Quality Account
2014/15
Looking after you locally
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part One
PART 1
PART 2
2
PART 3
Contents
Part One
1. Message from the Chair
2. Foreword by the Chief Executive
3. Statement from the Director of Nursing
and Quality
4.Our vision, our strategic priorities
and our services
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3.
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4.
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Part Two
1.
2.
Priorities for improvement 2015/16
1.1 Quality Goals 1.2 Commissioning for
Quality and Innovation (CQuIN)
1.3 Integration programme
1.4 Transformation programme
Mandated statements of assurance
2.1 Review of services
2.2 Participation in clinical audit
2.3 Participation in clinical research
2.4 Goals agreed with commissioners
2.5 Statement from Care Quality
Commission (CQC)
2.6 Data quality
2.7 Information Governance toolkit
attainment levels
2.8 Clinical coding error rates
2.9 Core Quality Account Indicators
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Part Three
1.
Review of quality performance in 2014/15
1.1Summary/Introduction
1.2 Care Quality Commission
(CQC) Inspection
1.3 Service developments
1.4 Transformation programme
1.5 Achievement of our Quality Goals
1.6 Commissioning for
Quality Innovation (CQuIN)
2. A Well-led organisation
2.1Introduction
2.2 Student Nurses
2.3 National Apprenticeship week
2.4 Staff Achievements
2.5 NHS Staff survey 2014
5.
6.
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7.
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8.
2.6 Health & wellbeing at work
2.7 Compliments and thanks
2.8 Clinical Ethics Group
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Responsive services
3.1 Review of Quality performance for 2014/15
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Caring services (Patient Experience)
4.1Summary
4.2 Patient and carer involvement
4.3 Patient voice at Board
4.4 Friends and Family Test
4.5 Patient Opinion
4.6 Local patient surveys
4.7 Complaints and compliments
4.8 Patient led assessment
of the care environment (PLACE)
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Safe services
5.1Introduction
5.2 Safe staffing
5.3 Being Open (duty of candour)
5.4 Norfolk Harm free care project
5.5 National Safety Thermometer
5.6 Management and learning from incidents
5.7 Mortality panel review
5.8 Never Events
5.9 Central Alerts
5.10Infection prevention and control
5.11Medicines management
5.12Safeguarding children and adults
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Effective services
6.1Introduction
6.2 Implementation of NICE guidance
6.3 Clinical Audit programme 6.4 Trust Research Performance 6.5 Specialist Palliative Care
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Explanation of who has been
involved in this Quality Account
7.1Introduction
7.2 Norwich Clinical Commissioning Group 7.3 Healthwatch Norfolk
7.4 Norfolk Health Overview and
Scrutiny Committee
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Directors’ Declarations69
Glossary of terms
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Part One
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part One
PART 1
PART 2
3
PART 3
1. Message from the Chair
Community. Compassion.
Creativity. These are the
three values we developed
with our staff and public
during 2014/15, and
they are central to how
we approach delivering
excellent care closer to
home for our patients.
This is what we mean by creativity. Finding clever ways
to improve the care we provide for the communities
we serve as cost-effectively as possible. As the new
Chief Executive of NHS England, Simon Stevens, has
advocated, we really do need to “think like a patient,
act like a taxpayer.” This year also saw us embrace the
need to integrate health with social care through the
development of an integrated management team with
Norfolk County Council’s Adult Social Services.
Our new values are the high cultural standards we set
for ourselves and, on behalf of the Board of Norfolk
Community Health and Care NHS Trust, I am pleased to
report in our Quality Account for 2014/15 that we are
living up to those values.
In terms of community, we continue to look after the
needs of a population of 882,000 across Norfolk, and
we also started to provide services in Suffolk. Building
on our expertise in Norfolk with early supported
discharge for people who have had strokes, we won a
three year contract to provide similar services to stroke
patients in Suffolk.
The Care Quality Commission (CQC) inspected our
services during the year and rated us as Good. That
positive CQC rating reflects the care and dedication of
our staff and highlights just how focused everyone is on
delivering compassionate, high quality patient care.
As an NHS community provider we have worked hard
over the past year to develop creative ways of making
our services more efficient. This does not simply mean
saving money, but looking at how we can improve the
care we provide for the communities we serve.
Our Transformation programme has set out to help
give our frontline NHS staff the tools they need to get
the job done more effectively. Serving large rural and
urban populations presents our staff with challenges
in terms of the time they spend travelling between
their work bases and their patients. The Transformation
programme has seen us invest in information
technology that allows our community nursing and
therapy teams to update patient records, remotely and
in real-time. This has increased their productive time by
cutting down on the need to return to base to update
records. The result? Time spent with patients has gone
up to nearly 63 per cent. This is good for our patients
and good for our staff.
We also appointed our new Chief Executive, Roisin
Fallon-Williams. Roisin has proved to be a real asset and
has demonstrated her commitment to always do the
very best for local people and patients, and our staff.
Looking to the future, NHS England has presented its
‘Five Year Forward View’ and we can see the challenges
and opportunities ahead. Meeting those challenges
will not be easy but we are in a strong position, we are
in charge of our destiny, and we remain committed to
looking after you locally.
Ken Applegate
Chair
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part One
PART 1
PART 2
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PART 3
2. Foreword by the Chief Executive
Although I only joined
Norfolk Community
Health and Care NHS Trust
(NCH&C) in the autumn, I
am fully aware of all of the
excellent work that has been
taking place across the Trust.
I have been impressed by
the way colleagues embrace
our vision to improve the quality of people’s lives, in
their homes and in the community through the best in
integrated health and social care.
The theme of integration will be a defining one for us
in the year ahead. Work on our integration with Norfolk
County Council’s Adult Social Services teams has taken
significant strides forward, with a new integrated care
management structure in place and bedding in.
In the autumn, NHS England’s Chief Executive Simon
Stevens unveiled his vision for the future through the
publication of the ‘Five Year Forward View’ which
looks towards a breaking down of boundaries between
primary care and hospitals, between physical and
mental health, and between health and social care.
It means developing models of care built around
the needs of patients rather than on historical or
professional divides. At NCH&C this is music to our
ears and we need to act now, with our partners in both
health and social care, to respond with local flexibility
and innovation. It really is up to us to embrace the
integration agenda and make it work for our patients
and our staff.
There will be those that say integration is just the
latest buzzword. At a recent Board meeting, however,
we heard from frontline colleagues in our Learning
Disability service in east Norfolk about the many
benefits they felt had been delivered for service users
through the integration of health and social care staff
around ten years ago. It is not an easy thing to do and
it doesn’t happen overnight, but they were very clear
about the benefits of working side by side.
This year, we also expanded our geographical boundary
with the launch of a new Early Supported Discharge
service in Suffolk, to allow patients who have had a
stroke to return home from acute hospital faster and
receive specialist rehabilitation in their own homes. This
type of service is all about working across organisational
boundaries and focusing on the needs of the patients.
Financial stability is the other major challenge facing
every NHS organisation. Although we are in relatively
good financial shape, delivering our cost improvement
programmes will be a major challenge, and we will
work hard to not compromise on quality and safety in
the delivery of care to patients.
I would like to thank everyone for their part in helping
us to deliver a service to the people in Norfolk and
Suffolk, which is focused on providing safe and
effective care while offering a consistent and positive
experience to those who use our services.
Roisin Fallon-Williams
Chief Executive
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part One
PART 1
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PART 3
3. Statement from the
Director of Nursing and Quality
The care, commitment
and compassion of our
frontline staff have made
possible the continued
success of our quality
achievements contained
within this Quality
Account. I am proud of all
our staff for the valuable
work they do every day. We know that nationally the
pressures and demands for services are high across
health and social care systems; despite this we know
that our patients are safe in our care.
The Care Quality Commission (CQC) found that our
services were caring across the board. Our staff spoke
with compassion, dignity and respect regarding the
patients that they cared for, and all services inspected
demonstrated compassionate care.
Looking back over the last year, our staff have
involved themselves actively and positively in the many
challenges we have developed to transform the way
that services are delivered to our patients. Our staff
have supported new projects such as the Virtual Wards,
extra winter beds, and the intravenous therapy team in
the central localities.
In addition, our staff have driven the expansion of our
Children’s Community Nursing Team and redesign of
School Nursing and Health Visiting. I am also pleased
to report colleagues have supported the increase in the
numbers of students in practice and have piloted new
models of support, such as Collaborative Learning in
Practice where students are enabled to have greater
responsibility of care under the supervision of our
experienced staff.
Looking forward to the coming year, we will be
implementing the new Nursing and Midwifery Council
‘Code of Practice’ for Nurses to ensure they are meeting
the required standards. We will also take forward the
recommendations from Lord Willis’s ‘Raising the Bar’
report which looks at the way that we support, educate
and train our staff to ensure that we are continuing
to provide a world class health and care workforce.
Our staff remain the key to successful delivery of our
services now and in the future.
Anna Morgan
Director of Nursing and Quality
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part One
PART 1
PART 2
PART 3
4. Our vision, our strategic objectives
and values
4.1 Our vision
4.2 Our strategic objectives
Our vision is to ‘improve the quality of people’s lives, in
their homes and community by providing the best in
integrated health and social care’. We often sum this up
as ‘Looking after you locally’.
Improving OUR QUALITY through…
The starting point for us is the patient: this means that
quality is at the heart of everything we do. Our services
are built up around the patient, working closely with GP
partners both as commissioners and providers. Wherever
possible, our services are delivered in an integrated way
with social care. We are therefore part of an extended
primary care team focused around the patient. The
patient should experience care as if it were from one
organisation, seeing the least number of staff necessary
and not having to repeatedly tell their story.
NCH&C aims to lead out of hospital community
healthcare, giving children a better start and adults
greater independence - we typically do so in their own
home or place of choosing. This, combined with the fact
that we are a major employer and operate from multiple
sites, means that we are both in and of the community.
Our staff are drawn from local communities and have
local knowledge. We want to work with communities,
not just serving their needs, but recognising that we have
a role to empower communities to make the most of the
resources within them.
Our vision will be delivered through the achievement of
a number of longer term, strategic objectives. The Board
has agreed three interconnected and mutually dependent
strategic priorities to achieve the Trust’s vision.
Delivering our vision and quality goals can only be
achieved by having a well-informed, engaged workforce
which understands, and is motivated to help us deliver,
our strategic objectives.
• D
elivering harm free, clinically effective and
compassionate care
• Involving patients and the public and delivering
excellent patient experience
Enabling OUR PEOPLE through…
• Inspiring staff and staff engagement
• Empowering staff to speak out and put things right
• Ensuring the right staff, with the right skills are
available to deliver compassionate care
• Integrating delivery with social and primary
care and having effective partnerships with
other organisations
• Transforming services
• Demonstrating effective leadership
Securing OUR FUTURE through…
• Delivering what commissioners require
• Delivering a financially sustainable organisation
• Investing in infrastructure
• Growth
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Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part One
PART 1
PART 2
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PART 3
4.3 Our values
Our values have formed a behavioural framework
for our staff in how they treat our patients and each
other, and are the foundation to our delivering our
strategic objectives.
These values will underpin all communication principles
for our Trust, forming the backbone of our key
messages. Everything we communicate will have
a clear association with one or more of our values.
Community
• As a Trust, we enhance the lives of our patients
through our commitment, support and education
• We are proud to serve our local community by
providing integrated quality services with our
partner organisations
• We respect and value the trust we are given to enter
our patients’ homes and lives
Compassion
• We provide compassionate, coordinated and
personalised quality care that is safe and effective
• We empower and educate our patients and their
carers in the effective delivery and management of
their own independence, health and wellbeing
• We are dedicated to holistic, compassionate care and
demonstrate this through our commitment to our
personal and professional development
Creativity
• Our expertise, commitment and creativity are key to
the successful delivery of our services
• We are always open to new ideas that support
us in delivering effective, compassionate care
to our patients
• We continuously innovate and implement efficient
delivery of care
The diagram above shows how our objectives and
values are integrated with each other and wrap around
our patients
Part Two
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Two
PART 1
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1. Priorities for improvement 2015/16
1.1 Quality Goals
High quality care means care that is as safe and effective
as possible, where patients are in control and are treated
with compassion, dignity and respect; their experience of
care being as important as the outcomes of care.
High quality care also means focusing on the prevention
of illness.
We believe that everyone within NCH&C has a role to
play in supporting this ethos – this is not just about clinical
staff and how they care for patients. Administrative and
support staff are also able to contribute in a number
of ways – simple things like answering a phone for a
colleague can make a real difference.
The three domains of high quality care are defined
nationally as being:
1.Patient Safety: The first dimension of quality must be
that we do no harm to patients. This means ensuring
that the environment is safe and clean, and reducing
avoidable harm such as drug errors.
2.Patient Experience: Quality of care includes the
quality of caring. This means how personal care
is – the compassion, dignity and respect with
which patients are treated. This can be improved
by analysing and understanding patient satisfaction
levels and experience.
3.Effectiveness of Care: This means understanding
the success rates of different treatments for
different conditions. Assessing this will include
clinical measures such as mortality or survival
rates, complication rates and measures of clinical
improvement. Just as important is the effectiveness
of care from the patient’s own perspective. Examples
include improvement in pain scores or returning
to work after treatment. Clinical effectiveness may
also extend to people’s well-being and ability to live
independent lives.
In order to support high quality care, each year we focus
on key Quality Goals. These goals are intended to inform
the practice of each member of staff across all three
domains of quality. After consultation with staff, patients
and the wider public we have developed the following
goals for 2015/16. At this stage, the goals are of a
strategic nature, and it is expected that local teams will
identify what each goal means for them and their practice.
The Quality Goals have been set under the same
headings. They are:
1.Safe services (harm free care): This domain
includes actions focussing on the safety
thermometer, falls causing harm in our inpatient
units, pressure ulcers, VTEs, catheter acquired
infections, effective use of medicines, and increasing
the percentage of patients receiving harm free care.
2.Clinically effective services: This domain looks at
improving clinical effectiveness and demonstrating
improvement through the clinical audit programme
for 2015/16. It also includes focus on NICE guidance
and the quality standard for Dementia.
3.Patient experience and involvement: This domain
seeks to increase the involvement of patients, their
families and carers in how services are delivered
and improved.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Two
PART 1
1.2 Commissioning for
Quality and Innovation
(CQuIN) 2015/16
CQuIN indicators are contractual commitments, some
are nationally mandated and some are developed in
partnership with our various commissioners. They are
intended to improve quality and encourage innovation
within key areas of local services. If these indicators are
achieved, they attract additional funding that can be
used to make further improvements.
The CQuIN indicators for 2015/16 that have been
negotiated and agreed with our commissioners are as
follows;
1.2.1 National Indicator - Dementia
a.Find, assess, investigate, refer and inform
b.Dementia training for staff
c. Dementia support for carers
1.2.2 End of Life Care
(a Pan-Norfolk indicator)
To ensure the priorities of care of ‘One Chance to
Get it Right’ correlate with the 16 Quality Statements
and are implemented throughout the community and
inpatient units.
1.2.3 Patient Self-Administration of
Clexane (west Norfolk CCG)
Clexane is a brand name for a medicine used to treat a
number of conditions; angina, blood clotting, heart attack
To develop a pathway to promote the selfadministration of Clexane injections by a designated
cohort of patients in the community setting.
Pre-elective surgery patients as part of their postoperative community care would be given the choice to
self-administer their Clexane. As part of this pathway
the patient would also have the option of a relative/
carer to administer the Clexane.
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1.2.4 ‘Your Village’ Improved
Collaboration and Integration
(Norwich CCG)
To adopt the traditional ‘Village Style’ District Nursing
approach through collaborative and integrated working
with Primary Care, Third Sector Providers and Voluntary/
Community Sectors.
To align current and existing services with the ambitions
and objectives of the ‘Your Norwich Programme’. The
scheme is designed to facilitate working together in four
city clusters and to provide improved communication and
integration with Primary Care and other local services,
such as Care Homes.
1.2.5 Lower Limb Care &
Management (North
Norfolk CCG)
To create a responsive and integrated local service for the
Care & Management of Lower Limb Ulcers, including
those identified as a Diabetic Foot Ulcer. This will enable a
greater patient choice within the locality and will develop
and retain the skill and competency of all involved.
To ensure that all patients presenting with a lower limb
ulcer receive a timely holistic assessment and accurate
diagnosis by a healthcare professional trained in
lower limb care and management, in order to achieve
improved healing times.
To ensure all staff that are responsible for lower limb
management are competent in the management of
these patients including the application of compression
bandages and hosiery.
1.2.6 Improved Integration –
Supporting Independence
for Older People (South
Norfolk CCG)
To improve relationships and promote a culture of
continuous improvement in the multi-disciplinary teams
in order to maximise independence and decrease
avoidable admissions for the most vulnerable patients.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Two
PART 1
1.2.7 In-reach into acute hospital
for amputees (Great Yarmouth
& Waveney CCG)
To enable patients to meet with a key member of the
Pine Cottage clinical team prior to their discharge
from the acute hospital. It is aimed at providing
information to patients, giving them the opportunity
to ask questions, provide reassurance and empowering
patients to take part in decision making around their
rehabilitation at a much earlier stage.
1.2.8 Prosthetics Service
(NHS England Specialist
commissioning)
To ensure patients are triaged within four weeks and a
multi-disciplinary team meeting is held within six weeks
of receipt of referral.
1.2.9 Environmental controls
(NHS England Specialist
commissioning)
Provision of training for stakeholders and staff.
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1.2.10 Child Health information
systems; Newborn and Infant
Physical Examination (NIPE)
72 hour (NHS England)
NIPE 72 hour screening information to be shared
by maternity services and recorded onto SystmOne
(electronic patient record system) by the Community
Health information systems team.
1.2.11 Suffolk Early Supported
Discharge (Ipswich and East
Suffolk CCG)
Support and training for carers of service users.
To improve the quality of life and carer experience of
people who care for patients who have had a stroke.
1.2.12 Admission avoidance – (North
Norfolk CCG)
Reducing the proportion of avoidable emergency
admissions to hospital.
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1.3 Integration programme
for 2015/16
1.4 Transformation
programme for 2015/16
In November 2014, a Section 75 Agreement was signed
between Norfolk County Council and NCH&C providing
the architecture for integrated working.
On two days in January 2015, approximately 100
staff came together to debate and design what
Sustainable Models of Care could be for NCH&C.
Delegates from operational and support services were
joined by external observers from HealthWatch and
commissioning organisations to consider five themes:
frail elderly pathway, end of life care, musculo-skeletel
services, children’s services, and specialist services.
This builds on a long history of joint working between
the two organisations, via joint Learning Disability (LD)
teams for some years, participation in the Integrated
Care Organisation pilots and more recently the
Integrated Management Structure in the West.
We now have a totally Integrated Senior Management
Structure, with a Director of Integrated Care, Deputy,
four Assistant Directors and four Heads of Integration.
These managers have a joint and equal responsibility for
both Health and Social Care Adult Services.
We are now moving to Phase 2 for the Integration
Pathway during 2015. We will further integrate
functions and pathways where it makes sense. Work
streams will include:
• Single point of access
• IT arrangements
• Joint Care Plan
• Generic worker
We aim to achieve a more seamless service for the
person receiving our services, and a more efficient and
cost effective way of working. We will also include
other partners as we progress.
Roisin Fallon-Williams, Chief Executive, launched the
events by describing the quality of services and the
scale of the financial challenge – the need to make cost
improvement savings of £12.7 million over the next two
years. The groups were asked to consider what services
should look like in the future to ensure that they were
clinically and financially sustainable.
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2. Mandated statements of assurance
2.1 Review of services
During the period April 2014 to March 2015, NCH&C held contracts for 64 service specifications, covering 33 broad
service areas as follows:
Community Nursing
Smoking Cessation
Admission Avoidance
Dental Services
Rehabilitation
Adult Learning Disabilities
Palliative and End of Life Care
Health Visiting Service
Long Term Conditions Management
School Nursing
Musculoskeletal Services
SureStart
Care Management
Children’s Community Nursing
Specialist Neuro- rehabilitation
Children’s Therapies
Stroke Rehabilitation
Community Paediatrics
Amputee and post surgical rehabilitation
Children’s Short Breaks
‘Hard to reach’ Community Care
Clinical Support Services
Diagnostics
Norfolk Early Supported Discharge
Adult Speech & Language Therapy
Suffolk Early Supported Discharge
Podiatry
Environmental Controls
Podiatric Surgery
Rapid Assessment Team
Wheelchair Assessment
IPAC Liaison Nurse
Continence
NCH&C has reviewed all the data available to them on the quality of the care in all of these NHS services.
The income generated by the NHS services reviewed in 2014/15 represents 100% of the total income generated
from the provision of NHS services by NCH&C for 2014/15.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Two
PART 1
Narrative
The Trust Board receives a monthly Integrated
Performance Report (IPR), which focuses on a number
of domains, including patient experience, safety,
quality and risk. The data is presented in a dashboard
format, using Red-Amber-Green (RAG) ratings to
highlight any areas of adverse performance against
agreed targets, standards and thresholds, and is
supported by a narrative explaining the reason for the
variance, and actions being taken to mitigate future
risks impacting on performance.
The Board also receives a monthly Quality Assurance
and Risk report which provides more operational
detail and context on those areas reported in the
IPR. This report is also presented to the Quality
and Risk Assurance Committee, and includes the
following areas:
• Serious Incidents Requiring Investigation (SIRIs)
• Medication Incidents
• Falls causing harm
• National Safety Thermometer data
• Pressure Ulcers
• Infection rates
• Patient Experience surveys (including the Friends
and Family Test and Patient Opinion)
• Complaints and compliments
• Results of external scrutiny (e.g., Care Quality
Commission, National Patient Safety Agency)
• Quality assurance assessments
• Corporate risk register
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Aspirant community foundation trust
benchmarking report
NCH&C is part of a group of 13 community
trusts who have agreed to share data in order to
benchmark performance against one another to
stimulate debate and identify opportunities for
sharing best practice. This monthly report includes
a number of patient safety and quality indicators,
as well as other finance and performance measures.
Cost improvement plan quality indicator
assessment dashboard
A Cost Improvement Plan Quality Indicator
Assessment (CIP QIA) dashboard has been
developed to highlight to the Quality and Risk
Assurance Committee, Trust-wide quality indicators
and standards that can be tracked over time. The
indicators presented are at an aggregate Trustwide level, and they can be found within a number
of individual schemes. Thus, they are intended to
highlight where a quality issue may be emerging,
which will enable drill down to a specific scheme,
area or locality.
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2.2 Participation in
clinical audit
During that period, NCH&C participated in 100%
of national clinical audits which it was eligible to
participate in.
During April 2014 to March 2015, 2 national clinical
audits and 0 confidential enquiries covered NHS
services that NCH&C provides.
The national clinical audits that NCH&C was eligible
to participate in during April 2014 to March 2015 are
as follows:
Name of National Audit
Lead Organisation
Included participation
from NCH&C?
National Audit of Intermediate Care
NHS Benchmarking Network
Yes
Sentinel Stroke National Audit
Programme (SSNAP)
Royal College of Physicians
(London)
Yes
Title of National
Confidential Enquiry
Applicable to NCH&C?
Included participation from
NCH&C?
None applicable
n/a
n/a
The national clinical audits that NCH&C participated in, and for which data collection was completed during April
2014 to March 2015, 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.
Name
Lead Organisation
Percentage
National Audit of Intermediate Care
NHS Benchmarking Network
100%
Sentinel Stroke National Audit
Programme (SSNAP)
Royal College of Physicians
(London)
n/a
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The reports of five national clinical audits were reviewed
by the provider April 2014 to March 2015, and NCH&C
intends to take the following actions to improve the
quality of healthcare provided:
Name
Lead Organisation
Actions
National Audit of Intermediate
Care 2014
NHS Benchmarking Network
None
Sentinel Stroke National
Audit Programme (SSNAP) –
Fourth Report May 2014 /
Acute Organisation Report
December 2014
Royal College of Physicians
(London)
Continue to review Early Supported
Discharge service and stroke ward
against relevant NICE guidance
and support participation in SSNAP
audit
National care of the dying
audit for hospitals, England
May 2014
Royal College of Physicians (RCP) /
Marie Curie Palliative Care Institute
Liverpool (MCPCIL)
Review Trust services against NICE
end of life quality standard
National COPD Audit Programme
November 2014 / February 2015
Royal College of Physicians
None
National Diabetes Audit
2012–2013 Report 2:
Complications and Mortality
Diabetes UK
None
2.2.1 Local clinical audits
The reports of 40 local clinical audits were reviewed
by the provider during the period from April 2014 to
March 2015, and NCH&C intends to take the following
actions to improve the quality of healthcare provided.
• Improve written information available for patients
and families about ‘do not attempt cardio-pulmonary
resuscitation’ orders
• Increase the use of pressure ulcer prevention plans
• Introduce a ‘named nurse for the day’ notice by the
entrance of each patient room on the stroke ward
• Ensure that patients with Parkinson’s disease have
an opportunity to discuss end of life preferences
and concerns
• Enhance the depth and breadth of information
contained in child protection referrals
• Offer more Chronic Obstructive Pulmonary
Disorder (COPD) patients the opportunity to
use self-management plans
• Continue the process of reducing the use of
abbreviations in clinical records
• Introduce the ‘activities of daily living’ assessment
as a measure of rehabilitation progress in the
STEPS service
• Revise and improve the Trust’s pain assessment tool
• Revise the Trust’s assessment process for Dysphagia
to meet new national guidance
• Extend the roll-out of the new referral
process for patients with memory problems
for dementia assessment
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Two
PART 1
2.3 Participation in
clinical research
The number of patients receiving NHS services provided,
or sub-contracted, by NCH&C in 2014/15 who were
recruited during that period to participate in research
approved by a research ethics committee, was 427
(compared with 453 in 2013/14).
Participation in clinical research demonstrates NCH&C’s
commitment to improving the quality of care we
offer and to making our contribution to wider health
improvement. We have developed further infrastructure
within the Trust over the last 12 months to allow
easier access for staff and patients to research, and will
continue to take these forward into 2015/16.
We were involved in 55 research studies during
2014/15, similar to last year; this includes 17 studies
that were new in 2014/15 and 38 ongoing from
previous years. The National Institute for Health
Research (NIHR) supported 58% of these studies
through its research networks.
Throughout 2014/15 we have taken steps to embed
research as core Trust activity and encouraged staff to
engage with local clinical research networks. The Trust
has recently opened a dedicated clinical research room
and trained dedicated research nurses to support the
delivery of research within the Trust.
The Trust’s first Research Conference was held in
September 2014 and feedback was overwhelmingly
positive, particularly for the emphasis on networking
and linking together interested individuals.
The Trust is actively engaging with the new Clinical
Research Network (Eastern), and NCH&C has been
selected as a pilot site for the introduction of research
patient ambassadors.
PART 2
16
PART 3
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Two
PART 1
2.4 Goals agreed with
commissioners
Use of the Commissioning for
Quality and Innovation (CQuIN)
payment framework
A proportion of NCH&C’s income for April 2014 and
March 2015 was conditional on achieving quality
improvement and innovation goals agreed between
NCH&C and any person or body that we entered into
a contract, agreement or arrangement with for the
provision of NHS services, through the CQuIN payment
framework. Details of NCH&C’s achievements against
the agreed CQuIN indicators for April 2014 to March
2015 are set out in Part 3, section 1.6.
The CQuIN indicators agreed with our commissioners
for the forthcoming year (April 2015 - March 2016)
can be found in Part 2, Section 1.2.
PART 2
17
PART 3
2.5 Statement from
the Care Quality
Commission (CQC)
NCH&C is required to register with the CQC and its
current registration certificate issued on 25th February
2014, confirms that the Trust is registered to provide
the following Regulated Activities:
1. Assessment or medical treatment for persons
detained under the Mental Health Act 1983
2. Diagnostic and screening procedures
3. Family planning
4. Surgical procedures
5. Treatment of disease, disorder or injury
6. Personal care
The only conditions of registration are that these
regulated activities may only be provided from the
following registered locations:
Registered Locations
Regulated Activity
(see above)
Cranmer House
1, 2, 5
Little Acorns (Children’s respite)
5
Mill Lodge (Adult respite)
5
Provider Services HQ
1, 2, 3, 5, 6
Squirrels (Children’s respite)
5
Benjamin Court
1, 2, 5
Colman Hospital
1, 2, 5
Dereham Hospital
1, 2, 5
Kelling Hospital
1, 2, 5
North Walsham Hospital
1, 2, 5
Norwich Community Hospital
1, 2, 4, 5
Ogden Court
1, 2, 5
Swaffham Community Hospital
1, 2, 5
The CQC has not taken enforcement actions against
NCH&C during the period April 2014 to March 2015.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Two
PART 1
2.5.1 Inspections by the CQC
Mill Lodge, (Adult respite), Taverham (RY3X4) was
inspected by the CQC in June 2014, and the following
standards were assessed as being met:
• Consent to care and treatment
PART 2
18
PART 3
All NCH&C’s services were inspected in September 2014
as part of the second pilot phase of the new inspection
process CQC introduced for community health services.
Please refer to Part 3, section 1.2, Responsive services,
for further details.
The Trust received an overall rating of GOOD broken
down as below:
• Care and welfare of people who use services
• Safety and suitability of premises
• Staffing
• Assessing and monitoring the quality of
service provision
NCH&C
OVERALL
RATING
Overall rating
Safe
Caring
Effective
Responsive
Well-led
GOOD
Requires
Improvement
GOOD
GOOD
GOOD
GOOD
The CQC identified three ‘Must do’s’ which the Trust
were required to address, these were:
1.Regulation 18 Consent to care and treatment The Trust MUST ensure all clinical staff
understand how the Mental Capacity Act
applies to their work and develop a mechanism
to monitor compliance of the MCA.
These actions, which relate to mental capacity,
are all complete. However it is recognised that this
area requires ongoing training especially as it also
relates to Deprivation of Liberty Safeguards (DOLS)
and the implementation of new guidance, as it
becomes available.
2.Regulation 13 Management of Medicines The Trust MUST carry out a review of
medicines management to ensure there
are suitable arrangements in place to safely
manage medicines.
All these actions have been completed which
included; updating standard operating procedures,
undertaking local audits and the negotiation of
a new pharmacy service level agreement with a
partner provider.
3.Regulation 9 Care and Welfare of people who
use services - The Trust MUST ensure that all
patients have a clear care plan in place which
takes account of their individual needs and
ensures their welfare and safety.
An initial review of all inpatient care plans and audit
was completed immediately. The current assessment
tool has been modified to underpin a personalised
care plan. The welcome pack has been updated to use
a standardised key message regarding individualised
care planning. These actions are all complete.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Two
PART 1
2.6 Data quality
High quality information underpins the effective and
safe delivery of patient care and is key if improvements
in quality of care are to be made. Improving data
quality, which includes the quality of demographic,
ethnicity and other equality data, should improve
patient care and improve value for money.
PART 2
19
PART 3
2.6.1 NHS Number and General
Medical Practice Code Validity
NCH&C submitted records during 2014/15 to the
Secondary Use System (SUS) for inclusion in the Hospital
Episode Statistics (HES) which are included in the latest
published data under the organisation code RY3.
The percentage of records in the published data which:
NCH&C is taking the following actions to improve
data quality:
(i) Included the patient’s valid NHS number was:
100% for admitted patient care (APC)
• A range of data quality reports have been designed
to monitor a range of key performance indicators on
a weekly and monthly basis
(ii) Included the patient’s valid General Medical Practice
code was:
100% for (APC)
• The Secondary Uses Service (SUS) dashboards are
reviewed regularly in relation to a number of national
key indicators
• A selection of these indicators are also reported to
the Data Quality Forum, where operational services
are held to account for the quality of data held
on the Patient Administration System (PAS) and
SystmOne (electronic patient record)
• These reports are held on a networked drive and can
also be viewed on an Intranet portal to ensure they
are accessible to key staff involved in the monitoring
and reporting of performance and activity data
The Trust has a Data Quality Strategy which will
be critical to a number of the Trust’s priorities and
objectives, including improving the quality of patient
care, compliance with the NHS Information Governance
(IG) Toolkit version 11 for 2014/15 and the need to
monitor the Community Information Data Set (CIDS).
This strategy is underpinned by a Data Quality policy which
is subject to annual review. The purpose of this policy is to
ensure the highest standards of data quality throughout
NCH&C are achieved and maintained. This policy is for all
staff collecting and using data and they must adhere to
the local and national standards as laid out.
The Trust has an internal audit on data quality carried
out each year by PricewaterhouseCoopers. The report
for 2014-15 returned a Low Risk opinion.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Two
PART 1
PART 2
20
PART 3
2.7 Information Governance 2.8 Clinical coding error rate
Toolkit attainment levels NCH&C was not subject to the Payment by Results (PbR)
On March 31, 2015, the Trust declared overall
compliance at Level 2 against 26 of the 38 requirements
of the 2014/15 Information Governance Toolkit (IGT)
v12, and the Board noted the Level 3 progress in the
submission of the IGT v12 for 2014/15. The remaining
12 requirements are maintained at Level 3 which gives
the Trust’s overall score as 76%.
clinical coding audit during 2014/15.
Evidence has been submitted to cover the following
six areas where assurance is required:
• Information Governance management
• Confidentiality and Data Protection
• Information Security
• Clinical Information
• Secondary User Information
• Corporate Information
The Information Governance Toolkit is available
on the Connecting for Health website:
(www.igt.connectingforhealth.nhs.uk)
The Information Quality and Records Management
attainment levels assessed within the Information
Governance Toolkit provide an overall measure of
the quality of data systems, standards and processes
within an organisation.
Assessment
Stage
Level
0
Level
1
Level
2
Level
3
Not
Relevant
Total
Req’ts
Overall
Score
Self-assessed
Grade
Version 12
(2014-2015)
Final
0
0
26
12
[1]
38
76%
Satisfactory
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Two
PART 1
PART 2
21
PART 3
2.9 The Core Quality Account indicators
Prescribed Information
Related NHS Outcomes
Framework domain and
who will report on them
Data / output
The data made available to the National Health
Service trust or NHS foundation trust by the
Health and Social Care Information Centre with
regard to the percentage of patients aged;
3: Helping people to
recover from episodes of ill
health or following injury
NCH&C considers that this
data is as described for the
following reasons:
All trusts
NCH&C does not re-admit
patients aged 16 or over following
discharge. All admissions to the
Trust’s beds are received from
acute trusts or from the patient’s
usual place of residence
5: Treating and caring
for people in a safe
environment and protecting
them from avoidable harm.
NCH&C considers that this data
is as described for the following
reasons:
(i) 0 to 15; and (ii) 16 or over, readmitted to a
hospital which forms part of the trust within
28 days of being discharged from a hospital
which forms part of the trust during the
reporting period
The data made available to the National
Health Service trust or NHS foundation trust
by the Health and Social Care Information
Centre with regard to the number and, where
available, rate of patient safety incidents
reported within the trust during the reporting
period, and the numbers and percentage of
such patient safety incidents that resulted
avoidable harm in severe harm or death
All trusts
Table 1 below; represents the rate
of patient safety incidents reported
against the number of face-to-face
contacts with patients, expressed
as a rate per 1,000
Number of patient safety incidents 2014/15
Harm
2014
Apr
2014
May
2014
Jun
2014
July
2014
Aug
2014
Sept
2014
Oct
2014
Nov
2014
Dec
2015
Jan
2015
Feb
2015
Mar
Total
No
193
253
262
269
251
217
295
276
279
255
225
198
2973
Low
277
330
306
312
296
292
315
289
313
352
297
288
3667
Moderate
78
100
78
90
85
106
90
110
98
119
104
84
1142
Severe
2
6
5
5
4
8
4
3
5
5
2
2
51
Unexpected 0
Death
1
0
0
0
0
1
0
1
1
1
1
6
Total
690
651
676
636
623
705
678
696
732
629
573
7839
7.2
7.5
7.5
7.1
8.6
7.0
550
Total incidents in clinical areas per 1,000 patient contacts
5.6
7.3
6.9
6.7
7.2
6.5
6.9
Part Three
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
PART 2
22
PART 3
1. Review of quality performance
in 2014/15
1.1 Summary/Introduction
‘Quality is at the heart of everything we do’ and this is
demonstrated throughout the organisation across all
services. We have measurably improved the quality of our
services in 2014/15, delivering better health outcomes,
high standards of safety, leading to excellent patient
experience and more patient involvement. This was in
line with our Quality Improvement Strategy 2014/16 and
confirmed by our CQC inspection in September 2014.
1.2 The Care Quality
Commission Inspection
In September 2014, NCH&C underwent one of the
‘new style’ CQC inspections of all its services under the
following headings;
• Community Dental
• Adult inpatients
• Community Adults services
• Children, young people and families
• End of life care
The Trust is incredibly proud of its overall GOOD rating
which was broken down as follows;
NCH&C
Overall rating
Overall rating
Safe
Caring
Effective
Well-led
GOOD
Requires
improvement
GOOD
GOOD
GOOD
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
PART 2
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PART 3
NCH&C was encouraged by the positive feedback
received by the CQC and this outcome supports the view
that ‘Quality Counts’ at the Trust. The results will inform
an improvement plan to ensure that the Trust is able to
provide assurance of the safety and quality of its services.
We welcome the opportunity the inspection
finding presents for learning, and intend to
ensure improvements are made.
The three compliance actions were all completed by
the end of February 2015 with a new pharmacy service
level agreement being agreed and signed with a partner
provider by the end of March 2015 (see Part 2, section
2.5.1, Inspections by the CQC, for more information).
• The care and compassion shown to patients by staff
in all of the areas inspected
A number of ‘should do’s’ were also identified and the
top 5 actions include the following;
1.Refurbishment of Squirrels Children’s Respite Centre
(completed 11/12/14)
2.Continue the action already in place to improve
the recruitment process and staffing levels in all of
the services (comprehensive analysis and planning
continues and wider system approach is in place)
3.Carry out a risk assessment of faith leaders who
have not been subject to Disclosure and Barring
Service (DBS) checks (the chaplaincy provision has
been reviewed and confirmed that all employed
by NCH&C have DBS checks in place). All other
multi-faith leads that we use have had DBS checks
undertaken by their employing organisation
4.Increase the number of nursing staff who participate
in clinical supervision (a policy on a page has been
developed and launched, and master classes for
‘train the trainer’ are being rolled out)
5.Review clinical leadership within inpatient settings
and ensure all clinical leaders have opportunities for
leadership development programmes. In addition to
our current leader development programme REAL,
the Trust is working with the Trust Development
Authority and the Leadership Academy to devise a
new programme for ward managers
The following are highlights of good practice identified
by the CQC;
• Our Trust’s mortality review process was a proactive
initiative for a community service
• The level of multi-disciplinary and multi-agency team
working within the end of life and children’s service
was exceptionally good
• A ‘silver call’ daily multi-agency discharge planning
teleconference had been introduced in the West
Locality which promoted patient discharges at the
earliest stage possible
• A daily capacity reporting tool had been developed
which enabled managers to have an ‘at a glance’
overview of the staffing pressure points with the
ability to divert resources where they were needed most
• An outstanding approach to the development of
pathways within the school nursing team based
on NICE guidance
• The Starfish plus team was an excellent example
of a responsive service
• The ability of the community dental service to
adapt care and treatment in order to meet people’s
individual needs
• We are an integrated provider of health and social
care with an agreed joint management structure with
Norfolk County Council
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
1.3 Service Developments
1.3.1 Urgent Care Centre (UCC)
The UCC commenced at the end of October 2014
as a joint Clinical Commissioning Group (CCG), two
year funded project involving NCH&C, the Norfolk
and Norwich University Hospital (NNUH), Norfolk and
Suffolk NHS Trust, Norwich Practices Limited, Norfolk
County Council and Norfolk First Response.
As the project involves NNUH premises and facilities
NCH&C agreed to their leading the project. We are
providing a therapy and nurse-led Early Intervention
team who are assessing acute frail elderly arrivals in the
Accident & Emergency (A&E) department at the same
time as the patients are medically assessed. This pattern
of working on the pilot scheme in 2013 resulted in the
discharge of an additional patient daily compared with
previous efforts. The additional 30 patients a month
whose admissions were avoided do make a significant
impact on admission numbers over a year. Providing a
care assistant led discharge car also aids prompt and
safe return home for patients when needed.
We also provide nursing oversight of the centre and
support to the GP along with triage of cases presenting in
A&E to the centre with experienced community nurses.
Norwich practices are providing GP cover, and we now
have a mental health multidisciplinary team in place and
more social work support to the benefit of the UCC and
A&E combined.
We are seeing over 30 patients daily – around 10-12% of
the A&E workload and are pleased that we have had no
four hour breaches despite some quite complex cases.
PART 2
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PART 3
1.3.2Hospital care at home service
(Virtual Ward)
The hospital care at home service (Virtual Ward) was
recommended for continuation of funding at the West
System Resilience Group. All agencies supported the
proposal, so the service will now continue with a 20
bed capacity. The highlights for February 2015 were;
• 113 patients were admitted in February. 28 were
admitted from the community and 85 were admitted
from the Queen Elizabeth Hospital
• Average length of stay was 5 days
(target is maximum 6 days)
• Occupancy was 112% (relates to timings and
number of discharges in a day)
• 7 patients were readmitted from the hospital care at
home service to QEH during February. 1 community
patient was admitted to QEH
• Patient and carer feedback has been very positive.
Friends and Family Test score 100%
The Home Ward service in Norwich is undergoing
redesign to offer an enhanced rapid response service
and to provide community IV services in Norwich. The
service has increased its referral pathways and now
accepts referrals from case managers, community
matrons, the A&D early intervention team, the
community liaison team, Priscilla Bacon Lodge and
the care at home team. The project team are currently
working with Norfolk First Support (NFS) to enable a
seamless transfer from the Home Ward to their service.
In addition, they aim to offer a step-up pathway if NFS
clients require extra nursing and therapy support to
prevent admission to acute care.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
1.3.3Ensuring the best
end of life care
New measures are being introduced across the county
to help ensure patients can receive joined–up care
at the end of their lives. Following withdrawal of the
Liverpool Care Pathway last year, we have revised our
End of Life policy which explains how we have adopted
five new priorities for care in line with the ‘one chance
to get it right’ national guidance.
In addition to the revised policy, new documentation
will be rolled out to replace the ‘Yellow folder’ which
our Trust was instrumental in helping to develop. This
new pack gives patients the opportunity to complete
an advance care plan and record their choices about
their future care and place of death, as well as their
preferences about resuscitation, if they wish.
Its aim is to standardise the documentation used for all
patients, regardless of where they live, to help GPs and
health and social care staff to work across boundaries
and provide the best possible end of life care in line
with each individual’s wishes.
PART 2
25
PART 3
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
1.4 Transformation
programme
PART 2
26
PART 3
1.4.1Hub and spoke working
The Transformation programme is ambitious, involving
large scale change, to deliver improved care for
patients. This has been achieved by a clinical and
systems re-design, by investing in technology and
improving our efficiency. We have invested in staff
capacity and capability, to ensure that they have the
right tools to deliver excellent, quality care. Better
deployment of staff and improved use of management
information will also improve productivity and our
competitiveness. A lot has been achieved, but there is
still work to do in areas which will require continued
support. We are also committed to learning lessons
from the programme which will improve our efforts in
the future.
Transformation has reduced clinical time
spent on administrative duties and
greater recognition of admin and clinical roles...
Kerry Jones, Locality Operational Manager,
West Locality
We have introduced a hub and spoke model for each
locality. Clinical staff can drop in to any spoke to use
the facilities, for handovers and to replenish stock. The
hub has created a single point of contact for the locality
and currently, Community Nursing and Therapy teams
have transformed into this new way of working. The
Continence Service and MSK service will also align to
hubs. Mobile working has been developed in tandem
with working on a hub and spoke basis.
From the hub perspective, there has been a streamlining
of processes and bringing them together in one
location. This makes it easier to monitor and support
the work that we do so that there can be an oversight
of patient care. Working in hubs will standardise the
processes that support all services. By centralising
these people and processes, and channelling the work
through a single point of referral we improve;
• Consistency of working processes across the teams in
all areas
• Coordinated administrative cover to support that
service in the event of sickness and absence
• Consistent support for all services
• Skills and information sharing
£1.9m
efficiencies created
within Community
Nursing and Therapy
to date
716
152
Care Plans
developed
99%
staff trained in
SystmOne
Optimisation
(Mar-Dec 2014)
of our patients in CN&T,
post Transformation,
would recommend
NCH&C to their
friends and family
(Dec 2014)
4
Recorded
patient-facing time
has increased from
locality hubs have
been created
36% to 62%
and continues to rise
60
teams using
eRostering
270+
engagement
sessions held
since January
2013
1100+
eBooks will have
been issued to
staff by March
2015
1270
Queries sent to
the localities’
mailbox
95%
of care recorded is
entered within 24 hours
with over 45% recorded
in real time with
patients (Jan 2015)
400+
people undertook
core competency
training
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
1.5 Achievement of our
Quality Goals 2014/15
Our Quality Goals for 2014/15 covered key areas such as
reducing falls and pressure ulcers, referral to treatment
times, length of stay, clinical effectiveness and patient
experience. These goals were developed following
consultation with staff, patients and stakeholders and the
wider public, and help to ensure that we deliver excellent
harm free care. The goals were developed to tie into the
CQC’s five quality domains of; safe, effective, caring,
responsive to people’s needs and well-led.
1.5.1 Safe, (harm free care)
• We increased the percentage of patients with harm
free care (new harms only) throughout the year
•We ensured that the number of falls causing harm to
patients in our inpatient units were below national rates
• We ensured that all patients were assessed for their
risk of falling on admission to our inpatient units
• We ensured that all inpatients received a pressure
ulcer assessment using the Waterlow risk tool within
six hours of admission
• We worked hard to ensure that patients, in our
inpatient units and in their own homes, did not
acquire avoidable pressure ulcers and we continued
to support and train all our staff in the prevention and
management of pressure ulcers
• We ensured that, where appropriate, patients in our
inpatient units had a venous thromboembolism (VTE)
risk assessment undertaken during their inpatient stay
• We created a group to lead on a project to reduce the
incidence of catheter acquired infections. The project
to raise awareness and train staff on the prevention
and management of catheter acquired infections
continues into 2015/16
•W
e worked to ensure the effective use of medicines
by developing a medicines’ optimisation strategy, all
patients’ medications are checked by a pharmacist on
admission to our inpatient units, and we have raised
staff awareness of the NCH&C medication formulary to
increase the effectiveness of prescribing
• We have worked with Community Children’s Services
to ensure that all clinical staff receive safeguarding
supervision in accordance with Trust policy
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1.5.2 Effective care
• We have reviewed Trust services against key NICE Quality
Standards including: Dementia; Stroke; VTE prevention;
End of Life Care for Adults; and the Health and
Wellbeing of Looked After Children and Young People
• We have also included audits of NICE guidance into our
annual clinical audit plan
1.5.3 Caring services
We improved our Friends and Family Test score (how
likely are patients to recommend our services) in both
the inpatient units and community nursing and therapy
teams. We also responded to all submissions provided
by patients/public on to our Patient Opinion website.
1.5.4 Responsive to people’s needs
We worked hard to ensure that our Trust and individual
service performance was equal to, or above, the target
for completed pathways. Nearly all patients referred to
us commenced treatment within 18 weeks of referral.
1.5.5 Well Led
• We implemented the ‘Friends and Family Test’ for
staff (asking how likely staff are to recommend our
organisation as a good place to work), we reviewed
the results of the short staff surveys and took action
to improve staff experience
• We developed and instigated an Organisation
Development Strategy, which included the revision
of the staff behaviour framework to support our
‘Community’ organisational value and to embed a
positive culture throughout the Trust
• We implemented a strategy to improve our staff
training compliance figures for mandatory and clinical
subjects and have achieved our contractual targets
• We reviewed and implemented the ‘Safe Staffing’
requirements in the inpatient units using the RCN
‘Safe Staffing for Older People Toolkit’ and created
a discharge coordinator role to support patient
discharges with positive results
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
PART 2
1.6 Achievement of our
Commissioning for
Quality Innovation
(CQuIN) indicators
for 2014/15
5. Breastfeeding initiative – UNICEF 3
CQuIN indicators are contractual commitments, some
are nationally mandated and some are developed in
partnership with our commissioners. They are intended
to improve quality and encourage innovation within key
areas of local services. If these indicators are achieved they
attract additional funding that can be used to make further
improvements. The indicators for 2014/15 cover the three
quality domains of patient experience, patient safety and
clinical effectiveness. Achievements are summarised below;
7. Neurology
1. Staff Friends and Family Test
To encourage and improve service delivery, and that
all staff should have the opportunity to feedback their
views on their organisation.
2. Friends and Family Test – Early Implementation
To improve the experience of patients in line with Domain
4 of the NHS Outcomes Framework. The Friends and
Family Test will provide timely, granular feedback from
patients about their experience. To roll-out to Community
Nursing and Therapy services, Muskulo-skeletal
physiotherapy and inpatient units.
2.1 Friends and Family – Phased expansion
To improve the experience of patients in line with Domain 4
of the NHS Outcomes Framework. The Friends and Family
Test will provide timely, granular feedback from patients
about their experience. Phased expansion, but to exclude
Adult Speech and Language and Lymphoedema service.
3. NHS Safety Thermometer
To measure and reduce harm. It is recommended
that organisations prioritise improvement in pressure
ulcer prevalence.
4. Inpatient Beds Dashboard
To develop an inpatient Data Management Information
System. This dashboard will enable commissioners and
providers to support improved system flow by making
sound and rapid operational decisions.
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NCH&C contribution across Norfolk to help increase the
numbers of women initiating breastfeeding in line with the
Department of Health target of 2% increase per annum.
6. Lymphoedema
Roll out of specialist service to include pre assessments in the
West locality. This will improve patient experience, bringing
care closer to home to reduce unnecessary admissions.
Expansion of existing service to provide a specialist nurse
for patients with Multiple Sclerosis. This service will
support patients experiencing problems with relapse,
ongoing symptoms and worsening of their condition
who would otherwise be admitted to hospital.
8. Development of sepsis education
To develop and produce a clinical competency training
programme for inpatient units and community teams.
9. Integrated care co-ordination
To develop working seven days allowing the co-ordination
of placements from the acute trust into the community
setting over a seven day week.
10. Dementia
Provision of tiered training at three different levels to
encapsulate all ranges of staff from non-clinical through
to dementia link worker.
11. Prosthetics
All new patients referred in to the service are to be triaged
within four weeks and offered a multi-disciplinary team
(MDT) assessment within a maximum of six weeks from
receipt of the referral.
The Trust achieved 100% against all the indicators except;
Indicator 6. Lymphodoema which achieved 93.7%
Indicator 8. Sepsis Education which achieved 90%
Indicator 9. Integrated care coordination which
achieved 75%
As a result of implementing these indicators during
the year, it is anticipated that the Trust will receive
£2,332,000 in additional income.
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2. A well-led organisation
2.1 Introduction
“It’s all about our staff...”
said Roisin Fallon-Williams, our Chief Executive, in the
March edition of the Exchange.
Our staff play a prominent role in the organisation and we
take time out to celebrate the success of our colleagues.
Whether this is through the progression of their careers,
giving up their own time to share best practice, or being
acknowledged for the outstanding work that they do by
being nominated for regional awards.
2.2 Student nurses
We welcomed our largest ever single cohort of
student nurses who will be taking up roles across
the county to help prepare them for their first jobs
after they have qualified.
A total of 80 students – twice the usual headcount –
started work at the end of November 2014, most are
in the second year of a three year degree course at the
University of East Anglia (UEA). They are completing
a 12-week placement so that they can gain direct
experience of patient care, with added responsibility and
autonomy. This means that they will be better prepared
for their first jobs as qualified nurses. Taking on the
super-sized group has been made possible following the
introduction of a new Collaborative Learning in Practice
(CLiP) initiative, being piloted by NCH&C in a number
of hospitals in the county. Whereas previously, training
consisted of a ‘one nurse to one student’ model, the new
initiative allows more student nurses to be taken on and
trained at the same time.
Launched in May this year, CLiP was piloted at
North Walsham and District War Memorial Hospital,
Community Nursing Teams in North Norfolk, and Alder
Ward in the Mulberry Unit at Norwich Community
Hospital. It has now been expanded to include Community
Nursing Teams in Norwich and South Norfolk.
In total, 65 of the students will be trained under the new
model, with 15 receiving training under the traditional
model. CLiP has been developed in partnership with
NCH&C, the UEA and Health Education East of England
(HEEoE). It gives students the chance to run a learning
bay or small community caseload, while taking on
responsibility for planning and delivering care under the
guidance of a registered nurse.
The aim is to provide a different experience for the
students, as well as essential practical skills, helping
build their confidence before they qualify. This style of
training has also been shown to improve quality of care
elsewhere on the ward by giving other staff more time
to spend with their patients.
Marcia Perry, Deputy Director of Nursing and Quality,
said: “It means we are providing trainee nurses with
a positive experience of community services. We’re
shaping practitioners for the future that will hopefully
want to come and work with us in the community and
will be better prepared for the role.
“Staff recognise the importance of investing in training
the future generation, and the patients love it! They are
able to build a relationship with student nurses over the
12 weeks. Students work in pairs and have dedicated
and focused time each shift where they can assess and
plan care for their patients.”
We will review the placement, alongside the formal
evaluation by HEEoE, in order to continue to improve
and plan for future cohorts of students.
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2.3 National
Apprenticeship Week
The Trust marked National Apprenticeship Week,
from 9 - 13 March 2015, by celebrating the
success of our apprentices, and our apprenticeship
programme, with a variety of events reaching
thousands of potential apprentices.
2.4 Staff achievements
2.4.1 Laying their career
foundations
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2.4.3 Staff shortlisted for
regional awards
Staff from across NCH&C were shortlisted for
regional awards in recognition of their contribution
to supporting learning and education across the
organisation. The awards, run by the Norfolk and
Suffolk Workforce Partnership, recognise individuals
and teams who have made an outstanding contribution
to the overall growth, development and education of
pre-registration healthcare students and learners. A
total of seven teams and individuals have been named
as finalists in the Practice Education and Learning
Support Awards 2015. They are;
Learning Support Award – Apprenticeships:
Congratulations went out to two members of staff
who have successfully completed foundation degrees
in Health Studies. Kate Mawby and Wayne Lowe, both
Nursing / Therapy Assistants working in the Specialist
Amputee Rehabilitation Service in Pine Cottage,
Norwich, studied for two years to earn the qualification,
which is designed to be the ideal first level in higher
education for healthcare workers.
• Pippa Bennett, Bands 1-4 Development Officer
2.4.2 Kelling trio the first to
complete Level Three Diploma
• Thetford Community Nursing Team
Three members of staff celebrated being the first
in our Trust to have successfully completed a Level
Three Diploma in Clinical Healthcare Support. The
trio, Heidi Ris, Dawn Shailes and Julie Harris, who are
all Healthcare Assistants at Kelling Hospital in North
Norfolk, embarked on the 18 month course to gain
the qualification which demonstrates knowledge and
competence in healthcare.
• Children’s Speech and Language Therapy Service
• Francesca Norton, Career Development Facilitator
• Pamela Lacey, Senior Staff Nurse
Mentor/Practice Teacher and Outstanding
Contribution to Learning:
• Lorna Young, Staff Nurse
Team Award:
• Caroline House, Specialist Neurological Rehabilitation
Nursing Team
2.4.4 Sally Tyler is honoured
with an MBE
One of our Children’s Epilepsy specialist nurses paid
tribute to the hardworking team around her after being
named as a Member of the British Empire (MBE) in the
Queen’s New Year’s Honours list. Sally has worked in
this role since 2001, and provides an holistic service for
young people aged up to 19 in central Norfolk. Anna
Morgan, NCH&C’s Director of Nursing and Quality,
said; “ We are absolutely delighted that Sally has been
recognised in this way. She provides a fantastic service
to children and young people with epilepsy, as well as
their families and carers, and ensures they receive the
treatment, advice and support they need to live with
the condition.”
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2.4.5 Health Visiting
2.5 NHS Staff Survey 2014
Our health visitors have won three awards for their
excellence in mentoring students who have been
training to become health visitors. The health visitors
were presented with their awards on Friday, March 6,
2015 by Professor Viv Bennett, Director of Nursing at the
Department of Health. The winners from the Trust were;
The 2014 National Staff Survey has provided an
invaluable insight into the views of our staff following
publication of the results last month by NHS England.
•K
ate Hillman: Workplace Advisor Award for supporting
the Building Community Capacity programme
• Glenda Booth: Preceptorship Award for her support to
newly qualified Health Visitors and pioneering work
with the Institute of Health Visiting (iHV)
• All Health Visitor Practice Teachers from across the
region were recognised for their hard work with the
‘Team Award for Excellence’.
2.4.6 Speech and Language
Therapy (SLT)
The SLT team won the team award in the Norfolk and
Suffolk Workforce Partnership Practice Education and
Learning Support Awards. The awards ceremony was held
at Dunston Hall, Norwich, on 16 March 2015, and the SLT
team was presented with the Team Award in recognition
of its dedication and commitment to student training.
The award recognised that University of East Anglia
students are routinely welcomed into the team with
close liaison between educators to capitalise on learning
opportunities. Therapists provide students with essential
experiences in clinical decision-making, therapy delivery,
inter-disciplinary working and interacting with the
people who use our service. Therapists collaborate with
students to plan their goals and enhance their personal
learning. The SLT team advocates high-quality, accessible
care for all and is dedicated to developing confident
and competent practitioners of the future. Libby ffrench
Mullen, Specialist Speech and Language Therapist,
collected the award on behalf of her colleagues.
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Nearly 300 NHS organisations in England took part in
the 2014 survey, and in our Trust a random selection
of 800 staff were invited to complete an on-line
questionnaire relating to the NHS constitution.
Nineteen Community Trusts participated in the survey,
which enables NCH&C to compare its results against
the national NHS picture and other community trusts.
2.5.1 Overview
The overall results show that the scores are not
statistically different to our 2013 results. However,
when compared to other community trusts, they have
moved further and faster with their results. This is in the
context of significant change and cost pressures across
the NHS.
Our response rate has decreased from 55% in
2013 to 36% in 2014. This is reflective of a decrease
in the national response rate (from 49% to 47%
respectively) and may have been affected by a move
from a paper questionnaire to an e-mail questionnaire
for the very first time.
Analysis of the figures show that NCH&C’s overall staff
engagement score is 3.60 compared with 3.65 in 2013
and the average for community trusts of 3.75 in 2014
(scores are between 1 to 5, with the highest figure
being positive).
Overall, of the 29 Key Findings, NCH&C scored average
or better than average in 9 and below average in 20
when compared to other community trusts.
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2.5.2 Top ranking scores
Our top ranking scores included;
• 91% of staff having had an appraisal in the last
12 months
• 94% of staff reported an error, near miss or incident
in the last month, and
• 74% of staff feel secure to raise concerns
• 94% of staff had received equality and diversity
training in the last 12 months
• 84% of staff had health and safety training in the
last 12 months
2.5.3 Areas for development
There are, however, areas for improvement required
when comparing ourselves against other community
trusts, specifically around work pressure felt by staff.
3.32 remains at the same level as our 2013 result but
behind the community trust average of 3.11.
Furthermore, staff recommending our Trust as a place
of work or to receive treatment has declined to 3.42,
compared with the community average of 3.66.
2.5.4 Next steps
We held a number of staff survey workshops during
March 2015 to gather employees’ thoughts and
opinions on the results to help shape our action plans
going forward.
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2.6 Health and
wellbeing at work
Staff interested in promoting health and wellbeing in
the workplace are being encouraged to join a new
group and help drive through a range of exciting
new initiatives designed to make a difference to their
colleagues at NCH&C. A group is being set up to help
drive our Trust’s Health and Wellbeing strategy, which
will ensure NCH&C continues to take a positive and
engaging approach to enhancing the wellbeing of all
our employees. The next part of the process will see our
Trust use the NHS Wellbeing Charter Self-assessment
Tool to see how well we are performing against key
standards, and where action can be taken to improve
still further. The assessment will look at a number of
issues, including; leadership, absence management,
mental health, smoking and tobacco, physical activity
and healthy eating.
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2.7 Compliments and thanks
Below is a selection of the compliments and thanks we
have received from our patients and stakeholders.
Benjamin Court, North
I would just like to say thank you for all the
kindness, love and excellent care you gave my
mum in the last few days of her life. It was a great
comfort that she was able to spend them in a
safe, loving environment…
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Thetford Leg Club, South Norfolk
To all the nurses and staff at the Thetford Leg
Club, thank you for the kindness you
have shown me over the past few weeks…
Alder Ward, Mulberry Unit, NCH
Thank you for everything – all your help and
all your kindness to me. I will always
remember you and I will miss you…
Dental Access Centre, King’s Lynn
To all the staff at Benjamin Court,
thank you for your excellent care when
looking after mum...
An excellent service - prompt, relaxed and
relatively painless. If only the whole
dental service could be like this…
District Nurses, South East
Foxley Ward, Dereham Hospital
I just wanted to thank the District Nurses who
made the last three weeks of my father’s life
so much easier and comfortable. I am so very
grateful to you all for your help and care…
A very big thank you to all the team for
your skill, kindness and encouragement
during my stay with you. I count myself very lucky
to have been in your care. I hope Foxley Ward will
be available for many others after me, for the
benefit of the community…
MSK Physio, Norwich
I came in feeling so frustrated with my back
and neck problems and the patience and
understanding I received has been exceptional…
Occupational Therapy, Aylsham
The therapist gave me invaluable help and advice
as I have mobility problems. They were very kind
and provided me with aids and I now have more
confidence and can move without pain…
Community Nursing &Therapy, Norwich
Just a note to say a very grateful thank you for the
very prompt and caring service given by the
district nurses to my mother during her final days...
Family Nurse Partnership (FNP)
Thank you for being my FNP nurse, I wouldn’t
have it any other way. Thank you for all
your help and support...
Physiotherapy, West Norfolk
The pain and my strength improved greatly
within a short time. The advice of recommended
diligent exercise by my physiotherapist was key
to my success...
33
Lymphodema Team, Swaffham Hospital
Excellent service. The therapist has
always been caring, helpful, hardworking
and professional...
Occupational Therapy Team, Norwich
Thank you for being a great OT, albeit for a short
time. We are very grateful for your care,
patience and your listening ear…
Physiotherapy Team, Kelling Hospital
I am 63. In the last 30 years I visited the
Kelling Hospital physiotherapy department
on four occasions. As ever, they are thorough,
charming, understanding and do a great job. I have
now finished my treatment, with good advice and
exercises to go away and continue on my own.
I’m feeling a lot better…
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2.8 Clinical Ethics Group
Since its inception, the CEG has received few enquiries
relating to acute/hot cases.
The Clinical Ethics Group (CEG) for NCH&C had its
first meeting in September 2012 and has continued
to meet quarterly since then. The meetings are well
attended with lively conversations and discussions.
The important links with Norfolk & Norwich University
Hospitals NHS Foundation Trust (NNUH) Clinical Ethics
Group remain strong.
Nevertheless, there appears to be no shortage of
complex case discussions covering a wide area of service
delivery. These discussions are minuted in brief, and
to date, it is left to the presenting clinician to include
information about a CEG discussion in the patient’s
records as appropriate. This will be further considered in
the meetings to be held in 2015.
The underlying objective is to provide a framework of
support for all of our clinicians, dispersed throughout
the Trust, to encourage the sharing of complex clinical
situations, and ultimately to improve the care, safety and
quality of care for our patients by enabling our staff.
During the coming year the CEG will continue to
progress this work by:
NCH&C joined the UK Clinical Ethics Network
(UKCEN) in December 2014, and according to the
web site (www.ukcen.net), we are the only community
trust with membership.
The core functions of the CEG are:
• To embed ethics in NCH&C
• To continue with the joint meetings with NNUH
• To consider ‘hot cases’ and promote discussion
of historic cases
• To develop the function of scrutiny of relevant
Trust polices
• To discuss subject areas (as opposed to individual
cases) which over the past year have included:
–– Mental Capacity Act
–– Deprivation of Liberties
–– End of Life Policy and related matters
• Running a programme of Trust-wide road shows
entitled ‘Ethics in Action’
• Agree the recording of case discussions and how
these may lead on to generic discussion
• Develop a Trust CEG intranet ‘room’
• Formalise the CEG’s involvement with the
development and scrutiny of Trust policies
• Consider the role of a CEG more broadly within
a community trust and test this through UKCEN
and through the Aspirant Community Trust
Benchmarking Group
In March 2015, some of the CEG members attended a
regional clinical ethics workshop facilitated by UKCEN.
This workshop was aimed at clinical ethics committee
members, and included ethical case study presentations
from each group.
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3. Responsive services
3.1 Review of quality
performance in 2014/15
The specialist epilepsy service is comprised of two
members of staff. Unusually high sickness levels in the
team led to an increase in waiting times, which was
resolved by the end of the year.
3.1.1 Summary
Three families out of a total of 19 had to wait over 18
weeks for their home based short breaks nursing service
to commence, following their referral to the team.
There have been no breaches of the 18 week target
since October 2014.
One of the key performance targets for the Trust is
the 18 week wait Referral to Treatment (RTT) target,
where 95% of non-admitted patients should receive
a definitive treatment or intervention within 18 weeks
of referral. NCH&C reports 18 week wait compliance
for 26 services. Overall, the Trust met this target for
2014/15 with a performance of 97%.
However, four services saw their RTT performance fall
below the agreed target for the year:
• Musculoskeletal (MSK) physiotherapy (93%)
• Podiatric surgery (67%)
• Specialist epilepsy nursing (84%)
• Children’s Shortbreaks Home Based Nursing Service
(84%)
MSK physiotherapy teams have increased the number of
clinics in order to manage the increase in demand which
they faced at the start of the year. This has seen them
reduce the number of patients waiting over 18 weeks
from 633 at their peak, to 148 at the end of the year.
The podiatric surgery service changed its clinical
pathway during 2014/15, resulting in the patients
requiring surgery being seen at the Norfolk and
Norwich University Hospital (NNUH). This change in
pathway, combined with staff absence, resulted in an
increase in the waiting list size and waiting time. By
the end of the year, all patients waiting for surgery had
either been seen by services in Suffolk, or had been
transferred to the NNUH or providers in Suffolk.
No patient has waited more than 52 weeks for any
treatment, and NCH&C has improved and maintained
waiting times for diagnostics, with less than 1% of
patients waiting longer than 6 weeks.
In 2014/15, there were seven reported cases of
Clostridium difficile against an annual ceiling of five cases.
There have been no reported cases of MRSA
bacteraemia since July 2012.
The Trust agreed an annual ceiling of no more than 4.0
injurious falls per 1,000 Occupied Bed Days (OBDs).
Despite in-month variation across the Trust’s inpatient
units, the overall performance year to date was 3.6 falls
per 1,000 OBDs.
All community service providers are required to report the
level of Venous-Thromboembolism (VTE) assessments for
patients admitted to its community hospitals. The Trust
achieved the 95% target for 2014/15.
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3.1.2 Meeting targets 2014/15
Indicator
Target or upper ceiling
Annual performance
Trend
Injurious falls
Number of falls resulting in harm per
1,000 Occupied Bed Days to be less than
4.0
3.6
Stable
Venous
Thromboembolism (VTE)
assessments
At least 95% of admissions have a VTE
assessment
97.2%
Stable
18 week wait referral to
treatment
95% patients receiving definitive treatment
within 18 weeks of referral
97%
Declining
3.1.3 Areas of non-delivery
We set some ambitious targets for 2014/15, and have
not met them in all cases.
Clostridium difficile
In 2014/15, there were seven reported cases of
Clostridium difficile against an annual ceiling of five
cases. All reported cases have been subject to Root
Cause Analysis (RCA) to review lessons learned. There
has been no link between the cases, and the increase
reflects a general increase observed across Norfolk in
2014/15. In recognition, the ceiling for 2015/16 has
been increased to seven.
Harm free care
We have continued to use the national NHS Safety
Thermometer to measure how many patients were
harm free during their care with NCH&C. Our Board set
a target of 97% of patients not being harmed whilst in
our care. Harm in this case is defined as patients who
develop a pressure ulcer, a catheter acquired urinary
tract infection or who fall. We achieved a harm free
care rate of 96.7%.
Delayed discharges
Throughout the year, the number of patients whose
discharge was delayed for non-medical reasons occupied
an average of 6.2% of the Trust’s community hospital
beds. This was above the Trust’s target of 5%. Analysis of
the data has shown delays have been attributable to both
health service related reasons (including patient and family
choice and waiting for continuing healthcare assessments
and placements), as well as social care delays.
We are working in partnership with social care and the
acute trusts to reduce the number of delayed discharges
from our hospitals.
Smoking cessation
The service agreed an annual target for 2014/15 of
2,000 quits with its commissioner, Norfolk County
Council. The Trust has struggled to generate the
number of referrals required into this service to meet
this target and as a result has only generated 1,550
quits. Commissioners have recognised that demand for
these services has reduced nationally, and as a result are
reducing the target next year to 1,251 which the Trust
is confident it will meet.
Health visitor recruitment and KPIs
We had a target to recruit 169 health visitors by March
2015. The final position was an establishment of 159
whole time equivalent staff in post. This was despite
specific recruitment campaigns, a major training
programme, and rolling adverts on NHS jobs.
The Trust has also failed to meet the KPIs for the 14 day,
12 month, and two and a half year reviews that each
child should receive. An action plan has been developed
and additional resources targeted on improving our
systems and processes to ensure that these targets are
met for 2015/16.
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3.1.4 Missing targets 2014/15
Indicator
Target or upper ceiling
Annual performance
Trend
Clostridium difficile
Five cases or less during 2014/15
(cumulative)
7 cases
Declining
% Patients who are
harm free
At least 97% of patients are harm free
according to the Safety Thermometer
96.7%
Improving
Delayed transfers of care
No more than 5.4% of beds occupied by
patients whose discharge is delayed for
non-medical reasons
6.3%
Stable
Smoking cessation service
Achieve a minimum of 2000 quits
per annum
Estimated quits to
March 1,550
Stable
Health visiting
New birth visits in 14 days (95%)
90% (Q4)
Improving
12 month reviews (95%)
90% (Q4)
2.5 year reviews (90%)
73% (Q4)
3.1.5 Mixed sex accommodation
requirements
NCH&C is compliant with mixed sex accommodation
requirements. No breaches were reported during
2014/15 and the Trust will be declaring continued
compliance against this standard.
3.1.6 Self certification
Our Board has risk assessed itself against on-going
compliance with Monitor’s NHS Provider Licence in
preparation for FT status. Compliance with all relevant
conditions has been confirmed and validated with
evidence. The Trust is therefore also compliant with
those conditions identified by the TDA as being relevant
to NHS Trusts.
The Board has confirmed compliance with all TDA
Board Statements, with the exception of statement
10 which relates to achieving all commissioner targets.
The target for smoking cessation has not been
achieved, and the Trust has not met the 18 week target
for podiatric surgery. There is a plan in place to get
performance back on trajectory in the coming year
and maintain targets over the next two years, subject
to further negotiations with commissioners. The Board
considers the TDA governance declarations and Board
statements every month.
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4. C
aring services Patient Experience
4.1 Summary
Our vision for Patient Experience and Involvement is
that NCH&C is a patient focused organisation actively
seeking the views of our patients and carers, and
engaging them in shaping and developing our services
whilst consistently providing high level, quality care. We
want our patients to have the very best experience of
community services in the East of England.
NCH&C has been innovative and successful in using
new methodologies and techniques to capture the
views and experiences of our diverse community patient
and carer population. This feedback has been used
to promote, share and celebrate good safe quality
care and high levels of satisfaction, but also to make
improvements where they are needed and inform
service redesign and business development.
It is against this backdrop that the three priority themes
have been identified:
1. Ensuring a systematic approach to capturing
feedback – empowering staff with knowledge
of how to capture patient experience feedback,
the tools and techniques with which to do it and
ensuring this informs a Trust-wide plan.
2. Action for improvement – using patient experience
information alongside other quality data to make
demonstrable improvements to care.
3. Building meaningful and systematic
engagement and involvement - spreading
and building on where good engagement and
involvement of our patients, carers and Members
exists and supporting development across the Trust.
To turn these themes into reality a number of specific
goals/workstreams have been identified. These will
inform the development of annual implementation plans.
1. Capture and use the views and experiences of
patients, families and carers, service user groups,
Healthwatch and other voluntary groups in the
evaluation, delivery, improvement and development
of our services. Success will be measured by citing
increased examples of how services have been
improved as a result and increased involvement
in developing services.
2.Develop and implement effective mechanisms for
capturing and measuring patient experience and
involvement. Success will be measured by extending
the range (e.g. social media) and scope (across
a wider range of services) of how we capture
feedback, and demonstrating improvement in
measures such as the Friends and Family Test.
3.Develop effective mechanisms for feeding back to
our patients, families and carers and commissioners
what we have done as a result of their feedback
and involvement. Success will be measured by
demonstrating improved and increased profile
of what actions have been taken, and increased
visibility and transparency of when things go well
(compliments) as well as when things go wrong
(e.g. complaints).
4.Develop a staff culture where listening to and
acting upon the patient experience is embedded
into everyday practice and informs organisational
development. Success will be measured by an
increase in participation in initiatives and profile.
5.Empower staff with the knowledge, tools and
techniques available to carry out effective patient
experience and involvement. Success will be
measured by the number of available tools and
the evaluation of their use.
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Patient experience information is also included in the
monthly Quality Assurance & Risk report and includes;
4.3 Patient Voice at Board
•A
n update on responses to the Friends and Family Test,
including comments from patients and actions taken
4.3.1 Introduction
• A review of patient’s stories uploaded onto the Patient
Opinion website (www.patientopinion.org.uk) and
actions taken by staff
The Patient Voice programme has been part of NCH&C
Board agenda since April 2012. The main benefit is that
it helps to ground discussions in the reality of patient
care. Patients are truly put at the heart of discussions
as stories are powerful reminders of the context within
which Board members are making decisions. Board
members are able to see how their decisions impact on
patients and carers, and helps them to better understand
the complexities of day to day life at an operational level.
• The Patient Voice at Board a regular feature at the
beginning of every Board meeting
• Complaints information including numbers, themes
and trends and a summary of learning from these
• Compliments received from patients, relatives and carers
4.2 Patient and carer
involvement
Patient and carer involvement in service redesign is
becoming increasingly important. The first of a new
style of ‘deep dive’ focus groups for patients and their
carers recently took place for MSK Physiotherapy, MSK
Occupational Therapy and Orthopaedic Triage. The
feedback is being collated and will be shared with
service leads to inform the redesign of the service.
This work will also provide the basis of a toolkit for
conducting focus groups.
A Patient Experience learning event was held in March
2015 for staff and the key objectives included;
• How to support patient/carer involvement
• Patient experience and involvement - networking /
learning / sharing good practice and problem solving
The Patient Voice at Board is heard at the very start of
the meeting before other items on the agenda. Board
members have reflected that this is very valuable and
reminds them of the core business of putting patients,
their carers and families at the centre of delivering high
quality care. It helps to highlight what the elements are
of a good patient experience, directly from the patient,
and how we can replicate this across the Trust, but
equally to address areas where there have been poor
experiences and how the Trust can support staff with
delivering improvements.
From November 2013 to February 2015 there have been
14 stories heard at Board, five of which were patients,
three were parents/carers with their children, four were
carers/family members, one was a case study given by a
member of staff, and one from an external organisation
describing how they receive stories from the public.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
4.3.2 What has changed as a result
of Patient Voice at Board?
Smokefree Norfolk service
We have worked closely with commissioners to redesign
this service to ensure that our staff can continue to
deliver a service that we feel passionate about in
influencing healthier lifestyles for our patients. The
new contract from April 2015 enables us to deliver
more training to other providers as well as retaining our
specialist interventions.
Intravenous Therapy Service
This service continues to be supported by patients
who are able to receive more care at home. We have
developed stronger relationships with the NNUH as a
result, and there is better joint working between our
clinical teams and the outpatient departments.
Patient with Neurological Condition
The experience shared by this patient has informed the
care strategy work and the case management level of
care that we are taking forward this year.
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PART 3
Urgent Care Unit
This experience has been reflected into the second
phase model of care now provided at the UCC. There
has also been a lot of work this year with all clinical
teams across adults and children’s services on the
Sepsis pathway. New guidance and standard operating
procedures are in place.
MSK Physiotherapy
The delays and early difficulties experienced by this
patient have been used to inform a new integrated
model of MSK with a triage service that will ensure
patients are put on the appropriate pathway at the
earliest time. A service user focus group has also been
held to develop the model further and serve as a group
that can feedback during the implementation phase of
the new model.
Breastfeeding
The ideas generated from the peer support workers
have been used to inform the Healthy Child Pathway
(HCP) tender and enabled us to develop clearer career
pathways for this valuable group.
Conclusion and next steps
The Patient Voice has been extremely valuable for the
Board as it enables them to hear about and understand
the experience of care directly from the patient or
carer. We will continue to have a Patient Voice at every
Board meeting, and use these experiences along-side
the wealth of other patient experience feedback to
systematically improve care and service delivery.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
PART 2
4.4 Friends and Family
Test (FFT)
One of the main areas of focus is the implementation
of the Friends and Family Test (FFT). The Trust has made
huge progress with FFT across all services, and as a
result we have achieved 100% of our Commissioning
for Quality and Innovation (CQuIN) indicators.
With FFT well underway, the focus will shift to closer
monitoring of results, increasing low response rates
and taking action as a result of feedback from patients.
To assist this, a new monthly monitoring programme
is being set up and services that are doing well will be
highlighted in the monthly staff newsletter.
97%
would recommend
our services
FFT results for 2014/15
In total, NCH&C received 5162 responses and of these
4648 comments were left with an overall percentage of
97% recommending our services.
Overall, the most positive comments received were
for care and treatment (3142), and time/appointment
delays received the most negative comments (176).
Extremely Likely (83.6%)
Likely (13.6%)
Neither likely nor unlikely (1.2%)
Unlikely (0.4%)
Extremely unlikely (0.3%)
Don’t know (0.3%)
41
PART 3
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
4.5 Patient Opinion
Patient Opinion (www.patientopinion.org.uk) allows
service users to feedback on their experiences via a
web-based tool and enables staff to interact with
patients to help improve care. This tool will be rolled
out to more services through 2014/15.
In 2014/15, there were 29 stories posted on Patient
Opinion, some of which were not directly related to
NCH&C services. These were highlighted to the most
appropriate organisation for acknowledgement and
follow up.
• 13 stories were wholly positive
• 10 stories were wholly negative
• 6 stories were a combination of positive and negative
• 6 of the 13 positive stories praised care, treatment
and professionalism at the Pine Cottage specialist
amputee rehabilitation service
• Other positive stories praised and thanked
community physiotherapy, Dereham, Swaffham
and North Walsham Cottage Hospitals
• Two of the negative stories related to health visiting
regarding identification of tongue tie and subsequent
follow up with the parent. Both of these stories were
directly responded to by the health visiting lead and
have led to changes being planned in the service
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PART 3
• Of the other negative stories, they related to a
range of different services and concerns including
care at North Walsham and Swaffham Community
Hospitals, NHS funding for eye tests and glasses in
school nursing, access to district nursing, end of life
information for a carer and pre x-ray questions prior
to podiatric surgery
• Of the rest of the stories, which were a combination
of positive and negative experiences, these often
praised the clinicians for excellent clinical care and
treatment, but had less positive experiences of waiting
times (MSK physiotherapy), privacy and dignity
(Beetley Unit, Dereham Hospital) and information
about appointments at a GP reception (community
physiotherapy but unknown location)
All stories on Patient Opinion are responded to online
by the relevant member of staff - where further
information is required, the author is asked to contact
the Patient Advice and Liaison Service (PALS). We will
be exploring ways in the coming year of increasing
promotion and uptake in the use of Patient opinion
across the Trust, and in sharing good practice in
responding online to ensure an open dialogue approach
to stories which leads to improvements in care.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
Highlights from this survey:
• 96% response rate
• 100% reported that they were treated politely and
with respect
• 98% felt they had received a thorough assessment
• 100% felt they could discuss worries or concerns
• 93% felt they were involved in decisions about their care
It was clear how much the service was valued by
those assessed, and a number of people expressed
their gratitude, describing a ‘caring’ and ‘excellent’
service. As a result of the survey, a patient information
leaflet including service contact details will be included
in new referral paperwork pack. Further work needs
to be done regarding the number of patients who
are not receiving a referral on discharge from hospital
promptly. Education and promotion work has been
undertaken but this remains an ongoing issue. This is an
area under review as part of the COPD pathway review
with West Norfolk CCG.
Re-enablement Services; conducted a carer survey
during November and December 2014. Five of the six
carers to respond said the service was good and two
responders described the service as “excellent” and
“fantastic”. There was a negative comment about the
patient transport service which the team reported to
the transport manager and G4S.
4.7 Complaints and
compliments
From 1 April 2014 to 31 March 2015, we received
271 complaints, in comparison to 207 during the year
2013/2014. As in the previous year, there was a spike in
complaints during October 2014 (36 complaints were
received, compared to 33 complaints during October 2013).
Patient compliments are also measured and this year
the Trust has received around 1,160 compliments.
Numerous discussions around complaint themes have
been held, but there does not appear to be any specific
explanation for the increase in numbers. Complaints
are generally spread across all localities, although the
introduction of the locality hubs this year has seen slight
increases in complaints in a couple of the localities.
The table below shows the number of complaints
received on a month by month basis:
40
35
30
25
20
15
10
5
0
pr
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ay
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ar
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5
West Norfolk Chronic Pulmonary Obstructive Disorder
(COPD) service; the service conducted a redesigned
patient satisfaction survey from October 1, 2013 to
September 30, 2014. One of the main objectives was
to identify if changes made to the assessment process
following previous patient experience reports have been
beneficial (use of quality of life tool). The survey was
distributed to all patients referred to the COPD Nursing
team who received a home visit from West Norfolk
COPD Team.
PART 3
A
4.6 Local patient surveys
PART 2
43
A continual process of learning from complaints is in
place. These are collated from the Investigating Officer
following completion of a complaint investigation,
and overseen by both the Quality and Risk Assurance
Committee, and the Trust Board. Further evidence is
now starting to be collated so that evidence is produced
of the learning that is put in place, and reporting will
start on this early in the 2015-16 financial year.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
4.8 Patient Led Assessments
of the Care Environment
Patient-Led Assessments of the Care Environment
(PLACE) are a self-assessment of a range of nonclinical services which contribute to the environment
in which healthcare is delivered in both the NHS and
independent / private healthcare sector in England.
The Health and Social Care Information Centre (HSCIC)
requires trusts to self assess their patient environment
annually using an assessment tool which reflects needs
of its various stakeholders and the policy priorities of
Ministers and the CQC.
Analysis has shown that despite changes to assessment
criteria and methodology between 2013 and 2014,
our Trust’s performance has improved in three areas
Cleanliness, Food, and Condition, Appearance and
Maintenance, but deteriorated in one area, Privacy,
Dignity and Wellbeing.
The Estates strategy has provided focus on investment
in the Trust’s estate, improving maintenance and
condition of buildings, particularly areas used for
patients delivering improvement during 2014 at a rate
higher than the national average.
Privacy, Dignity and Wellbeing will form the core focus
in 2014/15, with action planned through the Trust’s
Patient Environment & Nutrition Group (PENG).
The highest scoring locations for 2014 were:
• Benjamin Court and Cranmer House scoring 100%
in Cleanliness
• Colman Hospital, Cranmer House and Dereham
Hospital all scoring within the upper quartile (above
95.50%) for Food
• North Walsham Hospital scoring 93.06% for Privacy,
Dignity and Wellbeing
• Benjamin Court and Swaffham Hospital scoring within
the inter quartile range for Condition, Appearance
and Maintenance
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PART 3
The lowest scoring locations for 2014 were:
•D
ereham Hospital, North Walsham Hospital, Ogden
Court and Swaffham Hospital, scoring within the lower
quartile for Cleanliness but improving since 2013
• Benjamin Court, Kelling Hospital and Ogden Court
scoring below the middle quartile for Food (91.73%)
but improving since 2013
• Cranmer House, Dereham Hospital, Kelling Hospital,
Norwich Community Hospital and Ogden Court
scoring within the lower quartile for Privacy, Dignity
and Wellbeing. However, all except Dereham Hospital
have improved since 2013
• All, except Colman and Swaffham Hospitals scoring
within the lower quartile for Condition, Appearance
and Maintenance. However Benjamin Court, Cranmer
House, Kelling Hospital and Norwich Community
Hospital have improved since 2013
The largest contributing factors to lower scores in
the Privacy, Dignity and Wellbeing category include
the poor way finding and signposting facilities,
underutilised dayrooms and courtyards, and a lack of
WiFi and individual TV / radios for patients.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
PART 2
PART 3
Below is a summary of detailed scores by site for 2014.
These scores are risk assessed to show whether they fall
above or below the national average.
Site Name
Cleanliness %
Food %
Privacy, Dignity
& Wellbeing %
Condition,
Appearance &
Maintenance %
Benjamin Court
100
89.52
82.14
82.64
Colman Hospital
97.48
98.62
85.11
93.16
Cranmer House
100
97.9
80.16
80.51
Dereham Hospital
95.53
95.64
75.00
70.18
Kelling Hospital
99.10
89.98
75.76
79.73
North Walsham Hospital
92.67
95.13
93.06
85.71
Norwich Community
Hospital
98.19
92.86
74.07
83.33
Ogden Court
88.89
87.23
73.81
66.00
Swaffham Community
Hospital
96.34
93.24
87.14
91.96
AVERAGE SCORE
96.47
93.35
80.69
81.47
below national average for 2014
above national average for 2014
45
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
PART 2
46
PART 3
5 Safe services
5.1 Introduction
5.2 Safe staffing
The CQC inspected our services in September 2014,
and whilst the organisation was rated GOOD overall, the
CQC identified some concerns regarding the safety of
services, and judged this to require some improvement.
There has been an increasing focus on both ensuring
and evidencing safe staffing levels in inpatient units
both by the media and the public. Key guidance in
relation to safe staffing was published in November
2013, by National Quality Board entitled ‘How to ensure
the right people, with the right skills, are in the right
place at the right time’.
The key areas related to:
1.The refurbishment of Squirrels residential
respite unit for children
Response: this work had already been identified in the
estates plan and the work was brought forward and
completed by the end of December 2014
2.Responsibilities regarding the Mental Capacity
Act 2005 (MCA)
Response: a guidance document on the 2-stage MCA
assessment as a rapid guide and support tool to all
staff was created and circulated. Specific MCA training
provided to qualified clinical staff in inpatient units as a
priority, and a MCA Deprivation of Liberty Safeguarding
(DOLS) checklist developed to support staff while national
policy is being developed and in line with new legislation
3.Management of medicines in inpatient units,
relating to storage and stock control systems
Response: Standard operating procedures relating
to ordering and storage of medicines and for the
management of controlled drugs have been developed.
An updated service level agreement is in place for
pharmacy services.
4.At the time of the inspection, the Trust could not
be assured that all faith leaders had been subject
to Disclosure and Barring Service (DBS) checks
Response: A review of all faith leaders was undertaken
and it was confirmed that all faith leaders had
appropriate checks under DBS
NCH&C are confident that following completion of the
CQC compliance action plan, positive steps continue
to be taken to improve the safety and quality of all our
services. This section highlights the work that has been
undertaken during 2014/15.
The new guidance sets out a series of expectations
in relation to the role of the Board in ensuring safe
staffing, and since April 2014 the Trust has completed
the required monthly submission of it safe staffing
reports via the agreed “UNIFY” system. This information
is also published on the Trust intranet page.
We continue to maintain a high standard of patient care,
safety and experience. This is evidenced in many ways
such as low incident levels, positive external reviews,
Patient Safety Thermometer and Friends and Family Test
scores. The Trust is committed to ensuring that the levels of
nursing staff, including registered nurses, and care support
staff, are appropriate and meet the needs of patients
across the settings within which we provide services.
There is no clear guidance or specific modelling tools
available for community trusts to use to assist in
determining safe staffing levels, with the exception
of our specialist rehabilitation units. However, an
appropriate skill mix and level of nursing staff to provide
safe and effective care is ensured. These levels of staff
are viewed along with ‘registered nurse to patient
ratios’, the percentage skill mix ratio of registered
nurses to care support staff and the numbers per shift
to provide safe, effective patient care. The specialist
rehabilitation units use patient dependency tools to
demonstrate the level of intensity of care for each
individual patient, and that in turn sets out the staffing
and payment structure.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
•A
ll in-patient units have reviewed staffing levels across
all of our rehabilitation units using the RCN toolkit
‘Safe staffing for older people’s wards’ to compare and
potentially determine the correct levels of staff for the
required standard of patient care within these settings
• Community teams utilise recent Interim Management
and Support (IMAS) work completed locally which
presents a baseline and model for community nursing,
and for the first time sets clear levels of activity for
nursing teams as agreed with commissioners
The Director of Nursing and Quality reports monthly
to the Trust Board regarding the actual nurse staffing
levels, against the established staff levels, on a shift
by shift, unit by unit basis. This account includes
monitoring the numbers of shifts that have been
escalated, triangulated against the workforce and
quality metrics to indicate if there are issues that require
improvement i.e. high levels of maternity leave or short
notice sickness.
As new guidance and tools that are appropriate for
community settings and specialist areas are developed,
reviews of staffing levels will be undertaken. The on-going
work within transformation also supports regular overview
of the work and activity in relation to each member of
staff and team. The transformation model supports staff
in the allocation of appropriate levels of work, sufficient
time to complete and that staff work within contracted
hours. This is further supported by e- rostering as this is
rolled out across all units and teams.
PART 2
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PART 3
5.3 Being Open
(Duty of Candour)
The Trust has developed an updated Being Open (Duty
of Candour) policy which describes the process for staff
to communicate with patients, their relatives or carers
following an incident causing moderate or severe harm
(or unexpected death) which uses the National Patient
Safety Agency definitions;
• Moderate harm incidents (short term harm, patient
required further treatment or procedure – e.g. grade 3
pressure ulcers, some patient falls and medication errors)
• Severe harm incidents (permanent or long term
harm). All currently reported as SIRIs
• Death incidents (any unexpected or unintended
incident which caused the death of one or more
persons). All currently reported as SIRIs
We recognise that promoting a culture of being open
is a prerequisite to improving patient safety and the
quality of healthcare systems. For patients, effective
communication starts from a healthcare need being
identified and continues throughout their treatment.
For staff, there is an ethical responsibility to maintain
honest and open communication with patients and
carers even when things go wrong.
The terms of this requirement have been based on the 10
principles of ‘Being Open’ policy published by the National
Patient Safety Agency (NPSA) in November 2009.
1.Acknowledgement
2.Truthfulness, timeliness
and clarity of
communication
6.Risk management and
systems improvement
7.Multidisciplinary
responsibility
3.Apology
8.Clinical governance
4.Recognising patient
and carer expectations
9.Confidentiality
10.Continuity of care
5.Professional support
NCH&C has been compliant with the requirements of
a Duty of Candour during 2014/15, and in line with its
policy continues to support clinicians to be open and
honest with patients when things go wrong.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
5.4 Norfolk Harm Free
Care project
From September 2013 to September 2014, NCH&C
have been helping to deliver an innovative, new scheme
to improve health outcomes for Norfolk care and
nursing home residents which was funded by Norfolk
County Council (NCC) for 12 months.
The Harm Free Care (HFC) Project is looking to reduce
people’s risk of suffering a pressure ulcer, infection linked
to urinary catheters, or falls. These three major harms can
particularly occur in vulnerable, elderly and frail residents.
Working in partnership with the Norfolk Harm Free
Care Board, NCH&C joined up with NCC to commission
the development of an assessment tool and supporting
guidance and information for care homes, which
consisted of;
• Training for care home staff in addressing the three
priority areas of harm
• A paper assessment tool
• A ‘guide to harm free care’ paper booklet and
‘bundle’ to detail a series of evidence based
interventions for the care team to implement
• A website to serve as a repository of information to
support the carer by providing direction and guidance
in using the assessment tool
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PART 3
An online resource centre has also been developed to
signpost people to local and national learning resources,
while a Guide to Harm Free Care for patients and the
public has been developed and made available.
A total of nine care homes in Norfolk were involved
in the new scheme.
The evaluation of the project has been carried out in
conjunction with the HFC Project Manager, NCH&C
Clinical Audit and Effectiveness Team and NCC Public
Health information Team.
Achievements include;
• The production of a local HFC Assessment Tool
• Publication of a local HFC Guide to Practice booklet
• The construction of a website of HFC information
and guidance
• Evidence to detail compliance with key outcome
frameworks
• Patient and service user engagement and involvement
(e.g. Older People’s Forum, Suffolk and Norfolk
Partnership, Carers’ Partnership, Independent Care)
• E ngagement with the management teams of nine care
homes and integration of health and social care models
• Unilateral pathways of care to complement NCH&C’s
transformation programme
• Potential future partnership working with other
healthcare trusts
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
5.5 National Safety
Thermometer
PART 2
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PART 3
During March 2015, the Trust sampled 908 patients.
The results indicated that the overall proportion
of patients receiving ‘harm free care’ was 90.4%.
Furthermore, the percentage of ‘new harm free care’
was 96.9%, just below the Trust’s Quality Goal target
of 97%. It should be noted, that the reported figure is
based on a sample undertaken on a specified day in the
month, and will therefore depend on the sample size
and the case-mix or complexity of patients sampled.
The Safety Thermometer is a national measurement
tool, developed by the NHS for the NHS, to provide
a monthly ‘temperature check’ on harm which can
be used alongside other methods, such as analysing
incidents, to improve how the Trust treats it patients.
The table below shows the data collected (in percentages)
on one day a month from April 2014 to March 2015
against each of the ‘harms’:
The safety thermometer focuses on four areas of harm;
1.Catheter Acquired Urinary Tract Infections (CAUTI)
2.Falls
3.Pressure ulcers (avoidable and unavoidable)
4.Venous Thrombo-embolisms (VTEs) (blood clots)
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
14
14
14
14
14
14
14
14
14
15
15
15
Harm Free
90.4
90.3
90.4
90.1
89.0
90.0
90.2
90.7
90.2
88.7
91.6
90.4
Pressure Ulcers
8.2
7.7
7.8
8.3
8.6
8.2
9.1
7.4
8.2
10.5
6.9
7.9
Pressure Ulcers (New)
1.5
1.7
0.9
2.3
3.4
2.8
1.5
2.7
2.6
1.5
1.2
1.6
Patients Falls
1.2
4.2
2.7
2.3
3.4
2.8
1.5
2.7
2.6
1.5
1.2
1.7
Falls with Harm
0.1
2.0
1.2
1.1
1.9
1.6
0.6
1.4
1.3
0.3
1.0
0.5
Catheters & UTIs
1.4
0.8
1.1
0.9
1.0
0.6
0.1
0.5
0.4
0.5
0.7
0.9
New VTEs
0.1
0.2
0.0
0.1
0.0
0.0
0.1
0.0
0.1
0.1
0.2
0.4
Harmed (New or Old)
9.6
9.7
9.6
9.9
11.0
10.0
9.8
9.3
9.8
11.3
8.4
9.6
Harmed (New)
2.6
4.0
2.9
4.1
5.3
2.7
2.9
3.0
3.8
2.3
3.0
3.1
Patients Sampled
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
100.0
(New or Old)
(New or Old)
Harm Free (% of Patients)
92
91
91.6
90.4
90.3
90.4
90.7
90.1
90.0
90
90.2
90.4
90.2
89.0
88.7
89
88
M
ar
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15
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14
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A
l-1
4
Ju
14
nJu
4
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ay
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A
pr
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4
87
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
5.6 Management and
learning from incidents
60
50
-1
4
p14
O
ct
-1
N 4
ov
-1
D 4
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Ja 4
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4
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A
4
14
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pr
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0
Total SIRIs
Pressure ulcers
Other
SIRIs reported by Type (Excluding Pressure Ulcers)
5
4
3
2
1
pr
-1
M 4
ay
-1
Ju 4
n1
Ju 4
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4
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-1
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0
A
All serious incidents are investigated using root cause
analysis methodology. We aim to submit our 3 day
and 45 day reports to our commissioners on time, and
we have not reported any 45 day reports outside this
timeframe during 2014/15.
30
10
Number
Between April 2014 and March 2015, 379 SIRIs
were reported, 360 of which were grade 3 and
grade 4 pressure ulcers.
40
20
The policy contains flowcharts for reporting
incidents and serious incidents requiring investigation
(SIRIs), (as defined by the National Patient Safety
Agency), and describes the process for escalation
through the DATIX Incident Management System,
assignment of an investigator and level of investigation
required through to the final approval of the incident.
We report monthly on all levels of incidents,
including any learning and actions taken to
the Trust Board in public throughout 2014/15.
These reports are available on our Trust’s website
(www.norfolkcommunityhealthandcare.nhs.uk).
PART 3
SIRIs reported by Type April 2014 to March 2015
Number
NCH&C has an NHS Litigation Authority accredited,
Board approved, Incident Reporting, Investigation
and Management policy in place which reflects the
reporting requirements of the National Reporting and
Learning System (NRLS), which is monitored by the
Trust Development Agency (TDA) and the CQC.
PART 2
50
Unexpected death
Infection control
Accident - Slip/Trip/Fall
Staffing
Medication
Other
Information Governance
Accident - Other
Allegation of Abuse
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
PART 2
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PART 3
5.6.1 Pressure Ulcers prevention
5.6.2 Tackling falls and dementia
Staff were reminded of the steps which can be taken
to avoid and manage pressure ulcers as part of an
international campaign to ‘Stop the pressure’. This
month long campaign has been designed to eliminate
avoidable pressure ulcers in healthcare settings and
care homes across the world. During November 2014,
NCH&C ran a ‘Think Waterlow’ campaign to raise
awareness of the steps which can be taken to avoid
and manage pressure ulcers. Staff are consistently being
reminded about the importance of completing a risk
assessment by using the Waterlow assessment tool
within six hours of the patient’s admission, and during
initial contact with patients in the community.
Staff have performed well against two important targets
designed to ensure patients with suspected dementia
and those at risk of a fall get the best possible care.
Staff in the north locality referred 100% of inpatients
with a clinical presentation of dementia for further
medical assessment, in line with the CQuIN target
introduced last year.
Across the Trust, high scores have also been recorded
against a 2014/15 key performance indicator, which aims
to ensure all patients are screened for risk of falling, with
those at high risk offered an holistic assessment.
In addition, a special conference was held in November
2014, on international Stop the Pressure Day, with
special speakers who spoke about incontinence, moisture
lesions and the importance of protecting the skin.
The PUVG also identifies learning points which will be
included within the overarching Pressure Ulcer Action
Plan. The action and learning points arising from the
PUVG recently are;
• Inconsistencies of Waterlow scoring
• Capacity within operational teams
3
2
1
4
ay
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b1
M 5
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-1
5
0
M
The Pressure Ulcer Validation Group (PUVG) continues
to meet on a fortnightly basis to review Pressure Ulcer
Root Cause Analysis (RCA) and validate the avoidable/
unavoidable decision.
4
A
Our Tissue Viability Nurse said; “Reducing pressure
ulcers is a quality indicator and a quality goal for the
Trust. If patients develop pressure ulcers which are
avoidable, we need to be able to demonstrate we have
done everything possible to prevent them.”
5
Falls per ‘000 OBS
An updated staff information booklet called ‘Preventing
and managing pressure ulcers’ was distributed on the
day, and also sent to all modern matrons.
Injurious Falls per ‘000/OBDs Performance - Inpatient Units
2014/15 performance
2013/14 average
2014/15 target
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
5.7 Mortality Review
Group (MRG)
We reported two unexpected deaths of patients in our
inpatient units as SIRIs between April 2014 and March
2015, and these were investigated using root cause
analysis. These incidents are further reviewed through
our mortality review panels alongside all reported deaths.
Dr Katie Soden (PBL consultant) has started formal
mortality reviews. Over the next months, the MRG will
initiate a process for local reviews whereby all inpatient
units will undertake a first stage review shortly after
the patient’s death, led by the consultant at the regular
multi-disciplinary team meetings.
The MRG will receive these reviews and alongside
others, as described previously, (e.g. unexpected
deaths) complete a review focussing on the learning
and its dissemination. The Mortality Review policy and
the proforma will not require significant change. The
objective is to improve the ownership, the understanding
and the learning across the Trust.
The MRG continues to meet regularly. No significant
clinical or quality issues have arisen from any of the
recent reviews. Joint reviews with NNUH continue.
In February 2015, the medical director attended a
meeting alongside 19 other community trusts to discuss
what is now referred to as ‘Mortality governance in the
community: a care quality journey’. The title intends to
describe a supportive, ‘no blame’ continual improvement
culture, rather than a performance monitoring process,
whose primary objective is to improve quality of care
throughout inpatient settings, outside of acute hospitals.
A number of trusts presented their work, and the
attendees agreed to focus on the tools and frameworks
used by NCH&C, as well as Torbay and South Devon and
Lincolnshire community trusts.
It was agreed to consider community hospital inpatients
only at this stage, and not patients dying either in their
own homes or other care settings.
There was much interest in developing common
reporting and analytical tools, and a plan to meet
quarterly to share and develop the process.
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5.8 Never Events
Never Events are defined by the Department of Health as
‘serious, largely preventable patient safety incidents that
should not occur if the available preventative measures
have been implemented by healthcare providers’.
The Trust is pleased to report that there have not been any
‘Never Events’ during 2014/15 (or in any preceding years).
5.9 Central Alerts
Central Alerts are cascaded to the appropriate service
areas for action, and the Executive Directors’ Team (EDT)
monitors their communication and supporting actions
on a monthly basis in conjunction with the General
Health & Safety Committee.
5.10 Infection prevention
and control (IPAC)
Our Trust’s nominated Director of Infection Prevention
and Control (DIPC), currently the Medical Director,
has Board level responsibility for infection control.
The Deputy DIPC is responsible for the IPAC team,
and the strategic and operational planning of the
service across the Trust.
A consultant microbiologist, contracted from the local
acute trust as the infection control doctor, provides
advice and support to the team as necessary. The
organisation is locality based and the IPAC team work
autonomously within each locality, whilst being centrally
based. This gives each area an identifiable member of the
IPAC team, whilst also having access to the whole team.
Gaps in clinical practice, staff knowledge, environment or
equipment are identified locally and discussed centrally
for either a Trustwide or local solution.
The Infection Control Committee, chaired by the DIPC
or Deputy DIPC, is held on a quarterly basis and is
attended by internal and external staff, including clinical
and non-clinical. This committee reports to the Quality
and Risk Assurance Committee (QRAC).
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
The work of the IPAC team is led by a detailed
Annual Plan, which is reviewed and measured
against the requirements set within the Health
and Social Care Act, ensuring the Trust meets its
obligations and is able to assure the Board that
the organisation is meeting all standards.
A large part of organisational assurance comes via
the completion of regular auditing of clinical practice.
‘Clean, Safe Care’ (2008) identifies a set of IPAC audit
tools, ‘Essential Steps’ to monitor clinical practices
and gaps in practice. NCH&C has undertaken these
audits until recently when, in discussion with the
commissioners, ‘Essential Steps’ were replaced with a
more comprehensive set of audit tools.
All teams within NCH&C are now assessed for the most
appropriate audits for their service and follow a bespoke
programme of audit. This has led to more meaningful data
which allows greater learning across the organisation.
This data is analysed on a quarterly basis with exception
reporting via the Infection Control Committee, and
persistent areas of risk and/or concern escalated via the
risk register and QRAC.
All alert organisms are fully investigated with a root
cause analysis completed with learning identified and
shared with staff. Multi-disciplinary meetings ensure
a 360 view of the case is considered and appropriate
staff take learning back to their areas of work. Public
Health plays a key role throughout these investigations
ensuring appropriate challenge throughout the process.
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There is a suite (21 in total) of IPAC policies, as dictated
by the Health and Social Care Act, which are regularly
reviewed by the IPAC team, consulted on by the
Infection Control Committee, approved by Clinical
Policy Group, and ratified by Quality and Risk Assurance
Committee. There is routine oversight by a consultant
microbiologist and, where necessary and appropriate, a
consultant virologist. All policies are held on the intranet
for staff to access at any time required and, for the
more commonplace policies, we are also moving to a
policy on a page for ease of use.
Training of all staff from Board to ward and beyond
is a key focus within the IPAC department, and one
which has continued as a face to face service rather
than e-learning due to the differing services and
environments involved. All staff receive IPAC training
as part of induction and are identified as requiring
a mandatory annual update if necessary. Training is
reviewed each year to improve delivery and content,
and to ensure staff receive the information on the most
current issues at any given time.
The IPAC team network through a variety of areas
locally, regionally and nationally. There are good
network links within the county covering acute
hospitals, mental health trust, primary care, public
health, ambulance service and private care homes.
Cross boundary working ensures all providers are
working towards mutual high standards, sharing best
practice and planning together to ensure the best
possible pathway for the patient.
The two key areas of monitoring concern MRSA
bacteraemia and Clostridium difficile infection. NCH&C,
along with all other health care providers, has a zero
tolerance of MRSA bacteraemia and therefore the
ceiling is nil. NCH&C’s end of year figures are zero.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
5.10.1 Clostridium difficile (C. diff)
The C. diff ceiling for 2014-15 is five cases. NCH&C has
seen great reductions in cases of C. diff over the last
10+ years (see table)
Year
C. Difficile figures
for the year
2004-5
143
2005-6
15
2006-7
19
2007-8
36
2008-9
13
2009-10
19
2010-11
9
2011-12
8
2012-13
3
2013-14
3
2014-15
7
NCH&C has followed the national trend in reduction
of C. diff figures, through increased training, increased
IPAC team, heightened awareness and a greatly
improved environment.
Our seven cases for 2014-15 have shown a disappointing
rise, however, this has been a common trend locally and
nationally. This has been recognised in the release of the
new 2015-16 ceilings, which have increased across the
board with a ceiling of seven for NCH&C.
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Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
5.11 Medicines management
There have been 549 medication incidents reported
during 2014/15, 97% of these incidents caused no
harm or low harm - none caused severe harm to
patients. 14 moderate harm incidents were reported,
these were:
• 3 incidents involving prescribing for end of life
patients in the community
• 2 incidents involving the administration of medicines
via syringe drivers
• 3 adverse drug reactions
• Delay by care home in obtaining urgent antibiotics
• Insulin administered incorrectly by patient
• Insulin administered incorrectly by nurse
• 2 incidents on transfer of care
This level of incidents is set against an estimated
200,000 prescriptions written or medicines
administered each month.
The following graph shows the trend of severity since
April 2014:
Breakdown of medication incident trends by severity
60
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5.11.1 Controlled
drugs incidents
All controlled drugs incidents are reviewed by the
Trust’s Accountable Officer for Controlled Drugs, and
if necessary reported to external agencies. There were
87 incidents involving controlled drugs reported during
2014/15, broken down by severity and type of incident.
No harm incidents included:
•C
ontrolled drug recording or stock issues (25 incidents)
• Missed or delayed doses (10 incidents)
• Prescribing issues (10 incidents)
• Transfer of care issues (8 incidents)
• Administration errors (8 incidents)
Low harm incidents included:
• Issues with administration via syringe driver
(4 incidents)
• Incorrect use of controlled drugs by patient / carer
(4 incidents)
• Missed dose of medicine
• Adverse drug reaction
There were 6 incidents causing moderate harm to
patients (described above) and no severe harm incidents.
Further analysis of incident breakdown is reviewed
through the Trust’s Medication Safety Report at the
Medicines Management Committee.
50
40
This report reviews the trends in medicines incidents and
looks in more detail at incidents relating to:
30
20
• Controlled drugs
10
• Omitted and delayed doses of medicines
Number of controlled drug incidents by month and severity
12
8
4
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M
ar
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ay
Total
M
Low harm
• Syringe driver incidents
pr
-1
Moderate harm
• Moderate or severe harm incidents
A
No harm
• Insulin incidents
Number
A
pr
-1
M 4
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-1
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Fe 5
b1
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ar
-1
5
0
No harm
Low harm
Moderate harm
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
5.12 Safeguarding children
and adults
We have a duty to comply with national and local
legislation and policy. Our work is underpinned in
particular by the implementation of the ‘No Secrets’
(Department of Health 2000 & 2011) multi-agency
guidance in relation to adults, the Children’s Act (2004),
and Working Together to Safeguard Children statutory
guidance (Department of Health 2006 & 2013).
We contribute to performance and quality measures
as requested by the Care Quality Commission
(CQC), Norfolk Safeguarding Adults Board, Norfolk
Safeguarding Children Board (NSCB) and the Norfolk
Clinical Commissioning Groups (CCG’s). The monitoring
requirements are reflected in the respective trust
safeguarding adults and children’s work plans, which
aim to capture all of the expectations of the bodies
above in respect of safeguarding. Progress against these
plans is in turn monitored quarterly by the Quality and
Risk Assurance Committee (QRAC).
Since September 2013, inspection of safeguarding
processes and case management in health organisations has
been undertaken jointly by regulators OFSTED and CQC.
5.12.1 Working in partnership with
other organisations
The safeguarding children team has played a key role
in improving multi agency working by contributing to
a number of working groups to take forward Norfolk
wide initiatives. This includes contributing to the
development of a neglect strategy and plans are now
in place to progress the development of Trust neglect
champions, and also support the delivery of Graded
Care Profile training to staff. This training will support
the identification and management of cases where
children are subjects of neglect. The safeguarding
children team has also contributed to the development
of a Norfolk-wide Domestic Abuse strategy. Other
developments have included a joint working project
with the local authority to improve joint working
between social workers and health visitors, and this
model has been evaluated well and subsequently
embedded in practice.
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The safeguarding adult lead remains an active member of
the Safeguarding Adult sub groups for: Mental Capacity;
Deprivation of Liberty (DOLs). Training and health
outcomes from these groups include; standardising basic
training principles for all training providers and validating
training courses; development of assessment criteria and
guidance for the new DOL’s judgement outcomes.
5.12.2 Serious Case Reviews
Norfolk Safeguarding Children Board authorised four
Serious Case Reviews (SCRs) during 2014. The Trust has
contributed to all of these as employer of staff involved
in the cases. Director or deputy director level membership
of each SCR panel has been provided, together with
the Individual Management Reviews written by the
safeguarding team. Publication of the overview reports
will trigger action plans across all agencies, including
the Trust, where implementation of recommendations
is monitored by QRAC. The safeguarding team has
continued to present learning at dissemination events
arising from previous multi-agency reviews.
A requirement for The Norfolk Safeguarding Adult Board,
stipulated within the Care Bill (Department of Health
2013), is to implement SCRs for adult safeguarding cases.
Processes have commenced to develop a multiagency
procedural framework in line with the Children’s Board
SCR process.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
5.12.3 Health visiting (HV)
and school nursing
The safeguarding children team continues to contribute
to the HV Implementation plan for the Trust with
training of new health visitors, new team leaders, and
supporting the safeguarding supervision of front line
staff. With increased numbers of health visitors, our
focus is to ensure good safeguarding practice across the
spectrum of work, from early intervention with families,
to formal child protection procedures.
The safeguarding children team have worked with senior
children’s services managers around managing constraints
within school nursing, and the development of an action
plan to ensure robust systems and processes are in place
to underpin safeguarding children. The deficit in school
nurse numbers is on the safeguarding risk register. The
work of school nursing in supporting children and young
people of school age, including those at risk of sexual
abuse and exploitation, is very important.
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5.12.4 Securing of Sexual Assault
Referral Centre (SARC)
contract for 2015
The Trust was pleased to learn their recent proposal for
the delivery of a SARC service for under 13 year olds has
been accepted by NHS England. This is an opportunity
for the Trust to build on its long standing reputation for
child protection work, and ensure a high quality service
for children and young people at a most difficult and
vulnerable time. The new service will be delivered by our
experienced team of paediatricians at the newly developed
children’s SARC in partnership with Norfolk Constabulary
and the existing adult SARC service.
In addition, the Trust has been asked by NHS England to
investigate the possibilities for the setting up of a similar
service in Suffolk and a business case with this aim is
currently being prepared.
Norfolk Community Health and Care NHS Trust
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6. Effective services
6.1 Introduction
Most measures are used internally; however, some are
used to compare with other similar services elsewhere.
Quality care can be described as care which is delivered
according to the best evidence as to what is clinically
effective in improving an individual’s health outcomes.
NICE provides advice and support on putting NICE
guidance and standards into practice through its
implementation programme, and it collates and
accredits high quality health guidance, research and
information to help health and social care professionals
deliver the best patient care through NHS Evidence.
There are a number of examples where clinical
effectiveness measures are currently used in the Trust.
Most of these are benchmarking or Patient Reporting
Outcome Measures (PROMS); however, there are also
some examples of patient or carer experience and
research. Other examples include:
• The use of the Measure Your Own Medical Outcome
Profile (MYMOP) across a number of services
• In specialist rehabilitation, several tools are used
including the following which are used for inpatient
outcome measurement:
–– U
nited Kingdom Rehabilitation Outcomes
Collaborative (UK ROC)
–– Rehabilitation Complexity Score (RCS)
–– Neurological Impairment Scale (NIS)
–– Northwick Park Therapy Dependency Score
–– Northwick Park Nursing Dependency Score
–– Northwick Park Care Needs Assessment
–– Goal Attainment Scale (GAS) for inpatients
For outpatients in specialist rehabilitation:
–– Needs and Provisions Complexity Score (NPCS)
–– Neurological impairment scale (NIS)
–– Northwick Park Nursing Dependency Score
–– N
orthwick Park Care Needs Assessment and the
Goal Attainment Scale
–– C
hildren’s Services and Children’s Speech and
Language Therapy both use the East Kent
Outcomes Scale which is an outcome measures
system used to identify goals and timetables, and
an intervention plan with the family of patients
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
6.2 Implementation of
NICE guidance 2014/15
There has been a total of 141 pieces of NICE guidance
published in the period April 2014 to March 2015.
NICE guidance is published once a month, and then
filtered by the Trust’s NICE lead to remove guidance not
applicable to Trust services.
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Guidance is then reviewed in more detail by the
NICE Review Group and sent to relevant services for
assessment and, if appropriate, risk assessment and
action planning.
The following NICE guidelines issued have been
deemed relevant to the Trust:
Date
Ref
Name
Apr-14
CG179
Pressure ulcers
Apr-14
PH52
Needle and syringe programmes
Jun-14
CG180
Atrial fibrillation: the management of atrial fibrillation
Jul-14
CG181
Lipid modification: cardiovascular risk assessment and the modification of blood lipids
for the primary and secondary prevention of cardiovascular disease (CG181)
Jul-14
CG182
Chronic kidney disease (CG182)
Sep-14
CG183
Drug allergy: diagnosis and management of drug allergy in adults, children and young people
Sep-14
CG184
Dyspepsia and gastro-oesophageal reflux disease
Sep-14
CG185
Bipolar disorder: the assessment and management of bipolar disorder in adults, children
and young people in primary and secondary care
Oct-14
CG186
Multiple sclerosis
Nov-14
CG189
Obesity: identification, assessment and management of overweight and obesity in
children, young people and adults
Nov-14
PH56
Vitamin D: increasing supplement use among at-risk groups
Dec-14
CG191
Pneumonia
Dec-14
CG192
Antenatal and postnatal mental health: clinical management and service guidance
Dec-14
CG37
Postnatal care
Jan-15
NG1
Gastro-oesophageal reflux disease: recognition, diagnosis and management in children
and young people
Mar-15
NG7
Maintaining a healthy weight and preventing excess weight gain among adults and
children
Mar-15
NG6
Excess winter deaths and morbidity and the health risks associated with cold homes
Mar-15
NG5
Medicines optimisation: the safe and effective use of medicines to enable the best
possible outcomes
Mar-15
CG28
Depression in children and young people: identification and management in primary,
community and secondary care
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
All relevant guidance is reviewed by the applicable
services and risk assessed. Guidance that is particularly
pertinent to a Trust service will be reviewed in depth
and, for example, have a baseline assessment tool
completed or a clinical audit planned.
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The following technology guidance has been deemed
relevant to the Trust:
Date
Ref
Name
Jun-14
MTG19
The geko device for reducing the risk of venous thromboembolism
Jun-14
TA315
Canagliflozin in combination therapy for treating type 2 diabetes
Jul-14
TA318
Lubiprostone for treating chronic idiopathic constipation (TA318)
Nov-14
MTG20
Parafricta bootees and undergarments to reduce skin breakdown in people with or at
risk of pressure ulcers
Dec-14
TA327
Dabigatran etexilate for the treatment and secondary prevention of deep vein
thrombosis and/or pulmonary embolism
Mar-15
TA336
Empagliflozin in combination therapy for treating type 2 diabetes
Mar-15
TA335
Rivaroxaban for preventing adverse outcomes after acute management of acute
coronary syndrome
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
As per the management of NICE guidance process,
all TAs (technology appraisals) are reviewed and
recommendations made to commissioners by the
Therapeutics Advisory Group (TAG).
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All TAs for medicines that are applicable to Trust services
have been added to the Trust medicines formulary.
The following NICE Quality Standards have been
deemed relevant to the Trust:
Date
Ref
Name
Apr-14
QS59
Antisocial behaviour and conduct disorders in children and young people
Apr-14
QS61
Infection prevention and control
May-14
QS62
Constipation in children and young people
Jul-14
QS63
Delirium
Jul-14
QS64
Feverish illness in children under 5 years
Aug-14
QS66
Intravenous fluid therapy in adults in hospital
Sep-14
QS68
Acute coronary syndromes (including myocardial infarction)
Sep-14
QS70
Nocturnal enuresis (bedwetting) in children and young people
Oct-14
QS71
Transient loss of consciousness
Oct-14
QS74
Head injury
Nov-14
QS5
Chronic kidney disease
Jan-15
QS77
Urinary incontinence in women
Jan-15
QS79
Idiopathic pulmonary fibrosis
Mar-15
QS84
Physical activity: encouraging activity in all people in contact with the NHS
Mar-15
QS82
Smoking: reducing tobacco use
Mar-15
QS86
Falls in older people: assessment after a fall and preventing further falls
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
6.3 Clinical Audit
programme 2014/15
Definition of clinical audit — a quality improvement
cycle that involves measurement of the effectiveness of
healthcare against agreed and proven standards for high
quality, and taking action to bring practice in line with
these standards so as to improve the quality of care and
health outcomes. Clinical audit measures existing practice
against evidence-based clinical standards.
The annual clinical audit plan was approved by the
Trust in April 2014. This contained 45 clinical audits
across the Trust’s wide variety of services. The audit
plan is broken down into various sections depending
on the origin of the audit. A further 13 clinical audits
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1. Identify problem
or issue
5. Implementing
change
4. Compare
performance
with criteria
& standards
2. Set criteria
& standards
3. Observe
practice /
data collection
were submitted during the year that were not included
within the initial plan. The following table shows the
breakdown (final figures are in brackets):
Audit type
Description
Number of audits
National clinical audits
These are national audits the Trust participate in
3 (5)
Commissioner priorities
These audits are specifically requested by the commissioners
of our services to provide analysis or assurance of a service
6 (6)
NICE guidance
These are audits of the Trust’s services against specific pieces
of NICE guidance
18 (21)
Trust priorities
These are Trust wide audits of the Trust’s services against
other guidance or standards that are considered a priority
for the Trust
11 (17)
Clinical service evaluations
These are service evaluation audits and so measure the
quality of a service rather than the outcome for the patient
7 (8)
Clinical audits measure care provided against evidencebased standards. Where the target percentage is met
the audit is said to have achieved ‘high assurance’, if
the results fall short of the target the audit is moderate
or low assurance depending on the distance from the
target.
The following table outlines the clinical audit results
for 2014-15:
Audits completed
High assurance
6
Moderate assurance
13
Low assurance
9
No assurance level determined
10
Report not yet submitted
6
Audits cancelled
13
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
The increase in low assurance audits is due to services
being challenged this year to develop new topics for
clinical audits, and focus on new NICE guidance or clinical
issues that they had identified as needing to be improved
(for example from incidents or risks). All low assurance
audits will be repeated in next year’s clinical audit plan to
monitor for improvement.
Some clinical audits did not determine an assurance level,
due to their design, and five of these are national audits
which do not use assurance levels.
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PART 3
Some audits were cancelled during the year, either
because the standard they were intending to measure
was no longer pertinent to the service, they were merged
with other audits for simplicity, or data collection took
longer than anticipated and the audit has been continued
into the 2015-16 clinical audit plan. All clinical audits
are reviewed by the relevant Trust committee and any
recommended actions reviewed for implementation.
Examples of clinical audits completed in 2014-15
Clinical audit of ‘Do not
attempt resuscitation’
orders in inpatient units
• Overall compliance for the 12 standards increased from 77% last year to 86%
• Improvements were seen in 9 standards, including quality of the discussions with
patients and staff
• Further improvements needed in the amount of detail recorded in patient notes
Clinical audit of pressure
ulcers
• High assurance on 9 out of 10 standards measured (based on NICE guidance)
Antibiotic prescribing
audit
• High assurance on the prescribing of antibiotics against the Trust formulary and
prescribing standards
Clinical audit of treatment
of hypertension in
the inpatient
rehabilitation service
• Assessed treatment of hypertension against current NICE guidance
Clinical audit of ‘looked
after children’ care plans
• Good completion of health history and immunisation status
• Improvement needed on the use of pressure ulcer prevention plans
• Only around half of patients were on the treatment recommended by NICE
• All medicines initiated prior to admission - liaison with patients GP required
•Improvement needed in the recording of contact PREFERENCES, recording of care
plan reviews and place of education
•Strengths and difficulties questionnaire to be introduced into care plans
Clinical audit of
Parkinson’s disease
treatment - south locality
neurology service
63
• High assurance on the 8 standards measured, based on NICE guidance on
Parkinson’s disease
• Improvements to be made around offering discussion of end of life wishes /
concerns with the team
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
PART 1
6.4 Trust Research
Performance
We continue to be successful in recruiting patients
into studies, and NCH&C is already one of the most
active recruiters for National Institute for Health
Research (NIHR) studies among the community trusts.
Our aspiration is to be an acknowledged national
leader in research among community based NHS
organisations, and the Trust has many opportunities
for further active engagement in this area.
The 2013/14 national research recruitment figures were
released in March and NCH&C achieved 435 recruits into
research, making NCH&C the third highest recruiting
community Trust and the first in the eastern region.
There are currently 15 studies open within the Trust.
A further four are being set-up. The Trust has recruited
405 patients into clinical research in the period April
2014 to February 2015, which is slightly under target
(the Trust sets itself a target of 500 recruits into research
each year), but with existing projects recruiting well we
anticipate reaching the target by the end of March 2015.
The research team is also undertaking projects to increase
the Trust’s capacity to undertake research or improve the
quality of our research:
• Research ambassadors: 3 – 4 volunteers are
being recruited to act as patient ambassadors
to promote research awareness and participation
amongst patient groups
• Bank research nurses: 3 bank nurses are being trained in
research and developed to help deliver on more research
studies. This will increase our capacity to undertake
studies and ensure we are able to use resources flexibly
• Physiotherapy research clinics: bank physiotherapists
have also been identified to work in research clinics.
This will start at North Walsham, and the clinic
will ‘fast track’ shoulder pain referrals and offer
participation in a shoulder pain study. The clinic will
retain management of all patients referred to it,
even if they decline research participation therefore
supporting operational team capacity
• Good Clinical Practice (GCP): a further 13 NCH&C
staff have been training in GCP – ensuring that they
are ready to take on research when appropriate
projects become available
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6.4.1 Research conference
The first ever research conference organised to
celebrate the research carried out by NCH&C, while
developing new opportunities for collaborative working,
was hailed a success after attracting delegates from
across the eastern region.
The ‘Reach out to Research’ event took place in
September 2014, and was organised by the research
department to engage with current and new partners
through activities ranging from table top conferencing
to speed networking.
Feedback from those attending was positive, with patient
representatives describing the conference as “the most
informative and valuable NHS event attended”.
Norfolk Community Health and Care NHS Trust
Quality Account 2014/15 – Part Three
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6.5 Specialist Palliative Care
The multi-disciplinary specialist palliative care team
have monthly clinical governance meetings attended by
representatives from all aspects of the service including
the inpatient unit, the Rowan Centre day unit and
the community service. Both clinical effectiveness and
clinical audit are essential components of the clinical
governance agenda and the team actively encourage all
staff to be involved.
Over the last year, the team have had a working group
looking at the pain tools that are actively used within
the inpatient unit. They have been involved with
some national research regarding the use of the Carer
Support Needs Assessment Tool (CSNAT) – this is seen
as important as supporting carers as an integral part of
the service the team provide. Recent audits have been
undertaken against service guidelines regarding the
use of methadone, bisphosphonates and paracentesis
to ensure that the care provided is of the very highest
standard. At present, the team are currently exploring
IPOS as a symptom control outcome measure in line
with national work on this.
As well as taking part in the wider Trust patient
experience work, the specialist palliative care team have
also undertaken specific work with their patient group.
They have undertaken a survey of patients admitted
to Priscilla Bacon Lodge looking at the things that are
most important to them including symptom control,
the environment and the daily routine on the ward. The
team have a very active service user steering group and
are also involved in reflective case discussions both at
Gold Standard Framework meetings and on site multidisciplinary team (MDT) meetings.
The team are also part of the Palliative Care Academy for
Norfolk and the Suffolk Research Group.
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7. E xplanation of who has been involved in
this Quality Account
7.1 Introduction
There are a number of mechanisms for stakeholders,
patients and the public to be involved in the work of
the Trust throughout the year. For example; Norfolk
Healthwatch and public involvement at Trust Board
meetings and other committees, including Quality and
Risk Assurance Committee, Patient Experience Steering
Group and PLACE inspections. There is also patient and
public involvement in discussions regarding service
re-design and transformation.
Development of the annual plan, priorities and quality
goals was achieved in conjunction with the executive
directors, assistant directors, heads of service and
clinicians through a number of staff workshops and
discussions at the Management Forum. Involvement of
staff and public Governors and external stakeholders
was through an online survey.
The staff and public Governors received a draft version
of the Quality Account at their Council of Governor’s
meeting in May 2015 and further discussions are taking
place to agree how the Governors wish to be involved
in the development of the Quality Account in future.
Third party commentary received from the Norfolk
Clinical Commissioning Groups Norfolk Healthwatch
and Norfolk Health Overview and Scrutiny Committee
are presented below;
Norfolk Community Health and Care NHS Trust
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7.2 Statement from NHS
Norwich, north Norfolk,
west Norfolk and
south Norfolk Clinical
Commissioning Groups
The Central Norfolk Commissioners for the NCH&C
are very pleased to support the community trust in its
publication of a Quality Account for 2014/15.
We have reviewed the mandatory data elements within
this account and can confirm that those included are
consistent with the requirements.
The report presents detailed and comprehensive
information relating to the quality and safety of care
delivered within the priority areas identified by the Trust.
The Trust has been under significant pressure brought
about by the increase in acuity of patients received by
them, in part due to the over-all increased pressure in
the Norfolk-wide system. The clinical and managerial
staff have worked hard to ensure that standards are
maintained and that patients are treated as individuals
and with compassion. This is reflected in the consistent
high scores in the ‘Friends & Family Test’. The Trust has
played an active part in working with system partners
to increase flow and pressures internally as well as
elsewhere. We commend staff for their hard work and
dedication to the patients that they serve.
The report provides a balanced account of outcomes,
highlighting successes and noting areas where further
improvements are required and the steps in place to
ensure that targets are met. There is a clear ethos of
continuous improvement. It is clear that the priorities
are relevant and appropriate; however it is felt that
further work is still required to ensure that pressure
ulcers and quality issues with the new ‘locality hub
model’ decrease and a continued focus on recruitment
and retention of a skilled workforce is maintained.
NCH&C has had a positive impact upon the quality and
safety of patient care in helping to evolve an open, crossorganisational improvement culture.
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Of particular note continues to be the Trust’s active
participation in the monthly Clinical Quality and Review
meetings. Here both provider and commissioner senior
clinicians and managers review and constructively
challenge the quality and safety performance of the
Trust. The Trust takes these meetings very seriously and
they are attended by both the Nursing Director and
the Medical Director (as necessary). These meetings
remain vital to assuring the local population that services
contracted from the Trust are safe and of good quality.
They enable discussions concerning new initiatives and
current practice.
They also provide a vehicle for constructive challenge
regarding performance as appropriate. There has
been a notably high level of candour and transparency
that has allowed for issues to be openly aired and
addressed effectively.
The Trust’s innovative use of mortality review meetings
has continued throughout the year and has been
welcomed by patients, staff, governors and management
alike. A recent CQC inspection was positive and identifies
general improvements that are reflective of the hard
work undertaken.
We look forward to continuing to support and
constructively challenge NCH&C in the pursuit of
continuous improvement in the coming year.
Jo Smithson, Interim Chief Executive Officer, NHS
Norwich CCG (also on behalf of south Norfolk, west
Norfolk and north Norfolk CCGs)
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Quality Account 2014/15 – Part Three
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7.3 Healthwatch Norfolk
Healthwatch Norfolk appreciates the opportunity to
make comments on the Quality Account.
We welcome the introduction of the values of
community, compassion and creativity to develop a
patient-centre model of care, and its use as the basis for
the delivery of national and local quality requirements.
The use of patient experience and what has happened as
a result and the recognition of the achievements of staff
give a clear message about the Trust’s culture.
We welcome the comprehensive nature of Norfolk
Community Health and Care’s Quality Account for
2014/15 and its honesty in discussing areas of difficulty
as well as the Trust’s successes. We look forward to
seeing the results of the Trust’s work to improve the
results of the staff survey.
The explanation of the sources of quality goals and
indicators is particularly helpful, including the CQuINs
negotiated with the different Clinical Commissioning
Groups (CCGs). The number of CCGs in Norfolk
provides good opportunities for innovation; we will be
interested to see how the experiences from delivering
the CQuINs is evaluated and disseminated across the
county. We would be concerned if these initiatives led
to inequalities in service provision for individual client
groups across the county.
We are pleased to see the growth in the Trust’s
collaboration with other organisations within the health
and social care system within Norfolk, particularly the
development of integration in community services, and
its participation in national initiatives to improve quality
and safety of care.
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We have found that the level of detail, the repetition
and the use of language make the Quality Account
difficult to follow at times; the document assumes a
level of understanding that may not be found among
the general public. Where data on quality indicators
has been collected over a number of years it would be
helpful to give more than one year’s data to demonstrate
improvements in service delivery over time.
We will continue to work with Norfolk Community
Health and Care to ensure that the views of patients,
carers and their families are taken into account and to
make recommendation for change where appropriate.
Alex Stewart, Chief Executive
7.4 Norfolk Health
Overview and
Scrutiny Committee
The Norfolk Health Overview and Scrutiny Committee
has decided not to comment on any of the Norfolk
provider Trusts’ Quality Accounts for 2014-15 and would
like to stress that this should in no way be taken as a
negative comment. The Committee has taken the view
that it is appropriate for Healthwatch Norfolk to consider
the Quality Accounts and comment accordingly.
Norfolk Community Health and Care NHS Trust
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8. Directors’ Declaration
The following is a declaration; signed by all directors
in office at the date of the account, certifying that
they believe the contents to be true, or a statement
of explanation as to the reasons any such director is
unable or has refused to sign such a declaration.
I believe the contents of this Quality Account 2014/15
to be true:
Executive Directors
Name: Roisin Fallon-Williams
Chief Executive
Name: Roy Clarke
Director of Finance
Name: Dr Rosalyn Proops
Medical Director
Name: Anna Morgan
Director of Nursing and Quality
Name: Paul Cracknell
Director of Strategy and Transformation
Name: Matt Colmer
Director of Performance and Information
Non-Executive Directors
Name: Ken Applegate
Chairman
Name: Alex Robinson
Non-Executive Director
Name: Professor Ian Harvey
Non-Executive Director
Name: Derek Allwood
Non-Executive Director
Name: Heather Peck
Non-Executive Director
Name: Amanda Reynolds
Non-Executive Director
Name: Geoff Rivers
Designate Non-Executive Director
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Glossary of terms
AHP
Allied Health Professionals
Allied Health Professionals (such as Physiotherapists,
Occupational Therapists, Speech and Language
Therapists, Podiatrists) provide treatment and help
rehabilitate adults and children who are ill, have
disabilities or special needs, to live life as fully as
possible. They often manage their own caseloads.
AQP
Any Qualified Provider
When a service is opened up to choice of ‘Any Qualified
Provider’, patients can choose from a range of providers
all of whom meet NHS standards and price.
BAF
Board Assurance Framework
The Board Assurance Framework provides a record of
the principal strategic risks to the Trust achieving its
objectives. It identifies the controls in place, the methods
of assurance and the control and assurance gaps.
BGAF
Board Governance Assurance Framework
A key part of achieving FT authorisation is passing a
rigorous assessment of board capability and capacity
by Monitor, the Foundation Trust regulator. To support
aspiring Foundation Trusts to meet this competency,
the Department of Health has developed a mandatory
board governance assurance framework in partnership
with existing Foundation Trusts and other stakeholders.
BNF
British National Formulary
The British National Formulary provide UK healthcare
professionals with authoritative and practical
information on the selection and clinical use of
medicines in a clear, concise and accessible manner.
C. Diff Clostridium Difficile
A form of bacteria that is present naturally in the gut
of around 2/3s of children and 3% of adults. On their
own, they are harmless, but under the presence of some
antibiotics, they will multiply and produce toxins (poisons),
which cause illness such as diarrhoea and fever. At this
point, a person is said to be infected with C. difficile.
CADS Community Alcohol and Drug Service
The main aim of the service is to reduce problems
related to drugs and alcohol misuse, and support
recovery. In order to do this CADS provides a range of
modalities including advice and information, community
and specialist prescribing, structured psychosocial
interventions, structured treatments, harm reduction
interventions and aftercare.
CAUTI Catheter-acquired Urinary Tract Infection
A bladder infection that has occurred as a direct result
of the presence of an indwelling catheter (a mechanism
used initially to help the bladder)
CCG
Clinical Commissioning Group
These are groups of GPs that, from April 2013,
are responsible for planning and designing local
health services in England. They will do this by
“commissioning“or buying health and care services.
CIP
Cost Improvement Plan/Programme
The formal identification of an action which reduces the
budgeted cost base of the organisation. It can relate to
either pay or non pay costs.
CN&T Community Nursing and Therapy
Home delivered nursing and therapy services and
interventions for Adults such as; wound dressings, end
of life care, rehabilitation programmes.
CQC
Care Quality Commission
An organisation that checks whether hospitals,
care homes and care services are meeting
government standards.
CQuIN Commissioning for Quality and Innovation
The Commissioning for Quality and Innovation
payment framework enables commissioners to reward
excellence, by linking a proportion of English healthcare
providers’ income to the achievement of local quality
improvement goals.
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COPD Chronic Obstructive Pulmonary Disease
DoL
Chronic obstructive pulmonary disease (COPD) is the
name for a collection of lung diseases including chronic
bronchitis, emphysema and chronic obstructive airways
disease. People with COPD have trouble breathing in
and out. This is referred to as airflow obstruction.
DoL has no simple definition as what qualifies as
deprivation of liberty, it originates from case law rather
than definitive acts of parliament. Under the MCA though
it is now clear that someone cannot be made to do
something that they are resisting and a full assessment
should be made to enable decisions to deprive someone
from a liberty for their own safety or well-being.
CRR
Corporate Risk Register
The Corporate risk register is the aggregation of the
local team and corporate department risk registers
where the residual risk score is more than 12. It includes
any additional sources of risk such as external or
internal reviews.
DPA
Deprivation of Liberty
Data Protection Act (1998)
The Data Protection Act 1998 requires every organisation
processing personal data to register with the Information
Commissioner’s Office, unless they are exempt.
CSSD Central Sterile Service Department
EDT
A service that provides sterilisation for equipment
used by community services e.g. scissors, scalpels,
tool nail cutters.
The Team of Executive Directors of Norfolk Community
Health and Care NHS Trust, that meets weekly.
CSP
Chartered Society of Physiotherapy
The Chartered Society of Physiotherapy (CSP) is the
professional, educational and trade union body for the
UK’s 50,000 chartered physiotherapists, physiotherapy
students and support workers.
DASH Disability and Specialist Health Pathway
The DASH service pathways are for children with
medical, neuro developmental disorders and long term
health conditions who require additional or specialist
healthcare and whose needs cannot be met by the
Healthy Child Pathway
Datix DATIX risk and incident database
DATIX is a web-based risk management
monitoring tool that aids NCH&C staff in the
reporting and management of incidents, risk,
complaints and PALS enquires.
Executive Directors Team
EPRREmergency Preparedness, Resilience
and Response
In April 2013 NHS England introduced the EPRR Core
Standards detailing the roles and responsibilities
involved in EPRR, Major Incident and Service Continuity
planning, partnership working, resource allocation and
staff competencies.
EWTT Early Warning Trigger Tool
The Early Warning Trigger Tool is designed to capture and
bring together all of the factors that could impact on the
quality and safety of clinical services, to identify services
that may be at risk, and to help prevent serious incidents
and patient safety issues in the future. It is part of a
package of measures being used to ensure that quality
and patient safety remain a key priority for NCH&C.
FFT
Family and Friends Test
A nationally driven patient satisfaction survey using the
question ‘would you recommend this service to your
friends and family?’
FOIA
Freedom of Information Act (2000)
The Freedom of Information Act 2000 is an Act of
Parliament that creates a public “right of access” to
information held by public authorities.
Norfolk Community Health and Care NHS Trust
FT
Foundation Trust
NHS foundation trusts are not-for-profit, public
benefit corporations.
FTN
Foundation Trust Network
The Foundation Trust Network is the membership
organisation for NHS public provider trusts. They
represent every variety of trust, from large acute and
specialist hospitals through to community, ambulance
and mental health trusts. Members provide the full
range of NHS services in hospitals, the community and
at home.
IAG
Intelligent Application Gateway
A remote access method for access to IT services from
outside the Trust.
IBP
Integrated Business Plan
Document setting out the five year strategy of the Trust.
ICO
Integrated Care Organisation
This will build on the Integrated Care Organisation pilot,
the work in the West of the county and the work of
the current health and social care integration project.
KPMG have been commissioned to develop an options
appraisal which highlights the benefits and risks of
moving further on integration or continuing with our
current processes.
IG
Information Governance
Information Governance ensures necessary safeguards for,
and appropriate use of, patient and personal information.
IG Toolkit
Information Governance Toolkit
The Information Governance Toolkit is an online
system which allows NHS organisations and partners
to assess themselves against Department of Health
Information, Governance policies and standards.
It also allows members of the public to view
participating organisations’ Information Governance
Toolkit assessments.
Quality Account 2014/15 – Glossary
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IMCA Independent Mental Capacity Advocate
Introduced by the MCA 2005: Service that helps
particularly vulnerable people who lack the capacity to
make important decisions about serious medical treatment
and changes of accommodation, and who have no family
or friends that it would be appropriate to consult about
those decisions. The role of the Independent Mental
Capacity Advocate (IMCA) is to work with and support
people who lack capacity, and represent their views to
those who are working out their best interests.
INR
International Normalised Ratio
A laboratory measurement of how long it takes blood
to form a clot. It is used to determine the effects of oral
anticoagulants (an anticoagulant is a substance that
prevents clotting of blood) on the clotting system.
IPR
Integrated Performance Report
A report used to assure the Trust Board of
organisational performance, to flag exceptions to the
achievement of performance standards and corrective
action as appropriate.
KPI
Key Performance Indicator
Key performance indicators help an organisation to define
and measure progress towards organisational goals.
LADO Local Authority Designated Officer
The role of the LADO is set out in the HM Government
guidance Working Together to Safeguard Children
(2013). They work within the County Council’s
Children’s Services and should be alerted to all cases
in which it is alleged that a person who works with
children has:
• behaved in a way that has harmed, or may have
harmed, a child
• possibly committed a criminal offence against
children, or related to a child
• behaved towards a child or children in a way that
indicates s/he is unsuitable to work with children
LD
Learning Disability
A learning disability affects the way a person learns
new things in any area of life. It affects the way they
understand information and how they communicate.
Norfolk Community Health and Care NHS Trust
MCA
Mental Capacity Act 2005
The Mental Capacity Act (MCA) provides a framework to
empower and protect people who may lack capacity to
make some decisions for themselves. It states that:
• you should have as much help as possible to make
your own decisions
• people should assess if you can make a
particular decision
• e ven if you cannot make a complicated decision for
yourself, this does not mean that you cannot make
more straightforward decisions
• e ven if someone has to make a decision on your behalf
you must still be involved in this as much as possible
• a nyone making a decision on your behalf must do so in
your best interests
MCA often applies to people with a: learning disability,
dementia, mental health problem, brain injury and stroke
MRG
Mortality Review Group
All deaths (including unexpected deaths) are
reviewed by the MRG to ensure that any trends
are appropriately disseminated
MRSA Methicillin-resistant Staphylococcus Aureus
A bacterium responsible for several difficult-to-treat
infections in humans due to its resistance to methicillin
and other beta-lactam antibiotics. MRSA is especially
troublesome in hospitals and nursing homers, where
patients with open wounds, invasive devices, and
weakened immune systems are at greater risk of
infection than the general public.
MUST Malnutrition Universal Screening Tool
This is a five-step screening tool to identify adults who
are malnourished, at risk of malnutrition or obese. It
also includes management guidelines which can be
used to develop a care plan.
NED
Non Executive Director
A non-executive director is a member of the board
appointed by the Appointments Commission, to hold
the Executive to account, bring independence, external
skills and perspectives and challenge on strategy
development, risk management, shaping culture, and
the integrity of financial and quality intelligence.
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NHSLANational Health Service
Litigation Authority
The NHSLA is a Special Health Authority that
administers the Clinical Negligence Scheme for Trusts
(CNST) which provides indemnity to its members and
their employees in respect of clinical negligence claims.
They are also responsible for resolving disputes between
practitioners and primary care trusts, giving advice to
the NHS on human rights case law and handling equal
pay claims on behalf of the NHS. The NHSLA also aims
to help and support the NHS to improve patient and
staff safety through learning from claims.
NICENational Institute for Health and
Clinical Excellence
The National Institute for Health and Clinical Excellence
provides independent, authoritative and evidencebased guidance on the most effective ways to prevent,
diagnose and treat disease and ill health, reducing
inequalities and variation.
NPSNet Promoter Score
Net promoter score is a key measure of individual, team
and corporate performance and is used to drive up
positive patient experience.
NPSANational Patient Safety Agency
The National Patient Safety Agency leads and
contributes to improved, safe patient care by informing,
supporting and influencing the health sector.
NRLS National Reporting and Learning System
Through the National Reporting and Learning System,
the Patient Safety Division collects confidential reports
of patient safety incidents from healthcare staff across
England and Wales. Clinicians and safety experts help
analyse these reports to identify common risks and
opportunities to improve patient safety.
OD
Organisational Development
Plan that which sets out ambitions for the organisation
and its staff.
PALS
Patient Advice and Liaison Service
The Patient Advice and Liaison Service has been
introduced to ensure that the NHS listens to patients, their
relatives, carers and friends, and answers their questions
and resolves their concerns as quickly as possible.
Norfolk Community Health and Care NHS Trust
PAS
Patient Administration System
An information collection system that acute and
community hospitals use to collect patient related data.
PEAT
Patient Environment Action Team
This is an annual assessment of inpatient healthcare
sites in England that have more than 10 beds. The
assessment teams must be comprised of more than 50%
lay members/patients. It is a benchmarking tool to ensure
improvements are made in the non-clinical aspects of
patient care including environment, food, privacy and
dignity. The assessment results help to highlight areas for
improvement and share best practice across healthcare
organisations in England.
PLACEPatient-Led Assessments of the
Care Environment
Details are being finalised but the new assessments
were piloted in October. A total of 68 hospitals
were involved in pilot PLACE assessments. The Pilot
assessments ran from 1 October to 12 October 2012.
The assessments will be similar to the PEAT inspections
but with more lay members/patients on the teams (over
50% of the team members must be patients).
PMO
Project Management Office
A department or group that defines and
maintains the standards of process, generally
related to project management, or a particular
project, within the organisation.
QIPPQuality, Innovation, Productivity
and Prevention
Quality, Innovation, Productivity and Prevention is a large
scale transformational programme for the NHS, involving
all NHS staff, clinicians, patients and the voluntary sector.
It will improve the quality of care the NHS delivers while
making up to £20billion of efficiency savings by 2014-15,
which will be reinvested in frontline care.
RATs
Rapid Access Team
A team of nurses, therapists and social workers
who respond quickly to patients who are admitted
to accident and emergency at the Queen Elizabeth
Hospital to find alternative solutions to enable patients
to be cared for at home.
Quality Account 2014/15 – Glossary
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74
Root Cause Analysis
RCA is a process designed for use in investigating and
categorising the root causes of events. When incidents
happen, it is important that lessons are learned across
the NHS to prevent the same incident occurring
elsewhere. Root Cause Analysis investigation is a well
recognised way of doing this.
SARC Root Cause Analysis
SARCs are specialist medical and forensic services for
anyone who has been raped or sexually assaulted.They
aim to be a one-stop service, providing the following
under one roof: medical care and forensic examination
following assault/rape and, in some locations, sexual
health services. Medical Services are free of charge and
provided to women, men, young people and children.
SHA
Strategic Health Authority
NHS East of England is the regional headquarters of
the NHS, and provides strategic leadership to all NHS
organisations across the six counties. It is ultimately
accountable to the Secretary of State for Health.
SIRI
Serious Incident Requiring Investigation
The former National Patient Safety Agency has
developed a national framework for serious incidents in
the NHS, titled ‘National Framework for Reporting and
Learning from Serious Incidents requiring Investigation’.
An incident or event or circumstance that could have
resulted, or did result, in unnecessary damage, loss or
harm such as physical or mental injury to a patient,
staff, visitors or members of the public. A serious
incident requiring investigation is defined as an incident
that occurred in relation to NHS-funded services and
care resulting in for example Unexpected or avoidable
death of one or more patients, staff, visitors or
members of the public; Serious harm to one or more
patients, staff, visitors or members of the public etc.
SM
Solihull Model
Solihull Approach is an integrated model of working,
open learning resource packs and training programme
for care professionals working with families, babies,
children and young people who are affected by
emotional and behavioural difficulties.
Norfolk Community Health and Care NHS Trust
STEIS Strategic Executive Information System
A system to collect data for the Department of Health.
All serious incidents requiring investigation (SIRIs) are
recorded onto this system by all NHS organisations
SOP
Standard Operating Procedure
A SOP is a description of what staff are required to
do in a particular situation; this may be to fulfil the
requirements of a guideline, policy, procedure or
national guidance. It contains the specific steps to be
followed to complete the required procedure
SystmOneSystmOne
SystmOne is a centralised clinical system that
provides healthcare professionals with a complete
management system.
TDA
Trust Development Authority
The NHS TDA will play its part in safeguarding the
core values of the NHS, ensuring a fair and
comprehensive service across the country and
promoting the NHS Constitution. It will be accountable
nationally for the outcomes achieved by NHS Trusts
and for financial stewardship within the NHS Trust
system as it is wound down.
TMT
Trust Management Team
A Team that comprises the Executive Directors,
Deputy and Assistant Directors of the Trust.
TTO
“To Take Out”
This is the literal meaning Other Trusts sometimes
use the term “TTA” – “to take away”. It relates to
medications to take home.
Quality Account 2014/15 – Glossary
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TUPETransfer of Undertakings (Protection of
Employment) Regulations 2006
The purpose of the Transfer of Undertakings (Protection
of Employment) Regulations is to protect employees if
ownership of their employer changes hands.
UCC
Urgent Care Centre
During 2013 plans were developed with other providers
across the county in conjunction with the Urgent Care
Network and CCGs, to set up an Urgent Care Unit
at the Norfolk and Norwich University Hospital. The
unit was piloted in November and December over two
weekends and went live on 20 January 2014, to run
over the period of winter pressures.
VTE
Venous Thromboembolism
A blood clot that forms within a vein.
WaterlowPressure Ulcer Risk Assessment
and Prevention Tool
Waterlow pressure ulcer risk assessment/prevention
policy tool is, by far, the most frequently used system in
the U.K. and it is also the most easily understood and
used by nurses dealing directly with patient/clients to
assess risks of the individual.
XenApp
XenApp
XenApp is a type of software programme that runs on a
PC or laptop to allow users to connect to their corporate
applications. It can host applications on central servers
and allow users to interact with them remotely or deliver
them to user devices for local execution.
Head Office: Elliot House, 130 Ber Street, Norwich NR1 3FR
Online: www.norfolkcommunityhealthandcare.nhs.uk
Telephone: 01603 697300