Derbyshire Community Health Services NHS Foundation Trust
Annual Quality Account 2014/15
Contents
Part 1 ........................................................................................................................................................ 3
Introduction ............................................................................................................................................... 3
Declaration of Accuracy............................................................................................................................. 3
Part 2 ........................................................................................................................................................ 4
Driving quality improvements..................................................................................................................... 4
2014/15 Quality priorities ........................................................................................................................... 4
Part 3 .......................................................................................................................................................11
Evidence of quality improvements for 2014/15 .........................................................................................12
What have we done to improve patient safety? ........................................................................................12
Ensuring services are clinically effective ...................................................................................................25
What we have done to improve patient experience? ................................................................................32
Ensuring our services are responsive to patients’ needs ..........................................................................40
Appendix 1 - Workforce ............................................................................................................................47
Appendix 2 - Information Governance Toolkit submission for 2014/15 .....................................................53
Appendix 3 - Third party statements - CCGs/Healthwatch ........................................................................54
Appendix 4 - Statement of Directors’ responsibilities in respect of the Quality Account ............................58
Appendix 5 - Independent Auditors ..........................................................................................................59
Appendix 6 - The Core Quality Account Indicators ...................................................................................60
Glossary ...................................................................................................................................................63
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Part 1
Introduction
Welcome to our Quality Report for 2014/15 which sets out what we have done to safeguard and improve
the quality of our services during the year, where we still need to make improvements and what we want
to achieve in 2015/16.
Here at Derbyshire Community Health Services NHS Foundation Trust (DCHS) our vision is to be the
best provider of local healthcare and a great place to work. During the year we have implemented a wide
range of service developments and quality improvements in support of this vision. This report is an
important part of discharging our accountability to the local communities that we serve and describing the
progress we have made.
The organisation became an NHS Foundation Trust on the 1 November 2014, increasing our local
accountability through the establishment of an elected Council of Governors. This report covers the
quality of our services across the entire 2014/15 year, including the seven months we were an NHS Trust.
We feel that we have made good progress in the year in continuing to improve the safety and
effectiveness of our services, as well as the experience of our care, for everyone that we support. This
progress and the high quality of care our 4,400 colleagues provide was recognised by the Care Quality
Commission (CQC) during the year when they undertook a full inspection of the Trust. They noted that
the Trust provided safe care delivered by staff who were dedicated and compassionate and who
demonstrated excellent commitment in providing the best care they could and putting patients’ needs at
the centre of their care. They did highlight isolated areas where we were not found to be meeting the full
range of essential quality standards and we have successfully and effectively addressed these in the
year.
Tracy Allen, Chief Executive and Prem Singh, Chairman
Declaration of Accuracy
I confirm that to the best of my knowledge the information presented in our Annual Quality Report
is accurate
Signature
Tracy Allen, Chief Executive
Are we accessible to you? This publication is available on request in other formats (for example, large
print, easy read, Braille or audio version) and languages. For free translation and/or other formats please
call 01773 525099 extension 5587, or email us at: communications@dchs.nhs.uk
To see the full list of the services we provide, please visit www.dchs.nhs.uk or call us on 01773 525099
for support.
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Part 2
Driving quality improvements
2014/15 Quality priorities
This quality report demonstrates our achievements for the year 2014/15, describes the areas where we
would still like to make improvements and our quality objectives for the coming year.
Our quality improvement priorities are identified within the Trust’s overarching annual objectives, known
as the Big 9.
During 2014/15 we set ourselves three key quality priorities - known as the Big 3 - to focus the whole
organisation on quality improvement in areas of patient safety, clinical effectiveness and patient
experience. These priorities were to:
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keep people safe - reducing the number of serious medication errors by 50%
keep patients (and families) at the centre of care - to establish 10 active patient engagement
groups
ensure care is effective - 95% of patients with diabetes to have an appropriate care plan
We are pleased to report that we have achieved all of these objectives, reducing our medication errors
resulting in serious harm from 14 in 2013/14 to 0 in 2014/15.
DCHS BIG 3
In addition to our organisation-wide quality improvement targets in 2014/15 we have been working to
achieve a combination of quality objectives and service improvements which we set ourselves, together
with quality targets which are set out in our contract with local health service commissioners. These are
reported in more detail in the body of this report.
Our quality priorities build upon what we already know about our services, what our patients have told us
are important to them and in response both to commissioners’ and national priorities. We also place a
great emphasis on learning from our staff who are at the frontline of care delivery and we have developed
an effective network of ways to engage with them and hear their feedback. We are particularly proud of
our annual staff survey results 2014, which listed us as the best performing trust, based on feedback from
our staff.
Things we want to do better in 2015/16
We are continually striving to improve the quality of the services we provide and to learn from things that
did not go so well.
For 2015/16 our Board of Directors has agreed three strategic quality improvement objectives:
1) Patient Safety - Improvement in information sharing
Ensuring that clinicians have up-to-date information regarding their patients at all times is vital to
the delivery of effective, safe and responsive healthcare. During 2015/16 we will be asking our
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staff to ask patients, at initial consultation, if they give consent to their health records being shared
with other health practitioners to ensure better continuity of care.
2) Clinical Effectiveness - To increase the number of referrals to Smoking Cessation services
made by DCHS staff
Smoking has been demonstrated as one of the most significant issues with regard to poor health
in our population. All health professionals have a responsibility to advise patients on the ill effects
of smoking and to sign post them to services which can support them to stop.
3) Patient Experience - Identify where patients with a learning disability access our services
Individuals with a learning disability can access any of our services and as such have a right to
care and treatment appropriate to their needs. This target will help us to identify the specific needs
of patients with a learning disability and the changes we need to make to ensure they can access
our services equitably.
In addition we will continue to strengthen our internal processes for quality improvement and assurance
using our Quality Improvement and Assurance Framework.
Monitoring and measuring quality
We are actively committed to being able to demonstrate the consistency and quality of our services. We
want our patients and their families to feel safe and well looked after.
We recognise the need for a continuous focus on improving our quality assurance measures. During
2014/15 we have developed further processes for assuring the quality of our services. We have
implemented the Quality Improvement and Assurance Framework.
Quality Improvement and Assurance Framework
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DCHS Way
Clinical & Quality strategy
Patient experience and engagement
Effective communication
Highest quality staff
Raising concerns & whistleblowing
Board to ‘ward’ engagement
Staff engagement & feedback
Staff selection, training and
development
Governance structure
Board development
Risk strategy and policy
Management structure and job roles
Data quality
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Integrated performance dashboard
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Patient and carer feedback
This tiered approach
to quality assurance includes:
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Rapid Response monitoring
 Individual practitioners
and teams - working to agreed standards, policies and professional
Intelligence monitoring
guidelines. Benchmarking
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Peer review - Quality Always is our trust-wide clinical assessment and accreditation model which
aims to draw together all standards against which clinical teams are measured. Most importantly
the fundamental standards defined by the CQC are included and as such this will be our primary
method for assessing ongoing compliance with CQC standards.
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Board quality and safety visits - which ensure frontline staff are able to engage with board
members, senior managers and governors about things that concern them and which may prevent
them providing best care consistently.
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Independent review - working with our commissioners, external partners and professional bodies
to provide independent assurance of the quality of our services.
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Quality Always is underpinned by a robust approach to clinical leadership, in line with our People and
Organisational Effectiveness Strategy. A focus on capability and development will ensure that we
continue to develop our clinical leaders in line with the rapidly changing healthcare environment.
In addition to our Quality Improvement and Assurance Framework, we have a comprehensive governance
structure to monitor our compliance with essential standards of care, the quality of service delivery and
progress against key priorities. This is supported by a detailed clinical dashboard to monitor key
performance indicators, which in turn is supported by a data quality kite assurance process. Monthly
reports on the quality of services are presented to the Quality Services Committee and to the Board of
Directors and these meetings are underpinned by a broad range of quality groups providing assurance on
specialist topic areas.
We meet with our commissioners every month via the Quality Assurance Group which monitors and
reports on our quality schedule, our performance against Commissioning for Quality and Innovation
targets and any other issues which positively or negatively impact on the quality of our services.
During 2015/16 we will continue to strengthen our assurance processes and roll out Quality Always, our
clinical peer assessment and assurance process. We will be working with Southern Derbyshire Clinical
Commissioning Group (SDCCG) to establish an additional quality assurance group focused on services
commissioned directly by them.
Our services in 2014/15
During 2014/15 the DCHS provided and/or sub-contracted 36 relevant health services.
The income generated by the relevant health services reviewed in 2014/15 represents 100% of the total
income generated from the provision of relevant health services by DCHS for 2014/15.
Of these services, 32 were NHS commissioned services (£144m) and a further four were commissioned
by local authorities (£9m). Services included rehabilitation, community nursing, health visiting, school
nursing, sexual health services, community dental services for patients with mental health problems and
learning disabilities, as well as a wide range of planned care services such as podiatry, physiotherapy,
speech and language therapy and occupational therapy. Strategically we have continued to redesign our
services with an aim to support our patients as close to home as possible.
As part of our duty of care we continuously review the quality of all our services. DCHS has reviewed all
the data available to them on the quality of care in all of these NHS services.
It is important that we focus carefully on the way we spend the money allocated to us for provision of our
services. We need to ensure we are able to deliver best value for money at all times, whilst also striving to
provide the very best care for people in our local community.
National clinical audits
During 2014/15 a total of six national clinical audits and no national confidential enquiries covered NHS
services that DCHS provides.
During that period DCHS participated in 83% national clinical audits and 0% national confidential
enquiries which it was eligible to participate in.
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The national clinical audits and national confidential enquiries that DCHS was eligible to participate in
during 2014/15 are as follows:
Audit title
National COPD audit
Sentinel stroke national audit
National PROMs programme
National audit of intermediate
care
National diabetic foot care audit
NCEPOD sepsis audit
The national clinical audits and national confidential enquiries that DCHS participated in during 2014/15
are as follows:
Audit title
National COPD audit
National PROMs programme
National audit of intermediate
care
National diabetic foot care audit
NCEPOD sepsis audit
Our participation in the Sentinel stroke audit is currently being scoped both in terms of eligible clinical
services and workload implications for data collection. It is anticipated that we will join this audit fully in
2015/16.
The national clinical audits and national confidential enquiries that DCHS participated in, and for which
data collection was completed during 2014/15, are listed below alongside the number of cases submitted
to each audit or enquiry as a percentage of the number of registered cases required by terms of that audit
or enquiry.
Audit title
Percentage of the number of registered
cases submitted
National COPD audit
Participation ongoing
National PROMs programme
National audit of intermediate
care
Limited participation – less than 12% in Q1
and Q2. Future improvement in recruitment
expected.
No target set.
12 patients recruited to the PREM part of the
audit – 100%
National diabetic foot care audit
Participation ongoing
NCEPOD sepsis audit
Organisational audit only
DCHS always reviews national reports in conjunction with local results.
The reports of two national clinical audits were reviewed by DCHS in 2014/15 and DCHS intends to take
the following actions to improve the quality of healthcare provided:
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The national audit of intermediate care has reported its results and we reviewed the DCHS results
against the national benchmarks in March 2015 in order to agree an improvement action plan.
The PROMs results are reported slowly after each quarter and only Q1 is available so far. DCHS
is implementing a plan to improve patient recruitment for groin hernia day surgery over the next
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•
year before it can utilise the pre- and post-op outcomes data for a local patient outcome
improvement plan, given the low level of activity in DCHS for this surgical procedure.
The remaining audits have not been completed and reported yet.
The number of patients receiving relevant NHS services provided or subcontracted by DCHS in 2014/15
that were recruited during that period to participate in research approved by a research ethics committee
were:
Name of study
Number of
participants
Dementia and Imagination
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Nourishing Start for Health
3
Electrical muscle stimulation dysphagia study
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Further information on our approach to clinical audit is detailed in section 3 of the report.
Commissioning for Quality and Innovation (CQUIN)
A proportion of DCHS income in 2014/15 was conditional on achieving quality improvement and
innovation goals agreed between DCHS and North Derbyshire Clinical Commissioning Group (CCG) as
the lead commissioner on behalf of our four CCGs. This was part of our contract for the provision of NHS
services, through the Commissioning for Quality and Innovation payment framework.
Total CQUIN contract value for 2014/15 was £3,181,922 and we are predicted to earn approximately 96%
of this value, taking into consideration that we are likely to receive 20% of the final payment for the Safety
Thermometer CQUIN in relation to the stretched target of reducing pressure ulcer prevalence (CQUIN
value of £165,460). This indicates a total CQUIN payment of £3,049,554.
Further details of the agreed goals for 2014/15 and for the following 12 month period are available in
section 3.
Care Quality Commission (CQC)
DCHS is required to register with the CQC and its current registration status is: registered with the CQC
with no conditions attached to registration. The CQC has not taken enforcement action against DCHS
during 2014/15.
DCHS is subject to periodic reviews by the CQC and the last comprehensive inspection was between
26 February and 4 March 2014 with a further focused inspection between 11 and 12 November 2014. The
CQC’s assessment following that review was that the Trust is fully compliant with all essential standards.
DCHS volunteered to be in the first wave of new style CQC inspections and worked with the Commission
to develop their new inspection tool. Included within their inspection were the following services:
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Community services for children and families
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Community services for adults with long-term conditions
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End of life care
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Learning disability services
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Minor injury services
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Dental services
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Elective care services
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Mental health services.
There was a great deal to be proud of within the outcomes of the March 2014 inspection report. It was
reported that: ‘patients were overwhelmingly positive about the care and treatment they received’ and
‘patients and their families were treated with compassion and respect, and were involved in their care and
well informed’.
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The CQC did however find some areas for improvement. These included a focus on medication and
equipment safety, the need to develop personalised care plans further for patients, and to ensure
thorough processes were undertaken to support patients with cognitive impairment to make decisions
regarding consent to treatment.
A number of other suggestions to enhance the care we provided were also made. Our staff responded to
these challenges with enthusiasm and were justly rewarded for their efforts when the CQC revisited us in
the autumn and found the organisation to be fully compliant with all essential standards of care. The CQC
reported that we had responded positively to the findings of the previous inspection and that we had taken
appropriate action to achieve compliance with essential standards. Staff felt that the action taken had
made a positive difference.
In January 2015 the CQC undertook unannounced Mental Health Act 1983 visits to Spencer and
Riverside wards, part of our older peoples’ mental health services. These visits are part of the statutory
inspection regime for services provided under the auspices of the Mental Health Act. Again, the caring
attitude of our staff was positively reported. Some minor improvements in the management of patient
records were identified. However, overall the services were evaluated extremely positively. As a pilot for
the new style CQC visits, we were not rated as part of these inspections. However, a letter written to
Monitor by Sir Mike Richards, Chief Inspector of Hospitals, supported us at DCHS to progress our
ambition to become a Foundation Trust, which we achieved in November 2014.
At DCHS we continue to develop our quality assurance processes and this will be driven through our
Quality Always approach described in more detail later in this report. In addition we will continue to work
to improve standards and implement suggested improvements made during CQC’s assessment, including
embedding changes with regard to care of people with mental health conditions, specifically personalised
care planning and ensuring effective consent for patients with limited capacity. We will continue to
strengthen our arrangements for clinical supervision and care planning for all our patients. Ensuring safe
staffing levels is a key priority for us and with our commissioners we will continue to review demand and
ensure staffing levels reflect national best practice standards.
DCHS has made the following progress by 31 March 2015 in taking such action.
 Older people’s mental health
We have reviewed and implemented new documentation to improve personalised care planning,
improved training opportunities for staff with regard to the Mental Health Act, including taking
consent from patients with limited capacity, and reviewed our service level agreements with
partner organisations. Policies underpinning practice have been reviewed and staff supported in
their implementation. We have developed our strategy of care for patients with dementia and are
now taking this for approval through our governance processes.
 Medicines management
We have strengthened our governance arrangements regarding medicines storage and revised
the processes for monitoring and assessing patient group directions. Improvements in medicines
management have been evidenced through achieving our patient safety objective for 2014/15,
during which time we had no medicines management incidents resulting in serious harm to
patients.
 Equipment management
We have reviewed and strengthened arrangements for checking medical equipment.
 Estate management
We continue to manage our estate to ensure that it meets the needs of our individual patient
groups, protects our patients from harm and affords them privacy and dignity as appropriate.
During the year improvements included refurbishing the ward at Whitworth Hospital to ensure it
provides a dementia friendly environment, and improvements to roads and crossings at Walton
hospital in Chesterfield.
 Safe staffing
Ensuring we have the right number of staff with the right skills to meet our patients’ needs is an
essential foundation for good care. We have reviewed the number of nurses for our inpatient
wards, in line with national Safer Staffing guidance, and we monitor this on a continuous basis,
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reporting centrally through the Unify System. We are participating in work nationally to agree safer
staffing levels for other community services including community nursing, health visiting, learning
disability services and mental health services.
We have completed a review of workload and skill mix with our community nursing teams and are
working with our commissioners to agree appropriate staffing levels, based on the acuity of the
patient caseload.
We are rolling out our e-rostering tool and associated Safe Care acuity tool which facilitates
assessment of patient acuity during the 24-hour period.
As a consequence of this work we are able to provide assurance to our patients and their carers
that we have the right staff on duty to meet their needs, which is evidenced with ward-based
staffing boards indicating required and actual staff on duty at any given period.
Clinical supervision
Staff development events regarding clinical supervision have provided advice and guidance on the
value of supervision and the need for clear documentation. Participation in clinical supervision is
now linked with annual appraisal.
Documentation in patient records
Documentation of risk assessment processes have been streamlined to reduce the bureaucratic
burden and to support personalised care planning. We are working towards migration of
documents onto our electronic patient care system and continue to audit records on a regular
basis to ensure they meet the required standard. This has demonstrated that there has been
significant improvement in personalised care planning and management of consent with patients.
Quality governance and assurance
Our new quality improvement and assurance model has been introduced and we are rolling out
our Quality Always peer assessment and assurance programme across the organisation. We have
invested in a series of workshops for clinical staff to ensure they understand the purpose of the
programme and their role within it. .
DCHS has not participated in any special reviews or investigations during the reporting period.
Secondary uses service data
DCHS submitted records during 2014/15 to the secondary uses service for inclusion in the Hospital
Episode statistics, which are included in the latest published data. The percentage of records in the
published data up to and including March 2015:
which included the patient’s valid NHS number was:
100% for admitted patient care
100% for outpatient care
99.3% for accident and emergency care
which included the patient’s general medical practice code was:
100% for admitted patient care
100% for outpatient care
100% for accident and emergency care
Information governance
DCHS’ information governance assessment report overall score for 2014/15 was 73% and was graded
green from the IGT grading scheme). 95.8% of staff completed information governance training in year.
Further detail on our information governance toolkit score can be found at appendix 2.
Clinical coding audit
DCHS was not subject to the Payment by Results clinical coding audit during 2014/15 undertaken by the
Audit Commission.
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Part 3
Review of quality improvements for 2014/15
Commissioning for Quality and Innovation (CQUIN)
For 2014/15, at DCHS we jointly agreed nine CQUIN measures with our commissioners, demonstrating
our continuous commitment to improving services in terms of quality outcomes for patients, carers and
service users.
These quality indicators support and ensure ongoing innovation and improvement across all of our
services and in defined areas of clinical care. The nine CQUINs were classified into three national, one
regional and five local improvement areas.
The three national areas were:
 Friends and Family Test (FFT) - we have been an early adopter of the Friends and Family Test
initiative and have promoted its use across all services as an integral part of our patient
engagement strategy, as well as asking our staff the FFT question through the annual staff survey.
Feedback from the FFT has helped us to improve our services in line with user expectations.
 NHS Patient Safety Thermometer - the national safety thermometer tool requires us to collect
data on four ‘harms’ related to patient safety, in order to understand better how often these harms
occur and to put into place strategies which prevent or minimise harm in the future. The four
harms include: venous thromboembolisms (VTE), falls, urinary tract infections and pressure
ulcers.
 Training in dementia awareness - during the last year our primary focus has been on training
community staff, in conjunction with providing support to carers of patients with dementia through
the First Contact referral initiative. Whilst fully supported across our inpatient wards, the First
Contact approach has been particularly successful across our community services, championed
by our care coordinators who support patients and carers in the community with regard to
admission avoidance and in receiving the care they need following discharge from hospital.
The regional CQUIN was:
 Improving patient experience and complaints - we committed to undertaking a peer review of
our complaints standards and processes against the national Patient Association methodology in
order to highlight areas for improvement. The outcome of the report demonstrated that the
complaints reviewed were satisfactory, with one complaint reviewed as demonstrating good
practice.
The five local targets were:
 Pressure ulcers - our community nursing services undertook a review of how our staff engage
with patients in preventing the development of pressure ulcers with a view to understanding why
this is not always successful. Supporting work included patient interviews, a review of equipment
and the development of comprehensive guidance and documentation for patients and staff. We
are continuing to work with staff to embed lessons learned and improve practice. A DVD is being
produced to support staff training.
 Compassion and culture – we are committed to delivering against the national agenda for the
provision of compassionate care as part of embedding positive culture and values across the
organisation. A number of work streams were developed which aimed to enhance our patients’
experience of compassionate care across the organisation. These included developing a valuesbased recruitment process, commencing the roll-out of our Quality Always model of accreditation
for our inpatient wards and promoting the work of our Care Makers.
 End of life - following the national review of the Liverpool Care Pathway and its subsequent
replacement with a new End of Life ‘toolkit’, DCHS committed to supporting staff in understanding
how to enhance and deliver quality care in the last days and hours of a patient’s life within the new
framework. This continues to be supported by a comprehensive training programme and crossorganisational workshops.
 Community nursing - staffing for quality - this CQUIN focused on an innovative and
comprehensive review of activity across our Community Nursing services in order to determine
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what safe and effective staffing levels are required to ensure consistent quality of care for patients.
Specifically we considered: the time required to deliver quality care; what the patient need is in
terms of acuity and dependency, and what the available nursing resource, skill mix and training
requirements are across the county in relation to the demand. This important piece of work will
help shape the future community models across Derbyshire in 2015/16.
Discharge planning and patient flow - we continued the good work started in 2013/14 in
improving the quality of our patient discharges, the flow processes and practices across
organisations within the local health community. This has included sharing of best practice,
strengthening communication across different organisations and supporting a joined-up approach
to developing solutions to common challenges. Working as part of the wider health and social care
system we have been able to improve the safe discharge of patients from acute care and ensure
that the emergency care system works in an optimal way.
Developing services responsive to our patients’ needs
Evidence of quality improvements for 2014/15
This section describes in more detail our successes during the last year. We are also keen to present
examples of where we could do better, to ensure we give an open and balanced account. To help
understand this information we have presented this in the following sections:
What have we done to improve patient safety?
Safe care and the safety thermometer
We continue to contribute to the national Harm Free Care agenda and monitor and report on a monthly
basis using the patient safety thermometer which looks at prevalence of the four harms on a fixed day
each month. The four harms are: falls, venous thromboembolism, tissue damage and urinary catheter
infections.
2014/15
Harm free care scores
(Target for year 93%)
Across DCHS
92.37
Rehabilitation wards
87.22
Older people’s mental health wards
District nursing
Learning disability services
100
92.65
100
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The table above illustrates our overall harm free percentage score of 92.37%, as well as the scores for
different services we provide. Unfortunately we fell just short of our overall improvement target of 93% for
the year with our rehabilitation wards failing the target primarily due to the number of patients with
pressure ulcers being admitted to the wards, discussed further on page 15.
Falls
Encouraging patients to mobilise and maintain independence is a key objective of many of our services
and it is to be expected that on occasion some patients may fall. However, this has to be managed in an
appropriate way and the risk of injury from a fall avoided. Where injuries occur due to a fall, detailed
investigations take place to identify the cause.
In 2013/14 we identified that patients within our older people’s mental health services were more at risk of
serious injury from a fall than those being cared for in a rehabilitation ward. As a consequence, during
2014/15, we improved access to physiotherapists for these patients and introduced a general physician to
the team to support the work of the psychiatric doctors. Our general physician reviews all aspects of the
patients’ care and pays particular notice to their medications, diet and fluids, mobility and the general wellbeing of individual patients to help improve mobility and balance.
Last year we also improved staff falls training and personalised care planning and we are in the process
of recruiting a falls prevention practitioner to work with our multidisciplinary team to improve our
understanding of predisposing factors to falls and how they can be prevented. We are also introducing the
use of robotic seals which have been found to reduce anxiety and agitation in patients with dementia, so
reducing the risk of a fall. Across our rehabilitation wards we have introduced coloured wrist bands to
identify those patients with a higher mobility need and those who are at risk of falling.
Falls Partnership Service
Managing falls is also a feature of our wider health community work. In November 2013 Hardwick Clinical
Commissioning Group commissioned and launched a Falls Partnership Service (FPS) working
collaboratively with us at DCHS and also East Midlands Ambulance Service NHS Trust (EMAS) and
Chesterfield Royal Hospital NHS Foundation Trust. The FPS provides a fully integrated response to
people over 50 years who have fallen in their usual place of residence.
The FPS integrates into the emergency ambulance pathway and is provided as an alternative to an
emergency ambulance crew attending the patient, following appropriate triage by ambulance control. The
FPS also takes referrals directly from GPs.
Between 1 April 2014 and 31 March 2015
 633 patient referrals into the service were visited by the FPS team.
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391 patients referred into the FPS team avoided a hospital admission and remained at home/usual
place of residence following their fall.
Between 1 April and 31 March 2015 the FPS attended:
283 callouts for EMAS, this is in addition to the 633 patients already referred into the FPS.
In addition to this we can evidence that between 1 April 2014 and 31 March 2015 503 patients had not
been admitted into hospital 30 days after their fall.
The team can now admit directly to the Elderly Medical Unit and the Adult Reablement Unit when
appropriate, thus avoiding unnecessary waiting times for elderly patients in A&E.
The team liaises closely with the Clinical Navigation Team and Rapid Response Team at Chesterfield
Royal Hospital to improve the patient pathway and ensure safe/timely discharge planning for patients who
are admitted to A&E. They are also building links with the equivalent team at Kings Mill Hospital, part of
Sherwood Forest Hospitals NHS Foundation Trust in Mansfield.
Pressure ulcers
Pressure ulcers caused by damage to skin integrity continues to be one of the most challenging areas of
quality improvement for our clinical teams. There are a wide range of influencing factors which include
input from a variety of care teams across the health and social care community, patient choice and
compliance, ability to monitor and supervise in a home setting, use and availability of equipment.
One of the key priority areas relating to quality improvement in 2014/15 was to reduce the number of
pressure ulcers developing and/or deteriorating while patients are in the care of our staff. Operational
managers at all levels and clinical teams were required to engage fully in the harm free care agenda –
understanding their roles and responsibilities and to provide evidence to both our Trust Board and the
wider health community.
We set out to achieve zero avoidable pressure ulcers acquired under our care during 2014/15, caused by
an omission in our care planning or delivery. Whilst we have seen improvements in a number of service
areas unfortunately we have not yet achieved zero avoidable pressure ulcers across all of our services.
We are continuing to see a downward trend in severity of the pressure ulcers developing within our care.
It is also apparent that we are seeing a general reduction in pressure ulcers within the wider community
as collaborative work with other agencies and the public is helping to increase awareness and ownership
of the problem.
It is believed that the majority of pressure ulcers are avoidable and we are determined to prevent harm to
all of our patients, so we will continue to have pressure ulcer reduction as a key priority going into next
year. From our analysis of incidents and data reporting we can see that clinical teams are being more
proactive in ensuring all measures are put in place to avoid deterioration of ulcers and that improvements
in root cause analysis by managers ensures that learning is shared across the organisation. Supported by
our team of specialist tissue viability nurses, our multidisciplinary teams are working more closely together
to ensure effective communications are in place to help promote continuity of prevention strategies.
Through patient stories our Board of Directors is listening to the views of staff and patients and supporting
initiatives that will help us improve and maintain individualised patient centred care. Through these
patients’ stories we have raised our awareness of the issues that are important to our patients, which
have included the use of equipment by patients at home. As a result we asked our Board Members to
experience what it feels like to use such equipment so that we have a greater understanding of the impact
on the patient’s ability to remain independent and mobile. This has prompted us to review our equipment
catalogue to include alternative options based on what patients have told us about what they require.
The chart below provides a breakdown of where the reported incidents of pressure damage within DCHS
have occurred. We are working with other healthcare providers to identify how the number of patients
14
referred to our services with existing pressure damage can be reduced. It is anticipated that this number
will reduce during 2015/16.
The graph below clearly highlights that the majority of the pressure damage reported within DCHS occurs
within our community-based services where there is less control of the patient’s environment. Our
community services are working closely with patients, carers, family members and other organisations to
increase awareness of how to prevent pressure damage occurring. This work is starting to take effect as
the severity and size of the pressure damage has significantly reduced over the last year.
Although the incidence within community hospitals is small, this is a controlled environment and further
work is required to reduce this number even further.
Percentage of pressure ulcers which developed or
deteriorated whilst in DCHS care by service area
The graphs below compare the incidence of avoidable pressure damage from 2014/15 to 2013/14. The
root cause analysis process has highlighted that avoidable pressure damage usually occurs when:
 staff do not respond in a timely manner to a change in the patient’s condition and therefore, the
plan of care does not always reflect the patient’s actual needs or
 staff have not checked the patient’s skin on a regular basis which would highlight any early signs
of skin damage.
15
The teams involved in these patients are working to improve their response time and ensure that care
does reflect patient need.
Venous thromboembolism (VTE)
Venous thromboembolisms are blood clots in major veins which can lead to serious complications. As a
service we ensure all our patients at risk of VTE undergo an appropriate risk assessment and have a
personalised care plan in place for avoidance of VTE. During 2014/15 we have seen very few VTEs,
suggesting that our risk management strategies are appropriate.
New
VTE’s
%
Sample
size
Mar14
Apr14
May14
Jun14
Jul14
Aug14
Sep14
Oct14
Nov14
Dec14
Jan15
Feb15
Mar15
3
2
0
2
3
2
2
1
0
1
1
2
0
0.19
0.12
0
0.13
0.18
0.13
0.12
0.06
0
0.06
0.06
0.12
0
1593
1651
1618
1551
1647
1510
1622
1662
1617
1672
1677
1633
1614
16
Catheter related infections
Some of our patients need help with continence which is supported by the use of a catheter. Catheters
bypass the body’s natural defences against infection and therefore, if not managed carefully, can be a
source of patient harm. At DCHS we minimise the use of catheters as far as possible, and where
infections do occur we ensure that each case is carefully investigated to understand the cause. During
2013/14 there were 94 cases of catheter related infections and in 2014/15 this number has reduced to 55
cases.
Medicines management
The use of medicines to support and improve patients’ health is the most common medical intervention
used within the NHS and as an NHS Trust we have a responsibility that this is undertaken by staff who
have been adequately trained and who can practice safely. In DCHS we pride ourselves on the fact that
we have a rigorous process in place that provides us with assurance that our staff follow safe medicines
practice.
Given the very large volume of medicines prescribed, dispensed and administered each day across our
service it is inevitable that some errors do occur. Our high level of reporting in relation to errors is
important and demonstrates that our staff understand the significance of errors and the opportunity to
learn from errors when shared with colleagues. We are pleased to report that during 2014/15 at DCHS we
have had no medication errors resulting in significant harm to a patient and that we have an excellent
reputation for the reporting of near-misses from which we can review policies, procedures and training.
All medication errors are reviewed for trends bimonthly by our medication safety team that consists of
ward nurses, community nurses, pharmacists, prescribers and staff from our safety and learning teams.
Following the identification that many of the administration errors were simply caused by ‘human error’,
there was a widespread campaign within DCHS to remind all staff who administer medicines of the basic
“5 Rights” of medicines administration.
Figure: “5 Rights” of safe medicines administration
Following on from this, our specialist diabetes nurses have created, with our workforce planning and
development team a “5 Rights” card specifically for the administration of insulin. This is a diary sized
information card that can be carried by our nursing staff, as an aide-memoire. To support this, specific
training has been delivered to band 6 and band 7 community nurses reiterating safe insulin practice. In
addition, the diabetes specialist nurses within the workforce planning and development team are
developing an eLearning programme around diabetes and insulin administration for DCHS staff to access
online.
A bimonthly newsletter continues to be produced and distributed to clinical teams to update them of all
current medication-related issues. These include local and national guidance, updated local policies or
procedures and articles relating to medication training or audits undertaken.
17
National Institute for Health and Care Excellence (NICE) - technology appraisals relating to
medicines
All NICE technology appraisals related to medicines are discussed at the Derbyshire Joint Area
Prescribing Committee, which has representation from all four local NHS Foundation Trusts and all four
Clinical Commissioning Groups in Derbyshire. A decision is then taken to assign them with a particular
traffic light status according to the Derbyshire medicines management system. This designatory status is
related to whether they may be prescribed by practitioners in the community or reserved for prescribing
only by specialists.
Infection prevention and control
Reducing the risk of infection and preventing cross infection continues to be an important aspect of our
daily work in our hospitals and in the wider community.
We continue to be monitored nationally on the incidence of methicillin resistant staphylococcus aureus
(MRSA) blood stream infections (bacteraemia) and clostridium difficile infections. We are pleased to
report that for another year there have been no MRSA bacteraemia (blood borne infection) reported within
our services.
Over the past year we have had 12 positive clostridium difficile infections diagnosed within our services.
As of 2014/15, the 12 patients have undergone a review and, in line with new national guidance, any
lapse in care identified. Of the 12 patients, we have identified five significant lapses in care which is 42%
of those patients treated for clostridium difficile infection. The Infection Prevention and Control Team is
working with the services to ensure that these lapses are addressed and do not recur during 2015/16.
There are examples of good practice which demonstrate individualised care for patients with clostridium
difficile infection. For example patients with dementia or who are low in mood due to the need to isolate to
prevent cross infection.
Norovirus
Seasonal diarrhoea and vomiting caused by norovirus can have a significant impact on inpatient wards
and care homes due to its highly contagious nature. The graph below shows how many norovirus
outbreaks we have had this year. Each outbreak is reviewed and any lessons to be learnt shared across
the organisation. The main trend identified relates to communication between the different services to
ensure that the correct information is shared to enable effective and timely decision-making.
18
Hand hygiene compliance
Our infection control champions have continued to promote good hand washing practice through regular
audits and training sessions with their teams. We have seen a slight dip in performance when compared
with last year, with the overall compliance rate reporting 99.22% against our target of 100%. We continue
to work with the teams and infection control champions to ensure that good practice is consistently
adopted across the whole organisation.
Patient manual handling team
Ensuring that our patients are moved safely, and our staff are protected from injury, is a high priority. Our
specialist team work with our staff to ensure we provide our patients with equipment and promote
techniques that are effective in supporting and maintaining their level of independence and safety when
moving. Our specialist team have continued to see an increase in the number of referrals for the following
specialist and complex care needs assessments:
 bariatric
 therapeutic
 special circumstances
 emergency handling
 dental
19


non concordance
environment issues
We have continued our ongoing work with our staff to reduce the incidence of musculoskeletal injuries by
ensuring that they have the skills to assess patients’ needs and provide appropriate care. Training
is designed to give staff the skills they need specific to their role. We have also invested in a new
specialist bed for patients with complex care needs being cared for in our community hospitals, which will
support staff to care for patients safely and provide an improvement to our wards. The specialist team and
our clinical navigation service have reviewed our admission processes to effect a smoother transfer of
patients into one of our community hospitals or services.
Safeguarding children and adults
Safeguarding our clients from actual or potential harm continues to be a fundamental responsibility
delegated to all of our staff.
The safeguarding team employs specialist safeguarding nurses who work with staff and patients to
ensure that as an organisation we discharge that function effectively. During 2014/15 the safeguarding
team has continued to provide specialist safeguarding training, advice and supervision for our staff.
The key improvements this year include:
 bespoke safeguarding training that has been delivered to staff working in children’s services,
minor injury units, learning disability services and older people’s mental health units
 delivery of the ‘Think Family’ national agenda via staff training and briefings. Think Family
encourages staff to consider where there may be a risk to a child or vulnerable adult in a family
where another adult is being treated
 external partnership work with partners regarding the Prevent agenda. The Prevent agenda raises
staff awareness with regard to potential terrorist activity
 development of a Prevent policy
 an update to the safeguarding adults, children and security policy to reflect the issues raised by Sir
David Nicolson in relation to the Savile Inquiry
 continued collaborative work with partner agencies, including projects focusing on domestic
violence, substance misuse, safeguarding thresholds and IT solutions
 working with partner agencies on issues such as co-location arrangements of health staff in social
care, attendance at court and legal meetings, multi-agency risk assessment conferences
(MARAC), and multi-agency public protection arrangements (MAPPA)
 participation in multi-agency information sharing events such as the development of vulnerable
adults at risk meetings (VARM) to discuss safeguarding cases
 the introduction of regular supervision and advice clinics for DCHS staff in hospital and clinic
environments
 funding for ‘Best Interest’ assessor training for the safeguarding adult team
 Monday to Friday (9am – 5pm) safeguarding advice line for children and adult services
 funding of an additional safeguarding nurse to lead on the care home and community agenda
 establishment of a safeguarding governance group that reports to our Quality Services
Committee.
Patient safety
Incident reporting
Staff continue to retain a strong safety culture in relation to reporting patient safety incidents. This is
assisted by the provision of a monthly report outlining incidents and risks which are due to be reviewed
and which enable improvements to occur. More rigorous processes for review have been developed and
risks now form a standing item for discussion within all directorate governance meetings.
20
The following data represents incidents reported from 1 April 2014 to 31 March 2015 and are based on all Patient
Safety Incidents (not all of which have been reviewed and approved at the time of writing).
“Never Events”
During 2014/15 there have been no “‘Never Events” in services at DCHS. Never events are defined as
incidents that are wholly preventable. During this reporting period 12 incidents were reported under the
heading of “Never Events” as potential incidents, however, none of the incidents resulted in serious harm,
due to being identified and mitigated in a short time period or because the error had no trajectory to cause
harm.
Category
Classification
Details
Number
Actions
Maladministration of
Insulin
Near miss
Never Event
All incidents had
potential to cause
harm though did
not result in actual
severe harm.
9
The MOST group reviews all
medication incidents and checks that
improvements measures identified in
agreed actions are completed.
Additional training has been
implemented and numbers of
incidence in the latter part of the year
have reduced.
Wrong route
administration
Near Miss
Never Event
No resulting harm
1
As above action
Retained foreign
object post operation
Prevented
Never Event
No resulting harm
2
WHO theatre checklist actions were
revisited and strengthened, including a
revised check list with double checks
in place. No further incidents.
Quality checks
The Patient Safety Team reviews every patient safety incident reported, providing quality checks which
include: seeking additional detail or clarification; ensuring clear definition of incident and removing patient
identifiers. The data is then shared with the National Reporting and Learning System (NRLS). A
monitoring system is in place to check progress against identified root cause analysis to ensure
completion within the risk management policy timeframe.
Table 1: During the reporting period, a total of 9,559 patient safety incidents (PSIs) were reported, of
which 8,917 (93%) resulted in no or minor harm; 632 (7%) resulted in significant harm (262/43% of these
were inherited incidents i.e. pressure ulcer incidents observed on admission to DCHS); and 8 (0.08%)
resulted in major harm; these related to Grade 4 pressure ulcers. There were 2 (0.02%) catastrophic
incidents reported, one relating to notification of an infant death and one death of a deteriorating patient
on a ward (this was subsequently deemed not to be a patient safety incident as the patient’s death was
anticipated and all care measures were in place).
Table 1
Incidents by severity
No injury or harm
Minor harm/injury
Significant harm/injury
Major harm/injury including permanent disability
Death or multiple deaths or catastrophic event affecting DCHS (e.g. flood/fire)
Totals:
3756
5161
632
8
2
9559
21
Table 2 below illustrates the top five reported incidents and trends over the past three years.
Incidents by category
2014/2015
Pressure relief care
Slips, trips and falls
(patient)
Injury or damage to skin
(not pressure ulcer)
Medication
Ambulance/taxi transport
issue
Totals:
Incidents by category
2013/2014
3,941
1,186
573
457
398
6,555
Pressure relief care
Slips, trips and falls
(patient)
Ambulance/taxi
transport issue
Violence/abuse/
harassment
Medication
Totals:
Incidents by category
2012/2013
3,705
1,456
659
615
528
6,963
Pressure relief care
Slips, trips and falls
(patient)
Ambulance/taxi transport
issue
Violence/abuse/
harassment
Medication
Totals:
2,577
1,544
624
525
404
5,674
Pressure relief care - there has been a 12.4% increase in reported pressure damage compared to the
same period in 2013/14. Some of this will be related to improved awareness and a resultant increase in
reporting as our training and education programme raises awareness amongst clinical staff. We also
know that our staff are treating more and more patients each year, with ever increasing numbers of frail
and elderly patients. Significantly, 53% of incidents relate to inherited pressure ulcers i.e. those occurring
prior to admission to DCHS care. Focused and dedicated care improvements, support and monitoring is
provided to clinicians by the specialists within the Safe Care Group including improved access to the
tissue viability nurse specialists, and work continues in partnership with our commissioners to address
wider public health and health economy issues.
Ambulance/transport /taxi issues - there has been a 25% decrease in reported incidents related to
transport issues. It is difficult to determine if care by ambulance transport providers has improved or
whether staff have reduced reporting due to awareness that concerns are being addressed. The current
service is subject to a competitive tender at the time of this report being written and the trust will continue
to monitor performance against contractual standards.
Violence/abuse/harassment - there has been a marked decrease (46%) in reported incidents related to
patient violence and aggression. This is attributed to improved staff/patient ratios, resulting in improved
levels of observation by staff, increased anticipatory/intervention measures and a reduction in the
numbers of inpatients.
Table 3 shows the number of falls reported in 2014/15, compared with 2013/14, has reduced overall by
18%. Improvements made following Root Cause Analysis include increasing medical and physiotherapy
provision in our older people mental health wards, ensuring the continued acuity of patients is met, and
the introduction of a wristband scheme which alerts staff to patients at risk of falling. Initiatives to be
introduced include using Paro seals which are a therapeutic robot baby harp seal, intended to have a
calming effect on patients and elicit emotional responses from them.
22
Table 3
Falls incidents by severity 2014/15
No injury or harm
Falls incidents by severity 2013/14
713
Minor harm/injury
No injury or harm
907
Minor harm/injury
440
Significant harm/injury
Major harm/injury including permanent
disability
Death or multiple deaths or catastrophic
event affecting DCHS (e.g. flood/fire)
Totals:
33
0
0
1,186
519
Significant harm/injury
27
Major harm/injury including permanent
disability
3
Death or multiple deaths or catastrophic
event affecting DCHS (e.g. flood/fire)
Totals:
0
1,456
Risk management and protecting quality
The Risk Management Policy has undergone a periodic review with significant assurance received from
360 Assurance for the risk management processes in place. The review has streamlined and
strengthened areas of responsibility to enable improved understanding and implementation of policy
contents. Additional to this, to assist in achieving increased awareness and ownership, each assistant
director receives a monthly report of all open risks for their directorate (excluding BAF) - to confirm and
challenge that risks are being reported, escalated and appropriately addressed.
The head of patient safety & risk management attends the director of operations’ senior management
team monthly meeting where there is a dedicated risk management review session. Each governance
stream has both incidents and risks as a standing item on governance meeting agendas.
New last year was the introduction of a quarterly Quality Services Committee meeting to provide
opportunity to review the whole risk register and provide additional confirm and challenge to operational
services. Incidents are being mapped to ensure that risks appropriately reflect areas of concern. Risk
management is based on a fair culture that encourages an organisation-wide environment of openness
and learning.
Training & other patient safety resources
Following popular and very good evaluation, root cause analysis and risk management training continued
to be provided by the patient safety team during 2014/15 and will continue to be available on a monthly
basis with additional and bespoke sessions arranged as required. There is currently a dynamic and
interactive eLearning risk management package being developed which is anticipated to be launched in
the Spring of 2015 this will increase the opportunities for staff to improve their risk management
knowledge base.
Central Alert System & STEIS
The Central Alert System (CAS) is a national reporting system alerting health organisations to safety
issues. During 2014/15 a total of 170 alerts were received, only 39 (23%) applicable to us at DCHS. Each
alert was distributed and followed up without any breeches occurring in meeting any required actions and
or deadlines set by NHS England.
During 2014/15, 204 serious incidents have occurred, with a formal root cause analysis provided to the
CCG. Actions and recommendations from root cause analyses are disseminated through our Learning the
Lessons group.
23
Table 4 Central Alerting System 1/04/2014 to 31/03/2015
Alerts Received During Period
Total
Relevant
22
Not
Relevant
23
On-going
Response
not required
Medical Devices Alerts (MDA)
53
8
Chief Medical Officer Messaging
9
Estates & Facilities Notification (EFN)
59
Drug Alerts
19
19
MHRA Dear Doctors Letter
3
3
NHS England PSA
17
TOTAL
160
9
7
10
50
6
2
1
Table 5 STEIS Reportable Incidents 01/04/2014 to 31/03/2015
C. Diff & Health Acquired Infections
1
Communicable Disease & Infection Issue
8
Delayed Diagnosis
1
Pressure Ulcer Grade 3
134
Pressure Ulcer Grade 4
12
Slips, Trips & Falls
29
VTE
TOTAL
9
194
24
Ensuring services are clinically effective
Clinical effectiveness
We ensure that the services we provide achieve meaningful outcomes for patients and carers in a variety
of ways:
 Clinical audit - measures care and treatment against established standards
 Service evaluation - monitors how well a service delivers care and treatment
 Evidence-based practice - ensures that care and treatment follow proven best practice
 Patient outcomes - measures improvements in the health and well-being of the people who use
our services
We have maintained a commitment to improve patient outcomes through the use of clinical audit. This
approach has also influenced service improvements. One of our audits in 2014 involved a review of
wheelchair use. The results from this audit enabled us to develop our staff training to improve the safe
use of wheelchairs.
Audit continues to influence the care of our patients at the end of their lives and ensures we achieve the
highest standards at this very sensitive time. To ensure that the individual needs of our patients are met
we audit the records of patients who receive End of Life Care.
We will continue to develop the concept of clinical effectiveness within our services. This will ensure our
patient care is led by clinicians and continues to be effective and responsive. We will improve the way we
measure the outcomes of treatment.
National clinical audits
The following national audits (from the NCAPOP list for 2014/15) have been selected as relevant to the
clinical services provided by DCHS. We participate in far fewer national audits as a community trust
compared with an acute trust, as the programme has historically been biased to acute services, though
this is now changing as the NCAPOP list broadens to include more audits on long term conditions (e.g.
the national COPD audit), or existing audits broaden their scope (e.g. the Sentinel Stroke Audit). This year
we are participating in six national audits, compared with only two we joined last year. Some outcomes
from these audits are not yet available at the time of this report.
Ref number
(DCHS Priority
Audit
Programme)
17
18
Audit title
Percentage of cases
submitted
National COPD Audit
– Rehabilitation
Clinical Audit and
Rehabilitation
Organisational Audit
parts of this
programme
No data available as
the clinical audit
started in January
2015 and will
complete in July 2015
Sentinel Stroke
National Audit
Not yet participating.
Outcome if known
Actions to be taken
This audit has just
commenced and the
results will not be
available till
September 2015 for
the clinical audit and
November 2015 for
the organisational
audit
No data yet
submitted.
Data collection for
both parts of the audit
has commenced.
Scoping of services
to include in this audit
is underway. We are
also identifying the
workload implications
for clinicians
collecting and
inputting audit data,
before registering to
participate.
25
Ref number
(DCHS Priority
Audit
Programme)
19
Audit title
Percentage of cases
submitted
Outcome if known
Actions to be taken
Quarter 1 and 2
results show low
levels of participation
therefore the clinical
improvement
information is too
small to be acted on
yet.
Our trust has
maintained our
position of generally
being in the middle of
the range of national
benchmarks reported
for this audit.
Improvement is
expected when the
Q4 results for
2014/15 are
published, following
an action plan to
increase patient
participation.
We will review our
future participation in
this subscription audit
as our service
models for
Intermediate Care
are changing and it is
not clear how we can
use the data
collected by this audit
to improve our
services.
National PROMs
Programme
Result to end of Q2 less than 15% of
Groin Hernia surgery
patient participated at
our Ilkeston Day
Treatment Centre.
20
National Audit of
Intermediate Care –
organisational audit.
N/A for the
organisational audit.
21
National Diabetic
Foot Care Audit
No data yet available
as this audit started
in July 2014 and will
complete in June
2015
This audit has
recently commenced
in Podiatry services
and Report due in
March 2016.
To ensure that the
results are fed back
to DCHS Podiatry
services and any
improvements
required are planned
for.
22
NCEPOD Sepsis
Audit
There was a pre-set
sample of 13
questionnaires from
the audit organisers
for DCHS
No outcomes have
been reported to the
DCHS by the audit
organisers yet.
To ensure that the
results are fed back
to DCHS Medical and
Nurse prescribers
and any
improvements
required are planned
for.
Local clinical audits
The reports of 19 local clinical audits were reviewed by the provider in 2014/15 and DCHS intends to take
the following actions to improve the quality of healthcare provided as summarised within the clinical
outcomes/recommendations column.
Reference No
DCHS priority
audit
programme
1
Audit Title
End Of Life
Progress against Audit Plan
A revised audit tool for
Community Nursing and
Inpatients was launched in Oct
2014 to reflect the 5 Priorities
of Care. Data collection
continuing. Reports quarterly
to QSC. Findings shared with
End of Life Group, CIPP, ANP,
Clinical Outcomes /
Recommendations
Q4 report received. 100% of
audited deaths in community
hospitals were expected deaths.
Recommendations – Attendance
at team meetings to improve
completion of audit within
Community Teams. EOL audit to
be tabled at ICM meetings.
26
Reference No
DCHS priority
audit
programme
Audit Title
Progress against Audit Plan
Clinical Outcomes /
Recommendations
Matrons and ICM meetings.
Explore integration of Recognising
Dying Form within Community
teams. Increase attendance at
Individualised Care Planning
training. Case note review of
sepsis patients.
2
Falls Prevention
Core data collected as part of
the Clinical Records Audit.
This to be integrated into the
broader Falls report re Falls
Bracelets Project and tracking
incidents via Datix. Audit
Report due May 2015. Falls
wrist band project to be rolled
out across all wards.
Q4 data shows improved scores
on many of the indicators, e.g.
asking patients about recent falls
and including information on falls
in ward discharge letters.
3
Frail Elderly
Clinical Records Audit of small
sample to look at outcomes
from care plans proposed.
Reviewed Mar/Apr with
Locality Managers for
Chesterfield and NE Derbys, in
view of move to "hub"
approach to re-evaluate the
audit plan for 2015/16
programme. Audit in planning
stage.
No timetable set for reports.
5a
Mental Capacity Act
(previously OPMH)
Case Notes Audit
Data collection completed for
OPMH/LD inpatient and
residential services. DoLs
audit questions have been
added to Case Notes audit tool
for rollout. New timetable for
rollout of audit and re-audit of
OPMHH agreed with ICBS
Quality Team for 2015/16
programme.
Results show high level of
assurance re process, but
variable recording and need for
staff guidance re Best Interests
Decisions involving degrees of
restriction. Re-audit planned for
Q1 2015/16. Rollout to other
sectors is in planning.
5b
Mental Capacity Act
(previously OPMH)
DoLs Audit
Data collection completed,
Final report received from
Helen Head/Margaret ParryHughes
Report shows need to improve
recording and review of DoLs in
OPMH inpatient wards. Now part
of the Case Notes Audit.
5c
Mental Capacity Act
(previously OPMH)
Carers Experience
Recruitment of Carers on
OPMH/LD inpatient and
residential services is ongoing,
but failed to recruit any
patients in the audit period.
Now being extended to end of
Q4.
Report rescheduled for Q1
2015/16 from Patient Experience
Team
5d
Mental Capacity Act
(previously OPMH)
Amcat
Staff asked to use MHF Amcat
tool after MC assessment.
Rollout as per clinical records
audit. Data requested for
Report rescheduled for Q1
2015/16 due to data quality issues
with download from MHF.
27
Reference No
DCHS priority
audit
programme
Audit Title
Progress against Audit Plan
Clinical Outcomes /
Recommendations
analysis up to end of
November. Issues with data
quality in report from MHF.
6a
Medicines management
controlled drugs
management
Data collection ongoing. Q4
report due May 2015.
A new way of scoring the CD
audits has been agreed at the
Matrons’ meeting and this will be
used in the Q4 CD audit
report. This will grade the
standards according to risk, so
some standards may be breached
a small number of times without
the ward or department failing the
complete audit. The results are
now in and the report is currently
being written and will be
presented to the Matrons’ meeting
on June 8th
6b
Medicines management
treatment cards
Reporting twice a year, data
collection ongoing. Second
report for 2014/15 due in May
2015.
The Q4 treatment Card audit
results are currently being collated
and will be presented to the
Matrons’ meeting and also
discussed with the Medical
Director and the Clinical Assistant
with regards to the standards of
individual prescribers. This report
will be completed during June
2015.
6c
Medicines management
omitted doses
Rolling audit reported to
Inpatient Matrons Group.
Second report for 2014/15 due
in May 2015.
The Q4 Omitted Doses report is
currently being written by the
Head of Medicines Management,
in conjunction with Quality Always
and will be presented to the
th
Matrons’ meeting on June 8 .
7a
Control of Infection
antimicrobial prescribing
Q4 Community Hospitals
Report
The indication was recorded in the
medical notes for all the courses
prescribed. The indication was
recorded on the treatment card
either by the prescriber or the
ward clinical pharmacist for 10 of
the antibiotic courses prescribed
(71.4%) which shows increased
compliance with the “Start Smart
then Focus” guidance compared
to the previous audit where for
68.4% of the courses the
indication was recorded on the
treatment card. More detailed
finds are detailed within the
clinical effectiveness reporting
system.
Completed.
28
Reference No
DCHS priority
audit
programme
7b
Audit Title
Control of Infection
Progress against Audit Plan
Data collection ongoing. Q4
report completed.
Hand Hygiene
Clinical Outcomes /
Recommendations
96.05% of services reported
100% hand hygiene compliance
which is an increase of 1.27%
from Quarter 3 2014/15.
Of the 68 services/teams involved
in the hand hygiene audit
programme 30 services are
completing audits in line with the
IP&C requirements. The
managers of the remaining 38
services/teams who currently
have audits outstanding have
been notified and are monitored
via the IP&C Committee. Some of
the difficulties have related to staff
changes and training of
replacement Champions.
7c
Control of Infection
Data collection ongoing. Q4
report completed
The majority of patients are
isolated in a timely manner.
Delays have occurred where
symptoms were initially attributed
to an underlying bowel condition
and, in one case, the patient’s
symptoms commenced late at
night and to isolate the patient
would have involved moving other
sleeping patients. Training on
IP&C issues will continue as part
of mandatory programme
Isolation audit
8
Clinical Records
Data collection ongoing. Q3
report due in February 2015 now overdue. Q4 report is due
in May 2015.
Q2 sustains the Q1 improvement
by a further 2% in overall scores
to 76%, also reflected in the Q2
"core legal questions" score.
Standard 6 (re completeness of
the record) remains the lowest
scoring standard, and work is
ongoing to support clinicians to
reduce ambiguity over the
meaning of incomplete sections of
forms. The rollout of electronic
records is thought to have
contributed to this sustained
improvement.
12
Identifying LD Patients
Plan to a) identify services
using TPP LD flag, b) identify
equities data re LD in CRA, c)
set up rolling quarterly records
audit of 5 services drawn from
where LD flag in use in TPP,
sampling just LD patients, brief
set of questions looking at
adjustments (including
categories of adjustments
The Commissioners target of 95%
of audited records showing a full
care planning cycle for reasonable
adjustment for people with a
Learning Disability has not been
met. Issues identified including
how reasonable adjustments for
an LD are included in a care or
treatment plan, confusion over
identifying an LD, and ensuring
29
Reference No
DCHS priority
audit
programme
Audit Title
Progress against Audit Plan
Clinical Outcomes /
Recommendations
made) and recording of LD in
records.
that all electronic records have the
right documentation. Audit
working group to address these
issues. This will become one of
DCHS BIG 3 quality initiatives for
2015/16
13
Equality and Diversity
Data collection ongoing.
This year's overall result of 65.5%
shows an 8% improvement over
the 2013/14 results, particularly
for identifying transgendered
patients, though this remains
relatively low compared to the
higher scores for other questions
for gender and sexual identity and
identifying disabilities.
14
Safeguarding Children
Markers of Good Practice
Self-assessment completed
through the year
Report by end of Q4
15
Safeguarding Vulnerable
Adults Assessment
Framework
Self-assessment completed
through the year
Report by end of Q4
23
Antipsychotic Audit
Registration Form with plan
and audit questions based on
the POMH antipsychotics audit
agreed with MH trust medics.
Jnr DRs on OPMH wards
collecting data. Data to be
analysed in May 2015.
Report due in June 15
Research and development
The DCHS research team provides support to staff across the Trust, to Derbyshire County Public Health
Service and the four local CCGs. We work in partnership with other key research organisations in
Derbyshire, including:
 Collaboration for Leadership in Health Research and Care – East Midlands
 Clinical Research Network East Midlands
 Derby Hospitals NHS Foundation Trust
 East Midlands Academic Science Network.
In 2014/15 DCHS patients have been recruited to the following national research studies which were
approved by a research ethics committee:




Dementia and Imagination - 11
Nourishing Start for Health (NOSH) - 3
Electrical muscle stimulation dysphagia study - 3
Big CACTUS - A study to assess the clinical and cost effectiveness of aphasia computer
treatment versus usual stimulation or attention control long-term post-stroke 2
DCHS has also participated in the national guidance for measuring assistive technology, domestic
violence and women with learning difficulties studies, which involve clinical staff.
30
All these studies are on the National Institute of Health Research portfolio. This means that this research
is seen as having national significance.
A total of 23 clinical staff participated in these projects. They work in three specialties within DCHS:
speech and language therapy, older people’s mental health and health visiting.
In addition in the NOSH study 15 health visitors attended an induction session. The project research team
was invited to attend a Chesterfield health visitor general meeting on two occasions to give brief
presentations, one introducing the project and one giving a brief summary of feasibility findings.
A further four portfolio studies are in the process of being approved or set up at the moment.




Comprehensive geriatric assessment
CODES - Cognitive behavioural therapy vs standardised medical care for adults with Dissociative
non-Epileptic Seizures: A multicentre randomised controlled trial
Rehabilitation of memory following traumatic brain injury
Confidence after Stroke Measure.
Our participation in clinical research demonstrates our commitment to improving the quality of care we
offer and to making our contribution to wider health improvement. It means that our clinical staff are more
likely to stay up-to-date with the latest possible treatments and we know that active participation in
research leads to successful patient outcomes.
In addition, work continued on another local study which was approved by a research ethics committee.
This concerned a financial incentive to stop smoking in pregnancy, the project involved DCHS stop
smoking staff, the research team and midwives from Chesterfield Royal Hospital NHS Foundation Trust.
Focus on dementia
Our clinical strategy has a key work stream on dementia care and to underpin this we have participated in
a local research project ‘Dementia and Imagination.’ This £1.2 million national research study, aims to
improve the quality of life of patients with dementia by helping them to engage, or stay engaged, in social
activities and relationships through a visual arts intervention. The project delivers 12 weekly sessions of
arts-based activities, specifically designed for people with dementia. The study has taken place on two
inpatient wards in two hospitals in Derbyshire, as well as involving patients from the community via a day
unit. The sessions are facilitated by trained artists and include the display and discussion of current
exhibitions at Nottingham Contemporary Gallery, one of the research project partners.. The sessions
engage participants in thinking and discussing various artworks, before all are invited to create their own
works of art using a wide variety of media and techniques.
At the end of each 'wave' of sessions, a community exhibition takes place in order to engage the public in
thinking about dementia in more dementia-friendly ways. We hope that this work will be seen as best
practice across the health and social care community and influence the way in which future services are
commissioned.
31
What we have done to improve patient experience?
Caring Always - The DCHS Experience
During 2014/15 we worked with patients, staff and our public governors to agree eight promises about
what it should feel like to use our services.
We call these promises ‘Caring Always’.
1. During your time with us you will feel welcomed and valued. You will feel that your care meets
your individual needs.
2. You will have the opportunity to discuss with us what is going to happen at every stage.
3. You will understand the choices that you can make about your care. You will be supported to
make the best choices for you.
4. You will have all the support you need to feel comfortable and safe.
5. You will know who is providing your care and what to expect. You will have clear information
about how and when they can be contacted.
6. You will feel confident that you are being looked after by well trained staff who have the time to
care.
7. You will feel able to choose how much we involve your family, friends and carers.
8. You will feel able to tell us how we could improve.
Feedback
The promises inform patients and their families on how they should expect to feel. We ask them to
feedback to us about how we keep those promises. We can use their feedback to make improvements.
There is a growing number of ways for people to give us that feedback:
•
By telling any of our staff
•
Friends and Family Test (FFT)
•
Contacting the Patient Experience Team – by phone, email or through the DCHS website
•
By making a formal complaint
•
A new ‘Raising Concerns’ App
•
By telling their story
•
Through a follow-up phone call after discharge from hospital
•
Online: using Twitter, Patient Opinion, NHS Choices, or our DCHS website
•
Through a patient participation or service user group
•
Through Healthwatch Derbyshire.
We are proud to say that of the 24,809 patients who completed the Friends and Family Test this year,
97.2% said that they would recommend us to their friends and family if they needed similar care or
treatment. We also asked patients to tell us about their experiences and how we could improve the
services they used. The comments we receive are used to make improvements in local services and are
shared across the organisation through “You Said, We Did”.
32
Examples of improvements are given below.
33
A plan for Carers has been developed and further improvements in the way we support carers will be
made in the year ahead.
Complaints
Responding to patients and carers whose expectations of service have not been met continues to be a
priority for us at DCHS. During the year we have worked on improving our complaint response times and
the content of our responses.
Every complaint or concern is handled by the patient experience team in accordance with the Local
Authority Social Services and NHS Complaints (England) Regulations (2009). The patient experience
team supports complainants through the process, in line with principles of good practice published by the
Parliamentary and Health Service Ombudsman and endorsed by the Local Government Ombudsman.
During 2014/15 the patient experience team received and responded to 583 enquiries, concerns and
complaints compared with 627 in 2013/14 (these figures have not been adjusted for any change in our
service or activity). Of these, 118 complaints required an investigation under the NHS complaints
process. Four complaints were referred to the Parliamentary and Health Service Ombudsman, two of
which have not been upheld and we are awaiting the outcomes of the remaining two investigations.
34
Of the 118 complaints received 57% related to all aspects of clinical care, 11% related to appointments
and 14% related to communication.
At DCHS we are continuously making improvements to the way we manage complaints so that we learn
lessons and provide effective support to people who have made a complaint. The second Francis Report
(2013) gave us further opportunities to improve our management of complaints and support for people
who want to raise concerns about our services.
In line with new national guidance we have participated in our first External Complaints Peer Review
Panel held during November 2014. We were pleased with the overall results of this first peer review which
stated “It is exceptional that Derbyshire Community Services NHS Trust demonstrated satisfactory
practice or above for all six complaints” This worthwhile process will continue to be developed in
conjunction with our commissioners and will continue to support us in driving up our performance in
relation to management of complaints.
Friends and Family Test (FFT)
DCHS continue to perform well with regard to the question “Would you recommend this trust to your
friends and family?”
We take feedback across all our services on a monthly basis and have worked specifically on getting
feedback from some of our harder to reach groups including children and patients with a learning
disability.
Patient stories
Patient stories are a rich and valuable source of feedback from our patients and their carers and are used
regularly across the organisation including at our monthly Trust Board meetings, quality service
committee and safeguarding meetings. This year we have also introduced a staff story at our quality
people committee to learn more about the support our staff have received and need. These stories
provide a platform for sharing learning across our organisation and further afield and have been used to
inform partner organisations and our commissioners of service user needs.
Dignity in Care
DCHS continues to work with Derbyshire County Council (DCC) towards its Dignity in Care awards
Currently we have 67 bronze services engaged in this scheme which drives improvement in dignity in
care and is assessed independently by colleagues from our CCG and DCC with 19 services currently
35
working towards it. During 2014/15 five teams have achieved their silver dignity in care awards and six
further teams are working towards it.
PLACE 2014
NHS England recommends that all hospitals providing NHS‐funded care undertake an annual
assessment of the quality of non‐clinical services and the condition of their buildings. These assessments
are referred to as Patient‐Led Assessments of the Care Environment (PLACE).
Our assessment teams consisted of patient assessors and staff assessors of equal proportion (i.e. 4 plus
4).
The CQC will use data from the PLACE collection in formulating Quality and Risk Profiles of DCHS as a
healthcare provider.
Scores summary for DCHS for 2014
The percentage scores for each category below have been awarded by the NHS Information Centre
based on the information returned by us for 2014 Assessments.
Cleanliness
Food
Privacy & Dignity
Condition &
Maintenance
Ash Green
99.91%
92.86%
86.93%
97.59%
Babington
98.76%
97.47%
91.83%
91.88%
Bolsover
99.60%
97.45%
89.22%
98.00%
Cavendish
99.78%
94.89%
81.80%
95.92%
Clay Cross
99.72%
96.61%
80.47%
96.15%
Ilkeston
98.75%
96.06%
91.83%
98.29%
Newholme
99.79%
96.88%
87.20%
95.63%
Ripley
99.35%
93.54%
92.61%
96.97%
St Oswalds
100.00%
94.99%
94.15%
98.71%
Walton
100.00%
90.83%
92.42%
95.08%
Whitworth
99.78%
93.13%
85.20%
98.40%
Hospital
The overall scores for our hospitals were very favourable, as indicated below:
DCHS overall organisational scores:
Cleanliness
Food
Privacy & Dignity
DCHS
99.59%
94.97%
88.51%
Condition &
Maintenance
96.60%
National Averages
95.75%
85.42%
88.90%
88.78%
All our hospitals have achieved a score above the national average for cleanliness, food, condition and
maintenance.
Food, nutrition and hydration
August saw the national launch of the new NHS catering standards for patients and staff. We have
reviewed the standards and agreed an action plan to address any shortfalls. One of the main changes we
will be looking at will be the provision of catering services within the staff and visitor dining rooms and our
vending machines, to ensure that we offer healthy eating options on all of our menus.
36
We continue to produce freshly cooked food using fresh produce from local suppliers. This year we have
completed a number of food evaluations, including the supply to our community hospitals of fresh fruit and
vegetables and the supply of fresh meat.
In December new legislation was introduced relating to the presence of allergens in food. Patients, staff
and visitors should be informed of the presence of any one of the 14 Allergens that could be found in the
food prepared or bought in by external suppliers.
We have reviewed how we cater for our most vulnerable patients who may be at risk of malnutrition. In
order for patients to receive the assistance they require during mealtimes, we have reviewed our
Protected Mealtime Policy to ensure that the mealtimes are protected and that a Registered Nurse is
always available to supervise the meal service.
We have also purchased new crockery and water jugs that are colour coded orange to identify patients
who are at a risk of dehydration or who need nutritional support. We have undertaken a food evaluation of
the textured modified food we supply for patients with swallowing difficulties to optimise the presentation,
taste and overall quality of the food.
We have recruited a nutritional nurse specialist, who offers support, advice and guidance to patients and
clinicians. The nutrition nurse specialist has been concentrating on arranging the training for clinical staff
around the Malnutrition Universal Screening Tool (MUST) and training relating to completing the nutrition
treatment plans. Nutrition link leads have been established on all the wards, providing training and
support through regular meetings. This will be extended out to our community teams over the next year.
Making equality, diversity and inclusion a reality at DCHS
As an organisation, we are passionate about people – our service users and our employees – and want to
make a real and positive difference to people’s lives.
DCHS’s vision for equality, as clearly stated in our Equalities Strategy, is that we are: ‘a healthcare
community that promotes equality, values diversity and radiates inclusive practice in both employment
and service delivery. We want to attract, recruit and retain a wide range of staff from all sections of
society to work in a positive, inclusive and nurturing environment. We also want to deliver, with dignity
and respect, inclusive and accessible services that meet our patients’ individual needs.’
Over the past year, we have made further progress in embedding improved equalities practice in
everything we do. Some of our achievements include:
 Developed and signed off our new Equalities Strategy that clearly communicates our equalities
aspirations for the future and how these will be achieved
 Created a new Equalities Action Plan, based on our priority objectives that were identified through
public consultation. This is being actively performance managed by our Equality, Diversity and
Inclusion Leadership Forum that reports directly to our Quality People and Quality Service
Committees
 Developed two new equalities polices – our new Trans Equality Policy and Equality, Diversity and
Inclusion Policy
 Established an Equalities Forum Theatre group, which has travelled across the County to deliver
engaging and participative training sessions tackling issues of inequality and discrimination
 Procured equalities eLearning and created an ‘Introduction to Equality and Diversity at DCHS’
video that is being used for the induction of new employees into the Trust and at the Essential
Learning which all employees undertake every 2 years.
 Continued to deliver our Sexual Orientation Equality Masterclasses across all service areas to
raise awareness of homophobia, transphobia and heterosexism and to support staff to improve
their equalities practice
 Delivered a training session on equality, diversity and inclusion to Public and Staff Governors
37

Worked with the British Deaf Association (BDA), local deaf forums and service users to sign the
BDA’s British Sign Language (BSL) Charter

Improved our approach to Equality Impact Assessments or Analysis so that it is undertaken for all
key decisions that are relevant to equality
Run sessions promoting the importance of equality monitoring to all staff as part of the Staff
Briefing sessions delivered across the county
Produced a comprehensive Workforce Equality Data and Analysis report (for 2013), a copy of
which is available on our website
Produced a Service User Equality Data and Analysis report (for 2013), which is also available on
our website
Undertaken a comprehensive equality analysis of our 2013 Staff Survey results, which resulted in
additional equality related actions being embedded within the Trusts Staff Survey Action Plan
Established a third Employee Network Group for our staff with a disability or long-term health
condition; this brings our total number of groups to three, as we have already established groups
for our lesbian, gay, bisexual and trans staff and our black and other ethnic minority staff.
Membership of all three groups is open – and actively promoted - to equality allies, irrespective of
characteristic, who are passionate about equality and want to help DCHS to achieve it
Undertook a 360 Assurance review of our approach to embedding good equalities practice. This
review gave the organisation significant assurance that the work being undertaken to progress the
equalities agenda within the organisation is fulfilling its legal duties under Equalities Legislation
and the requirements of Department of Health’s Equality Delivery System 2
Increased our ranking in the Stonewall Workplace Equality Index in 2014 (to 168th from 230th the
previous year)
Made further progress on embedding Health Care For All (HC4A) to improve our approach to
providing services to people with a learning disability, and their overall experience of our services
Celebrated LGBT History Month in February 2014 and commemorated the International Day
Against Homophobia and Transphobia (IDAHO), and celebrated Black History Month in October
2014;
Established our first Access to Healthcare Forum which is representative of all protected
characteristics. This Forum will help us to check our equalities practice and identify new priority
equality objectives and actions for 2015 and beyond.










38
Further information about DCHS’ approach to equality, diversity and inclusion can be found on our
website at: http://www.dchs.nhs.uk/home/about/equalityanddiversity
Picture of members of our Employee Network Groups
Making every contact count
Making every contact count (MECC) has been a successful initiative across DCHS since 2010, raising
staff awareness of their responsibility to help patients, carers, families, friends and colleagues to adopt a
healthier lifestyle. We have increased staff awareness of MECC by providing training and awareness
raising sessions to over 3,500 DCHS staff. We have amended our documentation to make sure we can
identify and audit MECC activity, which helps patients and staff to address lifestyle choices that are
impacting on their personal health. We have evaluated training given to planned care services with very
positive outcomes. The initiative is now truly embedded in the culture and ethos of the Trust with staff
seeing MECC as part of their role.
A team of staff participated in the DCHS Improving Leaders Capability Programme, were tasked with
reviewing the MECC programme, within their own areas, and reported:
‘The conclusion was that MECC discussions were happening on a daily basis. We found that MECC was
about changing attitudes and culture within teams – the importance of promoting health and
conversations being individually tailored to patient needs. It was noted that MECC was not just a tick box
exercise but about lifestyle choices, having everyday conversations about health promotion.’
Being a responsible employer we have used MECC to engage with our own staff and ensure that we
provide them with the opportunity to improve their own wellbeing. DCHS received the Royal Society for
Public Health (RSPH) Health and Wellbeing Award for three years (the highest classification) for the
Trusts commitment to promote health amongst its workforce the impact this has had on staff wellbeing
and attitudes to health. We were proud to be recognised nationally in 2014 by being shortlisted for the
Nursing Times Award for Excellence in Supporting Staff Health and Wellbeing.
Healthcare for All (HC4A)
Throughout 2014/15 DCHS continued to monitor and seek to improve access to its services and
processes for people with a learning disability.
As in previous years our focus has been about improving the ways in which we identify service users with
a learning disability and then assessing and making the necessary reasonable adjustments that that
individual or their carer needs to ensure they achieve their optimum clinical outcomes along with the best
healthcare experience possible.
This is the essence of true ‘patient centred care’ and our approach in DCHS continues to be that
reasonable adjustments, though essential for, are not just for people with a learning disability and should
be identified, implemented and shared for all our patients as part of patient centred care and discharge
planning.
“Quality Always” and the DCHS “Equality and Diversity Strategy” together with the new “Equality Delivery
System” are the mechanisms by which we now monitor how well we are doing and the delivery of
improvements identified by individual services and the organisation.
39
The principles of “Healthcare for All” and how it fits with patient centred care remained a “golden thread”
in our new Corporate Induction and “Fundamentals in Care” programmes for new staff and our “Essential”
training programmes for new and established staff.
In January 2015 DCHS participated in the Derbyshire Joint Health and Social Care Learning Disability
Self-Assessment Framework and our Specialist Learning Disability Services lead on our input and
commitment to the “Derbyshire Transforming Care” care concordant.
Ensuring our services are responsive to patients’ needs
DCHS monitors carefully the how its services perform with regard to waiting times and responsiveness to
patients. During 2014/15, as part of our comprehensive monitoring dashboard, we have chosen three
specific metrics to report on within our quality report.
Minor Injury Unit waiting times
DCHS has four Minor Injury Units providing urgent care as part of the wider out of hours and emergency
care pathway across the health community. Ensuring our patients receive timely care is a key priority and
this is measured against a four-hour standard set by the Department of Health. As the table below
illustrates we have performed well in this area.
DCHS considers that this data is as described for the following reasons: there are proper internal
controls for the collection and reporting of this measure of performance and the controls are subject to
quality assessment using the trusts data kite mark quality assurance system.
2013/14
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
2013/14
Outturn
4 Hour Wait
for A&E
Attendances
(%)
99.8%
100.0%
99.9%
99.7%
99.9%
99.9%
99.9%
99.9%
99.9%
99.7%
99.8%
99.9%
99.9%
2014/15
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Year to
Date
4 Hour Wait
for A&E
Attendances
(%)
99.5%
99.8%
100.0%
100.0%
99.9%
100.0%
100.0%
100.0%
99.9%
99.9%
99.9%
99.5%
99.95%
DCHS will continue to monitor the quality of its services using its Quality Always framework and to work
with the wider health community to maintain the high percentage performance within its minor injuries
departments.
Comparative Data A&E 4 Hour Wait
It should be noted that DCHS emergency provision is limited to four minor injury units and that comparative data includes data
from type 1 accident and emergency departments.
Period
Q3
2015/16
Q4
2015/16
Performance
Rank
Total In
Cohort
Nat.
Average
Highest
99.96%
73
247
95.0%
66 Trusts
99.94%
78
245
94.2%
67 Trusts
Lowest
Cambridge University Hospitals
NHS Trust
Hull & East Yorkshire Hospitals NHS
Trust
40
Referral to treatment times
When our patients need care we aim to see them and undertake their treatment as quickly as possible.
The table below reports on our performance in year against the 18 week referral to treatment times and
demonstrates that performance has been consistently good in all areas.
DCHS considers that this data is as described for the following reasons: there are proper internal controls
for the collection and reporting of this measure of performance and the controls are subject to quality
assessment using the trusts data kite mark quality assurance system. The exception is in relation to RTT
for the dental pathway where plans are in place to improve data collection and validation through 2015/16.
2014/15
Referral to
Treatment Times
Incomplete
pathway (where
treatment is part
of a pathway)
against a standard
of 92%
RTT Waits admitted patients
seen within 18
weeks - 90%
(target) (%)
RTT Waits - non
admitted patients
seen within 18
weeks - 95%
(target) (%)
Apr-14
May14
Jun-14
Jul-14
Aug-14
Sep14
Oct-14
Nov14
Dec14
Jan15
Feb15
Mar-15
Year to
Date
99.0%
99.0%
100.0%
98.9%
99.4%
98.0%
98.0%
97.8%
98.8%
99.9%
99.9%
97.65%
98.86%
94.0%
95.0%
93.3.%
93.1%
90.1%
94.7%
95.2%
92.8%
95.5%
93.3%
92.5%
94%
93.63%
99.0%
99.0%
99.2%
98.6%
100.0%
98.5%
97.5%
99.6%
98.4%
98.8%
98.9%
98.9%
98.87%
DCHS intends to develop the data collection and validation processes for the RTT indicator for dental
pathways in advance of including the figures within the 2015/16 quality report.
Comparative data – Referral to Treatment Times Incomplete Pathway
Total In
Cohort
Period
Performance
Rank
Feb-15
99.00%
26
187
Mar-15
97.60%
45
186
Nat.
Average
Highest
Lowest
94.4%
Northamptonshire
Healthcare NHS
Foundation Trust
North East London NHS
Foundation Trust
94.4%
Bradford District Care
Trust
North East London NHS
Foundation Trust
Delayed transfers of care
When patients are ready for discharge from our services it is important that we are able to transfer them
to their next place of care as soon as possible. The measurement of this metric allows us to understand
what issues delay transfers of care and to work with partner agencies to improve this. This metric is
measured against a target of <7.5% of patients being delayed. The table below gives comparative data for
the last two years and demonstrates that whilst we have met this target in year there have been individual
months were we have fallen below the standard. Where this occurs an investigation is undertaken to
identify and learn from the cause. Most often delays are due to patients requiring complex and specialist
care packages within a long term residential setting.
DCHS considers that this data is as described for the following reasons: there are proper internal
controls for the collection and reporting of this measure of performance and the controls are subject to
quality assessment using the trusts data kite mark quality assurance system.
41
2013/14
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
2013/14
Outturn
Delayed
Transfers of
Care
2.4%
4.9%
6.0%
2.8%
4.5%
8.3%
7.7%
10.0%
10.6%
6.2%
7.8%
7.0%
6.6%
2014/15
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
Year to
Date
Delayed
Transfers of
Care
7.1%
3.2%
4.6%
4.3%
5.3%
3.8%
8.7%
8.7%
7.9%
4.7%
3.7%
1.0%
6.1%
DCHS has taken the following actions to improve the delayed transfers of care percentage, we have
reviewed the clinical pathway management within our older peoples mental health wards and worked
with partners across health and social care to ensure that effective discharge plans are in place for
patients.
Comparative data - DTOC Monitor Compliance Calculation
No national comparator data available
Development of a multidisciplinary foot care service at Buxton Hospital
Patients with diabetes are at risk of developing complex foot conditions which can severely impact on
their quality of life. In January 2014 in conjunction with our colleagues at Stepping Hill Hospital we
established a new foot care service. The service is led by the Consultant Podiatric Surgery team in liaison
with a consultant diabetologist.
This service enables patients who have complicated foot problems to be seen locally by a multidisciplinary team instead of having to be seen within an acute hospital. The staff have developed their
clinical skills to be able to offer intravenous antibiotics to patients who require these, this allows the
patients to receive intravenous antibiotics either as an outpatient at Buxton Hospital or an inpatient at the
Cavendish Hospital, thus enabling patients to receive a local service and reducing demand on our acute
hospitals.
DCHS in-reach service
DCHS has been commissioned to provide an in-reach service to our Derbyshire acute hospitals.
The purpose of the service is to provide a multi-disciplinary team to work in partnership with Social Care
to assess patients in acute hospitals and clinically navigate individuals to the most appropriate service to
meet their on-going care needs. Currently DCHS has teams based at Chesterfield Royal Hospital (CRH)
and Royal Derby Hospitals. In addition, the Chesterfield Royal in-reach team also provides a weekly
service to Kings Mill Hospital, Mansfield as well as Stepping Hill and Macclesfield acute hospitals.
The teams have developed positive working relationships with acute hospital staff improving timely
access to the wide range of available community services and facilitating safe discharges or transfers of
care. The CRH In-Reach team operate seven days per week which has reduced surges in activity and
improved patient flow to Community Services, enabling patients’ needs to be met in the right place, at the
right time by the right service. It is the intention that the RDH team will become a seven day service in the
near future.
Measure
RTT Waits admitted patients
seen within 18
weeks - 90% (target)
(%)
RTT Waits - non
admitted patients
seen within 18
weeks - 95% (target)
(%)
Apr14
May14
Jun14
Jul14
Aug14
Sep14
Oct14
Nov14
Dec14
Jan15
Feb15
Mar15
94.0%
95.0%
93.3%
93.1%
86.7%
94.7%
95.2%
92.8%
95.5%
93.3%
92.5%
94.0%
99.0%
99.0%
99.2%
98.6%
100.0%
98.5%
97.5%
99.6%
98.4%
98.8%
98.9%
98.9%
42
The teams collect data to evidence the impact of the service. During December 2014 and January 2015
there was a 30.5% increase in transfers from acute hospitals to DCHS Community Hospitals and a 15.2%
increase in transfers at weekends which has supported the reduction of acute hospital bed pressures.
The team also collate evidence of gaps and duplication in community service provision to support future
service improvement initiatives.
“Working together to deliver the best possible care for the people of Swadlincote locality, when
and where they need it"
This is the vision of the Swadlincote Integrated Community Team who continue to make phenomenal
progress developing partnership working with adult social care, GPs, voluntary sector, mental health
services, the CCG and with cross border health and social care providers. The integrated team
comprises of community matrons, community nurses, therapists, care coordinators, support workers and
admin staff who work together to provide responsive high quality care around the needs of their
community.
With a rapidly increasing ageing local population and with areas of deprivation partnership working with
adult social care is vital in meeting the challenge of providing great care. The teams work together to
provide preventative and responsive services. The teams are fully engaged in the working with the newly
commissioned Care Coordinators supporting the new community support teams. Other recent
partnership developments are the formation of the Single Point of Access Rapid Response Service and
the intermediate care beds at Oakland Village. Some members of the team work jointly with social care in
the reablement service providing short term care and rehabilitation.
At Oakland Intermediate Care Unit the therapists work together with adult care providing rehabilitation and
care for patients who are either "stepped up" from the community or "stepped down" from Queens
Medical Centre, Nottingham. The team have been praised for their flexible and open minded approach
which helps to facilitate partnership working. Trust and respect has been built between both partners. The
Single Point of Access (SPA) responds to referrals for urgent, rapid response assessments within 2
hours. The team have had considerable success together with adult social care in maintaining some very
complex patients in their own homes - reducing unnecessary hospital admissions and making a real
difference to patients.
The team take a lead role in the Swadlincote Integrated Care Group, a local forum of health and social
care leads, the voluntary sector and the CCG. At this forum service transformation is discussed with
engagement from all parties. The team are not standing still and further developments are already
underway with the virtual ward, the voluntary sector and with mental health to enhance local services. We
are immensely proud of the partnership working achieved by this team and the benefits it is bringing to
patients every day.
Telehealth pilot
In 2013 £250,000 of non-recurrent funding was identified by the four Derbyshire CCGs, for
implementation of a telehealth service which was delivered by our DCHS Heart Failure Service. The heart
failure telehealth service went live in September 2013.
Telehealth services offer a way to remotely monitor patients with long term conditions (LTCs) such as
heart failure, in order to reduce unplanned admissions to hospital and to allow clinically appropriate
interventions to be made in a timely manner. Heart failure patients on the heart failure specialist nurse
caseload were recruited using a set of agreed clinical criteria.
A monitoring profile was created for each individual patient with parameters set for vital signs recordings,
such as blood pressure and weight. If a patient failed to complete their readings within the agreed
timeframe then the telehealth system produced a non-conformance alert. If a patient returned vital signs
readings outside their set parameters, or indicated via their answers to a questionnaire that their condition
may be deteriorating, then a red alert was produced.
43
All alerts are monitored by heart failure nurses five days a week and are triaged and actioned according to
special alert pathways. Information from the evaluation of this pilot will be used to influence
commissioning decisions for future service development.
Key Data and information related to the telehealth service pilot.
Patients and carers were invited to participate in a patient satisfaction survey and heart failure staff were
surveyed as to their opinion of the telehealth service.

Heart failure related inpatient admissions costs for patients before the use of telehealth amounted
to £168, 978 while during the period of telehealth use the heart failure inpatient costs were
£35,814. This is a saving of £133,164.

Before the use of telehealth a total of 55 patients were admitted to an acute hospital for heart
failure related activity a total of 61 times using 637 bed days. During the period of telehealth use a
total of 13 patients were admitted to an acute hospital for heart failure related activity a total of 20
times using 222 bed days. This is a reduction in the number of admissions by 41, the number of
patients admitted reduced by 42 and the number of bed days saved was 415.

The cost for running the telehealth service during the period of the evaluation was approximately
£152,000. It should be noted that costs of approximately £17,000 were associated with set up of
the service and will not be incurred again.

The mean Length of Stay (LoS) prior to use of telehealth for all patients was 11.5 days with
inpatient spells ranging between 0 days and 30 days. In contrast the mean LoS post introduction
of telehealth rose to 18.5 days with inpatient spells ranging between 0 days and 49 days. This
showed an increase of mean length of stay by seven days. This was not an expected outcome but
may reflect a change in the complexity of the patients admitted to hospital as part of the telehealth
service. This indicates that more complex patients were admitted to hospital during the pilot of the
telehealth service while less complex patients, who may previously have been admitted to an
acute bed, were managed at home by heart failure specialist nurses.

A patient satisfaction survey was issued to telehealth service patients, who had been using the
equipment for up to 12 months, with a 46% rate of return. The results of the patient survey showed
that 91% either agreed or strongly agreed that they felt more involved in their care by participating
in the programme. 82% either agreed or strongly agreed that using the equipment gave them
peace of mind and reduced their anxiety about their heart failure. 82% of respondents also
strongly agreed or agreed that they felt that the telehealth service helped their heart failure
specialist nurse manage their care better.

The results from the staff survey were also encouraging with 100% of respondents agreeing or
strongly agreeing that the telehealth service helped them to provide better care for their patient.
100% of respondents also agreed or strongly agreed that the service gave their patient more
peace of mind on discharge from hospital. All respondents agreed or strongly agreed that
information gained from the telehealth service enabled them to look after their patient more
efficiently.
Non-weight bearing pathway
The non-weight bearing pathway pilot is an initiative utilising System Resilience monies which has been
set up to provide a service for patients who are unable to weight bear for a period of time and would
otherwise remain in an acute hospital bed for their non-weight bearing period. It is a therapy led service
with a small team of clinicians including therapists, a nurse and generic support workers.
Patients are referred by Chesterfield Royal Hospital once they have been assessed as unable to return
home for their non-weight bearing period, are medically stable and are safe to be discharged into a
community setting. The patient is then assessed by the team and, once accepted onto the pathway, a
bed is commissioned for the non-weight bearing period, usually in a residential or nursing home. During
44
this time the patient is monitored by the team and an individual exercise programme is set up by the
therapists. They are visited regularly by the generic support worker in order to keep the patient as mobile
as possible in the non-affected limbs until they have a follow up outpatient appointment at the hospital. A
member of the team accompanies the patient to follow up appointments and once the patient is able to
weight bear they are assessed and referred to the most appropriate rehabilitation service. This may be at
home with intermediate care, an intermediate care bed or in a community hospital. The non-weight
bearing team then hand over patient care back into mainstream community services.
Erewash care home support service
Erewash CCG has commissioned a new service to provide local care homes with dedicated specialist
nursing support. The team provide continuity of care, via a rapid response service and regular ward
rounds with the aim of reducing unnecessary admissions to hospital and to reduce the number of visits to
care homes that GP’s have to make, therefore enabling more appointments to be available in the GP
surgeries.
The service is delivered by a small team of advanced nurse practitioners (ANP’s) linking closely to the GP
practices and supported by care coordinators. ANPs are able to assess, diagnose, investigate and treat a
wide range of conditions and illnesses.
Although the service only started towards the end of 2014 the early information is demonstrating a real
impact on reducing the number of care home patients admitted to hospital and who continue to be
successfully cared for in the environment in which they are familiar.
Erewash welcome home service
We recognise that settling in at home following a spell at an acute hospital can be difficult, sometimes
resulting in a readmission if the necessary components are not in place. This may be as simple as not
having food in the fridge, or not being able to make it upstairs to bed on the first night, to more complex
issues e.g. not having the right equipment or medications in place.
The Erewash welcome home service was established with the aim of reducing the number of older people
readmitted to Nottingham University Hospital (NUH) shortly after discharge. The service forms part of the
Erewash Integrated Care Team and involves care coordinators, linked to GP practices, proactively
contacting by telephone, every patient over the age of 65 as near to the day of discharge as possible.
Staff check patients awareness of their health needs, understanding of their medication, mobility, access
to appropriate food and drink, and that their home is adequately heated.
If any concerns are identified the care coordinators make relevant contact / referrals to address them. The
partnership working enables patients to remain at home and avoids readmissions to hospital.
Dental services - accessible patient information
The dental service is currently striving to ensure the availability of an identified range of patient
information leaflets. These will be related to oral and dental care for those people with a learning
disability. A good way for us to improve our communication is by using different written formats. In
addition to our Communicate in Print - Widgit symbols package, we have now purchased Photo-symbols
to create further Easy Read information.
It is important to be responsive to our patient’s needs and inform our patient’s how to continue self-care
once they are within their own home environment. The range of key subjects in Easy Read will also
explain ‘the process of and risk’ as well as ‘instruction’ leaflets on oral health or dental treatments.
The Oral Health Promotion team are currently working with the public and multi-agency teams at Health
Care For All and the Learning Disability Good Health Group meetings. These groups have given valuable
suggestions in presenting these leaflets.
Dental nurses who have attended our Certificate in Special Care Dental Nursing course were asked to
create Easy Read leaflets. This awareness of other accessible information formats was to highlight the
45
need and importance of providing Easy Read leaflets to the public accessing general dental practices
within the Midlands.
The Francis Report – how we have responded
In response to the Francis Report (February 2013) DCHS established a Francis Working Group which
reported monthly to our Quality Services Committee (QSC) until March 2014 with a detailed outcome
report going to QSC in March 2014 prior to a detailed report on the actions in response to Francis
featuring in the Quality Account 2013/14. In addition the Board of Directors approved the Derbyshire
Community Health Services’ Response to the Government Response to the Robert Francis QC’s Inquiry
into Mid Staffordshire NHS FT at the January 2014 Board and this was published on the public facing
website.
It was agreed at the March 2014 QSC that the reporting mechanism for each remaining work stream
(Safe Staffing, Clinical Supervision, Developing an Open and Transparent Culture, Complaints Reporting
including better complaints information and Patient Safety) would be monitored by the Deputy Chief Nurse
formally reviewed and reported six monthly to Quality Services Committee. These key elements form
strands of work that are embedded within our established governance processes.
46
Appendix 1 - Workforce
2014 NHS staff survey
In 2014 we used our NHS Staff Survey to invite staff to take time out to tell us what they thought about the
organisation and their working lives. This was performed independently by the Picker Institute Europe
which ensured absolute confidentiality and supported detailed analysis. We received a 62.1% response
rate to our full census which enabled us to have a rich source of data to look at the key areas we can
improve for our staff.
NHS England published its Staff Survey results in February 2015, taking a sample to provide results
across 29 key findings, benchmarked against all other Community Trusts.
The table below gives a summary of ranking, compared with all Community Trusts in 2014.
29 Key findings:
Above (better than) average
Below (better than) average
Average
Above (worse than) average
Below (worse than) average
2014
12
5
11
1
0
Overall staff engagement
The overall staff engagement score for 2014 is 3.83 and was above (better than) average when compared
with trusts of a similar type, this has increased from 3.76 in 2013. It also compares favourably against a
national NHS engagement score of 3.76 and national Community Trust engagement score of 3.75. The
overall indicator of staff engagement is calculated by NHS England using the questions that make up key
findings 22, 24 and 25. These key findings relate to the following aspects of staff engagement:



Staff members’ perceived ability to contribute to improvements at work
Staff members’ willingness to recommend the trust as a place to work or receive treatment
The extent to which staff feel motivated and engaged with their work
Staff friends and family test questions
The table below shows how we compare with other Community Trusts in England to the two key staff
friends and family test questions:
Birmingham Community Healthcare NHS Trust
48.03
If a friend or relative
needed treatment I would
be happy with the standard
of care provided by this
organisation
61.55
Bridgewater Community Healthcare NHS Trust
44.19
63.71
Cambridgeshire Community Services NHS Trust
58.55
65.73
Central London Community Healthcare NHS Trust
44.13
54.73
Derbyshire Community Health Services NHS Foundation Trust
54.24
65.12
Hertfordshire Community NHS Trust
46.69
59.14
Hounslow And Richmond Community Healthcare NHS Trust
52.66
62.24
Kent Community Health NHS Trust
46.84
60.10
I would
recommend my
organisation as
a place to work
47
Leeds Community Healthcare NHS Trust
36.30
If a friend or relative
needed treatment I would
be happy with the standard
of care provided by this
organisation
56.28
Lincolnshire Community Health Services NHS Trust
47.51
62.23
Liverpool Community Health NHS Trust
36.75
55.08
Norfolk Community Health And Care NHS Trust
36.80
54.06
Shropshire Community Health NHS Trust
44.89
60.00
Solent NHS Trust
44.69
60.64
Staffordshire And Stoke On Trent Partnership NHS Trust
43.39
55.42
Sussex Community NHS Trust
50.61
59.80
The Gloucestershire Care Services National Health Service Trust
47.06
59.86
Torbay and Southern Devon Health and Care NHS Trust
55.31
62.09
Wirral Community NHS Trust
50.15
66.16
I would
recommend my
organisation as
a place to work
Top 5 ranking areas
This page highlights the 5 key findings for which DCHS compare most favourably with other Community
Trusts in England.





KF3: Work pressure felt by staff (2.89 compared to average of 3.11)
KF11: Percentage of staff suffering from work-related stress in the last 12 months (7% variance
from average)
KF1: Percentage of staff feeling satisfied with the quality of work and patient care they are able to
deliver (7% variance from average)
KF5: Percentage of staff working extra hours (6% variance from average)
KF8: Percentage of staff having well-structured appraisals in the last 12 months (10% variance
from average)
Bottom 5 ranking areas
This page highlights the 5 key findings for which DCHS compare least favourably with other Community
Trusts in England. It is suggested that these areas might be seen as a starting point for local action to
improve as an employer.
According to the National NHS England data the five key findings for which DCHS compares least
favourably with other Community Trusts in England are:





KF17: Percentage of staff experiencing physical violence from staff in the last 12 months (1%
variance from average)
KF28: Percentage of staff experiencing discrimination at work in the last 12 months (1% variance
from average)
KF16: Percentage of staff experiencing physical violence from patients, relatives or the public in
the last 12 months (no variance from average)
KF26: Percentage of staff having equality and diversity training in the last 12 months (1%
variance from average)
KF22: Percentage of staff able to contribute to improvements at work (no variance from average)
Key areas of improvement
According to the National NHS England data our key areas of improvement are as follows:
 KF20: Percentage of staff feeling pressure in the last 3 months to attend work when feeling unwell
(7% decrease since 2013)
48




KF9: Support from immediate managers (3.63 in 2013 to 3.80 in 2014)
KF4: Effective team working (3.76 in 2013 to 3.88 in 2014)
KF23: Staff job satisfaction (3.61 in 2013 to 3.75 in 2014)
KF16: Percentage of staff experiencing physical violence from patients, relatives or the public in
the last 12 months (12% in 2013 to 8% in 2014)
Pulse Checks
The DCHS pulse check was launched back in July 2013 and provides an indicator throughout the year as
to how staff, as employees, are feeling. The pulse checks are run on a quarterly basis and provide an
opportunity for staff to give anonymous feedback on how well they feel they are being managed, engaged
and supported. This is now linked with our Staff Friends and Family Test.
It allows DCHS senior leaders to work closely with their teams about the issues that are important to
them. The pulse checks provide information to facilitate focus and relevant action to be taken each
quarter rather than once a year. The way they are structured facilitates swift feedback after the
questionnaire has been completed. The positive impact high staff engagement can have on other Trust
KPIs - such as attendance, patient safety and productivity - is recognised and well researched. It is also a
significant measure for the leader as to how well they are engaging with their teams to deliver the results
we need, primarily around quality care for our patients.
The trust wide response rates for each quarter to date are:
 July 2013: 39%
 October 2013: 37%
 January 2014: 36%
 April 2014: 31%
 July 2014: 38%
 January 2015: 33%
The overall engagement scores for each quarter to date are:
 July 2013: 77%
 October 2013: 77%
 January 2014: 79%
 April 2014: 76%
 July 2014: 76%
 January 2015: 77%
Our Staff FFT scores for the past 2 Pulse Checks are as follows:
How likely are you to recommend DCHS to friends and family if they needed care or treatment?
 July 2014: 90%
 January 2015: 89%
How likely are you to recommend DCHS to friends and family as a place to work?
 July 2014: 71%
 January 2015: 71%
Raising concerns
DCHS is committed to achieving the highest possible standards and actively encourages openness and
honesty in the workplace. This year we have developed an ‘App’ to assist staff who wish to raise a
concern as part of our ongoing commitment to creating a culture where members of staff are encouraged
and empowered to raise concerns without fear of recrimination.
We have reviewed our Whistleblowing Policy to make it simpler for staff to understand and clarified how
concerns will be dealt with. We are looking at new ways of feeding back to staff so that they feel confident
we have dealt appropriately with the concerns they have raised.
49
In the last year we have received a small number of formal concerns raised through our Whistleblowing
Policy. All of these have been thoroughly investigated and detailed action plans have been produced to
ensure that any issues that need addressing are dealt with. We have implemented a new process which
entails the Chief Executive, Senior Independent Director and Trust Secretary reviewing the action plans
on a regular basis and receiving assurances from the relevant managers that they have been
implemented.
How we develop and support our staff

Staff appraisals

Staff Training

Learning and Development

Leadership Development
Appraisals
The introduction of a revised leadership appraisal system in 2012 has enabled alignment of the NHS
Leadership Framework, DCHS Way appraisal process and KPI’s. The process is now embedded within
the Trust providing a valuable mechanism for measuring performance whilst, also identifying the
development areas and support required by staff so as to enable them to achieve their full potential.
In 2015 we intend to enhance e-appraisal systems piloted in April 2014 and we will roll out the use of eappraisals across all directorates. Appraisal training continues to be offered across the Trust to ensure
both the appraiser and appraisee are equipped with the knowledge and skills to develop and receive an
effective, meaningful appraisal. 86% of our staff received an appraisal within the year and we will be
working hard during the coming year to improve on this.
Training
We have a dedicated development centre which provides a wide range of in-house training opportunities
for the workforce. The development centre houses a skills lab, IT training suite plus clinical and nonclinical training rooms. Training programmes are also commissioned from external providers to meet
workforce needs.
In 2015 we plan to revise our annual training needs analysis process so as to ensure better alignment
with Health Education England commissioning cycle. The development of divisional training plans linked
to organisation objectives and business plans will also assist in the identification of workforce
development needs particularly, in relation to the knowledge skills and competences required for delivery
of integrated care.
We also plan to strengthen the clinical practice facilitator role, to provide training locally and support
changes in delivery of care while ensuring quality is maintained.
Learning and development
We are committed to provide a learning environment that supports and enables our workforce to attain the
right skills, competence and professional capabilities to deliver excellent care in a challenging and
changing environment.
As we develop new services and models of care we will use a broad range of development opportunities
to equip our staff with the qualities, skills and competencies to fulfil and enhance their roles and career
progression to deliver high quality, efficient and effective services. This will be achieved through the
provision of development opportunities such as rotations to enhance job enrichment and growth
opportunities supported by strong preceptorship and mentorship. In addition increasing the number of
Advanced Clinical Practitioners will be integral to supporting new models of care delivery.
All new staff undertake an in-house induction programme over 5 days to ensure they receive all training
relevant to their role prior to commencing in post. We launched a new induction programme in 2014 and
we are pleased to say that 100% of staff attended the corporate induction within the first month of
employment.
50
% DCHS
Compliance
(April 2014)
% DCHS Compliance
st
(March 31 2015)
% DCHS Target
Essential learning
95%
93%
95%
Information governance
91%
95%
95%
Fire training
91%
92%
95%
Appraisal
92%
93%
100%
Training programmes reported against a
target of 95% of available staff
All clinical support staff undertake a 10 day fundamentals in care course prior to commencing in post. The
fundamentals in care course will ensure all clinical support staff meet the criteria for the Care Certificate to
be launched in April 2015. Staff will be supported to undertake a diploma in health / health and social
care within 18 months of commencement in post.
In 2014 we recruited an e-learning co-ordinator / developer. In the past 12 months we have seen a steady
increase in staff undertaking some elements of mandatory training via eLearning. We will continue to
increase the number of eLearning packages and provide IT access and training to all staff to enable
increased productivity, efficiency and engagement in the work place.
The Mental Health Lead Trainer has successfully delivered Dementia Friend courses across the trust.
Dementia training is a key priority so as to ensure patients with Dementia and their carers receive
excellent care. We aim to significantly increase the number of Dementia champions within the trust this
year.
Future plans include a review of existing essential and clinical essential training programme so as to
streamline programme delivery, increasing apprenticeship and traineeship opportunities across the trust,
in particular, encouraging clinical apprenticeships. There will be an increased focus on the impact of
learning and development on practice. This will be captured by reviewing and implementing effective
evaluation of learning and development programmes.
During 2015 we plan to submit a 5 year learning and development strategy to the board for approval,
outlining our learning and development priorities for 2015-2020. It will provide a framework for
improvement and success, a key aspect of the strategy will be the commitment to continue to develop as
a learning organisation promoting a culture of reflection, innovation and shared learning and passion for
continuous professional development.
Leadership development
Leadership Development is a key priority for 2015, we will continue to develop our leaders through a
range of targeted leadership interventions so as to equip our clinical leaders, business leaders and people
managers with the necessary values, skills, behaviours and experience to maximise their potential in
leading the trust forward. We will build the capacity and capability of our clinical leaders through a robust
development and assessment model through our Quality Always programme both developing the
capability of our clinical leaders as well as further developing our systems of assessment and outcome
measures in care delivery.
Fire safety training
Since April 2014 fire training figures as reported to board have continued to be around the 90% mark
based over rolling 12 month period, i.e. March 2014 – April 2015 the figure is 92% (3875 staff). This figure
includes all staff who have attended essential training, induction, e-learning, completed the internal fire
workbooks or attended a face-to-face fire training session at one of our sites. In addition to the standard
fire training sessions specialist training sessions are also held for Nominated officer fire and fire warden
roles and also training in the use of evacuation equipment such as ski sheets, pads and evacuation chairs
where required.
51
Reporting of Injuries, Diseases and Dangerous Occurrence Regulations (RIDDOR)
Staff health and safety
At DCHS we take Health and Safety very seriously, our objective is to ensure that ALL our staff to go
home safely at the end of each and every day. Our approach to Staying Safe is simple. We believe that
all injuries are preventable and through good leadership and engagement of staff you can create a safety
culture in which everyone takes responsibility for health and safety both on a personal and a collective
level.
In 2015/15 we have had 942 reported incidents versus 912 in 213/14. Out of the 942 incidents reported
there were 552 with no harm or injury, 375 minor injuries and 15 RIDDOR Reportable injuries.
Staff Minor Injury Incidents by Category
Collision
Contact with hazard
Exposure to harmful agent
Display Screen Equipment
Environmental Issues
Equipment (not medical device)
Ergodynamics
Lifting / handling injury
Needle stick / Sharps Injuries
Occupational Stress
Road Traffic Accident
Slips, trips and falls
Trapped
Violence / abuse / harassment
Totals:
2014/15
29
38
2
2
6
8
1
45
24
6
7
53
10
144
375
2013/14
52
54
7
0
7
6
3
51
30
6
8
57
15
143
439
In 2014/15 we have had a 17.06% decrease in incidents.
Reporting of injuries, diseases and dangerous occurrence regulations (RIDDOR)
This requires us to report any workplace incident that falls into a specific category to the Health & Safety
Executive (HSE). Workplace injuries are reportable to the HSE if they are a result of our work activity and
constitute a major injury or absence from work for more than seven days. If a visitor or member of the
public visiting one of our hospitals suffered a major injury as a result of our work activity we would also
have to report this to the HSE. We had 15 RIDDOR reportable injuries to staff in 2014/15 and none to
members of the public or visitors.
Staff RIDDOR Incidents by Category
Collision
Contact with hazard
Exposure to harmful agent
Ergodynamics
Lifting / handling injury
Slips, trips and falls
Violence / abuse / harassment
Totals:
2014/15
1
0
1
1
5
5
2
15
52
Appendix 2 - Information Governance Toolkit submission for 2014/15
We are required to make sure that the information we hold about patients and staff is held and managed
safely and confidentially and that it is used only for the purpose for which it was collected. The
Information Governance Group is responsible for maintaining and improving the Information Governance
Toolkit scores.
We can confirm that we had no requirements that were not applicable and all requirements were
answered.
Level
0
Level
1
Level
2
Level
3
Total
Req’ts
Overall Score
(%)
Information Governance
Management
0
0
2
3
5
86%
Confidentiality and Data
Protection Assurance
0
0
7
2
9
74%
Information Security Assurance
0
0
13
2
15
71%
Clinical Information Assurance
0
0
5
0
5
66%
Secondary Use Assurance
0
0
1
1
2
83%
Corporate Information
Assurance
0
0
3
0
3
66%
Overall
0
0
31
8
39
73%
Assessment
53
Appendix 3 - Third party statements - CCGs/Healthwatch
Healthwatch Derbyshire is able to comment on the 2014/15 Quality Report as a member of the Trust’s
Patient Experience Group and as a contributor of patient feedback for action, triangulation and feedback
from the Trust about processes and actions. Healthwatch Derbyshire has passed on a range of patient
feedback during this period, both positive and negative, about a wide range of Trust services. The Trust
have responded to Healthwatch regularly to keep us abreast of any action and learning from both specific
comments and any emerging themes.
This Quality Report refers to the patient feedback provided by Healthwatch Derbyshire, and many other
sources in a section called ‘What have we done to improve Patient Experience?’ The feedback section
comprehensively sets out the range of feedback available to the Trust, but does not always set out to the
reader how all of this feedback is actively used by the organisation. This might be helpful to include in
future, by demonstrating through real examples how this feedback has been taken through a process to
have an impact on patient experience.
Along similar lines, the 2014 NHS staff survey is shown in this report, along with the staff, friends and
family test. These results give the reader a good assessment of scores in these areas. However further
information about how these results have been hard wired in to some of the Trust’s strategic plans would
be useful to summarise for the reader.
This report provides a useful summary of the position of DCHS as a provider, its performance over
2014/15 and its plans for 2015/16. It would just be useful to the reader to draw more obvious parallels
between the range of performance data and feedback systems, to understand how this is used by the
organisation to learn and influence its priorities going forward.
With kind regards
Tammi Wright
Office Manager
Healthwatch Derbyshire
54
North Derbyshire Clinical Commissioning Group
Quality Report 2014/15
Derbyshire Community Health Services Foundation Trust
Commissioner Statement
General Comments
NHS North Derbyshire Clinical Commissioning Group (NDCCG) is responsible for providing the
commissioner statement on the quality account provided by Derbyshire Community Health Services
Foundation Trust (DCHSFT) and in doing so has provided NHS Hardwick Clinical Commissioning Group,
NHS Southern Derbyshire Clinical Commissioning Group and NHS Erewash Clinical Commissioning
Group as associate commissioners with the opportunity to make comments and contribute to the
commissioner statement. Careful consideration has been given to the content and accuracy in line with
the national guidance. NDCCG can confirm that DCHSFT has produced a Quality Account that meets the
guidance and that the information provided appears to be accurate and representative of the information
available to NDCCG through contract monitoring and quality assurance processes during the year.
Measuring and Improving Performance
The Quality Account describes the quality of services provided this year by DCHSFT measured against
national, regional and local standards as detailed within the NHS contract and also within the local quality
schedule and quality incentive scheme (CQUIN). The Trust has worked well to achieve all of the
requirements set out for them in the Quality Schedule and fully achieved eight of the nine CQUIN
measures. The indicator not fully achieved was that relating to reduction of pressure ulcers, 1 of the 4
harms outlined in the NHS Safety Thermometer, we would however like to note the significant
improvements in care and considerable efforts made by staff in working on this indicator even though the
final target was not achieved and look to the outcomes in 2015/16 as this work continues.
The 3 quality priorities outlined by DCHSFT for improvement over the year have been achieved. It is clear
that the Trust’s commitment to these areas has continued to lead to significant achievements and
developments which have enhanced patient care. It is noted from the Quality account that this work has
led to a particular reduction in the number of medication errors and has reduced medication errors
resulting in serious harm from 14 in 2013/14 to 0 in 2014/15.
All DCHSFT services continue to perform well against the Friends and Family Test as a measure of
patient experience and have continued to perform above local and national averages. The same has been
achieved for the annual PLACE assessments (Patient Led Assessments of the Care Environment). We
are also pleased to note that in their drive to improve dignity in care, 61 services have achieved the
Bronze Dignity in care award and 5 have achieved their Silver award.
A significant amount of work and focus has gone into dementia across the year, improving care and
support for patients as well as carers. This work has also engaged the public in thinking about dementia in
more dementia friendly ways through a local research project and the outcome has resulted in best
practice examples which have been shared across the health and social care community. The Trust has
also fully implemented and achieved the dementia CQUIN this year and has provided a good base for the
National Dementia CQUIN 2015/16.
55
The most challenging area of quality improvement for DCHSFT continues to be pressure ulcers. Despite
improvements in service areas the target of zero tolerance has not been met. We are pleased to see a
downward trend in the severity of pressure ulcers occurring in DCHSFT care and greater collaborative
working with other agencies across the health community. Commissioners will continue to closely monitor
progress in this area and work jointly with providers to raise public awareness and ownership of the
problem.
In relation to patient safety Commissioners continue to receive all serious incident reports and root cause
analysis work. Improvements have been sustained in the timeliness of the reports as has the focus on
themes and evidencing of Improvements as the result of action plans. Commissioners will continue to
work closely and collaboratively with DCHSFT across the coming year.
The three strategic quality objectives that DCHSFT has set for 2015/16 reflect the key quality domains
and ongoing commitment to learn from experience and improve the quality of care provision –
 Reducing pressure ulcer prevalence
 Delivering consistently safe and effective discharges
 Improving rates of breast feeding initiation through to sustainment
Additional comments
The Quality Account is an annual report to the public that aims to demonstrate that the Trust is assessing
quality across the healthcare services provided.
The Trust has worked collaboratively with commissioners and all key stakeholders to ensure patients
receive high quality care in the right care setting. NHS North Derbyshire Clinical Commissioning Group
and associate commissioners look forward to continuing to work with the Trust to commission and deliver
this high quality patient care.
Jayne Stringfellow
Chief Nurse & Quality Officer
On behalf of NHS North Derbyshire Clinical Commissioning Group
28th April 2015
56
East Midlands Academic Health Science Network Patient Safety Collaborative
Quality Account Statement (2015)
EMAHSN has established a local Patient Safety Collaborative whose role is to offer staff, service users, carers and
patients the opportunity to work together to tackle specific patient safety problems, improve the safety of systems
of care, build patient safety improvement capability and focus on actions that make the biggest difference using
evidence based improvement methodologies.
Derbyshire Community Health Services NHS FT is committed to working with the EMPSC and has pledged to
contribute to the emergent safety priories below (omit any not relevant)
 Discharge, transfers and transitions
 Suicide, delirium and restraint
 The deteriorating patient
 The older person: focussing on what ‘good safety’ looks like in the care home setting.
In addition we pledge to support the core priorities identified below:



Developing a safety culture/leadership
Measurement for improvement
Capability building
No formal response has been received from the Improvement and Scrutiny Committee at Derbyshire
County Council
.
57
Appendix 4 - Statement of Directors’ responsibilities in respect of the Quality Account
The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts)
Regulations 2010 as amended to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality
Accounts (which incorporate the above legal requirements) and on the arrangements that foundation trust
boards should put in place to support the data quality for the preparation of the Quality Account.
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
 The content of the Quality Account meets the requirements set out in the NHS Foundation Trust
Annual Reporting Manual 2014/15
 The content of the Quality Account is not inconsistent with internal and external sources of
information including:
 Board minutes and papers for the period April 2014 to May 2015
 Papers relating to quality reported to the board over the period April 2014 to May 2015
 Feedback from commissioners dated 6th May 2015
 Feedback from Governors dated 24/02/2015 / 26/02/2015, 02/03/2015 & 13/05/2015
 Feedback from Healthwatch dated 07/04/2015
 Feedback from Overview and Scrutiny Committee ,(declined by DCC)
 The trusts complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009 dated March 2015
 The national patient survey – n/a to DCHS
 The national staff survey dated 02/2015
 The Head of Internal Audit’s annual opinion over the trust’s control environment dated
09/04/2015 (interim report)
 Care Quality Commission Intelligent Monitoring report (not available for community trusts)
The Quality Account presents a balanced picture of the NHS foundation trust’s performance over the
period covered; the performance information reported in the Quality Account is reliable and accurate:
 There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to confirm
that they are working effectively in practice
 Data underpinning the measures of performance reported in the Quality Account is robust and
reliable, conforms to specified data quality standards and prescribed definitions, is subject to
appropriate scrutiny and review; and the Quality Account has been prepared in accordance with
Monitor’s annual reporting guidance (which incorporates the Quality Account Regulations)
(published at www.monitor-nhsft.gov.uk/annualreportingmanual) as well as the standards to
support data quality for the preparation of the Quality Account (available at www.monitornhsft.gov.uk/annualreportingmanual)
The directors confirm to the best of their knowledge and belief that they have complied with the above
requirements in preparing the Quality Account.
By order of the Board
58
Appendix 5 - Independent Auditors
59
Appendix 6 - The Core Quality Account Indicators
The last indicator, Friends and Family Test – Patient, is for consideration and is not a statutory
requirement.
Prescribed Information
Related NHS Outcomes
DPC
Framework Domain & who will report
on them
The data made available to the National Health
1: Preventing People from dying
No
Service
prematurely
trust or NHS foundation trust by the Health and
2: Enhancing quality of life for
Social
people with long-term conditions
Care Information Centre with regard to—
Acute trusts
(a) the value and banding of the summary
hospital-level mortality indicator (“SHMI”) for the
trust for the reporting period; and
(b) The percentage of patient deaths with palliative
care coded at either diagnosis or specialty level for
the trust for the reporting period.
*The palliative care indicator is a contextual
indicator.
The data made available to the National Health
1: Preventing People from dying
No
Service
prematurely
trust or NHS foundation trust by the Health and
2: Enhancing quality of life for
Social Care Information Centre with regard to the people with long-term conditions
percentage of patients on Care Programme
All trusts providing mental health
Approach who were followed up within 7 days
services
after discharge from psychiatric in-patient care
during the reporting period.
The data made available to the National Health
1: Preventing People from dying
No
Service
prematurely
trust or NHS foundation trust by the Health and
Social Care Information Centre with regard to the Ambulance trusts
percentage of Category A telephone calls (Red 1
and Red 2 calls) resulting in an emergency
response by the trust at the scene of the
emergency within 8 minutes of receipt of that call
during the reporting period.
The data made available to the National Health
1: Preventing People from dying
No
Service trust or NHS foundation trust by the Health prematurely
and Social Care Information Centre with regard to
Ambulance trusts
the percentage of category A telephone calls
resulting in an ambulance response by the trust at
the scene of the emergency within 19 minutes of
receipt of that call 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 percentage of patients with a pre-existing
diagnosis of suspected ST elevation myocardial
infarction who received an appropriate care bundle
from the trust during the reporting period.
1: Preventing People from dying
prematurely
3: Helping people to recover from
episodes of ill health or following
injury
No
Ambulance trusts
60
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 with suspected stroke
assessed face to face who received an
appropriate care bundle from 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
percentage of admissions to acute wards for which
the Crisis Resolution Home Treatment Team
acted as a gatekeeper during the reporting period.
The data made available to the National Health
Service trust or NHS foundation trust by the Health
and Social Care Information Centre with regard to
the trust’s patient reported outcome measures
scores for—
(i) groin hernia surgery,
(ii) varicose vein surgery
(iii) hip replacement surgery, and
(iv) knee replacement surgery, during the
reporting period.
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—
(i) 0 to 14; and
(ii) 15 or over,
Readmitted to a hospital which forms part of the
trust within 28 days of being discharged from a
hospital which forms part of the trust during the
reporting period.
The data made available to the National Health
Service
trust or NHS foundation trust by the Health and
Social Care Information Centre with regard to the
trust’s responsiveness to the personal needs of its
patients during the reporting period.
1: Preventing People from
dying prematurely
3: Helping people to recover from
episodes of ill health or following
injury
No
The data made available to the National Health
Service
trust or NHS foundation trust by the Health and
Social Care Information Centre with regard to the
trust’s “Patient experience of community mental
health services”
Indicator score with regard to a patient’s
experience of contact with a health or social care
worker during the reporting period.
2: Enhancing quality of life
No
for people with long-term conditions
4: Ensuring that people have a
positive experience of care
Ambulance trusts
2: Enhancing quality of life
No
for people with long-term conditions
All trusts providing mental health
services
3: Helping people to recover from
episodes of ill health or following
injury
No
All acute trusts
3: Helping people to recover from
episodes of ill health or following
injury
Yes
All trusts
4: Ensuring that people
have a positive experience of care
To include
FFT final
score
All acute trusts
All trusts providing mental health
services
61
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 who were admitted to
hospital and who were risk assessed for venous
thromboembolism during the reporting period.
5: Treating and caring for
Yes
people in a safe environment and
protecting them from avoidable harm
The data made available to the National Health
Service
trust or NHS foundation trust by the Health and
Social
Care Information Centre with regard to the rate per
100,000 bed days of cases of C difficile infection
reported within the trust amongst patients aged 2
or over during the reporting period.
The data made available to the National Health
Service
trust or NHS foundation trust by the Health and
Social Care Information Centre with regard to the
number and, where available, rate of patient safety
incidents reported within the trust during the
reporting period, and the number and percentage
of such patient safety incidents that resulted in
severe harm or death.
5: Treating and caring for
We use per
people in a safe environment and
1,000
protecting them from avoidable harm occupied bed
days
All acute trusts
All acute trusts
5: Treating and caring for
Number of
people in a safe environment and
incidents
protecting them from avoidable harm (causing harm
or otherwise)
All trusts
per 1,000
WTE
budgeted staff
(no) We also
record never
events
Friends and Family Test - Question Number 12d – 4: Ensuring that people have a
Staff – The data made available by National
positive experience of care
Health Service Trust or NHS Foundation Trust by
the Health and Social Care Information Centre ‘If a All acute trusts
friend or relative needed treatment I would be
happy with the standard of care provided by this
We just record
organisation' for each acute & acute specialist
the friends
trust who took part in the staff survey.
and family
score on the
Friends and Family Test – Patient. The data made 4: Ensuring that people have a
Board report
available by National Health Service Trust or NHS positive experience of care.
Foundation Trust by the Health and Social Care
This indicator is not a statutory
Information Centre for all acute providers of adult requirement.
NHS funded care, covering services for inpatients
All acute trusts
and patients discharged from Accident and
Emergency (types 1 and 2)
62
Glossary
APO
AQP
ARU
AV
BAF
CCG
CFD
CFT
CQC
CQUIN
CRHFT
DCC
DCHS
DHFT
DHU
DTC
EoL
EMU
ERE
FT
GP
HCAI
HCCG
HFN
HFSN
KPIs
LD
LoS
MIU
MRSA
MUST
NDCCG
NED
NHS
NICE
NUH
OPMH
PLACE
PROMS
SLT
SPA
VTE
WTE
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
Autonomous Provider Organisation
Any Qualified Provider
Adult Reablement Unit
Amber Valley
Board Assurance Framework
Clinical Commissioning Group
Chesterfield
Community Foundation Trust
Care Quality Commission
Commissioning for Quality and Innovation
Chesterfield Royal Hospital Foundation Trust
Derbyshire County Council
Derbyshire Community Health Services NHS Foundation Trust
Derby Hospitals NHS Foundation Trust
Derbyshire Health United
Diagnostic & Treatment Centre
End of Life
Elderly Medical Unit
Erewash
Foundation Trust
General Practice
Healthcare Associated Infection
Hardwick Clinical Commissioning Group
Heart Failure Nurse
Heart Failure Specialist Nurse
Key Performance Indicators
Learning Disabilities
Length of Stay
Minor Injury Unit
Methicillin-resistant Staphylococcus aureus
Malnutrition Universal Screening Tool
North Derbyshire Clinical Commissioning Group
North East Derbyshire
National Health Service
National Institute for Clinical Excellence
Nottingham University Hospital
Older Peoples Mental Health
Patient-Led Assessments of the Care Environment
Patient Reported Outcome Measures
Speech & Language Therapy
Single Point of Access
Venous-thrombo Embolism
Whole Time Equivalents
63