for prostate cancer, and tests are ongoing to see if it is a more sensitive and specific marker than the existing PSA test. North Cumbria
University Hospitals was one of only five hospitals in the UK to be involved in this study organised by the company UroSens Ltd.
EMMACE4
Patients who have a myocardial infarction are asked about the emotional and practical impact that this event has on their lives. Developed by Leeds University and open in more than thirty different hospitals in the UK, North Cumbria University
Hospitals is the 4th highest recruiting Trust for this national observational study.
Summary of local research output
Various members of staff are regularly involved in local research projects, case series and service evaluations that lead to publications in international peer-reviewed scientific or medical journals. Some of this work is done independently, whereas other projects are done in collaboration with the R&D Department or other NHS Trusts and Universities. A flavour of the scientific output is given here:
Ear, Nose & Throat (Mr N Murrant):
Powell J, Powell S, Lennon M, Ho A, & Murrant N (2015).
Paediatric ventilation tube insertion: Our experience of seventy
‐ five children in audiology led follow
‐ up. Clinical
Otolaryngology. In press
Surgery (Mr Fraser Smith):
Smith FM, Rao C, Perez RO, Bujko K, Athanasiou T, Habr-Gama A,
& Faiz O (2015). Avoiding Radical Surgery Improves Early
Survival in Elderly Patients With Rectal Cancer, Demonstrating
Complete Clinical Response After Neoadjuvant Therapy: Results of a Decision-Analytic Model. Diseases of the Colon & Rectum,
58(2), 159-171.
Orthopaedics (Mr Matt Dawson):
Elson DW, Dawson M, Wilson C, Risebury M, & Wilson A (2015).
The UK Knee Osteotomy Registry (UKKOR). The Knee,
22(1), 1-3.
Radiology (Dr Farshid Fallahi):
Fallahi F, Oliver R, Mandalia SS, & Jonker L (2014). Early MRI diagnostics for suspected scaphoid fractures subsequent to initial plain radiography. European Journal of Orthopaedic
Surgery & Traumatology, 24(7), 1161-1166.
Oncology (Ms Helen Roe):
Roe H (2014). Scalp cooling: management option for chemotherapy-induced alopecia. British Journal of Nursing,
23(Sup16), S4-S12.
Local ‘home-grown’ research is an essential part on a trainee doctor’s path to becoming a consultant. It is also a prime opportunity for e.g. nurses to help develop their clinical and academic skills en route to becoming a specialist nurse or nurse consultant.
Research finance
Over the years, CRN funding for the Trust to support NIHR research delivery has increased over the last five years.
The budget to support clinical research for the coming financial year, 2015-16, will reach £700,000. Apart from funding research delivery staff, i.e. research nurses and research practitioners, a number of consultants now also receive CRN funding to be able to devote time to leading clinical research at a local level. As in previous years, the CRN also funds deployment of extra staff in support services, including pharmacy, pathology and blood sciences. This is all designed with the intention to create additional capacity to ensure ‘core’ services are not affected.
North Cumbria University Hospitals NHS Trust now also collaborates with pharmaceutical companies to conduct clinical trials. The added benefit of this kind of work is that it incurs additional income to the Trust, which in turn helps to build capacity. Therefore, the anticipated total budget for the R&D
Department for the coming financial year is anticipated to reach circa of £800,000 when both CRN monies and commercial income are taken into consideration.
28 | Quality Account 2014/15

The Trust is fully registered with the Care Quality Commission.
However the Trust is current in special measures. Progress with maintaining full registration is monitored by the Trust Board and the table summarises the Trust position with compliance against the CQC Essential Standards for
Quality & Safety.
Key Exceptions
Outcome 2 - Consent audits are not demonstrating good
practice across the Trust in accordance with the
policy particularly in respiratory medicine
awaiting results of re-audit.
Outcome 4 - NEWS audit results and process requires
improvement and cancer peer review
improvement actions to be completed.
Outcome 6 - Documentation of handover audits are required
to demonstrate compliance.
Outcome 7 - Safeguarding level 2, MCA, control and restraint
and prevention of suicide training require greater
completion rates.
Outcome 8 - High level of Norovirus outbreaks, MRSA over
trajectory, cleaning audit assurance require.
Outcome 11 - Medical Devices training, P2 & P3 equipment
maintenance position needs to improve.
Outcome 12 - Audit improvement actions require progress/
completion to demonstrate compliance with
staff recruitment checks for volunteers, agency
and Interserve staff.
Outcome 13 - Staffing levels remain an issue, particularly
medical staffing.
Outcome 14 - Improvements made, however, resuscitation
mandatory training requires greater completion
rates and appraisal rates need to improve.
Outcome 16 - NICE position, clinical audit. COSH risk assessments. www.ncuh.nhs.uk | 29

PRIORITIES FOR IMPROVEMENT
CARE QUALITY COMMISSION REGISTRATION AND INSPECTIONS
CQC Intelligent Monitoring
Intelligent Monitoring is a tool which the CQC use to assess risk within care services. It has been developed to support regulatory function and purpose of ensuring that health and social care services provide people with safe, effective, compassionate, and high-quality care. Intelligent Monitoring highlights those areas of care to be followed up through inspections and other engagements.
CQC will use the indicators to target their inspections to decide when, where and what to inspect. The Intelligent Monitoring will be used in conjunction with inspections and other information to make the final judgement on ratings.
The high risks outlined in the last publication for our Trust in the
May 2015 report are summarised below: l Proportion of patients risk assessed for Venous
Thromboembolism (VTE) (01-Oct-14 to 31-Dec-14) l The proportion of cases assessed as achieving compliance
with all nine standards of care measured within the
National Hip Fracture Database (01-Jan-13 to 31-Dec-13) l Composite of PLACE indicators (29-Jan-14 to 17-Jun-14) l TDA - Escalation score (01-Nov-14 to 30-Nov-14) l NHS Staff Survey - The proportion of staff who would
recommend the Trust as a place to work or receive
treatment (01-Sep-14 to 31-Dec-14) l NHS Staff Survey - KF21. The proportion of staff reporting
good communication between senior management and
staff (01-Sep-14 to 31-Dec-14) l Snapshot of whistleblowing alerts (case status as at
04-Mar-15) l CQC Share Your Experience - The number of negative
comments is high relative to positive comments (01-Feb-14
to 31-Jan-15)
A high risk item predominantly relates to the Trust’s under performance in comparison to national averages or peer groups.
Action plans are in place against all of the risk items identified in order to ensure improvement is achieved during 2015/16.
30 | Quality Account 2014/15

CQC Inspections during 2014/15
The Trust has not taken part in any special reviews during 2014/15. In April 2014 the Trust was inspected as part of the CQC’s
Chief Inspector of Hospital’s regime; this was because the Trust had been placed in a high risk band 1 in CQC’s Intelligent Monitoring
System. The inspection focussed on five core questions: l Are services safe?
l Are they effective?
l Are they caring? l Are they responsive?
l Are they well led?
Following each inspection the individual hospitals, services as well as the Trust as a whole are rated. The ratings are based on four levels of inadequate, requires improvement, good and outstanding . The table below summarises the ratings for the Trust, including the two main hospital sites and individual service level:
How have we taken forward the improvements identified by the Chief Inspector of Hospitals?
The priorities for the Trust have focussed on four main themes as part of our improvement plan: l Improvement in the inadequate rating for outpatients l Improvement in the inadequate rating for acute medicine at West Cumberland Hospital & Medical Workforce l Improving the safety and quality of obstetric services l Improving nurse staffing levels l Implementing our clinical strategy www.ncuh.nhs.uk | 31

PRIORITIES FOR IMPROVEMENT
CARE QUALITY COMMISSION REGISTRATION AND INSPECTIONS
Improvement in the inadequate rating for outpatients
What did the CQC inspection identify and recommend?
The CQC identified that there was an unavailability of medical records that resulted in delayed clinic start and finished times, longer waits for patients and on occasions patients’ appointments being cancelled. This lack of medical records impacted on the clinician’s ability to deliver safe care.
The CQC recommended that we: l Improve how patient records are made available for
outpatient appointment and clinics (CIC) l Ensure that patient records are complete and up-to-date
and made available in a timely way for all outpatient clinic
appointments (WCH) l Ensure that infrastructure is in place before establishing
additional outpatient clinics
What did we do?
l Recruited a fulltime manager to ensure compliance of all
national standards l Medical records service capacity extended to improve
capacity and retrieval l Creation of further storage space secured, and
commissioned external company to reduce number of
stored ‘live records’ l Daily auditing of progress for each clinic since
September 2014 l Full business case approved for the centralisation
of records l New medical records developed to a 5cm standard l Pilot audit of clinic start and finish times completed l Business case approved for a contact centre to provide
centralised booking system for new outpatient appointments
What have we improved?
✓
Achieved sustained delivery of 95% note availability and
✓
improvement from 72% in April 2014
New location agreed for central records facility and lease
✓
due to be signed in March 2015
PERFORM clinically led improvement work has
✓
commenced to improve the flow of outpatient activity
Implemented change for staff across all sites and, whilst
this has been challenging for teams and for individuals, they
✓
have worked hard to initiate improvements
Intensive Support Team (IST) commissioned and worked
with Trust from July - December 2014 to work with teams
to develop capability and support the development of robust
demand and capacity plans that delivers a sustainable
18 week referral to treatment time (RTT) standard
Improvement in the inadequate rating for acute medicine at
West Cumberland Hospital & Medical Workforce
What did the CQC inspection identify and recommend?
The CQC emphasised that the system wide plans to secure financial and clinical sustainability supported by the entire health and social care system was now imperative and must be delivered at pace. They identified continued concerns about the appropriate supervision of trainees as well as identifying the need for a long term strategy to address the operational fragility of the medical workforce. The CQC recommended that we: l Address the numerous consultant vacancies l Ensure medical staffing is sufficient to provide appropriate
and timely treatment to patients at all times l Improve the support given to junior doctors
What did we do?
Consultant vacancies: l Developed a medical workforce strategy and medical
recruitment plan l Risk assessed posts and agreed the use of recruitment
enhancements (recruitment premium of 10% of the
starting salary), extended (international) campaigns and
innovative collaborations for those posts l Developed and implemented a medical engagement strategy
Medical staffing is sufficient to provide appropriate and timely treatment: l Agreed with the wider health system robust contingency
plans and escalation triggers for the WCH site -
acute medicine l Working with all partners developed a clinical strategy,
with the focus on four key pathways including cardiology,
upper GI, stroke and the deteriorating patient l Established clinical led work streams to develop options for
delivery of any future clinical pathway changes
Support for junior doctors l From August 2014, FY1 at WCH placements focused in
acute medicine and coronary care (and only work to 10pm)
to ensure better supervision and support from substantive staff l Implemented an innovative nurse practitioner service at
WCH in August 2014 to support consultants and clinical
teams on ‘back of house’ wards l Worked with HENE to improve trainee experience across
North Cumbria
What have we improved?
✓
An increase in consultant numbers and appointments
despite a higher turnover of staff associated with special
✓
✓
measures and predicted retirements.
Medical staff engagement
Contingency plan and escalation triggers successfully
implemented in December 2014
✓
Reduction in our mortality rates
✓
Four key pathways including cardiology, upper GI, stroke and
the deteriorating patient agreed by clinical senate
32 | Quality Account 2014/15

Improving the safety and quality of obstetric services
What did the CQC inspection identify and recommend?
There was a lack of dedicated medical staff cover, lack of a dedicated second theatre and non-compliance with NICE standard for pain relief at CIC. The Trust had a high rate of caesarean sections. There was a lack of an electronic information system to support the service. Risk management required improvement. The CQC recommended the following: l Ensure it meets national guidance of having an anaesthetist
available at all times for obstetrics at WCH and there is a
second theatre for use l Ensure there is an epidural service at CIC l Ensure risk management is embedded in order to
implement a quality assurance process l Improve IT l Clarify a leadership role to promote normality in child birth
What did we do?
l Convened a risk summit and agreed for CCG to commission
an independent review of maternity services l Commissioned an expert in risk and governance to
strengthen risk management processes and quality assurance l Creation of further storage space secured, and
commissioned external company to reduce number of
stored ‘live records’ l Clarification of arrangements and monitoring processes
established in relation to compliance with second theatre
for obstetrics requirements l Strengthened processes around availability of a second
anaesthetist on both sites l Recruited anaesthetists and started training advanced
critical care practitioners l Epidural provision project at CIC commenced l Clarified that provision is adequate to carry out caesarean
sections as indicated against NICE guidance l Strategy for reduction of caesarean section rate developed
What have we improved?
✓
All clinical guidelines reviewed against NHSLA and CNST
✓
Level 1 standards
Robust process of audit, triangulated with user feedback in
place to provide evidence of improvement against CNST
and CQC standards
✓
A second theatre is readily available for emergency
obstetric cases and this has not necessitated any
✓
cancellations of elective obstetric or gynaecology cases
Mitigating actions in place for having adequate obstetric
✓
and anaesthetic cover
Clear implementation plan for providing an epidural service
at CIC in place. Training has already commenced
✓
Defined pathway for Vaginal Birth After Caesarean Section
(VBAC) implemented
✓
Maternity Services Liaison Committee (MSLC) reinstated to
ensure user voice is heard and able to influence
✓
Independent review report published February 2015 which is
being consider by the commissioners and key stakeholders in
terms of next steps
✓
Recruited to a second tier of anaesthetists at CIC
Improving nurse staffing levels
What did the CQC inspection identify and recommend?
CQC identified that they could see that some improvements had been made in nursing staffing levels; however, nursing staff were still describing the need to work double shifts and feeling under pressure to do this in order to maintain safer staffing levels.
The CQC recommended that: l Ensure there are sufficient numbers of suitably qualified,
skilled and experienced nurses to meet the needs of
patients at all times l Ensure nurse staffing levels are appropriate in all areas,
without substantive staff being forced to work excessive
additional shifts
What did we do?
Safer Staffing l Completed a third acuity exercise using the Safer Nursing
Care Tool, underpinned by professional judgement.
Results presented to Board in December 2014 l Weekly safe staffing meeting in place l Reviewed and agreed SOP for escalation of staffing issues l Director of nursing personally led development of nursing,
midwifery and AHP strategy engaging all front line setting
clear standards of practice l Heat map developed aligning ward quality KPIs to staffing
levels for Board review
Recruitment l Recruitment plan developed and implemented including
a rolling recruitment programme l Strengthened links with local HEIs to facilitate increased
student commissions l International recruitment exercise l Established a three year pre-nursing cadet scheme l Developed and implemented a Nurse Practitioner service
at WCH
What have we improved?
✓
✓
Surgical vacancies at lowest level since 2011
Nursing, midwifery and AHP strategy launched Dec 14 with
✓
input from over 500 front line staff
Ward Accreditation Framework piloted and fully rolled out
✓
in inpatient areas
Student nurse commissions increased to two intakes per
year- 25 students March and 56 students September www.ncuh.nhs.uk | 33

PRIORITIES FOR IMPROVEMENT
CARE QUALITY COMMISSION REGISTRATION AND INSPECTIONS
✓
✓
First tranche of international recruitment undertaken with
seven nurses appointed. Second planned for July 2015
✓
Cadet scheme commenced at WCH with 25 cadets
supporting access to nurse training
27.48 WTE Nurse Practitioners trained and in post
Implementing our clinical strategy
What did the CQC inspection identify and recommend?
Staff and patients told the CQC that they were uncertain of what future service provision would look like at the Trust.
Some services were being delivered with significant consultant vacancies. The CQC recommended that: l The Trust must be open and engage with staff about
future plans l The Trust must address the numerous consultant vacancies
What did we do?
l Whole system clinically led care design groups considered
future service scenarios based on ‘right care, at the right
time and in the right place’ in May/June 2014 l NCUH completed work with clinical and managerial
leaders, Northumbria Healthcare NHS FT and an external
reviewer to produce a clinical strategy published in October
2014. This outlined the ‘clinical options appraisal and
potential way forward’ with an emphasis on practical
solution for securing clinically sustainable services l Following publication NCUH embarked on a period of staff
and public engagement l NCUH produced summary information and ‘Z card’ leaflets
plus numerous mechanisms for direct discussion and
feedback to ensure staff were kept updated on and engaged
in developments l Healthwatch commissioned to facilitate series of well
publicised public meetings attended by over 200 members
of the public l An independent Cumbria wide review of maternity services
commissioned and completed in November 2014; report
recommendations received in March 2015
What have we improved?
✓
Engagement plan targeted to our staff through staff
roadshows and anonymous survey (159 members of staff).
A summary leaflet explaining the proposals attached to all
staff pay slips in October 2014
✓
✓
Anonymous questionnaire provided over 500 responses
Formal response provided to Healthwatch following public
meetings; response to issues raised published on internet
✓
in May 2015
Five key acute medical pathways outlined in the clinical
strategy reviewed by the clinical senate are being taken
forward by clinically-led workstreams; cardiology, and
upper GI pathways changes successfully implement;
respiratory pathway changes awaiting OSC consideration.
Stroke strategy supported by Board and awaiting
agreement with the CCG; work ongoing in relation to
✓
pathways for deteriorating patients
A new model of care being refined cross-system for children
and young people; an acuity audit completed to consider the
acute needs of children presenting at WCH
✓
Robust governance arrangements internally to progress the
work; recognising the importance of clinical engagement
the project Board for each workstream is led by a
senior clinician
✓
A Trust change team has been established to support the
workstreams and to facilitate Trust wide improvements
Recommendations where we have ongoing improvement plans in place at 31 March 2015
What did the CQC inspection identify and recommend?
In addition to the ratings the Trust had 43 ‘must do’ actions and 32 ‘should do’ actions to implement. As at the end of
March 2015 the Trust has implemented 58% of the ‘must do’ actions and 75% of the ‘should do’ actions. For those actions that have not been fully delivered by 31 March 2015, improvement plans are in place which are linked to longer term programmes of work across the Trust.
This includes: l Recruitment of additional medical and nursing staff l Implementation of the epidural service at the
Cumberland Infirmary l Implementation of the clinical strategy and planning
services to meet best practice l Delivery of NHS Constitutional standards l Improvement in estates, equipment and storage l Improving the services for children with mental
health needs l Continuing to develop an open and transparent culture
In March and April 2015 the Trust has had a follow up re-inspection by the CQC and the report is awaited.
34 | Quality Account 2014/15

Comprehensive accessible information is an asset of fundamental value to the NHS. It is a critical factor to support decision making in clinical and management settings. Accurate and timely information is essential to ensure high quality patient care, to improve patient safety, thus ensure a safe environment and to protect them from avoidable harm (The NHS Outcomes
Framework 2012/13 at a glance and NICE Quality Measures) and to maximise income recovery.
The Trust again was not scheduled for a national external clinical coding audit in 2014/15.
The information team have a responsibility to improve data quality across clinical and management systems. Existing and new activities are detailed below to maintain and improve
Data Quality initiatives: l Improve and maintain the quality of data within the Trust l Manage and maintain standard operating procedures
(SOPs) Trust wide for the data collection and validation l Raise awareness of the Data Quality Standards l Work closely with clinicians and managers to reduce
replication in data recording of clinical and
management data l Discuss, agree & make recommendations to the Executive
Team regarding the most appropriate technical definition
in relation to recording of patient attendances &
admissions where there is lack of clarity l To discuss and reconcile schedules to legally
binding contracts l Review monthly published national Data Quality (DQ)
dashboards to ensure DQ performance is maintained
and improved l Ensure that staff take responsibility for the data that they
record and manage l Review and action audit reports in relation to Data Quality l Review the Data Quality standards within the Information
Governance Toolkit.
l Review and develop the Business Intelligence Portal to
improve access and use of data across the Trust
Information Governance
Information Governance (IG) is the way in which the NHS handles all information; in particular the personal and sensitive information of patients and staff. Following strict Information
Governance guidelines enables the Trust to ensure that personal information is dealt with legally, securely, efficiently and effectively, in order to deliver the best possible care to our patients. The Information Governance Toolkit (IGTk) is the way we demonstrate our compliance with Information Governance standards.
The table below shows the Trust’s IGtk position against previous years’ results:
Financial Year
Overall IGtk Result
2014/15
85%
2013/14
85%
2012/13
84%
The Trust’s results have overall remained steady, with an emphasis on consolidating the previous year’s achievements and ensuring that the evidence provided for compliance is robust.
www.ncuh.nhs.uk | 35

This part of the Quality Account describes our review of our quality performance. This includes what we have delivered against last year’s priorities, our core performance against the NHS Constitutional Standards as well as a review of other significant quality issues during the year. For 2013/14 we set 23 safety and quality priorities. What we have delivered is summarised in the table below.
What we said we would improve
Staffing levels to match patient acuity
What success measures did we set? What did we deliver?
We will continue to make reductions in our overall mortality rate to the lower quartile and continue to reduce our harm rate
>90% of accurately recorded and escalated early warning scores
We have failed to be consistently > 90% on all 4 NEWs audits and so have failed to achieve the goals set this year
However of the 4 measures (Observations,
NEWs calculations, Escalation at Moderate and High) we are above 90% for all except the moderate escalation category and have improved performance in all parameters, this is as a result of changed tools and support for ward staff
We have undertaken an Rapid improvement workshop NEWs on admission and have a clear process for that as well as identifying goals for 2015/6 (and means to implement them), including reduced cardiac arrest as measured by NCAaudit
We will establish a system to review and reduce surgical site infections (SSI)
Safer Surgical Checklist
Reduction in Never Events
50% improvement for the number of patients with a care bundle in place for key conditions
The numbers of bundles continue to increase across the Trust across all conditions
100% of handovers will be done using standardised documentation
We will see a 20% reduction in our SSI rate
100% compliance with safer surgery checklist in theatres and day surgery
We will reduce the number of Never
Events and have no repeat events
SBAR tool introduced but not all handovers are standardised. This is a continued priority for us in 15/16
We have introduced robust systems for SSI monitoring but these have not been running long enough to demonstrate a reduction in
SSI rate
This has been implemented and regular audits are in place to ensure compliance is monitored
The Trust had a retained swab and wrong site never event in 2014/15
Access and quality of healthcare records
50% reduction in the number of lost or unavailable medical notes
Repeat the nursing acuity review
95% case note availability achieved from a baseline starting position of 72% availability
The third nursing acuity review was completed and recommendations presented to the Board
36 | Quality Account 2014/15

What we said we would improve
What success measures did we set?
What did we deliver?
Our compassion and kindness
20% improvement in our baseline for kindness and compassion
In 2014 5263 patients gave a score of
97.2% for kindness and compassion - in the first 4 months of 2015 this had improved to 98.8% according to feedback from 1485 patients
100% of all wards to have completed the timeout programme
All wards have completed the time out programme
Care for vulnerable patients
We will develop and approve a
Dignity Framework for implementation with our partners
We have agreed to chair a multi-agency
Dignity and Prevention group on behalf of the Cumbria Safeguarding Adults Board involving our key partners
Care of the frail elderly
90% of patients to receive a comprehensive elderly care assessment
The Trust use the ‘Silver Book’ for comprehensive geriatric assessment and is currently auditing compliance to target improvement for 15/16
Our co-ordination of improvement priorities from our patient experience programme and associated surveys.
End of life care
Improvement priorities will be triangulated from the evidence from patient experience feedback and complaints
‘You said, we did’ boards implemented in all clinical areas
80% of appropriate patients will have completed ‘deciding right’
Deciding right piloted during Q4 2014/15 and Q1 2015/16 www.ncuh.nhs.uk | 37

REVIEW OF QUALITY PRIORITIES
What we said we would improve
What success measures did we set?
What did we deliver?
Our performance in NHS
Constitutional Standards
Achieve A&E 95% standard, 18 weeks
RTT and cancer standards
The Trust will continue to work with key partners across health and social care to deliver compliance with the standards set out in the NHS Constitution.
This will involve an active approach to managing capacity and demand in elective and non-elective services. The Trust will improve performance against the four hour standard by reducing non elective admissions and developing a robust discharge criteria with community and social care.
All cancer standards will be reviewed at modality level to ensure capacity is aligned to demand.
Number of patients cancelled
50% reductions for patients cancelled for outpatients and operations
The Trust will continue to work with key partners across health and social care to deliver compliance with the standards set out in the NHS Constitution.
This will involve an active approach to managing capacity and demand in elective and non-elective services. The Trust will improve access to elective care by reducing cancelled operations and increasing out patient and theatre efficiency.
Quality of responses and action taken on complaints
Car parking
Patient environment
20% reduction in second time complaints, 20% reduction in complaints re compassion, 10% improvement in complaint satisfaction, 80% compliance within agreed timeframe
20% reduction in complaints and concerns regarding car parking
We will meet the national average for
PLACE scores
During the reporting period we have seen an increase in the quality of our complaint responses following the introduction of an improved checking process. The Director of Nursing and
Midwifery sees all complaint responses and assesses them for the tone and level of compassion. As a result the second time complaints whilst these have not reduced by the target 20%, the analysis shows it is the clear understanding of the outcomes within the responses that have resulted in the second complaint, rather than the level of compassion.
There are instances where the sincere apologies given have been gratefully accepted. The complaint satisfaction questionnaires have revealed there has been a small increase in satisfaction from 25% to
30%. The Trust has responded to more than 93% of complaints within the agreed timeframe.
The Trust has approved a plan to improve car parking availability but this remains a patient and public concern
The national averages were not met in any domain apart from Food & Hydration at WCH.
Work has been carried out to improve all domains at CIC for the next assessment and at WCH some work has been carried out although scores will not fully improve in the environment/condition domain until the new building is occupied due to the age of the hospital
38 | Quality Account 2014/15

What we said we would improve
The reporting and benchmarking of clinical outcomes
What success measures did we set?
What did we deliver?
Clinical outcome and benchmarking data will be included in the Trust’s quality performance reports
Improved reporting on surgical outcomes has been achieved during the year
The development and standardisation of clinical guidelines
100% of standardised clinical guidelines are in place
Strengthened governance processes have been implemented on clinical guidelines which will continue during 2015/16
Quality of responses and action taken on complaints
We will repeat the gap analysis against the national requirements to ensure our progress is in line with national requirements. The clinical and financial strategy will set out plans for achieving seven day working
The Trust undertook the NHSIQ Seven Day
Services Self-Assessment tool during
2014/15. Clinical strategy development and improvement initiatives were designed to enable achievement of seven day standards www.ncuh.nhs.uk | 39

REVIEW OF QUALITY PRIORITIES
What we said we would improve
What success measures did we set?
What did we deliver?
Our organisational strategy for safety and quality improvement
We will develop our strategic approach to safety and quality, including 4 key quality improvement programmes which will be implemented systematically across the
Trust. We will achieve all wards having
100% of board to ward system in place
We developed a quality strategy for the Trust and the change team have led on key improvement programmes during the year, including NEWs on admission and handovers.
A heat map has been developed to measure ward to board indicators. All wards have the board to ward quality boards in place
Our Quality Governance scoring
Improve our score of less than 9.5
The Trust was independently reassessed in
June 2014 and a score of 6.5 achieved
The overall experience of our staff
Achieve the national average for staff who have received relevant job training, communication with senior management and support from line manager
2014 staff survey results outline that we are average for relevant job training, but we are in the worst 20% performance for communication with senior managers and support from line managers
The recruitment of more nurses and doctors
Reductions in vacant consultant and nursing posts by 31 March 2015
Nursing vacancies have decreased, however medical staff vacancies have increased.
We continue to use significant locum medical staff.  We are pursuing more international recruitment for qualified nursing staff and we have recently recruited 44 student nurses to commence in qualified posts in September 2015.  We have also recently recruited 16 qualified nurses who are new starters to the Trust
40 | Quality Account 2014/15

As stated earlier a proportion of North Cumbria University Hospital NHS Trust’s income in 2014/15 was conditional on achieving the agreed quality and innovation goals as agreed with our commissioners through the Commissioning for Quality and Innovation
Payment Framework (CQUIN).
The Trust is currently in discussions with Cumbria Clinical Commissioning Group (CCG) to agree the final position in terms of our performance and income earned against the following indicators. Once agreed, this information will be published on the
Trust’s website.
Indicator Name
Friends and Family Test – Implementation of staff FFT
Friends and Family Test - Early Implementation
Friends and Family Test - Increased or maintained Response Rate
Friends and Family Test - Increased Response Rate in acute inpatient services
NHS Safety Thermometer - Improvement Goal Specification
Dementia - Find, Assess, Investigate and Refer
Dementia - Clinical Leadership
Dementia - Supporting Carers of People with Dementia
Transition to adulthood for young people with specific long term conditions
Seven day service clinical standard 2
Seven Day Working - improved turnaround and Length of stay
Patient Flow early in day discharge
Patient Flow short stay adult pathways
Improving Falls Care
Improved standardisation of care
Medication Safety Thermometer National Pilot
Specialist Commissioning Quality Dashboards
Shared Haemodialysis Care
Post-Operative Discharge Information
Improved Access to breast milk in preterm infants
Available Income
£143,000
£71,000
£191,000
£71,000
£286,000
£114,000
£19,000
£57,000
£429,000
£429,000
£429,000
£343,000
£429,000
£429,000
£429,000
£515,000
-
£110,000
£81,000
£110,000
£4,685,000 www.ncuh.nhs.uk | 41

REVIEW OF QUALITY PRIORITIES
Complaints are a vitally important source of information for the Trust as they provide a window into patients’ views regarding the quality and standards of care they receive within the Trust.
During 2014/15 we have continued with the refining of the data entered onto our systems and this has enabled us to provide increasingly detailed analysis by hospital site, service, department and personnel that ensure the clinical and management teams within the Clinical Business Units to identify areas for improvement.
The NHS Complaints Regulations (2009) requires the Trust to report on a number of key performance indicators and the table below demonstrates performance for 2014/15 in comparison to that of 2013/14.
Complaint Performance Indicators
New complaints received
Acknowledged within three working days
Complaints closed
Closed within agreed timeframe (target 95%)
Number of well-founded complaints
2013/14
366
354 (99%)
404
128 (32%)
280
2014/15
377
373 (99%)
378
353 (93%)
263
The Trust has a target of responding to 95% of complaints within the agreed timeframe. The above data demonstrates the significant improvements made in comparison to 2013/14 and that we narrowly missed the 95% target. This was due to a reduction in performance during the first quarter of 2014/15 but following this we have improved performance and the graph below demonstrates that even though we exceeded the 95% target for quarters three and four it was insufficient to achieve the target for the year.
42 | Quality Account 2014/15

The Trust received a visit from the Chief Inspector of Hospitals during 2014/15 and whilst there was acknowledgement of the improvement in performance in the handling of complaints the Trust has built upon the following key areas that were identified as requiring further targeted work:
Process l Revision of the facilitation of decisions for independent
reviews of complaints
Training l Bespoke training to staff as required l Revision of the “Trust Guide to Investigating Complaints”
Scrutiny and assurance l Independent Assurance Panel of shadow Patient Governors
meetings increased to monthly
Performance l Development of further key performance indicators (KPIs)
along with escalation were introduced during January 2015,
this specifically includes and internal KPI to monitor
complaints which have been open greater than 50 days. l Weekly performance review meetings with complaint leads
to support the achievement of these revised KPIs
Learning from complaints l Identification and reporting of themes within the quarterly
Safety & Quality Report to Trust Board
Acting on the complaints we receive
The Trust takes very seriously the learning from complaints and believes it equally important as the robust handling and compassionate responses needed. Analysis was performed on the key themes from complaints and identified three specific areas:
Diagnosis & Treatment Appointment Issues Information & Communication
Some of our serious complaints relating to diagnosis and treatment have also been investigated as serious incidents.
These in-depth investigations result in recommendations and robust action plans that are showing improvements in the quality of care provided.
Care bundles continue to be developed and implemented which standardise and improve the standards of care for specific conditions.
The Hospital at Night team continues to evolve with plans in place to standardise working practices.
The plan to improve medical and nursing recruitment remains in place and is yielding results but there are some areas that remain a challenge which the Trust
Board is monitoring closely.
The main issue with the appointments is the delays and waiting times in outpatient departments along with cancellations of outpatient appointments.
With the opening of the Contact
Centre in February 2015 the processes are being finalised. The move to full recruitment will support the improvements required to reduce delays and cancellations.
Some of the complaints received relating to information have been as a result of missing or mislaid medical records during patient outpatient appointments.
The Medical Director led a project during 2014/15 to improve the management of records within the
Trust and the progress has been reported to the Trust Board during the year.
Communication has also been a theme during 2014/15 and this has been from medical and non-medical staff.
Teams have participated in reflection to better understand how their behaviour affects the patient experience.
In addition there is a patient story shared at each Trust Board so the learning is available throughout the organisation. www.ncuh.nhs.uk | 43

REVIEW OF QUALITY PRIORITIES
Independent review of complaints
The Trust has commissioned 15 independent reviews of complaints during 2014/15. Five of these were internal with the remaining ten performed by external experts. This was in response to a recommendation from the Chief Inspector of
Hospitals’ visit in April 2014. The learning from these reviews has been implemented within the Trust and reported and shared at the Clinical Policy Group and within the Business structures.
Independent Complaints Assurance Panel
This has been introduced during 2014/15 and the shadow patient governors review the way the Trust has handled complaints. This panel focusses on standards of communication, accurate documentation of the processes followed during the handling and the standard of the response sent to the complainant. The results of these panels are shared with the
Business Units by reporting to the Safety & Quality Committee and there is evidence that there is improvement in the handling of complaints within the Trust.
Parliamentary Health Service Ombudsman (PHSO)
During 2014/15 the Trust received seven new enquiries from the
Ombudsman compared to the 16 received during 2013/14.
All these seven progressed to investigation and at the time of writing all have been concluded with five not upheld, one partially upheld and one terminated at the request of the family.
In addition the Ombudsman concluded six further investigations; five from 2013/14 with four being partially upheld and one from
2012/13 also partially upheld. The Trust has responded as requested by the Ombudsman within the timeframes given and the action plans have been completed.
44 | Quality Account 2014/15

The National Patient Safety Agency (NPSA) Seven Steps to Patient Safety (2004), notes that organisations that promote incident reporting create a safety culture amongst all disciplines of staff to learn, share lessons and implement solutions to prevent harm.
The Trust submits patient safety incidents to NRLS each month and as described in section 2.4.6 and we are now benchmarked against other Acute (non-specific) Trusts.
The latest benchmarking data for the period April to September 2014 confirmed the Trust reported 33.92 incidents per 1000 bed days against an average of 35.9 per 1000 bed days.
This demonstrates the Trust has maintained the improvement in reporting commenced during 2013/14, and this key safety and quality priority continues to be monitored on a monthly basis and reported to the Trust Board. The graph below summarises the levels of incident reporting during the last three years:
Never Events
Never events are a sub-set of serious incidents that are described as:
“serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers”
During 2014/15 the Trust reported two never events; both have been subjected to thorough investigations and have robust action plans in place that fulfil the recommendations. These action plans have been implemented, audited and monitored by the Trust
Board during the year. In addition, following the completion of the investigation they have undergone an external independent review to ensure all the recommendations have been fully embedded throughout the Trust.
www.ncuh.nhs.uk | 45

REVIEW OF QUALITY PRIORITIES
The Trust continues to monitor mortality rates by using the Summary Hospital Mortality Indicator (SHMI). The Summary Hospitallevel Mortality Indicator (SHMI) is an indicator which reports on mortality at Trust level across the NHS in England using a standard and transparent methodology. It has been produced and published quarterly since October 2011. The Trust’s current performance falls well within the control limits.
The SHMI is the ratio between the actual number of patients who die following hospitalisation 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. The SHMI, which includes deaths within 30 days of discharge, continues to improve and falls within expected limits.
46 | Quality Account 2014/15

Weekly Mortality Reviews
A specific quality improvement for the Trust has been the weekly mortality reviews which occur at both hospital sites. The focus of the reviews is on the delivery of quality care and understanding the reasons why patients die whilst in our care. This is fundamental to learning and embedding a culture of safety within our organisation. The learning from the reviews is published regularly by the
Associate Medical Director and is communicated directly to nursing and medical staff.
The Trust has been successful in continuing to reduce the actual (observed) death rate and the graph below illustrates this improvement. Some of the key interventions which have been taken over the last three years are also identified.
www.ncuh.nhs.uk | 47

REVIEW OF QUALITY PRIORITIES
Safeguarding covers all aspects of ensuring the safety of children and vulnerable adults.
“Safeguarding children is more than child protection and can be defined as the action we take to promote the welfare of children and protect them from harm. It is everyone’s responsibility.
Everyone who comes into contact with children and families has a role to play.” Working together to safeguard children
(HM Government 2013).
Safeguarding Adults procedures apply to an adult who has needs for care and support and is experiencing or at risk of, abuse or neglect and as a result of those needs is unable to protect themselves from the experience of or the risk of abuse or neglect
(Care Act 2014).
Serious case reviews
All serious case reviews are reported to Trust Board through the Safety and Quality Committee report and summarised in the Trust Board safeguarding report. All actions and recommendations are included in the work plan and monitored through the quarterly Safeguarding Board. As part of the Trust’s contract with the commissioners an annual safeguarding audit is required and monitored through the CCG quality group.
Safeguarding training
Safeguarding training forms part of the mandatory requirement for all staff. All staff, volunteers and contractors have to undergo safeguarding training to ensure that they are aware of the signs of abuse and neglect and know how to respond. However there are varying levels of safeguarding training as determined nationally and those staff who work directly with vulnerable patients have a more comprehensive training.
A local training target of 80% of NCUHT health practitioners to have completed the appropriate level of safeguarding training during 2014/15 was agreed with our commissioners.
The table below demonstrates the results for 2014/15 of those staff required to complete the different levels.
Safeguarding adults
The Trust has executive representation at the Cumbria
Safeguarding Adults Board (CSAB) and information is shared internally through the Trust Safeguarding Board. The Care Act
2014 has placed Safeguarding Adults on a statutory footing with the key principles being: l l l
EMPOWERMENT - making safeguarding personal, person
led and outcome focussed l PREVENTION - raising awareness, multi-agency training l PARTNERSHIP - co-operation with relevant partners l ACCOUNTABILITY - policies and procedures, information
sharing and reporting
PROPORTIONALITY - least restrictive outcomes
PROTECTION - recognising and reporting neglect or abuse
Training Level 1 2 3
Safeguarding Children
The Trust has representation on all relevant Cumbria Safeguarding
Children Board (LSCSB) sub-groups and information is shared internally through the Trust Safeguarding Board.
Safeguarding Children 94 91 81
Safeguarding Adults 91 71
During 2014 ‘Safeguarding children and young people: roles and competences for health care staff’ (3rd edition) was published by Royal College of Paediatrics and Child Health and this guidance has provided the benchmark for both the content and frequency of training. Formal safeguarding children training is by monthly drop in sessions and informal supervision.
Our training records are monitored through the Workforce
Committee, Safeguarding Board and the Safety and
Quality Committee.
CQC Inspections for safeguarding
The CQC undertook a review of health services for safeguarding and looked after children arrangements in North and South
Cumbria in December 2013 and the report was published in
January 2014. The review focused on the effectiveness of health services for looked after children and the effectiveness of safeguarding arrangements in the Trust for all children.
The review evaluated how risk factors were understood, whether needs were identified, assessed and responded to, how staff communicated with children and their families and our contribution to multi-agency working across the child’s journey.
The review followed a joint Ofsted/CQC inspection carried out in April 2013 which found that local health safeguarding arrangements and provision of health care for looked after children and care leavers was inadequate.
A number of recommendations for the Trust were made and the majority have been fully addressed:
48 | Quality Account 2014/15

l NCUHT now has an alert system which is monitored
weekly to ensure accuracy. This informs frontline staff of
children on child protection plans and those who are looked
after. The alerts are used consistently to contribute to the
child’s safeguarding assessment when they attend
the hospitals.
l Work continues across the safeguarding economy to
strengthen systems for data management and information
sharing to ensure it is secure, up to date, and enables
timely transfer and follow up of concerns between
local organisations.
l A fully comprehensive training programme which meets
the requirements of the intercollegiate standards and NICE
guidance for safeguarding and looked after children has
been introduced. Safeguarding champions have been
identified in A&E and medical assessment units, child
health business unit, ITU, Midwifery and Obstetrics &
Gynaecology departments. These champions have received
two days additional training in supervision skills and a
supervision framework has been ratified by the
Safeguarding Board. Quarterly Safeguarding Supervision
commenced at the end of 2014. l The Trust’s annual safeguarding children record keeping
audit highlights that changes are becoming embedded
- 87% of children attending the Trust underwent a routine
safeguarding assessment, that in the majority of cases
concerns are discussed with parents and/or the young
person and a clear action plan is determined.
l The audit also showed that 91% of the sample had a record
of key information about children’s identity, faith and
ethnicity to ensure practice is sensitive to and reflective of
all aspects of a child’s life.
l The Trust has introduced electronic safeguarding children
operational guidance to support staff when managing the
varied aspects of safeguarding children, this guidance
clearly highlights the appropriate referral pathways in the
management of young people and those with parental
responsibilities who present at Accident and Emergency
Departments (A&E) or minor injury units under the
influence of alcohol or drugs. Work is on- going across the
health economy to strengthen joint systems to ensure a
seamless service.
l The annual safeguarding children audit highlighted that
100% of the sample were referred to the paediatric liaison
nurses. Joint working between the paediatric liaison service
and the safeguarding team continues to strengthen and
work is ongoing to standardise this service across
the county.
l Multi-agency threshold guidance is fully explored within
safeguarding children training to strengthen joint
approaches to risk management with children’s social care,
ensuring cases are managed at the appropriate level.
Referrals to the Multi-agency Safeguarding Hub have
massively reduced (quarter 1-2 – 55 referrals, quarter
3 - 11 referrals). As the amount of information to named
nurse forms hasn’t reduced it is speculated that
practitioners have an increased awareness of community
support services and are referring to more appropriate early
help services.
l Work continues across the health economy to implement
clear pathways for managing the care of children and
young people who self-harm. The Trust has introduced
training in mental health challenges for paediatric nurses
to promote their confidence and competence in providing
the very best care for these vulnerable young people.
l Multi-agency work is being co-ordinated by the LSCB to
implement clear strategies for the identification and
reporting of sexually harmful behaviour and child sexual
exploitation to ensure a robust shared response in meeting
individual need.
The recommendation that NCUHT ensures full coverage of appropriately trained nursing and medical staff working with children and young people in A&E has proved difficult to address in full given financial constraints and this is the sole action to be at risk of not being completed within the required timescale.
A business case to obtain funding to increase the establishment of paediatric nurses with the Emergency Department was unsuccessful. Therefore systems have been instated to ensure timely and appropriate assessment of children and young people.
l All practitioners have undergone paediatric life support to
promote their skill in recognising and responding to serious
illness in a child.
l All staff undergo formal level 3 safeguarding children
training which is supplemented by bespoke safeguarding
supervision and monthly drop in sessions.
l Triage assessment includes an explicit safeguarding
assessment tool (CWILTED). Practitioner’s use of this tool
is randomly audited on a monthly basis.
l Triage assessments also include recognising and responding
to children’s pain. There are specific tools available for this
and all practitioners have had further training in recognising
and responding to children in pain.
l Play specialists have been requested to assess the children’s
area within the Emergency department to offer advice and
support in providing appropriate play and
distraction for children.
l Work has commenced in designing a leaflet for parents to
give information about what they can expect during their
child’s attendance at NCUHT.
l Much work has been done with safeguarding partners from
community health and the local authority to promote the
use of the early help framework and assessment tool. www.ncuh.nhs.uk | 49

REVIEW OF QUALITY PRIORITIES
An initial early Help Assessment is completed with all
teenagers to analyse need and improve outcomes for
children and their parents. l Teenage Pregnancy Pathway - fully implemented May
2014 across both sites. From 1 April targeted at age 18
and under at delivery.
Children Act (2004) Section 11 Audit
The Trust’s annual Children Act (2004) Section 11 audit in 2014 determined that the Trust was not fully compliant with the requirements of section 11 in four aspects; we have fully addressed three challenges: l The commissioning process of services procured by NCUHT
includes a requirement upon the commissioned
organisation to safeguard children. Interserve have now
evidenced that they have a safeguarding children and
adults policy and provide training for staff to ensure that
they are aware of what constitutes abuse and staff
responsibilities when abuse is suspected. Assurance has
been given that all Interserve employees undergo DBS
scrutiny before employment l An effective complaints process is in place and available to
all child and adult service-users
Age appropriate information about the complaints
procedure is widely available in paediatric areas l Staff and volunteers are aware of their responsibilities if
they are concerned about a child or young person and know
the procedures to follow in such circumstances
All education and training materials reflect local and
national guidance as directed by the intercollegiate
document (2014).
Much progress has been made in meeting the final challenge that: l Service development plans are informed by the views of
children and families.
The Operational Service Manager, Child Health is leading
work to ensure that the views of children indicated in ‘I
want great care’ and ‘family and friends’ survey is fed into
service development plans. The manager also represents
the Trust at the Cumbrian Parent and Carers’ forum.
For 2015/16 our challenge remains to ensure that safeguarding children and adults continues to be embedded within the role of each practitioner and that everyone recognises it is their responsibility. This ethos is furthered by the provision of the safeguarding team newsletter, safeguarding drop in sessions and safeguarding case reflection. It is a challenge for all practitioners to make time to attend safeguarding education/reflection sessions but the team continue to consider ways in which we can address this.
We continue to consider ways service development plans are informed by the views of children and families.
We must also work with our safeguarding partners to ensure that there are consistent, robust referral pathways once children and those with parental responsibilities experiencing challenges with substance misuse.
It is vital that we continue to highlight and address the lack of suitable accommodation for those children and young people who self-harm and/or experience mental health challenges within our county.
50 | Quality Account 2014/15

Developed for the NHS by the NHS as a point of care survey instrument, the NHS Safety Thermometer allows teams to measure harm and the proportion of patients that are harmed. Harms that occur prior to admission and post admission are recorded.
The NHS Safety Thermometer provides a ‘temperature check’ on harm and can be used alongside other measures of harm to measure local and system progress.
‘Harm free’ care is a national programme that helps NHS teams to eliminate harm in patients from four common harms: l Pressure ulcers l Falls l Urinary tract infections in patients with a catheter
New venous thromboembolism (VTE)
These harms affect over 200,000 people each year in England alone, resulting in avoidable suffering and additional treatment for patients and a cost to the NHS of more than £400 million.
The ‘harm free’ care programme supports the NHS to eliminate these four harms through one plan within and across organisations. It helps organisations to consider complications from the patient’s perspective, with the aim of every patient being ‘harm-free’ as they move through their care pathway.
How we assess our performance
The ward manager/deputy ward manager assesses all patients on their ward against the four harms on a nationally set day each month.
The National CQUIN target set by the Department of Health for all Trusts was to deliver 95% harm free care on the four identified harms. The Trust achieved this and reported 96% harm free care in March 2015.
On average from April 2014 to March 2015, the Trust reported
96% harm free care.
Preventing Healthcare Associated Infections
MRSA
The Trust has a trajectory of zero-apportioned MRSA bacteraemia cases in 2014/15. There was a single case of MRSA in March 2015,
18 months after our last case. The case has undergone a post infection review and this has been submitted to Public Health
England. It involved an elderly patient who was admitted with falls probably due to postural hypotension, the patient was subsequently identified as having possible septic arthritis and later died due to a bowel malignancy. The MRSA bacteaemia was identified shortly after admission but outwith the time interval for a community-acquired case, the main area of concern was commencing intravenous antibiotics prior to taking blood cultures.
C-DIFFICILE
The Trust was given a trajectory of 37 cases of C-difficile for
2014/15, this was achieved with 36 recorded cases for the year.
Although this was a significant improvement on earlier years
(we had 56 cases in 2012/13) it was a 50% increase from
2013/14. When we have analysed the reason for this we believe the main causes are an increase in testing, we had 25% more samples in 2014/15 some of which will be due to significant issues with norovirus infection on both hospital sites; we also have significant concerns in relation to cleaning on the
Cumberland Infirmary site with the norovirus outbreak highlighting these issues; finally we believe we can make significant improvements in antibiotic prescribing.
A robust service improvement plan has been developed to address all of the above.
NOROVIRUS
Over the first 16 weeks of 2015 there were 333 cases of norovirus seen in the hospital or community; 62 of these cases occurred within the first 48 hrs of admission (33 at Cumberland Infirmary,
29 at West Cumberland Hospital). 261 of the cases occurred after
48 hours (215 at Cumberland Infirmary, 46 at West Cumberland
Hospital). This represented a major outbreak for the organisation.
Additional support was provided from the Trust Development
Authority (TDA) in weeks 3 and 4 and the Clinical Commissioning
Group (CCG) reviewed control measures in place within clinical areas. The multiagency debrief meeting identified a number of contributory factors in particular the following required improvement in preparation for any future outbreaks: l Better staff compliance with infection prevention and
control measures l Where possible alter the physical design of the Cumberland
Infirmary site so as to reduce the risk of spread such as doors
on open bays which facilitated the spread of norovirus l A higher standards of cleaning and waste management
is required
SURGICAL SITE INFECTION
The Trust has appointed two surgical site infection surveillance nurses who have commenced performing Root Cause Analysis on all deep seated infections following hip or knee replacement surgery. They will follow up all patients who have undergone surgery to ensure the data we collect is as accurate as possible and have worked with others to develop and audit measures such as peri-operative warming so as to minimise the risk of surgical site infection.
Financial year
2012/13
2013/14
2014/15
Financial year
2012/13
2013/14
2014/15
MRSA cases
1
1
1
C-difficile cases
56
24
36
NCUH rate per
100,00 bed days
0.5
0.5 (estimated)
0.5 (estimated)
NCUH rate per
100,00 bed days
30.6
13.1 (estimated)
19.8
National average rate per 100,000 bed days
1.2
Not available
Not available
National average rate per 100,000 bed days
17.3
Not available
Not available www.ncuh.nhs.uk | 51

REVIEW OF QUALITY PRIORITIES
The Department of Health (DH) Operating Framework details the compliance regime of minimum standards that NHS organisations must achieve. The DH describe these as the most significant priorities. We monitor our performance and report the outcomes to the Trust Board at each meeting.
The Trust has a number of improvement plans in place to support the delivery of the NHS Constitutional standards, which includes support and scrutiny by the Trust Development Authority.
The table below summarises the Trust’s performance during 2014/15:
Compliance Framework
The Trust has registered the 16 essential safety and quality standards without conditions with the Care Quality Commission
A 30% reduction in Clostridium difficile
Zero MRSA cases
31 day wait for second or subsequent treatment: anti cancer drug treatment
31 day wait for second or subsequent treatment: surgery
31 day wait for second or subsequent treatment: radiotherapy
Target 2014/15 Q1
Yes
37
0
98%
94%
94%
Yes
4
0
Q2
Yes
10
0
97% 98%
Q3
Yes
10
0
98%
Q4
Yes
12
1
95%
100% 94% 100% 96%
88% 96% 100% 97%
62 days from urgent GP referral to first treatment for all cancers, each quarter
62 days for first treatment from national screening service, each quarter
85%
90%
80% 83%
94% 86%
82%
78%
75%
73%
96% 98% 98% 99% 96% 31 days from diagnosis to first treatment
Maximum waiting time of 14 days from urgent
GP referral to first appointment
Maximum 2 week waiting time when a GP refers to the breast clinic
A & E 4-hour waiting
18 week referral to treatment:
93%
93%
95%
90% 89%
92% 91%
94% 96%
89%
94%
88%
91%
88%
80%
90% 79% 70% 72% 75% i) admitted patients ii) non-admitted patients iii) incomplete pathways
Self certification against compliance with requirement regarding access to healthcare for people with learning disabilities
95%
92%
93% 91%
88% 85%
90%
88%
91%
89%
2014/15 Met/Not Met
Yes
36
1
97%
97%
95%
81%
83%
98%
90%
91%
90%
74%
91%
89%
Met
Met
Not Met
Not Met
Met
Met
Not Met
Not Met
Met
Not Met
Not Met
Not Met
Not Met
Not Met
Not Met
Met
The Trust Board are committed to delivering the targets; improvement plans are in place to secure compliance as early as possible during 2015/16.
52 | Quality Account 2014/15

Patient-Led Assessments of the Care Environment (PLACE) are a self-assessment of a range of non-clinical services which contribute to the environment in which healthcare is delivered in the both the NHS and independent/private healthcare sector in England. Participation is voluntary. These assessments were introduced in April 2013 to replace the former Patient
Environment Action Team (PEAT) assessments which had been undertaken from 2000 – 2012 inclusive. These are the second results from the revised process.
The PLACE programme aims to promote the above principles and values by ensuring that the assessment focuses on the areas which patients say matter, and by encouraging and facilitating the involvement of patients, the public and other bodies with an interest in healthcare (e.g. local Healthwatch) in assessing providers in equal partnership with NHS staff to both identify how they are currently performing against a range of criteria and to identify how services may be improved for the future.
PLACE
Cleanliness
CIC
90.98
WCH
91.30
NATIONAL AVERAGE
97.25
Lower than average
Food &
Hydration
79.75
91.96
88.79
Lower than average (CIC)
Higher than average (WCH)
Privacy,
Dignity &
Wellbeing
76.12
82.90
87.73
Lower than average
Condition,
Appearance &
Maintenance
77.11
75.92
97.97
Lower than average
Due to changes in the assessment methodology and scoring, the
2014 results for Food & Hydration and Privacy, Dignity &
Wellbeing are not considered to be directly comparable with
2013 results.
Where the need for improvement has been identified, this will be addressed via the Trust’s CQC Compliance framework.
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REVIEW OF QUALITY PRIORITIES
Patient experience is a fundamental part of how we now think about the quality of healthcare. Our approach has been to identify effective ways to spread good practice in order to accelerate the changes we need to make to become more person, family and staff centred.
We know there is good evidence of the benefits of delivering care in this way in terms of clinical outcomes, staff satisfaction and retention, appropriateness of service use and length of hospital stay.
Throughout the year, North Cumbria have continued to provide effective measurement and recording of patients views of our care and listening to the feedback of over 30,000 people.
Hospital
Workington Community
Hospital
West Cumberland Hospital
Penrith Hospital
Cumberland Infirmary
Score
84%
83%
82%
82%
Respondents
119
462
50
2076
Outpatient results (externally produced and validated)
There were no national outpatient surveys carried out in
2014/15. To understand our patients’ experience of outpatient services, the Trust uses a company called Patient Perspective, a
CQC approved contractor, who follow up and survey patients two weeks after they have received care.
We call this our ‘right time’ data, it is a time when research shows that most patients are likely to be at their most dissatisfied about their care and perhaps most free to tell us why.
The survey methodology is similar to the national patient survey programme - the survey is based around questionnaires mailed to patients at home shortly after discharge. However, the survey is also available online for respondents. Questionnaires are mailed out each week throughout the year with reminders sent after two and four weeks to non-responders.
During 2014 Patient Perspective sent out 7,500 outpatients questionnaires on the Trust’s behalf; 2,740 people responded which equated to a 37% response rate.
Key areas to note l The Trust is in the top 20% of all Trusts for 9 of the 19 most
important questions for patients l On the remaining questions, the Trust is in the middle
60% of Trusts l On average 96% of outpatients would rate the Trust as
excellent, very good or good l There is little variation between the sites, as follows
(sites with more than 20 responses)
Communication between doctors and patients was shown to be good.
However there were areas that we can improve: l Cleanliness of toilets l Copies of letters to patients l Information given when leaving the hospital l Information on treatment l Overall organisation of the Outpatient department
54 | Quality Account 2014/15

The next table shows a comparison of data between our hospital sites providing outpatient services in relation to national benchmarks.
National / Local
Comparisons
Cumberland
Infirmary
Penrith
Hospital
West
Cumberland
Hospital
Workington
Community
Hospital
NHS
Bottom
20%
NHS
Average
NHS Top
20%
NHS Best
Doctors 90% 94% 91% 91% 85% 87% 90% 95%
Cleanliness
Dealing with the issue
Information about discharge
Information about treatment
Dignity and respect
Organisation of the outpatients department
Overall Score
85%
88%
60%
81%
95%
72%
82%
94%
91%
41%
72%
98%
83%
82%
89%
89%
56%
82%
96%
77%
83%
94%
89%
57%
80%
97%
79%
84%
83%
83%
49%
80%
92%
74%
78%
84%
86%
56%
83%
94%
78%
81%
90%
88%
65%
86%
95%
82%
85%
96%
93%
81%
93%
99%
87%
92%
Inpatients
In 2014 we understood more about our patients’ experience of care during their stay in hospital by measuring in a number of different ways. We listened to feedback from l 1673 people who responded to Patient Perspective surveys.
l 3067 people who agreed to be interviewed as part of our Real Time programme.
l 16575 people who posted 2 minutes of your time cards to give us our Friends and Family scores.
l The published results of the National Inpatient Survey in 2014.
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REVIEW OF QUALITY PRIORITIES
Patient Perspective surveys
During 2014, 5000 inpatient questionnaires were mailed out;
1673 people responded which equated to a 33% response rate.
The Trust is in the top 20% of all Trusts on 1 question and in the bottom 20% of all Trusts in 5 of the 19 most important questions for patients. On the remaining questions, the Trust is in the middle 60% of Trusts.
The average score for the Trust is 79.4%, an improvement of
2.3% since 2013. This is above the bottom 20% of Trusts
(77.5%) but below the NHS average (80.6%).
92% of inpatients rate the Trust as excellent, very good or good.
The scores for our two hospital sites are very similar:
Site
West Cumberland Hospital
Cumberland Infirmary
Score
82%
79%
Results could be improved in these areas: l
Respondents
301
709
Involving patients in care and discharge decisions l Cleanliness and hand washing l Confidence and trust in doctors (through improved
communication) l Information about purpose of medicines and medication
side-effects
Real Time 2013/14
We a started a pilot of our Real Time programme in April 2013.
It was developed to include those things that really matter to patients and the results are demonstrating improving standards across both hospital sites.
The programme involves interviewing patients whilst they were in our hospitals. The initial pilot was on eight wards across both hospital sites - in 2014 we rolled the programme out across 24 wards in 2014 with 3067 patients agreeing to be interviewed by a team who are independent of the clinical team.
The results are collated and the ward managers receive fortnightly reports on what their patients have said about care whilst on the ward.
These results once collated are immediately available to the ward manager and his/her team and it is their responsibility to review the responses and make improvements where necessary.
The advantage of this Real Time reporting is that ward managers and their teams can act upon issues as they arise including the response to any identified themes. Changes can be made that will benefit patients in a more timely way rather than waiting for the national survey results. It is interesting to note that by the end of quarter three all but a single ward area was achieving the Trust standard of a domain average score of more than nine.
The tables below provide an end of year summary position.
Sample Size Domains KPS
No of
Patients
Surveyed
3067
Coordination
Respect & dignity
Involvement Doctors
8.96
9.78
9.32
9.60
Nurses Cleanliness
Pain
Control
Medicines
Kindness &
Compassion
Domain
Average
Recommendation
9.83
9.62
9.68
8.70
9.72
9.47
9.43
56 | Quality Account 2014/15

The improvements made comparing 2013 with 2014 is illustrated in the graph below. There have been significant statistical shifts in the domain averages and recommendation scores.
In April 2014 we chose to introduce a new measure for kindness and compassion with over 3000 patients giving an average score of 97% for this aspect of our care. The on-going improvement in communicating about medicines is also encouraging.
www.ncuh.nhs.uk | 57

REVIEW OF QUALITY PRIORITIES
58 | Quality Account 2014/15

www.ncuh.nhs.uk | 59

REVIEW OF QUALITY PRIORITIES
Inpatient friends and family scores
In line with the national programme, patients in A&E and inpatients were again invited to rate how likely they were to recommend the care they had received to friends and family.
In quarter 4 the Trust friends and family score for inpatients went above the national average for the first time. This shift indicated that there were now more patients who were highly likely to recommend the Trust than ever before. The combined percentages for recommending care are also shared in graphs to the right. This shows the Trust is either in line with the national average or slightly above.
North Cumbria University Hospitals Trust considers that this data is as described for the following reasons: l The month on month improvements are a tribute to the
hard work and dedication of front line teams who have
been part of a systematic way of measuring and improving
patient experience.
l Ward teams have received rapid feedback of results which
allows for greater ownership of the data and the
opportunity to respond.
l All qualitative comments received by patients are highly
valued by teams and used to focus improvement efforts in
the areas that matter to patients.
l Staff have been supported and trained to provide better
more compassionate care.
In March 2015 the Trust had friends and family feedback from
43.7% of inpatients - this compares to only 11.1% who had given feedback in May 2013. The Trust has taken the following actions to improve this rate, and so the quality of its services: l Weekly reporting of response rates by ward.
l Transparent sharing of results with patients, families and
the public.
l Trust Board commitment to the programme and dedicated
response from the Chief Executive to ensure results are
talked about and feedback acted upon.
60 | Quality Account 2014/15

National inpatient results 2014
The results from the 2014 inpatient survey were published on the Care Quality Commission website http://www.cqc.org.uk
/provider/RNL/survey/3#undefined in May 2015. Between
September 2014 and January 2015, a questionnaire was sent to
850 of our recent inpatients. Responses were received from 426 patients at North Cumbria University Hospitals NHS Trust which represents a 50% response rate. Each trust received a rating of better, about the same or worse on how it performs for each question, compared with most other trusts.
The inpatient survey focuses on eleven key areas including: the emergency/A&E department, waiting lists and planned admissions, waiting to get to a bed on a ward, the hospital and ward, doctors, nurses, care and treatment, operations and procedures, leaving hospital, overall views of care and services and overall experience.
Key areas to note during 2014/15
For each question in the survey, patient’s responses are converted into scores where the best possible score is 10/10.
Overall, the Trust scored about the same for each of the key areas identified above. Analysis of each key area showed that the Trust was better compared with most other trusts with regard to ensuring a timely discharge and feeling safe whist they were an inpatient. However, there were some areas where improvements could be made in relation to the quality of food, the ability to talk to someone about their worries and fears, being told about the side effects of medications, warned about what danger signs to watch out for when they went home, the provision of written information about should and should not’s on discharge and patients being approached about their views.
This learning will be incorporated into our quality improvements priorities and addressed via our Care Quality Commission compliance framework.
Accident and emergency departments
The Patient Experience of A&E was better understood in two ways during 2014/15: l 843 returned Patient Perspective surveys after they
left hospital.
l 13402 people posting tokens as they left the A&E
department to indicate how likely they were to
recommend care to friends and family.
Patient Perspective A&E surveys
1847 questionnaires were mailed out on behalf of the Trust with
843 (45%) responding.
Results for the Emergency Departments are good. The Trust averages in the top 20% nationally, and is in the top 20% on 24 of 27 questions.
Average scores across the two sites are similar: Cumberland
Infirmary scores 77% and West Cumberland Infirmary 82%.
Overall, results are good in these areas: l Privacy at reception l Waiting time to being examined l Communication with doctors and nurses l Cleanliness l Overall ratings
There is room for improvement in these areas: l Information on waiting times l The amount of information given l Pain management www.ncuh.nhs.uk | 61

REVIEW OF QUALITY PRIORITIES
Friends & Family A&E quarterly response rate and scores
The friends and family scores for A&E remained very consistent throughout the year and within the top 20% of Trusts nationally.
The graphs detailing performance in relation to patients recommending care are provided in a series of graphs.
Maternity care
Friends and Family measurement
We saw big improvements in friends and family score for maternity services since April 2014. These improvements meant that there were now more women who were highly likely to recommend their care than ever before.
The % of women who are either highly likely or likely to recommend remains extremely high and consistently above the national average - see graphs below.
62 | Quality Account 2014/15

Each year, the Trust takes part in a national staff survey which provides randomly chosen members of staff with the opportunity to say how they feel about working in the hospitals and for the Trust. The survey is viewed by the Care Quality
Commission together with our action plans for improvement.
The 2014 survey was sent out in October 2014 to 795 selected members of staff and our Trust achieved a 57% response rate which is an above average response rate for acute trusts.
The staff survey results for 2014 demonstrate a steady improvement in a number of key areas and these results should be viewed as a positive reinforcement of all the work that has been undertaken across the trust to date.  Whilst the Trust remains amongst the lowest 20% of acute NHS organisations, tangible improvements continue to be made across all indicators of staff engagement during the past 12 months. The Trust is committed to improving the care for our patients and the working lives of all staff.
We have seen a number of improvements in the results since last year and these include: l A strong increase in scores to 81% from 73% in 2013
around statutory and mandatory training provision and
job-relevant training with scores l A positive increase in scores from 23% to 30% for staff
who felt that they had received a well-structured appraisal
which was an area for improvement from 2013 and
followed the introduction of a values based
appraisal process l With regards to equality and diversity, there has also been
a notable increase in scores to 82% (75% 2013) relating
to staff receiving equality and diversity training in the past
12 months and belief that the Trust provides equal
opportunities for career progression and promotion.
This puts us in the top 20% of acute trusts  l Effective team working is recognised as improving steadily
3.68 (3.52 2013) l A small continued increase in scores of staff reporting good
communication between senior management and staff to
17% (in comparison to the national average of 30%),
and an increase in staff feeling able to contribute to
improvements at work
Our areas for improvement based on either those that have deteriorated from last year or have not yet improved from last year are in the following areas: l Staff recommendation of the trust as a place to work or
receive treatment was 3.14 (in comparison to the national
average for acute trusts of 3.67) l Percentage of staff experiencing physical violence from
patients, relatives or the public in last 12 months was 22%
(in comparison to the national average for acute trusts
of 14%) l Percentage of staff experiencing physical violence from
staff in last 12 months was 5% (in comparison to the
national average for acute trusts of 3%) l Percentage of staff witnessing potentially harmful errors,
near misses or incidents in last month was 42%
(in comparison to the national average for acute trusts
of 34%)
The Trust will focus on improvement in these areas whilst maintaining momentum in those areas already moving in a positive direction from last year’s action plan, especially in relation to engagement which will continue to evolve to meet the changing needs of the Trust.
Areas for improvement will be incorporated into Business Unit action plans as well as Trust wide focus being given to promoting good practice and training provided where necessary to ensure clear understanding of processes to be followed. Business unit action plans will be reviewed at workforce committee on a regular basis.
Ongoing developments supporting the Trust improvement plan include: l Comprehensive OD action plan reviewed quarterly and
providing support to achieve improvement in engagement,
values and behaviours and capability l In-house mediation service now operational and
providing support.
l Recruitment of occupational psychologist to provide
support to staff and promote health and wellbeing agenda.
l MSC engagement plan continues l Introduction of values based recruitment on a planned roll
out basis
Further changes and improvements will continue to be introduced as the Trust develops and evolves. www.ncuh.nhs.uk | 63

REVIEW OF QUALITY PRIORITIES
Independent Auditor's Limited Assurance Report to the
Directors of North Cumbria University Hospitals NHS Trust on the Annual Quality Account
We are required to perform an independent assurance engagement in respect of North Cumbria University Hospitals
NHS Trust’s Quality Account for the year ended 31 March 2015
(“the Quality Account”) and certain performance indicators contained therein as part of our work. NHS trusts are required by section 8 of the Health Act 2009 to publish a quality account which must include prescribed information set out in The
National Health Service (Quality Account) Regulations 2010, the
National Health Service (Quality Account) Amendment
Regulations 2011 and the National Health Service (Quality
Account) Amendment Regulations 2012 (“the Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following indicators: l percentage of patients risk-assessed for venous
thromboembolism (VTE); l rate of clostridium difficile infections.
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of directors and auditors
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 Regulations).
In preparing the Quality Account, the directors are required to take steps to satisfy themselves that: l the Quality Account presents a balanced picture of the
Trust’s performance over the period covered; l the performance information reported in the Quality
Account is reliable and accurate; l 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; l 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; and l the Quality Account has been prepared in accordance with
Department of Health guidance.
The Directors are required to confirm compliance with these requirements in a statement of directors’ responsibilities within the Quality Account.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: l the Quality Account is not prepared in all material respects
in line with the criteria set out in the Regulations; l the Quality Account is not consistent in all material
respects with the sources specified in the NHS Quality
Accounts Auditor Guidance 2014-15 issued by DH in
March 2015 (“the Guidance”); and l the indicators in the Quality Account identified as having
been the subject of limited assurance in the Quality
Account are not reasonably stated in all material respects
in accordance with the Regulations and the six dimensions
of data quality set out in the Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations and to consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Account and consider whether it is materially inconsistent with: l board minutes for the period April 2014 to June 2015; l papers relating to quality, performance and safety reported
to the Board over the period April 2014 to June 2015; l feedback from the Commissioners dated 3 June 2015; l feedback from Local Healthwatch dated 29 May 2015; l the Trust’s complaints report published under regulation 18
of the Local Authority, Social Services and NHS Complaints
(England) Regulations 2009, dated June 2015; l feedback from other named stakeholder involved in the
sign off of the Quality Account; l the latest national patient survey dated 2014; l the latest national staff survey dated 2014; l the Head of Internal Audit’s annual opinion over the trust’s
control environment dated 28 May 2015; l the annual governance statement dated 3 June 2015; l the Care Quality Commission’s Intelligent Monitoring
Report dated May 2015; and l the Trust's progress against the Chief Inspector of Hospitals
Improvement Plan.
We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with these documents (collectively the “documents”).
Our responsibilities do not extend to any other information.
This report, including the conclusion, is made solely to the Board of Directors of North Cumbria University Hospitals NHS Trust.
We permit the disclosure of this report to enable the Board of
Directors to demonstrate that they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permissible by law, we do not accept or assume responsibility to anyone other than the Board of Directors as a body and North Cumbria University Hospitals NHS Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing.
64 | Quality Account 2014/15

Assurance work performed
We conducted this limited assurance engagement under the terms of the guidance. Our limited assurance procedures included: l evaluating the design and implementation of the key
processes and controls for managing and reporting
the indicators; l making enquiries of management; l testing key management controls; l analytical procedures; l limited testing, on a selective basis, of the data used to
calculate the indicator back to supporting documentation; l comparing the content of the Quality Account to the
requirements of the Regulations; and l reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Account in the context of the criteria set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the Department of Health. This may result in the omission of information relevant to other users, for example for the purpose of comparing the results of different
NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or non-mandated indicators which have been determined locally by North Cumbria University Hospitals
NHS Trust.
Basis for qualified conclusion
The indicator reporting the percentage of patients risk-assessed for venous thromboembolism (VTE) did not meet the six dimensions of data quality in the following respects: l Accuracy and Validity - the Trust calculated the indicator
based on patients discharged in the reporting period rather
than those admitted, consequently the Trust cannot
demonstrate that the correct numerator and denominator
have been used; l Relevance the data used to calculate the indicator incorrectly included patients that did not meet the definition for inclusion and incorrectly excluded patients that should have been risked assessed for VTE in 2014/15; l Completeness as a result of the Trust basing the indicator on those patients discharged in 2014/15 rather than those admitted in 2014/15 some patients will be incorrectly included in the indicator and other patients will be incorrectly excluded from the indicator. We are therefore unable to conclude whether the number of VTE assessments and the number of adult inpatient admissions used to calculate the indicator are complete.
Qualified conclusion
Based on the results of our procedures, with the exception of the matters reported in the basis for qualified conclusion paragraph above, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2015: l The Quality Account is not prepared in all material respects
in line with the criteria set out in the Regulations; l the Quality Account is not consistent in all material
respects with the sources specified in the Guidance; and l the indicators in the Quality Account subject to limited
assurance have not been reasonably stated in all material
respects in accordance with the Regulations and the six
dimensions of data quality set out in the Guidance.
Grant Thornton UK LLP
4 Hardman Square
Spinningfields
Manchester
M3 3EB
30 June 2015 www.ncuh.nhs.uk | 65

REVIEW OF QUALITY PRIORITIES
The Trust has consulted with the following groups on the production of this Quality Account and the Priorities for 2015/16: l Clinical Commissioning Group l Cumbria Healthwatch l Health and Wellbeing Overview and Scrutiny Committee
Clinical Commissioning Group
NHS Cumbria CCG welcomes the opportunity to comment on the 14/15 quality account for North Cumbria University
Hospital Trust.  The CCG has worked closely with the Trust throughout the year, gaining assurance of the delivery of safe effective services. Patient quality and experience is monitored via the CCGs clinical insight walk round programme and more formal joint CCG and Trust quality performance meetings.
External independent reviewers and support systems including
CQC regulators, and the Trust Development Agency have ensured a strong collaborative approach for quality improvement across the Health economy has been adopted by the Trust.    The Trust has in turn demonstrated collaborative working with CCG in their commitment to respond to patient safety and enhanced patient experience.
With regard to the report, the CCG notes that there is only one statement in the report regarding the prolonged norovirus outbreak that was experienced by the Trust during the course of last year, although this may not be required to be reported in this document given the issues that the outbreak presented the
CCG feels that an appropriate level of reference should have been made to it.
Given this outbreak and the Infection Prevention and control issues that became apparent during and following it the CCG would also request that the 50% figure for staff sepsis training should be increased to ensure that the majority of staff within appropriate roles receive this training.
The CCG would ask for clarification as to why the Trust believes that having access to Community Hospital beds increases the readmission rate at their hospital sites.
The CCG would request that the Trust identifies why VTE was poor in the quarter 3?
The CCG notes that a number of the audit results discuss a need for extra staff, in addition the CCG notes that the theme of staffing levels appears with some frequency as a contributory cause to a number of reviews of Serious Incidents and it was also highlighted by the CQC in their review of the Trust in 2014.
The CCG would request that the Trust continues to address shortfalls in staffing and reports to the CCG on a regular basis the successes or issues they are experiencing with regard to ensuring that the staffing levels in all areas is appropriate to need.
The CCG requests that the trust clearly identifies if the CQC colours /rating is a CQC rating or a trust self-rating.
The CCG would point out that although the Trust took a full, active and positive involvement in the independent review of maternity services, they did not commission this review as this report states. The review was commissioned by the CCG on behalf of the population of Cumbria.
The CCG would request that the trust outlines how it will improve its performance for the many standards of the compliance regime that the department of Health states that
NHS organisations must achieve.
As a whole the CCG welcomes that the Trust is able to articulate a number of improvements and developments over the past year within this report. The CCG would also commend the Trust on its application of Harm Free Care with specific reference to the positive work the Trust has undertaken to improve pressure area care across its patients group. The CCG would also like to commend the Trust for its continued openness in sharing the issues it experiences with the CCG. Finally the CCG welcomes the large number of Audits that the trust has undertaken and the excellent uptake of research the Trust has been involved with as highlighted in this document. The CCG looks forward to the continued developments the Trust will undertake in the coming year and its continued proactive approach in providing assurance to its commissioners.
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Cumbria Healthwatch
Introduction
Healthwatch Cumbria is pleased to be able to submit the following considered response to North Cumbria University
Hospital NHS Trust’s Quality Accounts for 2014-15.
Having read the report we would like to commend the Trust on producing an easy to read, public facing document, which provides necessary information without compromising the quality of data included.
Part 2. Our Priorities for Improvement
We would like to commend the Trust on signing up to the national Sign up to Safety Campaign and the subsequent development of its improvement plan to support the delivery of safety pledges. We feel that this demonstrates a strong commitment to improving patient safety across the Trust.
2.1 Safety & Quality Priorities 2015/16 (page 8)
This is a clearly laid out table, which is easy to understand and clearly sets out improvements and measurements.
Re: Improve the safety and effectiveness of medical and nursing handovers - it may be useful to include an explanation of the action to be taken when agreed SOP’s are not delivered i.e. what support will be provided to staff who fail to meet this standard, what training is provided for the revised SOP?
2.2 CQUIN Priorities for 2015/16 (page 10)
Actual data not included and therefore unable to comment at this stage.
2.4 Statements of Quality Standards (page 12)
2.4.2 Patient Reported Outcome Measurements (PROMS)
(page 13)
‘Feedback from patients in the results of their surgery is not always received, resulting in low numbers fir some procedures.
Where this is the case we cannot report performance’
The explanation for this comment is in draft format at the stage of submitting our response. We would recommend that the explanation remains in the report to provide clarification of the current arrangements.
2.4.3 Emergency Readmissions to Hospital within 28 Days
(page 14)
We welcome the introduction of the integrated discharge planning team, which will improve the development of discharge plans for patients with complex needs.
2.4.4 Responsiveness to the Personal Needs of Patients
(page 14)
It is disappointing to see that the Trust was below average in a number of areas, however we note that much is being done to improve responsiveness to patient needs.
2.4.5 Staff who would recommend the Trust to Family &
Friends (page 15)
It is disappointing to see the scores for the Family and Friends, although we appreciate that the Trust faced many challenges over the past 2 years which understandably impacts on staff satisfaction rates. Clearly the Trust has developed plans to address and improve scores and we look forward to seeing improvements over the next 12 months.
2.4.7 VTE Risk Assessment (page 16)
This section is slightly confusing in that the table shows performance as being ‘worse than expected’ but there is no explanation of why this is the case and what is being done to rectify the situation other than ‘In order to deal with exceptions earlier and reduce the reliance on coded notes the Trust plans to implement an electronic system in 2015. We recommend further clarification of this section before publication.
2.4.8 C-Difficile (page 17)
Daxta incomplete and therefore unable to comment.
2.5 Review of Services
2.5.1 Quality Panels (page18)
Could the Trust explain whether the Quality Panels will be reintroduced in 2015-16 or if this is no longer a priority?
2.6 Clinical Audits
All duly noted
2.6.5 Other National Clinical Audits (page 25)
Re: Section 4 of table 3 - National Cancer Patient Experience
Survey 2014
4. Providing information for patients, we are aware that a significant number of cancer patients do not receive information on making a complaint (HWC Patient Experience Review of
Cancer Service - May 2015). We recommend that the Trust also includes complaint information within this improvement area.
It may also be helpful to patients to include ‘improving communication between the Trust and GP’s’ and ‘ensuring that all patients are provided with a treatment plan which is explained to them by a suitably qualified and experienced nurse/professional’.
2.7 Clinical Research
All duly noted.
2.8 Care Quality Commission Registration & Inspections
The information included within this section demonstrates the
Trust’s openness and transparency along with a clear commitment to continual improvement particularly towards
CQC recommendations.
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REVIEW OF QUALITY PRIORITIES
Part 3 Review of Quality Priorities
In most cases it is clear to see planned improvements and progress being made, however there is still work to do which will take longer to realise and we appreciate and understand the change may take considerable time to achieve. We commend the Trust on progress to date.
3.2 DOMAIN: Caring (page 37)
3.15 Patient Experience
It is clear to see that the Trust places great emphasis on patient experience and is committed to the new programme of gathering and analysing feedback in order to bring about swift service improvements. We commend the Trust on their approach to patient experience across all sites.
3.16 Staff Experience
Data incomplete therefore unable to comment.
3.3 DOMAIN: Responsive (page 38)
Data incomplete therefore unable to comment.
3.7 Complaints
This is a comprehensive account of the Trust’s complaints system and demonstrates that the Trust values complaints at a senior level and is committed to learning from complaints.
However, we are aware from a recent review of complaints handling across health and social care services in Cumbria that the value of complaints is not always shared by all staff.
The Trust may want to develop complaints training for staff at all levels.
All duly noted
For and on behalf of Healthwatch Cumbria
Sarah Allison
Health & Wellbeing Manager
3.7.1 Acting on complaints we receive (table page 43)
In addition there is a patient story shared at each Trust Board so the learning is available throughout the organisation. It is not clear from this statement how learning is disseminated from
‘board to ward’.
3.8 Staff Reporting Incidents
All duly noted
3.9 Mortality
All duly noted
3.10 Safeguarding
This section demonstrates a clear commitment to safeguarding of children and adults and we commend the Trust on developments and improvements made.
3.11 Harm Free Care
All duly noted
3.12 Preventing Healthcare Associated Infections
All duly noted
3.13 Performance against Key National Priorities
Where the Trust has not achieved key performance indicators/compliance requirements it may be useful for the reader to see cross referencing to improvement plans.
3.14 Patient Environment
Without demonstrating how the scores will improve it is unclear how much value the Trust places on Patient-Led Assessments of the Care Environment. What measures will the Trust put in place to improve the patient environment?
68 | Quality Account 2014/15

Health and Wellbeing Overview and Scrutiny Committee
The Cumbria Health Scrutiny Committee again welcomes the opportunity to comment on the Trust’s draft Quality Account for 2014/15, and would like to acknowledge the good working relationship it has with the Trust.
The document is generally well laid out and reasonably straightforward to understand and enables Members to explore the Trust’s performance over the year. It is a detailed and thorough report which honestly admits to some of the Trust’s shortcomings.
To support the lay reader in reviewing this document it is recommended that further developments are made where possible in this year’s document, and also in future accounts including; l There was a feeling from members that the length of the
document might limit its accessibility l Members welcomed the prioritisation of the appropriate
information towards the front of the document
Some more general comments on the report which should be considered when finalising the report l There was felt to be a valuable emphasis on patient
engagement and quality l Still seems to be missing data from some sections of
the report
Overall, we appreciate the co-operation received and look forward to continuing to work with the Trust during the coming year to help drive up quality.
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GLOSSARY OF TERMS
70 | Quality Account 2014/15

www.ncuh.nhs.uk | 71

The Cumberland Infirmary
Newtown Road, Carlisle,
Cumbria CA2 7HY
Tel: 01228 523444
West Cumberland Hospital
Hensingham, Whitehaven,
West Cumbria CA28 8JG
Tel: 01946 693181