South Warwickshire NHS Foundation Trust
Quality Accounts 2011/12
2
Part 1: Statement on Quality
Our core purpose is to provide high quality, clinically and cost effective NHS healthcare services that meet the
needs of our patients and the population that we serve.
I am delighted to introduce the Quality Report for the year ended 31 March 2012. As we mature as a Foundation Trust, it
is great to see greater emphasis on measuring quality indicators that really matter to our patients as well as continuing to
benchmark ourselves against some of the standard national indicators. The enlargement of the Trust this year, through
the acquisition of Community Services and our growing Membership base, has allowed us to engage with 6,000 staff and
public members which has helped us to influence the priorities and actions that we have implemented.
The acquisition of Community Services also brought the challenge of measuring outcomes outside of hospitals with a
particular emphasis on things that matter to service users. The Trust has continued to make an impact on a national scale
including very positive results in this year’s Dr Foster Hospital Guide as well as national recognition for the quality and
progress of our Children’s Nursing Services.
Within this report you will see some very positive improvement across hospital and community services in areas such
as falls reduction, reducing pressure ulcers and a continuing improvement in infection control practice. We have also
been able to introduce new and innovative solutions to delivering better and faster care in the community including the
continued success and expansion of virtual ward programmes. At last year’s Annual General Meeting, it was also very
encouraging to be able to identify individual and team nursing performance through our Nursing Awards including the
community based Parkinson Disease Nurses who have now established themselves as an ongoing service within the
Foundation Trust.
So the signs of improvement are very encouraging, it is however important that we continue to address areas where
we have not achieved the improvements that we would have liked to have seen. So over the coming year we will be
focusing on these including improving our performance against delivering single sex accommodation and improving our
emergency pathways to reduce the number of unnecessary ward moves at Warwick Hospital. Both of these issues are
driven by a level of bed occupancy which has a negative impact on quality and therefore both inside the hospital and
through the development of community teams we will be tackling this over the coming year. We have always had a very
low level of complaints as an organisation but over the latter half of the year we saw this increase. My strongly held belief
is that these are best managed at a local level and therefore we will be working with frontline staff to ensure that we avert
this trend quickly.
Most days I receive letters of appreciation of our staff and see examples of their excellent clinical practice and caring
approach to their work as I move around the organisation. It was therefore particularly encouraging this year to see
such fantastic results in the National Staff Survey. The survey measures a whole range of indicators of connection with
organisational objectives, communication, engagement and attitude. I strongly believe that these are the best markers
of delivering the best possible care to patients and service users, and our Members and stakeholders should take great
encouragement from these fantastic results.
I hereby state that to the best of my knowledge the information contained within the Quality Report is accurate.
30 / 05 / 2012
Glen Burley
Chief Executive
3
Part 2: Priorities for improvement
Within these objectives we have agreed 8 priorities for quality
improvement next year and these are detailed below. We will report on
their progress in our 2012/13 Quality Report.
The Trust has 5 key
objectives for the
forthcoming year
covering all aspects
of the Trust:
Patient Outcomes
• To improve systems and processes to further reduce mortality rates
1. To Continue to
improve the quality
of our services
• To improve the process for emergency medical admissions leading to faster safer care
• To fully implement the Community Emergency Response Team(CERT)
2. Use technology to
equip ourselves for
the future
Patient Experience
3. Integrate hospital and
community services
• To ensure that there are no single sex accommodation breaches
4. Develop our
workforce to be fit for
the future.
Patient Safety
• Improve the patient experience of food service
• To reduce the numbers of non clinical ward moves
• To improve patient safety by implementing the Safety Thermometer and achieving 95%
harm free care
5. Maintain finances and
improve efficiency
• To implement the Delivering Excellence in Dementia Care project improving care for
patients with dementia.
How these priorities were decided and why they are our priorities.
Engagement in Quality Development
Throughout the past year we have sought the views of clinicians and managers about what quality looks like, how it
should be measured and how to improve quality. We have run a series of workshops on this subject during a leadership
development programme for senior clinicians and managers at the Trust. There is a consensus that we should measure the
three dimensions of quality - patient safety, clinical effectiveness and patient experience.
Patient Safety
Patient Outcomes
A number of engagement events have taken place including feedback from members, a SWOT(Strengths, Weaknesses,
Opportunities and Threats) and PEST (Political, Economic, Social, Technology) analysis, workshops and a Governors
Round table event. From this feedback the Chief Executive and the Executive Team agreed a long list of priorities for
quality improvement based on what our staff and patients and stakeholders have told us. This list was developed into to
questionnaire and was sent to 6,000 stakeholders of the Trust (which included 3881 staff) and who were asked to vote on
their top 5 priorities. The stakeholder’s included the Trusts Board of Directors, Council of Governors, Management Board,
Patient Forum, all staff and members of the Trust. A number of the initiatives identified are ongoing from the previous year
as they remain high priorities for the Trust. Figures 2-4 illustrates feedback received:
To reduce mortality rates
To reduce the number of pressure ulcers
To increase the number of natural births
To reduce the number of falls
To increase breast feeding rates
To reduce catheter related urinary tract
infections
To implement a pathway for frail, elderly patients
To improve the process for emergency medical
admissions
To improve the pathway for stroke patients
To develop a nutritional care pathway between hospital
and community
To reduce healthcare associated infections
e.g. MRSA and CDiff
To improve care for patients with Dementia
Other
Other
0
4
To develop and implement a trauma pathway from
admission through rehabilitation and to discharge
To ensure compliance with the nurse care indicators
across every ward in the Trust
To develop ambulatory care to reduce admissions in
some specialties, eg VTE
13
26
39
52
65
78
[Figure 2]
How we will achieve our priorities;
measure, monitor and report them
Last year we agreed 6 priorities for quality
improvement please see the following pages to see
our progress:
Our Board of Directors receives a monthly report of
standards and targets that contains a broad range of
performance measures. The Board Assurance Framework
provides assurance to the Board for delivery of all key
objectives including our quality improvement priorities.
Each objective has a Lead Director that is accountable
for the delivery of that objective. Our management and
Governance Structure provide a mechanism for reporting
progress against the priorities, for implementing change
and assurance on risk.
We are introducing use of quality dashboards at Board and
Service levels in the Trust with sets of key quality indicators
as identified by the Services. These will incorporate
time-trend graphs and RAG rating against benchmarked standards. Board and Service involvement in the
development and use of these measures will help ensure
full engagement of clinicians and managers in quality.
a. Improve systems and processes to further reduce
mortality rates (pages 98-99)
b. Improve the process for emergency medical
admissions leading to faster safer care (page 10)
c. Implement a pathway for frail elderly patients
(page 112)
d. Improve the discharge pathway both in the Trust
and with partner agencies to reduce the number of
patients delayed in hospital when their need for a
hospital environment is complete (pages 103-104)
e. Improve the patient experience of food service
(pages 95-96)
f. Improve patient safety by reducing the number of
falls (page 80) and pressure sores (page 76)
Management and Governance Structure:
Board of Directors
Charity Trustee
Chief Executive
Executive Team
Membership
Development
Committee
(joint with CoG)
Clinical
Governance
Committee
Audit
Committee
Management Board
Appointments
and Remuneration
Committee
Risk Board
Infection
Prevention
Board
Patient
Safety
Group
Patient
Experience
Group
Divisional
Clinical Governance
Committees
Finance and
Performance
Executive
Policy
Review
Group
Patient Experience
[Figure 1]
To improve the discharge pathways both in the hospital and with
partner agencies to reduce the number of patients delayed in hospital
To improve patients experience of booking appointments with the
hospital
To achieve single sex accommodation standards
To reduce the number of patient moves between wards
To improve the quality of hospital food
To improve patient information
To implement a local pathway supporting patients at the end of their
lives
To improve patient transfer and discharge communication
Other
0
13
26
39
52
65
[Figure 3]
0
16
32
48
[Figure 4]
64
80
5
96
Statements of Assurance
from the Trust
Review of Services
Participation in Clinical Audits
During 2011-12 the South Warwickshire NHS Foundation
Trust provided and/or sub-contracted 61 NHS services.
During 2011-12, 37 national clinical audits and 3 national
confidential enquiries covered services that South
Warwickshire NHS Foundation Trust provides. During
that period South Warwickshire NHS Foundation Trust
participated in 70% national clinical audits and 100%
national confidential enquiries of the national clinical audits
and national confidential enquiries which it was eligible to
participate in.
The South Warwickshire NHS Foundation Trust has
reviewed all the data available to them on the quality of
care in 100 per cent of these NHS services.
The income generated by the NHS services reviewed
in 2011-12 represents 91 per cent of the total income
generated from the provision of NHS services by the South
Warwickshire NHS Foundation Trust for 2011-12.
Clinical Audit Information :
Column A
Column B
Column C
National Clinical
Audits that South
Warwickshire
Foundation Trust
were eligible for
and participated In
2011-12
National Clinical Audits
that SWFT participated
in and for which data
collection completed,
% completion
Perinatal mortality (MBRACE-UK)
No
N/A
Paediatric Pneumonia (British Thoracic Society)
Yes
100%
Paediatric Asthma (British Thoracic Society)
No
N/A
Pain Management (College of Emergency Medicine)
Yes
100%
Childhood Epilepsy (RCPH National Childhood Epilepsy Audit)
Yes
100%
Diabetes (RCPH National Paediatric Diabetes)
Yes
100%
Emergency Use of Oxygen (British Thoracic Society)
Yes
100%
Adult Community Acquired Pneumonia(British Thoracic Society)
Yes
. Deadline is May 2012
Non invasive ventilation – adults (British Thoracic Society)
Yes
. Deadline is May 2012
Pleural procedures (British Thoracic Society)
No
N/A
Cardiac Arrest
No
N/A
Severe Sepsis & septic shock (College of Emergency Medicine)
Yes
100%
Adult critical care (ICNARC CMPD)
Yes
100%
Potential donor audit (NHS Blood & Transport)
Yes
100%
Seizure Management (National Audit of Seizure Management)
No
N/A
Yes - National
Inpatient Survey
Inpatient survey only
Yes
100%
National Clinical Audits that South Warwickshire Foundation
Trust is eligible to participate in 2011-12
Diabetes (National Diabetes Audit)
Heavy Menstrual Bleeding (RCOG National audit of HMB)
[Table A]
6
Column A
Column B
Column C
National Clinical
Audits that South
Warwickshire
Foundation Trust
were eligible for
and participated In
2011-12
National Clinical Audits
that SWFT participated
in and for which data
collection completed,
% completion
Yes
100%
Yes – Therapies
element
Therapies element only
Adult Asthma (British Thoracic Society)
Yes
100%
Bronchiectasis (British Thoracic Society)
No
N/A
Hip, knee and ankle replacements (National Joint Registry)
Yes
100%
Elective surgery (National PROMS Programme)
Yes
100%
Acute Myocardial infarction & other ACS (MINAP)
Yes
100%
Heart Failure (Heart Failure Audit)
No
N/A
Acute Stroke (SINAP)
No
N/A
Cardiac arrhythmia (Cardiac Rhythm Management Audit )
No
N/A
Lung Cancer (National Lung Cancer Audit)
Yes
100%
Bowel Cancer (National Bowel Cancer Audit Programme)
Yes
100%
Head & neck cancer (DAHNO)
Yes
100%
Oesophago-gastric cancer (National O-G Cancer Audit)
Yes
100%
Hip fracture (National Hip Fracture Database)
Yes
100%
Bedside Transfusion (National Comparative Audit of Blood
Transfusion)
Yes
100%
Medical Use of Blood (National Comparative Audit of Blood
Transfusion)
Yes
100%
Risk factors (National Health Promotion in Hospitals Audit)
No
N/A
Care of dying in hospital (NCDAH)
No
N/A
National Confidential Enquiry into Patient Outcome and Death
(NCEPOD)
Yes
100%
Confidential Enquiry into Maternal and Child Health (CMACH)
Yes
100%
National Confidential Inquiry (NCI) into Suicide and Homicide by
People with Mental Illness (NCI/NCISH)
Yes
100%
National Clinical Audits that South Warwickshire Foundation
Trust is eligible to participate in 2011-12
Ulcerative colitis & Crohn’s disease (UK IBD Audit)
Parkinson’s disease (National Parkinson’s Disease Audit)
[Table A continued]
7
The reports of 3 national clinical audits were reviewed by the provider in 2011-12 and South
Warwickshire NHS Foundation Trust intends to take the following actions to improve the quality
of healthcare provided.
National Sentinel Stroke Organisational
Audit Report 2010
National Dementia Audit
(Final Report Dementia Part 1 2010)
Main actions:
Main action:
• Weekend pathway being developed in collaboration
with UHCW for TIA cover.
• Participation in a trial of the ‘Delivering Excellence in
Dementia Care in Acute Hospitals’ model outlined by
New Cross Hospital, Wolverhampton. The plan is to
have a dedicated dementia ward.
• CNS for stroke to commence weekend working, to
include TIA screening and specialist stroke input.
• Use of ring-fenced stroke bed commenced 2011,
resulting in direct admissions to the stroke unit
Acute Myocardial Infarction and other ACS (MINAP)
The annual report ‘How the NHS cares for patients with heart attacks’ was published in September 2011. The emphasis is
on patients with ST elevation myocardial infarction (STEMI) and whether they are receiving primary angioplasty. Patients
with STEMI in South Warwickshire that dial 999 and have a STEMI are taken to University Hospital of Coventry and
Warwickshire (UHCW.) The Trust does manage patients with non STEMIs (NSTEMI) and they are recognised to be at risk
of a fatal cardiac event over longer term (>1 month) and therefore their medical management is crucial. The Trust has
performed well in the management of these patients during 2011–12.
The reports of 25 local clinical audits were reviewed by the provider in 2011-12 and South Warwickshire NHS Foundation
Trust intends to take the following actions to improve the quality of healthcare provided. Audit actions from local audits
reported to the Trust Board during 2011-12 have been précised and grouped together where possible.
• Review of the leg ulcer local enhancement service agreement with the aim of improving leg ulcer management across
the community and at leg ulcer clinic.
• Redesign of DNAR form to improve compliance with Do Not Attempt Resuscitation (DNAR) documentation and form
completion.
• Amendments to Peripheral Venous Access Documentation (PIVA) forms to improve compliance of completion of PIVA
form.
• Screen saver has been developed to highlight areas of consent which required improvement; documentation of
information leaflet given, extra procedures.
• Construction of a new anaesthetic form to improve completeness of documentation.
• Continue to increase doctors’ awareness of Venous Thrombo Embolism (VTE) assessment forms during induction by
providing leaflets on ‘Undertaking risk assessments for VTE.’
• Increasing focus on the Time Out and Sign Out elements of the World Health Organisation (WHO) checklist by ensuring
staff complete team Time Out before knife to skin.
• Following a patient satisfaction questionnaire on the Nicol Unit key themes highlighted have been incorporated into the
redesign of the Unit.
• To improve management of patients receiving parenteral nutrition the Trust’s parenteral nutrition guidelines have been
updated and published.
• Enhanced antibiotic prescribing sessions continued at Trust induction and mandatory training sessions for all
prescribers.
• Oncology patients now have an ‘end of chemo review,’ with a pack of end of cancer treatment information.
• Cardiac Arrest Trolley checking sheets have been amended to ensure that daily checking of the cardiac arrest trolley
equipment is undertaken as per Trust Guidelines. The final check ensures that staff are aware that their signature
indicates that all aspects of the trolley have been checked.
8
Research
NIHR Portfolio Studies
Speciality
Number
of
Studies
Percentage of Total
Number of Patients
Recruited
Participation in Clinical
Research
Oncology
43
58%
Paediatrics
6
8%
Breakdown of National
Institute for Health
Research (NIHR) portfolio
Studies
Gastroenterology
5
7%
Musculoskeletal
5
7%
Neurology and Stroke
4
6%
The number of patients
receiving NHS Services
provided or sub-contracted
by South Warwickshire NHS
Foundation Trust between
April 2011 and March 2012
that were recruited during
that period to participate
in research approved by a
research ethics committee
was 244.
Reproductive Health and Childbirth
4
5%
Cardiovascular
2
3%
ENT and Eyes
2
3%
Blood (Non-malignant haematology)
1
1%
Congenital Disorders
1
1%
Infectious Diseases and Microbiology
1
1%
Participation in clinical
research demonstrates
the Trusts commitment to
improving the quality of care
we offer and to making our
contribution to wider health
improvement.
South Warwickshire NHS
Foundation Trust was involved
in conducting 98 clinical
research studies during
2011/2012. Of these 74 were
supported by the National
Institute for Health Research
(NIHR) through its research
networks. 100% were given
permission by an authorised
person within 5 days from
receipt of a valid completion.
[Table B]
Non-Portfolio Studies
Speciality
Number
of
Studies
Percentage of Total
Number of Patients
Recruited
Educational (PhD, MSc etc.)
12
50%
Other
8
33%
Commercial
3
13%
Trust
1
4%
[Table C]
The Trust continues to partake in multi-centred studies supporting high quality
research for the benefit of our patients.
Our involvement in research has resulted in over 40 publications in the past 3 years,
helping to improve patient outcomes and experience across the NHS.
Goals Agreed With Commissioners
A proportion of South Warwickshire NHS Foundation Trust’s income in 2011-12 was conditional on achieving quality
improvement and innovation goals agreed between South Warwickshire NHS Foundation Trust and NHS Warwickshire,
through the Commissioning for Quality and Innovation payment framework. The value of income in 2011/12 conditional
upon achieving quality improvement and innovation goals was £2.5 million. The value of income for the associated
payment in 2012/13 is £4.2 million.
Further details of the agreed goals for 2011-12 and for the following 12month period are available electronically at:
www.institute.nhs.uk/world_commissioning/pct_portal/cquin.html.
9
What Others
Say About Us
such is registered without conditions. The CQC has not
taken enforcement action against South Warwickshire NHS
Foundation Trust during the period of 01/04/11 – 31/03/12.
South Warwickshire NHS Foundation Trust has participated
in special reviews by the CQC relating to the following
areas during the period of 01/04/11 – 31/03/12. The
reviews are detailed below, including how we responded to
the findings of the reviews.
Dignity and Nutrition for Older People –
June 2011
Outcome 1: People should be treated with respect,
involved in discussions about their care and treatment
and able to influence how the service is run.
The CQC found that the Trust was meeting this essential
standard.
Outcome 5: Food and drink should meet people’s
individual dietary needs
The CQC found that the Trust was meeting this essential
standard but, to maintain compliance, suggested some
improvements were made.
What we did:
• Carried out spot checks to ensure compliance with the
protected mealtime process
• Engaged volunteer services to help at mealtimes
• Implemented the ‘Let’s do lunch’ campaign aimed at
encouraging family, friends and carers to visit during this
time.
• Offered hand wipes to all patients
• Provided information to all patients regarding snack
availability
• Participated in regular audits on ‘belt to service’
Care Quality Commission
South Warwickshire NHS Foundation Trust is required to
register with the Care Quality Commission (CQC) and as
10
Inspection of Safeguarding and Looked
after Children Services for Warwickshire –
November 2011
Main Findings
Safeguarding services – Good
Safeguarding outcomes – Good/Adequate
Inspection of the termination of pregnancy
process – March 2012
The CQC carried out a themed unannounced visit on 20
March 2012. The purpose of the visit was to assess our
termination of pregnancy (ToP) process. During the visit,
members of staff were interviewed and 15 sets of notes
were audited.
Services for Looked after Children - Good
Outcomes for Looked after
Children and Care Leavers – Good
Main Findings
What we did:
The Trust remains compliant with the Essential
Standards of Quality and Safety and as such will
continue to be registered without conditions; however
there were some recommendations for improvement.
All improvements were undertaken in conjunction
with the Arden Cluster, Warwickshire County Council,
Warwickshire Public Health, Coventry and Warwickshire
Partnership Trust and Warwickshire Police
The CQC were satisfied with what they observed and
commented how professional and knowledgeable they
had found the Lead for the Early Pregnancy Assessment
Unit.
• Unscheduled care notifications are received by GPs,
Health Visitors and School Nurses and quality of
information is monitored.
What we did:
• Improved communication pathways between
agencies with particular reference to child protection
strategies.
The Termination of Pregnancy Medical Termination of
Pregnancy Management
Guideline reviewed and amended.
• Health Visitors and School Nurses invited to
‘Looked after Children’ reviews
• All health assessments shared and actions monitored
• Consistent referral thresholds implemented county
wide
• Further development of children and young person
A& E Department.
• Provided access to clinical supervision
• Implemented consistent teenage maternity service
county wide
• Improved approaches to domestic violence
• Development of a Sexual Assault Referral Centre
• Development of Specialist Safeguarding Training
11
Information Governance Toolkit Attainment Levels
South Warwickshire NHS Foundation Trust Information Governance Assessment Report overall
score for 2011-12 was 74% and was graded red by the Information Governance Toolkit Grading
Scheme. The new toolkits RAG status has been altered to only give a red or green outcome
with no amber rating. A red in previous years would have been for a score of 39% or less. This
year, to be graded as satisfactory, the Trust would require a score of 75% or above and all 45
requirements at level 2 or above.
The Trust narrowly missed this target having achieved level 2 or above in 44 of the 45 requirements. However this
compares favourably with other Trust submissions.
Clinical Coding Error Rate
During 2011/2012 South Warwickshire NHS Foundation Trust was subject to the Payment by
Results clinical coding audit carried out by the Audit Commission. The audit covers the accuracy
and completeness of diagnosis and operation codes recorded against hospital admissions
together with other key data items (age, admission method, sex and length of stay) that determine
the Payment by Results tariff applicable to the hospital admission.
A random sample of 200 Finished Consultant Episodes (FCEs) was audited from inpatient activity during September
2011. One hundred sets of the FCEs audited were selected from the General Medical specialty. There was a high volume
of multi-episode spells in this audit with the 200 FCEs grouping to just 132 spells. It is important therefore the results of
the audit should not be extrapolated further than the sample audited. The relevant sets of patients’ notes were audited
against the clinical information recorded on the hospital administration system.
Results
The audit resulted in 15% of all the spells having a coding error that affected the price. Overall the Trust had
undercharged its commissioners by £6,818 – or 2.4% of the total pre audit income of £285,338. The other data items
mentioned above that were also part of the audit and also affect the Payment by Results income were 100% complete
and accurate.
The coding errors were largely as a result of co-morbidities not being coded on complex multi-episode medical spells.
This was either because different coders had been involved in coding the spells, and diagnoses had been missed, or
because the clinical information was difficult to extract from some of the notes that were difficult to navigate.
Recommendations
The key recommendation from the audit was to allocate responsibility for all coding in a spell to the coder who codes the
discharge episode and that the coder should adjust the coding appropriately for the coding of the whole spell. This has
been given high priority and has already been implemented within the Coding Department at South Warwickshire NHS
Foundation Trust.
The Trust will be comparing its audit performance against all other Trusts when 2011/2012 benchmarking data is
available.
12
Part 3: Review of Quality Performance
Quality objectives and performance
At the beginning
of 2011 the Trust
identified and
published 5 key
objectives for
2011/12.covering all
aspects of the Trust.
1. To improve efficiency
to maintain financial
performance and
sustainability
2. To Continue to
improve the quality of
our services
3. Equipping ourselves
for the future
4. Develop an integrated
hospital and
community service to
ensure that patients
are treated in the right
place at the right time
5. Develop our
workforce to be fit for
the future
From 1st April 2011 Warwickshire Community Health (WCH) transferred
to South Warwickshire Foundation Trust this quality report is inclusive of
both acute and community services.
Within these objectives 6 priorities for quality improvement were agreed:
• To improve systems and processes to further reduce mortality rates
• To improve the process for emergency medical admissions leading to faster safer care
• To implement a pathway for frail elderly patients
• To improve the discharge pathway both in the Trust and with partner agencies to reduce
the number of patients delayed in hospital when their need for a hospital environment is
complete.
• Improve the patient experience of food service
• To improve patient safety by reducing the number of falls and pressure sores
This part of the quality accounts includes our progress against the priorities identified and
a review of quality under the headings of patient safety, patient experience and clinical
effectiveness.
Following the acquisition of Warwickshire’s community services under the Transforming
Community Services programme in April 2011, the organisational leadership and
management structure was redesigned.
The principles of the restructure were to develop the clinical, operational and medical
leadership structure along care pathway lines that make sense to clinical staff and will
assist in breaking down the barriers between traditional acute and community work and
facilitate integrated working.
The redesign led to four new divisions: Elective Care, Emergency Care, Integrated and
Community Care and Support Services.
The new structure was consulted on with staff, received widespread support and was
implemented in October 2011.
13
Patient Safety
NHS Litigation Authority Risk Management Standards
In November 2011 the Trust retained Level 2 with the NHS Litigation Authority Risk Management
Standards. The Trust acquired Community Services from NHS Warwickshire in April 2011,
however decided to exclude these services from assessment in November 2011 and is therefore
required to undergo reassessment for all services across all its sites in November 2012.
Following a thorough review of the Trust’s preparedness for assessment and in order to ensure that its systems and
processes were robust; thereby enabling sound building blocks for future progress to higher levels, the executive team
took the decision to be assessed at Level 1 in November 2012.
Clinical Negligence Schemes for Trusts (CNST)
The Trust gained level 2 for the CNST Maternity Risk Management standards in 2009, and will be reassessed at this level
in November 2012.
How the Trust reports the levels of claims made against it
The Clinical Governance Committee receives a Patient Safety Report which contains the aggregated analysis data of
incidents, complaints and claims. The claims data includes:
•
Total number of claims:
o Open at end of previous quarter
o New claims received
o Claims settled
o Open at end of the quarter in question
• Claims by division/area with a summary of allegation
• Review of any cluster, themes or trends occurring in the present rolling financial year.
In addition an annual report is presented to the Confidential Board of Directors containing information made under the
Clinical Negligence Scheme for Trusts and the liabilities to Third Party Scheme. It summarises claims by division, costs
and also identifies any learning points.
14
Incidents, Serious Incident’s,
Never Events and Lessons Learnt
Incidents within the Healthcare environment do occur. Serious Incidents are relatively uncommon.
The Trust has a responsibility to make every effort to reduce the likelihood of repeat occurrences
of incidents by investigating events, understanding their root causes and taking appropriate
preventative action. The Trust is committed to proactive incident management processes rather
than reactive and encourages and supports the reporting of incidents and near misses. Building
a strong safety culture by reducing error is a key priority.
The Trust has two groups who direct work and monitor progress which are the Infection Prevention Board and the Patient
Safety group.
The infection Prevention Board ensures that that there is Zero Tolerance to Healthcare Associated Infections within the
Trust.
The Patient Safety Group oversees the work required to reduce incidents occurring and develop a learning culture.
Incident Reporting
The overall aim is to reduce incidents with harm and increase incident reporting in a fair blame culture.
The new divisional structure is now in place and the Audit and Operational Governance Groups are now receiving monthly
updates detailing incidents.
An updated version of the electronic incident reporting system has been implemented which will enable all staff to report
incidents electronically, wherever their work base is in the county.
Total Patient Safety Incidents April 2011 - March 2012
450
350
300
250
200
150
100
50
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
0
Apr 11
Total Patient Safety Incidents
400
Months
[Figure 5]
15
There has been one ‘never event’ reported within the past year. The incident involved a piece of equipment which had
been recommended for use by the National Patient Safety Agency,(NPSA) The Trust has notified them of the incident.
Learning from the event resulted in the purchase of alternative equipment, to be used Trust wide. The lessons learnt have
been shared through the Medical Grand Round and with Divisional Audit and Operational Governance Groups.
Serious incidents are reported through the Governance team. A member of the Executive team reviews the incident and
will nominate a lead investigator for the incident. All of the investigators have undertaken training in root cause analysis.
(RCA) The incident is then reported on both a national and local database.
Once the investigation is completed, a report is submitted to the Clinical Governance Committee who will recommend
closure of the incident to the Primary Care Trust.
Q1 2011-12
Measure
Q1 2011-12
Q1 2011-12
Q1 2011-12
Total
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
**SI – Other
8
3
4
5
1
8
6
3
3
4
3
4
52
MRSA
0
1
1
0
1
0
0
0
0
0
0
0
3
* C.Diff
0
2
2
0
1
1
1
1
1
0
2
1
12
Infection – Other
0
3
1
0
1
0
0
1
1
1
1
0
9
Pressure ulcers
7
2
2
3
8
2
4
2
0
2
2
1
35
Total
15
11
10
8
12
11
11
7
5
7
8
6
111
*Criteria introduced that SI to be reported if C. Difficile recorded on Death Certificate
**Criteria for Maternity services altered to include 8 new categories for reporting
[Table D]
Serious Incidents – Lessons Learnt
• Ensure that any patient that is nil by mouth is NOT given oral fluids
• Fluid balance should be closely monitored and charts added up on a daily basis
• If a problem has been identified it is important to increase observations and record these to demonstrate that the
problems have been acted upon.
• Please ensure correct reports are filed in correct medical records
16
Safety Thermometer
‘Safety Express’ is the national work stream focusing on harm-free care and is part of the Quality, Innovation, Productivity
and Prevention (QIPP) agenda. QIPP aims to provide a safer, more reliable care across the healthcare economy with
improved outcomes at significantly lower cost. Part of this work stream is the Safety Thermometer.
The Safety Thermometer was introduced into the Trust during February 2012.The overall aim is to provide prevalence data
from every patient on a given day each month, to include any patient in a hospital bed and any patient seen by a trained
nurse within the community setting. The data is then collated in a central database and returned to the Strategic Health
Authority (SHA) The aim is to achieve 95% harm free care in four areas by December 2012:
•Falls
• Pressure ulcers
• Catheter-acquired urinary tract infection
• Venous thrombo embolic assessment, prophylaxis and treatment
The Patient Safety Team, Compliance Team and the Matrons provided training to ward managers and professional Team
Leaders throughout February 2012 and have assisted with the data collection. For community staff, collection points for
data were designated.
Each area receives a copy of their data and are asked to complete an action plan to address areas where there are with
low results, or areas of concern.
Each area will analyse their data, share with colleagues and develop interventions to improve harm-free care.
The next step is to identify any problem areas and develop action plans to address these.
Overall results for the Trust show improvement with 84.44% Harm free care in February and 88.98% harm free care in
March.
The split between acute and community areas can be seen in the table below
Measure
Acute
Community
February
March
February
March
Overall harm free care
84.87%
92.31%
84.01%
85.65%
No of pressure ulcers
42
24
100
72
Falls
4
4
20
12
Catheters and UTIs
15
6
10
3
VTEs
0
0
0
0
423
429
807
655
Sample no
[Table E]
17
Pressure Ulcers
Pressure ulcers, more commonly known as bed sores, are considered an avoidable complication
of care. They are distressing to patients and may prolong the time a patient spends in hospital.
We know that prevention and treatment of pressure ulcers is a significant concern to patients and
for this reason it will remain a Trust priority.
Our current status
Pressure ulcers are graded using the European Pressure Ulcer Advisory Panel (EUPAP 2010) grading scale. During
2011/12 the Trust have been actively working towards the reduction of service acquired pressure ulcers in the year and
have reduced Grade 3 and 4 pressure ulcers by 75%. The Trust has also reduced Grade 2 pressure ulcers by 25%.
What we have done to reduce service acquired pressure ulcers:
The Tissue Viability Team is a nurse led speciality that focuses on the prevention and management of people with wounds
including pressure ulcers. The team provide expert knowledge and leadership in the following areas:
• Assessment and treatment of people with complex needs
• Comprehensive training programmes
• Clinical Audit to monitor and improve standards
• Development and promotion of evidence based resources for the prevention and management of pressure ulcers
• An active and effective Tissue Viability link nurse network
• Equipment provision including flow chart for product selection
• Regional pressure ulcer awareness event
• Implementation of new technologies
• Healing rate cards
• First dressing initiatives
• Patient information to improve healing rates and reduce post birth complications
During 2011/12 we have:
• Supplied all patients with pressure relieving equipment
• Commenced intensive training where we will work with
individual teams on specific projects to reduce service
acquired pressure ulcers
• Piloted and implemented a SKIN bundle in the acute
setting
• Undertaken equipment audits
During 2012/13 we will continue with the
ongoing work and:
• Contribute to the UK Consensus for agreeing national
definitions and reporting mechanisms
• Continue to investigate all grade 3 and 4 pressure ulcers
and report through the governance framework
• Provide Tissue Viability Nurse assessment for patients
with a grade 3 or 4 pressure ulcer
• Facilitated the overall wound management strategy
though service redesign and provision of equitable
services
• Provide training for partner agencies
• Continued to educate/inform patients, families and staff
• Participate in the regional pressure ulcer awareness/
educational events
• Monitored the contributing factors including nonconcordance
• Developed an e-learning packages
• Updated and developed guidelines and protocols
including the alignment of Trust documents
• Evaluated wound care products
18
• Develop further topical negative pressure practices for
seamless care
• Continue team based training including moving
and handling equipment to increase pressure ulcer
prevention and bariatric equipment
• Continue to audit clinical practice, cascading findings to
clinical teams
• Contribute to the complaints service where Tissue
Viability concerns have been raised
Infection Prevention
During the last year the Trust has continued to focus on the importance of improving patient
safety and reducing Health Care Associated Infections (HCAI). MRSA bacteraemia and Clostridium
Difficile Associated Disease (CDAD) mandatory targets were both successfully achieved.
The Root Cause Analysis (RCA) process has continued to be rigorously applied by the Infection Prevention Team for the
investigation of cases of MRSA bacteraemia, CDAD outbreaks (2 or more linked cases) and deaths where CDAD has
been certified as a leading cause of death. This has enabled the Trust to understand how these infections have occurred
and if we could have prevented them. This then leads to an understanding of the measures that must be implemented to
prevent further patients developing these infections or being seriously effected by the complications of such infections.
This targeted approach to reducing infections has enabled the Trust to reduce the morbidity associated with such
infections and ultimately improve patient outcomes.
The Infection Prevention Board, chaired by the Chief Executive, continues to meet monthly. Departmental managers
and clinicians are required to attend this board and present their infection prevention audit results, rates of infection and
findings of any RCA associated with their areas. This has helped ensure managerial responsibility for infection acquisition
and these managers and clinicians have assisted greatly in the RCA process.
There have been 3 cases of hospital attributed MRSA bacteraemia identified earlier in the year and since September 2011
there have been no further cases reported. The focus on reducing infections associated with invasive devices, which has
been emphasised for several years within the Trust, has enabled this success.
Number of Hospital Acquired
MRSA Bacteraemias
Number of Hospital Acquired
CDiff Cases
9
2.5
8
2
7
6
Cases
Cases
1.5
1
5
4
3
2
0.5
1
0
2011/2012 MRSA
 Target
 Number of MRSA Bacteraemias
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
Apr 11
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
Apr 11
0
2011/2012 CDiff
[Figure 6]
The Trust also achieved the mandatory CDAD target
with 42 cases of hospital attributed cases across both
Community and Acute Trust services identified against a
target of 43 cases. Of particular benefit to our patients has
been the commitment to maintain the specialist “C.Diff
ward round” when all patients with CDAD are seen by this
team comprising of key experts in the management of
patients with CDAD.
 Target
 Number of CDiff Cases
[Figure 7]
The programme of auditing hand hygiene compliance
and compliance with the Department of Health’s Saving
Lives initiative at “shop floor” level continues, with clear
lines of ownership and accountability within clinical teams.
These audits have been rolled out within the in-patient
Community Services’ settings and all results are fed back
to all ward and departmental managers, the Infection
Prevention Board, Clinical Governance Committee and the
Trust’s Divisional Governance Groups on a monthly basis.
19
Improving Medication Safety
Medicines Management
Background
Almost all patients receive a medication when they attend hospital. Medication is the second
highest category of expense for the Trust (after staff), and the second highest patient safety
incident type (after falls). The side effects of medicines, or the failure of medication, accounts
for many hospital attendances, and extends inpatient stays, and can cause readmissions to
hospital. Inappropriate controls on medicines can prevent new and more efficient ways of working
elsewhere in the hospital and the community. All of the above, highlights the importance of the
development of our Medicines Management service and the improvement of its quality.
Advances this year
In 2011 the software for the prescribing and management of cancer chemotherapy went live in
the Trust. This has improved the legibility of prescriptions, supported paperless communication
of that prescription, provided decision support to prescribers, and contributed to a database for
medication audit and research.
A pilot of software for the prescribing of medicines to take home, and (in future) the speedy communication of those
prescriptions to GPs as part of electronic discharge letters, was rolled out almost Trust wide following a pilot.
An agreement was negotiated with Warwickshire and Coventry Social Services, on home carer support for patients not
able to self medicate at home. This has improved care quality, but also released pharmacy time previously allocated to
discharge arrangements which can now be redeployed to the wards.
Ward Medicines Managers have been retrained this year for an extended role, to improve our reconciling of home
medicines with inpatient prescriptions on admission and on discharge. This National Patient Safety Agency standard
optimises medication quickly, so hospital stays are shorter.
A partnership has been established with Aston University and Warwick Medical School, so that Pharmacists will
strengthen the teaching of therapeutics to Medical and Pharmacy students. The aim is to make them more confident and
competent after graduation, so that their prescribing on wards is safer and more efficient supporting ‘Right First Time’.
The outpatient dispensing service has been outsourced to a wholly owned subsidiary of the Trust. In the long term this
provider will be able to respond to patient needs more flexibly than the Trust itself.
Following the medicines safe custody incident at Stepping Hill, practice in this Trust was reviewed and the Trust was
identified as an exemplar site for medicines safety.
Some medicines make it more likely that a patient will acquire an infection whilst in hospital. We benchmark ourselves
against other Trusts in the West Midlands, and this year our tight management of those medicines was the best in the
Region.
We now collate and analyse details of the clinical interventions that Pharmacy staff make, to identify any areas of
prescribing that can be improved, and how the risk can be reduced. Action plans have been drawn up and implemented
this year, not least to fulfil the national alert on those medicines which require an initial ‘loading dose’.
Research has investigated the reason for delay in administering ward medications that are intended to be given
immediately on prescribing. By raising Nursing staff awareness of the risk of these delays, and of the added risk of
omitting a dose of a critical medicine, practice has changed and both delays and omissions have greatly reduced.
20
Implementation of Nurse Care
Indicators
During 2011/12 the nurse care indicator results for the Trust have remained consistent with
regards to overall Trust compliance which is currently at 91.1% and therefore still under the
overall target of 95%.
The Elective Division have performed better overall scoring 93.8% in March with the Emergency Division at 91.2%.
There has also been the addition of the Integrated Division, which is currently scoring 88.2% however they were only
incorporated into the process in January 2012. This Division is primarily made up of wards and departments that have
not previously been involved in this key performance indicator and are therefore still becoming familiar with the required
standards of the audit.
For the majority of the year the Elective Division achieved in excess of 95% with the Emergency Division performing less
favourably. In the latter part of the year, the there has been a marginal decrease in the Elective Division, whereas there has
been a marked improvement in the overall Emergency Division performance. Therefore the result of the three combined
divisions gives the Trust the performance indicator of 91.1% overall at year end.
Overall Trust Compliance with the Nurse Care Indicators
92.5
92.4
92.16
91.26
Feb 11
90.5
Jan 11
91.92
Dec 10
91.67
Nov 10
92.22
Sep 10
90.2
Aug 10
91.5
Jul 10
91.3
May 10
90
Apr 10
100
91.1
80
Percentage
70
60
50
40
30
20
10
Months
Mar 11
Oct 10
Jun 10
0
[Figure 8]
The Ward and Department Managers receive their results directly from the compliance department. These results are
discussed with the relevant matron and General Managers.
The reoccurring themes are in areas of nutrition, tissue viability and falls assessments. Patients are mostly assessed
correctly on admission, but there is lack of evidence of a minimum weekly re-assessment and adequate care planning for
those patient’s who are ‘at risk’ in some departments. In the last month’s audits, some areas failed to display up to date
hand hygiene results failure to do so affects the scores.
21
Reducing Patient Falls in Hospital
What We Have Done
Next Steps
A considerable amount of work has taken place in the
Trust, in order to achieve a reduction in the number of
falls with harm. To date, the Trust has seen a decrease in
the rate of injury to patients, from a fall. This is despite an
increase in the age profile of our patients who fall, from an
average age of 81 years in 2010, to 83 years in 2011. The
Nurse Care Indicator audits have shown an increase in
compliance, with the falls documentation and care plans,
from 68% in August 2011, to 90% by the end of 2011.
In 2012/13, we will:
Some of the work that has been carried out
in 2011/12 includes:
• Increase our review of frequent fallers
• Raising the profile of falls prevention through a Falls
Prevention Day in June,
• Promoting an Energising for Excellence Campaign
• Streamline the falls pathway, assessment and evaluation
process, in line with guidance from the Royal College of
Physicians
• Improve falls education for nurses and patients
• Introduce a Falls Link Nurse Team
• Improve our provision of safer footwear for patients
• Continue to work with complimentary work streams in
the Trust, which also contribute to falls prevention, such
as the dementia, frail elderly and pressure ulcer work
streams.
• Continuation of falls education
• Introducing a post falls protocol
• Increasing falls prevention equipment, such as low beds
and falls alarms
• Combining our community and acute falls teams
• Improving our data collection and presentation
• Gathering feedback from patients about their perception
of falls
Falls Rates with Injury per 1000 Bed Days
3.00
2.50
2.00
1.50
1.00
0.50
0.00
TOTAL 2010/11
Q1 2011/12
Q2 2011/12
Q3 2011/12
Q4 2011/12
[Figure 9]
Falls Rates with Injury per 1000 Bed Days
83.5
83
82.5
82
81.5
81
80.5
80
Year 2010
22
Year 2011
[Figure 10]
Patient Experience
Our aim is to continually improve the patient experience within the Trust. The Director of Nursing
chairs a Patient Experience Group (PEG) and through this group a range of work is overseen,
in all departments across the Trust. The PEG holds clinicians and mangers to account for the
patient experience in their area through direct reporting to the group. Each manager/ clinician is
expected to provide actions plans for improvement.
Care Survey
he bedside TV survey CARE (Communication, Attitude, Responsiveness and Environment) was introduced to the Trust in
2009 and continues to be used to provide a forum for patients to rate aspects of the care they have received in the acute
hospital. The aim of the survey is to understand what patients think and their experience of care at SWFT.
Ward managers can access their ward’s results on a daily basis enabling real time feedback and responsiveness to any
issues that may arise. As some of our patients are unable to use the electronic version we also use paper based surveys.
The Trust has a set target of 300 completed surveys per month, this provides a good sample size for analysis. This
monthly target has been consistently achieved since October 2009.
Total Number of Surveys Received
500
400
300
200
100
Months
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
Apr 11
0
[Figure 11]
Patients are asked how they would rate their overall care whilst in the hospital, over the last year there has been an
increase in patients rating their care as good or very good, with an average over the year of 94% of patients positively
rating the care they received.
Patients rating their care as good or very good.
for the duration of their stay at the hospital
100
80
70
Months
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
May 11
50
Jun 11
Patients are asked how they would rate their overall care whilst in the hospital, over the
last year there has been an increase in patients rating their care as good or very good,
with an average over the year of 94% of patients positively rating the care they received.
60
Apr 11
Percentage
90
[Figure 12]
23
Smiley Face Cards
We have developed a smiley face postcard that patients can use to give feedback on their
hospital experience.
Cards are available for each patient
who stays or attends one of the Trusts
hospitals. Each card has a choice of
3 faces that require a tick response,
space is provided on the reverse of the
card where patients can write about
the care they received and if they wish
to, leave their contact details.
urvey
Patient Satisfaction S
as
We are NOT performing
we should
We are performing
SATISFACTORILY
We are performing
WELL
Tick Here
Tick Here
Tick Here
The feedback postcards were initially
trialed in 3 areas and feedback from
patients to date has been extremely
positive. So far we have distributed
nearly 3000 postcards across the
Trust. Feedback is given via the
Patient Experience Group and
departments are be expected to
display their results to the public.
Smiley Face Cards Results 2011-12
100
90
80
Percentage
70
60
50
40
30
20
10
Good
Satisfactory
Ward EHB
Day Unit EBH
Feldon
Stratford OPD
Radiology, Statford
Nicol Unit, Stratford
Squire Ward
Radiology
Outpatients
Nicholas Ward
Malins
Hatton
GUM
Farries Ward
Fairfax Ward
Endoscopy
ENT
Dugdale Ward
Coronary Care Unit
Colposcopy
Avon Ward
23 Hour Ward
0
[Figure 13]
Poor
The results demonstrate that most areas are receiving positive feedback. However some areas have received satisfactory
(Yellow) and Poor (red feedback).
24
Positive comments include:
“Excellent service - highly competent and very caring. Found time for each individual patient. Taught student nurse
patiently and thoughtfully.”
“Excellent care.”
“Exceptional. Friendly. Absolutely no complaints. Nurses very knowledgeable and informative. Thank you.”
“Excellent. I have been looked after very well. Nothing was too much trouble. I had the best professional care. Sorry to
go home.”
“Have been very impressed with all the staff and everybody involved with my care. Thank you all.“
Amber comments include:
“Sometimes the waiting is much longer than expected.”
“Long wait for blood test. Suggestion: Could consultants’ nurses be trained and then take the test whilst waiting for the
next patient.”
“Bit slow. Running late, but friendly and helpful.”
“After sitting for 20 minutes in the waiting area after our appointment time, we were told that the clinic was running 50
minutes late. And with no explanation. People react more favourably when kept informed.”
Red Comments include:
“Cold not nice looking food.”
“When attending fracture clinic, you put A&E appointment. The receptionist says she requested the correct information
on the appointment.“
“Reception could speak louder given that I had a hearing-aid appointment. I came for an appointment with audiologist
who was excellent, but I had not been told to get my ears de-waxed so I have to come again. Another wasted journey.
No problem with Audiologist, but appointment system is awful.”
We always act upon feedback from patients. Departments have been displaying the completed cards and where feedback
has been less favourable they have displayed what they have done to make improvements.
A catering appraisal is currently underway so we can supply our patients with hot nutritious food that looks appealing, we
hope to have this fully installed during 2012/13.
The fracture clinic and A&E departments have recently undergone refurbishment work, following this our appointment
letters have been changed directing patients to the correct reception. The refurbishment creates more space and a more
welcoming area for our patients.
Communication is extremely important in Outpatients, screens have been installed notifying patients of any additional
delays and reception staff inform patients on arrival if clinic appointments are delayed. Reception staff also receive
communication skills training.
25
Complaints
The Trust recognises that patient feedback, comments and complaints are effective measures of services delivered and
necessary learning. The information gained assists the Trust in:
• Recognising standards of service delivery and continuing to improve those services
• Being aware of patient experience, perspective and expectations
• Identifying problematic areas
• Identifying actions needed
• Monitoring service delivery requirements
There were 153 complaints received in 2010 – 2011 and 187 in 2011 – 2012 which is inclusive of the 12 complaints
relating to community services The Trust has introduced a new complaints policy this year which includes a process to
record and report actions taken as a result of complaints made. In addition a new reporting process is being introduced
to ensure that complaints are responded to in a timely fashion and senior managers are involved from all divisions, in all
complaints.
Comparison of Complaints by month
35
30
Complaints
25
20
15
10
5
 2010-11
Months
 2011-12
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
Apr 11
0
[Figure 14]
During the year the complaints process between hospital and community services has been merged and streamlined.
26
There were 3 complaints referred to the Health Service Ombudsman (HSO), following contact 2 were not investigated and
closed by the HSO, the other has not as yet been notified to the Trust.
Of the 187 complaints received 36 complaints were upheld
The top 5 complaints for the year are:
• Clinical Care
• Communication/Information
• Nursing Care
• Delay/wait to be seen
• Staff Attitude
Complaint themes by quarter
80
70
60
50
40
30
20
10
0
Clinical Care
Q1
Q2
Communication/Information
Q3
Five complaints were not
acknowledged within 3
working days. There has been
an increase in the number of
late responses this year and
a new policy and procedure
has been introduced to ensure
this is addressed. Of the 187
complaints, 43 to date have
been responded to over 25
working days. This has been
due to the complexity of the
complaint and slow responses
from staff involved in the
complaint investigation. Late
responses are now reported
through the General Managers
and Associate Directors of
each division and further
delays will be reported to the
Medical Director, the Director of
Operations and the Director of
Nursing.
Nursing Care
Delays
Staff Attitude
[Figure 15]
Q4
Month
No. of
complaints
Acknowledged in
3 working days
Response >25days
April
10
100%
3
May
9
100%
0
June
11
100%
3
July
13
100%
5
August
19
98%
6
September
16
100%
4
October
11
100%
2
November
17
100%
4
December
10
100%
3
January
15
98%
5
February
29
100%
8
March*
27
99%
TOTAL
187
43
[Table F]
27
Complaints by Division
From April to October there were 42 complaints received concerning the Medical division and 41 received concerning the
Surgical Division and 7 received by the Support Services Division.
From October to March there have been 75 complaints received by the Emergency Division, 38 received concerning the
Elective division, 9 concerning the Integrated & Community division and 6 concerning the Support Services division.
Areas Relating
to Complaints
The table below details the
top 6 areas over the year
with the activity related to
that area with the number
of complaints as a
percentage of the activity.
Area
Number
Activity
%
All ward complaints
103
54,900
0.18
A&E
46
51,884
0.08
Maternity
23
9,749
0.2
Orthopaedics
14
1,675
0.8
Radiology
12
95,040
0.012
[Table G]
The total number of complaints were graded on receipt and were rated as follows; 15 red, 30 dark amber, 110 amber and
32 green complaints.
Complaints are then re-graded on completion and there were 0 red, 4 dark amber, 48 amber and 101 green.
Lessons Learnt and Actions from Complaints:
• Development of additional patient information leaflets across the Trust and specialities.
• Improvement in cleaning regimes and monitoring at department level
• Introduction of Triage protocol in A&E
• Extra capacity areas appropriately staffed and equipped ensuring there is an overall management responsibility for the
ward
• Introduction of a structured hand over tool for use at ward handovers
• Introduction of the Night Charter to improve noise at night and provide protected sleep for patients
• Information sessions for all nurses detailing community services available
• Full implementation and ongoing audits of the WHO safety checklist
• Ongoing review of nurse staffing levels using e roster software
• Increase staffing levels in preceptorship team to improve support and skill development for newly qualified staff
• Improved communication and information regarding side effects of medication
28
Patient Advice Liaison Service (PALS)
PALS is an independent and confidential advice and support
service for patients and their relatives/friends. It offers
the opportunity to raise any concern at a very early stage,
enabling them to be dealt with promptly. The service works
in partnership with patients and staff to identify where the
Trust can improve the patient experience.
Year
Number of contacts
2011/12
1828
2010/11
1711
Top Five Contact Topics Year, 2010/11 v 2011/12
350
Number Contacts
300
250
200
150
100
50
0
Clinical Care / Decision
Communication
Patient Property
Outpatient Appointments
Discharge & Transfer
Category
2010/11
2011/12
[Figure 16]
Examples of where PALs has supported and improved patient experience
• Liaison with appropriate staff to assist the patient e.g. blood or X-ray reports, and follow up appointments
• Time spent with relatives to explain the difference in funding of care in the community to enhance their understanding
• When a concern is highlighted to staff, particularly where there has been a misunderstanding or miscommunication, it
encourages small changes in individual practice to improve future patient care.
• Hospital admission, either planned or unexpected is stressful and signposting by PALS to a variety of outside agencies
for information and practical help to assist the patient’s wellbeing is essential.
29
Privacy and Dignity
Privacy & Dignity remains a high priority for the Trust. In 2007 we introduced 7 dignity promises
in response to themes from patient complaints. Following a further review, and in order to also
encompass the Community Services the Dignity Promise have been updated to reflect the entire Trust.
We promise:
• Not to allow language or other communications issues to become a barrier to understanding
• You will be introduced to the staff who are caring for you
• You will be called by a name of your choosing
• To respond to your questions promptly, or find someone who can
• Your privacy and modesty will be maintained at all times
• You will be treated in a courteous manner that respects equality, diversity and your human rights
• Our staff will deliver the highest standard of safe care and customer service
The Promises are presented to all new staff at Corporate Induction sessions, these are held monthly. The session is also
presented to student nurses at induction training. The training is delivered by the Matron team. At these sessions staff are
informed of the Trusts expectations and standards.
The application of ‘The Promises’ continues to be assessed against the CARE survey
responses and 6 specific Questions as detailed in the charts below:
1. What is your experience of the courtesy of the staff?
2. Were staff friendly and sensitive to your needs?
3. Were you asked what name you prefer to be called?
4. Have the staff talked in front of you as if you were not there?
5. Were you given enough privacy when discussing your condition or treatment?
6. Were you given enough privacy when being examined or treated?
30
100
90
80
70
60
50
40
30
20
10
What staff friendly and sensitive to your
needs? (Always)
Percentage
Month
Were you asked what name you prefer to
be called? (Always)
100
90
80
70
60
50
40
30
20
10
[Figure 18]
Have staff talked in front of you as though
you were not there? (Never)
Percentage
Month
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
Apr 11
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
0
Apr 11
0
100
90
80
70
60
50
40
30
20
10
May 11
Month
[Figure 19]
[Figure 20]
Where you given enough privacy when
discussing your condition or treatment?
(Always)
Percentage
100
90
80
70
60
50
40
30
20
10
Where you given enough privacy when
being examined or treated? (Always)
Month
[Figure 21]
Month
Mar 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
Apr 11
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
0
Apr 11
0
100
90
80
70
60
50
40
30
20
10
Feb 12
Percentage
Mar 12
Month
[Figure 17]
Percentage
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
Apr 11
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
0
Apr 11
0
100
90
80
70
60
50
40
30
20
10
May 11
Percentage
What is your experience of the courtesy of
the staff? (Very Good & Good)
[Figure 22]
31
The Matron Team also co-ordinate and lead an annual audit to ensure national privacy and dignity standards are achieved
and maintained. This was last conducted in November 2011, with a subsequent action plan has been developed and is
currently being implemented.
The audit confirmed that public and patient areas are consistently clean and well maintained and in addition, separate male
and female toilet and washing facilities are clearly accessible and labelled.
However, the main issue identified at this years audit was the inconsistent quality of curtains around patient’s bed areas.
This finding was also supported by the Essence of Care benchmark reported by ward staff and where a problem has been
identified, these curtains are currently being replaced.
Care of Patients with a Dementia
The past year has seen the very successful implementation of the Freedom Project in the Nicol Unit at Stratford Hospital
in conjunction with the King’s Fund. This project has focused on enhancing the healing environment for patients with a
dementia, maximising the principles of meaningful occupation, inclusion, comfort, attachment and identity. These principles
focus on person centred care and improve the patient and relatives experience of the services and the staff involved.
The impact of the training delivered in the previous year appears to have had a very positive impact on the care of patients
with a dementia and their families by reducing complaints regarding lack of dignity of care extended to patients with a
dementia and their families.
We have worked closely with the League of Friends co-ordinator to reenergise the campaign for recruiting volunteers with
the specific intention of offering person centred activities and championship whilst in hospital.
The focus group for the implementation of the National Dementia Strategy waned during the course of 2011/12 because of
role changes and organisational pressure; however this has been reinvigorated with a new medical lead. Representatives
from the focus group have been working closely with the Royal Wolverhampton Hospital NHS Trust who are a flagships for
Delivering Excellence in Dementia Care in Acute Hospitals which has been recognised as a best practice program adopted
fully or partially across the NHS. This program of care is closely linked to the national Commissioning for Quality and
Innovation (CQUIN) target regarding dementia care management.
Same Sex Accommodation
What We Have Done
During the year the Trust continued to make a significant improvement in reducing the numbers of patients who
experienced mixed sex accommodation, with a month on month improvement compared to last year (Chart 1). This was
also reflected in patient feedback, with the highest number of patients, to date, reporting that they did not experience
mixed sex accommodation, (chart 2). This was also mirrored in the 2011 National Inpatient Survey: 91% of patients in
2011, compared to 83% in 2010, reported that they did not share mixed sex accommodation when first admitted to
a ward. The improvements have been due to continuation of the Ward to Board monitoring and route cause analysis
process, continuing efforts by the Bed Management and Ward Teams to make same sex accommodation a priority, and
continuation of work streams to increase the efficiency of the Trust’s bed capacity.
Next Steps
Unfortunately despite our improvements the Trust has not been able to achieve zero breaches, as is the case in our
neighbouring hospitals. It remains a challenge to totally eliminate mixed sex accommodation at times of stretched capacity,
for example, during the severe norovirus outbreak during January 2012. Therefore, the Trust continues to maximise
the benefits of its community services and to engage in work streams to ensure that the Trust’s bed capacity is utilised
appropriately, for example: ambulatory care pathways, improved access to diagnostic services, Cutting the Cost of Frailty
and community intravenous services.
32
Quarterly Performance - Same Sex Breaches
600
500
Number of Patients
400
300
200
100
0
Q1
Q2
-
Q3
2010/11
Q4
[Figure 23]
- 2011/12
Did you share sleeping accommodation with the opposite sex?
% patient response - NO
99
98
97
96
95
94
93
Jan - Mar 11
Apr - Jun 11
Jul - Sep 11
Months
Oct - Dec 11
Jan - Mar 12
[Figure 24]
33
Non-Clinical Ward Moves
The monitoring and analysis of non-clinical ward moves for patients continue with data being reported to the Patient
Experience Group monthly. This reporting mechanism also includes a more detailed analysis of a sample of patients
experiencing more than 3 moves on a quarterly basis. Patients are randomly selected from the higher numbers of moves
and the healthcare records are reviewed to explore the indications, the times and the issues that arise from patients’
moves. The matron team have continued to work with ward managers, their teams and the bed management team in
an attempt to minimise the number of moves a patient experiences, which can result in disruption to communication and
continuity of care. The concept of outlying patients with the Trust still exists within the organisation due to capacity and the
number of patient’s whose discharges are delayed due to complexity and lack of availability of community placements and
services.
It is anticipated and expected that patients will move from wards and departments to receive specialist care, treatment
or diagnostics which is clinically indicated. Currently the Trust has a standard whereby patients should not expect to be
moved more than 3 times during one hospital stay which is reflective of the patient flow processes within Acute Services
however this has been impacted on the integration of community hospitals which would previously have been regarded as
a discharge are now regarded as a transfer as although the patients have moved to another hospital, they remain within the
same organisation.
Emergency and Elective Ward Moves
April 2010 to March 2012
Ward Moves: Emergency Admissions with more than 2
18%
16%
14%
12%
10%
8%
6%
4%
2%
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
Apr 11
Mar 11
Feb 11
Jan 11
Dec 10
Nov 10
Oct 10
Sep 10
Aug 10
Jul 10
Jun 10
May 10
Apr 10
0%
Months
- - Trust Emergency Target
- Trust Emergency Performance
- - Trust Elective Target
- Trust Elective Performance
[Figure 25]
Following the integration of Acute and Community Services within South Warwickshire, processes are being improved and
an early supported discharge service the Community Emergency response Team (CERT) which facilitates a faster transition
for patients back into the community with appropriate support services is being fully implemented across Warwickshire.
During 2011-12 the Trust has seen similar percentages of patients experiencing more than 3 moves but the number of
moves exceeding 3 has reduced from the very high levels of 11, 12 or 13 to a maximum of 7, during the course of the
year. March 2012 did see the lowest number of patients exceeding the 3 moves standard, since monitoring of this patient
experience measure began over 3 years ago. This was in spite of the greatest number of admissions and discharges.
34
Percentage of patient moves
April 2011 to March 2012
Oct 11
Nov 11
2
3
>3
9
4.5
5.5
23
9.5
9
4
3.5
Mar 12
9
64
23
21
4.5
4
Sep 11
1
10
8
5
23
21
64
Feb 12
9
64.5
63.5
Jan 12
23
5
4
64
Dec 11
23
10
10
5
4
May 11
Apr 11
10
8
4
65
65
22
Jul 11
10
23.5
23
22
Jun 11
25
63
62.5
62
Aug 11
65
61
The continued monitoring, publication and
discussion of non-clinical patient moves
has contributed to the development and
very recent implementation of a new
process which includes the appointment
of Elderly Care physicians who lead a team
on wards that previously accommodated
‘outliers’. This new process and way of
working is in its infancy however it permits
patients to be appropriately streamed into
speciality care and transferred from the
assessment unit to a ward which has a
resident consultant to manage their care
until discharge. It is anticipated that this will
have a steady influence on reducing and
potentially eradicating patient movement
around the Trust unless clinically indicated
for diagnostics, intervention or specialist
treatment.
[Figure 26]
Cleanliness
Hospital Cleanliness Trust Performance for Very High
Priority and High Priority Ward Areas
National Hospital Cleanliness Key Performance Indicators
have been met at all four of the Trust’s hospitals on a
continuing basis over the last year.
99%
98%
Each area i.e. wards, departments etc, are categorised into
the following risk group.
97%
Very High Risk – 98%
96%
High Risk – 95%
95%
Significant Risk – 85%
94%
The Trust has a robust monitoring process and the positive
performance is reflected in the patient surveys carried out.
93%
Very High Priority Ward Areas
The National
Cleanliness Survey
Trust Overall Score for Warwick
Hospital, Stratford Hospital, Royal
Leamington Spa Rehabilitation Hospital
and Ellen Badger Hospital
Target exceeded last 3 years
Patient Bedside Survey – Warwick
Hospital and Stratford Hospital, Royal
Leamington Spa Rehabilitation Hospital
and Ellen Badger Hospital
High Priority Ward Areas
Target Performance
2010/11
2011/12
[Figure 27]
Patient Bedside Survey - Question “What is your
experience of the cleanliness of the ward you are in?”
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
-
2010/2011
-
2011/2012
Every month during the financial year 2010/2011 and 2011/2012, over
90% of inpatients thought the cleanliness of their ward was either good
or very good.
Mar
Feb
Jan
Dec
Nov
Oct
Sep
Aug
Jul
Jun
May
87%
Apr
Question “What is your experience of
the cleanliness of the ward you are in?”
[Figure 28]
35
Patient Environment Action Team
(PEAT)
Formal PEAT inspections were carried out in February 2012 at Warwick, Royal Leamington Spa Rehabilitation, Ellen Badger
and Stratford Hospitals. The PEAT teams consisted of representatives from the Trust’s Hotel Services Team, the Associate
Director for Support Services, Director of Nursing, Matrons, Infection Prevention, Dietetic Services, Trust Estates staff and
3 management representatives from G4S Integrated Services (the Trust’s service provider for Domestic, Catering, Portering
and Security services at Warwick and Stratford Hospitals). There were also 3 independent members from the Stratford and
Warwick Patient Forum and representation from Local Involvement Networks (LINKS). At each hospital the team was also
accompanied by an external validator.
The Trust has close connections with both LINKS and the Stratford and Warwick Patient Forum. Members of both
organisations have been involved in the PEAT process for many years and once again this year we were again fortunate
that members were able to join the team along with one of the Trusts Governors. This input is of huge value, giving
reassurance that the formal PEAT assessment and scoring process carried out, meets the full requirements set out by the
NHS Information Centre.
The Patient Environment Action Team (PEAT) programme is an annual self assessment process. In 2000 the programme
was initially established to assess NHS Hospitals quality standards relating to cleanliness, the environment and food. Since
2006 the system has been regulated and managed by the NHS Information Centre.
Under the programme every inpatient NHS facility with more than 10 beds must be assessed annually and given a
rating against a set of standards to achieve a score of excellent, good, acceptable, poor or unacceptable. The scores
demonstrate how well individual healthcare providers believe they are performing in key areas such as cleanliness, food,
infection prevention and privacy and dignity. After applying the weighting element to the cleanliness/environment score, the
following results can be used as a guide until the NHS Information Centre officially publish formal PEAT scores for all Trusts
in June/July 2012.
Warwick
PEAT score
Hospitalachieved
Royal Leamington Spa
rehabilitation Hospital
Cleaning/ Condition & appearance Good
Cleaning/ Condition & appearance Food and Hydration
Good
Food and Hydration
Excellent
Privacy and Dignity Good
Privacy and Dignity
Good
PEAT score
achieved
Good
Stratford
PEAT score
Hospitalachieved
Ellen Badge
Hospital Cleaning/ Condition & appearance
Good
Cleaning/ Condition & appearance
Food and Hydration
Good
Food and Hydration
Excellent
Privacy and Dignity
Good
Privacy and Dignity
Excellent
36
PEAT score
achieved
Good
Nutrition and Hydration
The chart below highlights the results for the catering surveys carried out at Warwick and Stratford Hospitals. In total 1281
responses were received.
Surveys are distributed and completed by inpatients randomly selected across all wards. On average 87% of in-patients
felt the service they received was either excellent or good.
Overall rating of Food (Excellent/Good) Warwick & Stratford Hospitals
100
90
Percentage
80
70
60
50
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
Apr 11
40
Months
[Figure 29]
The chart below highlights the results for the catering surveys carried out at Royal Leamington Spa Rehabilitation Hospital
and Ellen Badger Hospital. In total 296 responses were received
Surveys are distributed and completed by inpatients randomly selected across all wards. On average 84% of in-patients
felt the service they received was either excellent or good.
Overall rating of Food (Excellent/Good) Royal Leamington Spa & Ellen Badger Hospitals
100
90
70
60
50
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
40
Jun 11
Percentage
80
Months
[Figure 30]
37
The Trusts Hotel Services Team and Matrons continue to focus on improving the overall patient meal experience. At
Warwick Hospital the emphasise has been particularly around food temperatures with the focus on boosting the meal
trolleys after the meals have been loaded just prior to the trolley leaving the Catering Dept. This process has shown a heat
retention benefit of around 4 -5C. We continue to monitor portion sizes, the quality of food provided to patients and we are
working closely with Ward Managers and staff to improve the meal service delivery at ward level.
The menus for Macgregor ward (Paediatrics) have been revised and now provide a wider choice of menu items. This was
in response to feedback received from patients and parents around certain dishes. New menus were introduced at the
beginning of November and have been well received.
Earlier in the year there were concerns relating to what options were available if a patient missed the meal trolley or there
was no meal for that particular patient. G4S continue to provide hot food options from the restaurant for patients that
require a hot meal. The snack box option is also still available.
Re-training for all healthcare cleaning staff in the use of the patient diet strips and notice boards above the patient’s beds was
completed during 2011/12. Competent checks are carried out by G4S Managers and Supervisors on an on-going basis.
Comments were received from patients and following audits that the food at the Ellen badger Hospital was not as hot
as liked, this has been addressed (April 2012) and now food is plated at ward level. Further work is planned to change
the lunch meal service from 12 noon to 12.30pm. This is also following comments received on the patient catering
questionnaires. This change in meal time will also mean that there will be more nursing staff available to help with the meal
service.
There have been concerns from the patients on Campion ward at the Royal Leamington Spa rehabilitation Hospital
regarding choice on the menu. Although there are separate menus available for patients to suit individual requirements,
these had not been offered on the ward. However, this has been resolved and improvements in surveys results from
December 2011 have been noted.
At all hospitals, some of the choices on the patient menus have been changed to reflect comments received either after
discussion with patients, from patient surveys or from discussions with ward staff.
G4S have recently achieved BS 22000 for Food Safety & Hygiene.
All the hospitals have also retained the Gold Award for Food Hygiene and safety awarded by Warwick District council.
Visiting Hours
In October 2011 we changed our visiting hours at Warwick Hospital, these changes were made after feedback the previous
year from staff, visitors and patients. Our new visiting times allow visitors to get involved with the Trust’s ‘let’s do lunch’
campaign, where visitors are encouraged to come into the hospital and help support their loved ones to eat their lunch
Lets Do Lunch Campaign
International nurses day saw the launch of our “Let’s Do Lunch” campaign, the opportunity to highlight the benefits of
good nutrition in hospital and to promote the good practice of helping patients to eat their lunch. As part of this campaign
staff welcomed patient’s families and friends to come and sit with the patient to eat lunch and watch the busy lunchtime
round and our Executive Directors helped nursing teams to deliver lunches and tested the food themselves, which is freshly
prepared in onsite kitchens to ensure that the Trust is providing nutritional meals.
We involved Age UK who hosted a stand highlighting the ‘seven steps to better nutrition in hospital’, part of its ‘Hungry to
be Heard’ campaign. The ‘seven steps’ was created to help tackle the issue whilst highlighting the concern to the nursing
profession as well. The Trust is already implementing the ‘seven steps’ process.
Tea for Two
In October 2011 the Trust introduced ‘Tea for Two’ into some of the wards. This scheme encourages nursing staff to sit and
chat with the patient and have a cup of tea with them. Often patients perceive that nursing staff are generally ‘too busy’
to disturb, but this initiative allows time for patients to talk about anything they like and sometimes the patient will share
worries and anxieties that they otherwise would not express. The scheme has been well received by patients and staff alike
particularly in our wards that have predominately elderly patients who sometimes do not have many visitors.
38
Outpatient Booking Service
Improvement
Outpatient Booking Services over the last year have continued to focus on the issues that matter most to patients,
challenging Managers and Clinicians to improve the Patient Experience. The key areas for improvement to be addressed
in 2012-13 will be to continue to communicate better using a range of media and to further reduce the number of
appointments rescheduled, particularly Short Notice Cancellations .
Communication has improved during the year with an increase in the number of patients using e-mail to cancel or change
their appointments. We also use text reminders, sent out 7 and 3 days prior to appointments, for those patients who have a
mobile phone. This is a useful tool where occasionally an appointment letter has not been received. In addition the booking
centre staff endeavour to contact patients by telephone where short notice appointments, changes or cancellations are
necessary, only sending a letter as a last resort.
Building on last years much improved booking centre response times the target of 90-95% of all calls answered has been
achieved in 2011-12, a 5% improvement on 2010-11.
A project has been implemented to use partial booking for follow up appointments rolling out to all specialties by the
middle of 2012. This system invites patients to contact the hospital approximately six weeks in advance of their expected
appointment date to negotiate the date and time of their appointment. This initiative is expected to reduce the number of
patients who forget or do not attend their appointment and also reduce hospital initiated reschedules.
The Trust is looking at further initiatives using new technologies to make processes more efficient offering patients
continuous improvement when booking and attending an outpatient appointment.
39
Patient Outcomes
Hospital Mortality Rates
In the last year, our overall mortality rates remain within the average range for NHS Trusts in England. A variety of mortality
indicators have been developed which use different methods to adjust for differences in age, gender, time range and
palliative care coding. Trends for SWFT are similar on all these measures and continue downward.
0.0
0.00%
Months
-CHKS RAMI
40
- - Estimated Rebased RAMI
- NEL Age 65+ Mortality
[Figure 31]
- Criude Mortality
Mortality Rate
2.00%
Feb 12
20.0
Dec 11
4.00%
Oct 11
40.0
Aug 11
6.00%
Jun 11
60.0
Apr 11
8.00%
Feb 11
80.0
Dec 10
10.00%
Oct 10
100.0
Aug 10
12.00%
Jun 10
120.0
Apr 10
14.00%
Feb 10
140.0
Dec 09
16.00%
Oct 09
160.0
Aug 09
18.00%
Jun 09
180.0
Apr 09
RAMI (Risk Adjusted Mortality Index) (100=”Expected” Rate)
SWFT Mortality Index Measures
What we have done
Within our different specialities, we compare well in most areas, however there are concerns about our mortality rates in
people with some respiratory and cardiac conditions. Detailed case-note reviews have been undertaken in these areas and
the CQC are satisfied with the steps we have taken to address these concerns.
We have strengthened our systems for mortality surveillance and review of deaths, including the use of the global trigger
tool (GTT) ensuring that all deaths are subject to scrutiny, to provide the Clinical Governance Committee and the Board of
Directors with greater assurance about mortality.
Summary Hospital - level Mortality Indicator (SHMI)
SHMI is the ratio between the actual number of patients who die following a treatment at the Trust and the number that
would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.
It covers all deaths reported of patients who were admitted to acute, non-specialist trusts and either die while in hospital or
within 30 days of discharge.
The data used to produce the SHMI is generated from data the Trust submits to the Secondary Uses Services (SUS)
linked with data from the Office for National Statistics (ONS) death registrations to enable capturing of deaths which occur
outside of hospitals. Additional contextual indicators are also published alongside the SHMI to add some context to the
interpretation of the SHMI.
How to use the SHMI
The SHMI requires careful interpretation, and should not be taken in isolation as a headline figure of trust performance.
The SHMI is an indication of whether individual trusts are conforming to the national baseline of hospital-related mortality.
Mortality within a trust is described as either ‘as expected’ as, ‘lower than expected ‘or ‘higher than expected’ All trusts are
encouraged to explore and understand the activity which underlies their SHMI from their own data collection sources.
The Trust’s latest SHMI value for the 12 months ending Sept 2011 is 1.10. This is unchanged from the previous quarter’s
figures and this is “as expected” To compliment SHIMI the Trust also reviews routinely Dr Foster intelligence, Hospital
Standardised Mortality Rates and conducts a multidisciplinary reviews of case notes. In utilising this data the trust
continually monitors patients in high risk groups that present with Acute Myocardial Infarction, COPD and Heart Failure.
Following an early warning alert in June from the West Midlands Strategic Health Authority for patients at this Trust with
COPD and Bronchietasis, we undertook further case note reviews. It is from this process that the Trust strengthened its
current arrangements in the clinical management of these vulnerable groups of patients by implementing new pathways of
care by ensuring early access to the Intensive Therapy Unit and critical outreach teams.
The Trust has an established Mortality Surveillance Committee and is chaired by the trust’s Medical Director, who also
provides quarterly reports to the Board.
41
Global Trigger Tool
Twenty sets of records are reviewed on a monthly basis relating to patients who have been admitted to the Trust for a
minimum of one day and a maximum of thirty days. Triggers are grouped into categories (see below) and when identified in
the medical records, each trigger is assessed to see if they have caused the patient harm – the harm is graded as follows:
Category E
Contributed to or resulted in temporary harm to patient and required intervention
Category F
Contributed to or resulted in temporary harm to patient and required initial or prolonged hospitalisation
Category G
Contributed to or resulted in permanent patient harm
Category H
Required intervention to sustain life
Category I
Contributed to patient’s death
[Table H]
Harm events are predominantly in the first two categories E & F and relates to the impact of the trigger on the length of the
hospital stay. The rate of harm identified through the note reviews ranges from 0.0 to 3.7% and the summary of triggers /
harm events is as follows (since April 2010):
Trigger Category
Event Category
General
Care
Surgical
Care
Intensive
Care
(ITU)
Medication Lab Test
Total
E
F
G
H
I
Total
Length Rate of
of stay harm
(days) (%)
90
5
9
3
187
62
34
1
1
0
98
5678
80
1.7
[Table I]
The majority of triggers relate to three main categories:
General care – Readmission of patients within 30 days
Failure to respond to early warning score
Further work is being done to develop a specific work stream to address these events.
42
Process to Improve Emergency
Medical Admissions
In March 2012, the Trust completed a three year Acute Flow Programme, which had been focussing on improving
emergency care for our patients. A key aim of the programme was to provide our patients with a safer and better
experience by removing unnecessary delays from their hospital stay and by making sure we have the right staff and
systems in place to deliver care appropriate to each patient’s needs.
Over the past year, we have introduced a number of changes which have meant that we can now see emergency patients
more quickly and many patients are able to return home sooner.
What have we done?
• Early assessment,
diagnosis and decision
making by senior doctors
– Our emergency doctors
have changed how they
work so that they are
available to see patients
throughout the day rather
than at fixed rounds in
the early morning and
evening
– Our on-site laboratory
is now turning round
85% of blood tests in 1
hour so that results are
available for doctors more
quickly
• Ambulatory emergency
care
– We have developed ‘outof-hospital’ pathways
for a set of emergency
conditions
– Patients with these
conditions receive tests
and scans within 24hrs
– The majority of these
patients can be
discharged home
early with booked
appointments to come
back for any follow up
care they need
What have we
achieved?
Our plans for the
coming year include
Between September 2011
and March 2012
• The management of more
emergency conditions
through the Ambulatory
Emergency Care Unit
• We have supported 317
individual patients to
receive their emergency
care without having to
stay in hospital
• These patients have been
seen on an outpatient
basis in the Ambulatory
Emergency Care Unit
which has provided
over 800 separate clinic
appointments
• We have avoided in the
region of 15 admissions
per week releasing beds
so that we can continue
to see our growing
emergency demand
– We are now managing the
majority of patients with
the conditions Deep Vein
Thrombosis, Pulmonary
Embolism and Cellulitis
through our Ambulatory
Emergency Care Unit
• Extending the Ambulatory
Emergency Care Clinics
to run on weekends as
well as weekdays
– “Specialty Response”
– Medical specialist
consultants and nurses
are changing how they
work so that they have
time available every
weekday to see new
emergency patients in the
Emergency Assessment
Unit
– The specialty can then
respond to patients
referred by the acute
medical team and pull
them into the right ward
environment if they
require further specialist
care.
What will we achieve?
• On weekdays, new
emergency patients
needing either a
Cardiology, Respiratory,
Gastro-enterology
or Elderly Medicine
assessment will be seen
by the right consultant
within 24hrs
– Where it is clinically
appropriate, patients
can be discharged
home early with booked
appointments to come
back for any follow up
care they need
– For patients with specific
conditions, we will
develop more Fast- Track
pathways so that patients
can be admitted directly
to the specialist ward
from home or from A&E
– to add to the pathways
for acute coronary
syndrome and stroke that
are already in place.
– For cardiology patients,
we have developed
a Fast-Track cardiac
assessment area where
patients get a full set of
tests from a one-stop
service
43
Readmission Rates
Readmissions are an indicator of the effectiveness of clinical care and the discharge process. Readmissions are monitored
for patients who are readmitted as an emergency to the hospital within 28 days of discharge form our care. A high
readmission rate could be an indictor of either poor quality care or poor quality discharge necessitating readmission to
hospital.
The Trusts admission rate has traditionally been low as compared with trusts of a similar size and case mix. Our own year
on year trend has increased.
Emergency Re-Admissions Within 28 Days of Discharge
April 2009 to February 2012
9.00%
300
250
7.00%
6.00%
200
5.00%
150
4.00%
3.00%
100
2.00%
50
1.00%
0
2009/2010
- Re-Admissions as % Total Admissions
- - Clinical Peer Group Average
2011/2012
Mar
Jan
Feb
Dec
Oct
Nov
Sep
Jul
Aug
Jun
Apr
2010/2011
May
Mar
Jan
Feb
Dec
Oct
Nov
Sep
Jul
Aug
Jun
Apr
May
Mar
Jan
Feb
Dec
Oct
Nov
Sep
Jul
Aug
Jun
Apr
0.00%
May
Percentage of Re-admissions
8.00%
[Figure 32]
- Number of Patients Readmitted after 28 Days
What we have done
We have commenced an audit of readmissions to identify any areas for improvement
The Discharge co-ordinators continue to provide support to families and patients during the discharge process to ensure
the process is of high quality and that there is appropriate and timely communication between the Trust and external
agencies. Alongside the discharge co-ordinators considerable work has been done in improving the discharge pathways as
detailed later in the report.
44
Improving the Discharge Pathway
What we have done:
The discharge planning team have a dedicated database for the sole purpose of recording and monitoring all complex
patient discharges. This allows the Trust to identify trends and local delays, whether internally or externally by other
organisations and allows solutions to be jointly explored by both health and social care, at a weekly meeting discussing
complex cases.
The team continue to provide education and training to all Trust staff, through the ‘Essentials for Nursing Day’, dedicated
training days for ward staff to attend, and on the wards. The Discharge Planning Team welcome any staff members or
teams to shadow the team and the Intermediate Care Team based in the South have recently taken this opportunity.
Building on from the close collaboration with social care, for patients that require the same level of support in the form of a
package of care on discharge as they did prior to admission, not to be reassessed by a social worker, as long as they were
discharged within 7 days of admission, has been extended to 10 days. Can probably get you some data here on impact
Following on from the pilot for ward attached social workers last year, this has now been fully implemented to ensure
effective multi-disciplinary team partnerships.
We have implemented the ‘Cutting the Cost of Frailty’ project in the Stratford locality and have started to roll this out to
both Leamington and Warwick. The ethos being that for most frail, elderly patients assessments in their own environment
(homes) tends to be more accurate and effective than those completed in hospital, with better outcomes for both the
patients and families involved.
A new ‘acute geriatric take’ service has commenced for frail elderly emergency admissions involving the A&E Observation
Unit, Fairfax and Nicholas ward from Monday to Friday. This has 2 streams, that ensures elderly patients are not kept in
a hospital environment any longer than clinically necessary. This has been achieved by designated Care of the Elderly
Consultants being responsible for the clinical management plan whilst collaboratively working with a strong, skilled multi
disciplinary team in determining whether a short/medium or longer length of hospital stay is required, as well as exploring
all the available options and services for a safe, timely discharge, such as the CERT team to support rapid discharge home.
The chart below sets out the progress to date.
Acute Delayed Discharges - Calculated as a Percentage of Occupied Beds
120
10.0%
110
9.0%
8.0%
90
7.0%
80
70
6.0%
60
5.0%
50
4.0%
40
3.0%
30
2.0%
20
 Delayed Patients
Months
- Target
Mar 12
Feb 12
Jan 12
Dec 11
Nov 11
Oct 11
Sep 11
Aug 11
Jul 11
Jun 11
May 11
Apr 11
Mar 11
Feb 11
Jan 11
Dec 10
Nov 10
Oct 10
Sep 10
Aug 10
0.0%
Jul 10
0
Jun 10
1.0%
May 10
10
Apr 10
Number of Delayed Patients
100
[Figure 33]
 % Delayed
45
Next Steps:
To implement the discharge database to the community hospitals in the South of the county.
Work with Social care to look at reducing the reassessment time by local Residential Homes commissioned by the Local
Authority, which can be up to 72 hours in order to reduce unnecessary prolonged hospital stays for many patients waiting
to return to their Residential Home (their usual place of residence).
In conjunction with the Local Authority (Social care team) to determine a pathway for the discharge team to refer
directly into ‘reablement’ to ensure a timely discharge and prevent irrecoverable loss of independence for many patients
by a prolonged hospital stay. This supports the ‘Trusted assessment’ principle and eradicates duplication of patient
assessments by health and social care.
Work with commissioners to establish whether it is feasible to provide alternative suitable care settings for patients awaiting
eligibility assessments for Continuing Health Care.
To assist the Trust in meeting the new initiative / standard of ‘Home for Lunch’ to help all patients and their families plan
effectively for discharge from hospital.
To continue to improve patient information pertaining to discharge from hospital, including updating the Trust website for
both families and patients to access. To clarify both what patients can expect from the Trust and what the Trust expects
from patients and their families when planning for discharge.
46
Transformation Programme
Why the Transformation Programme was developed
Following the integration of Community Services with South Warwickshire NHS Foundation Trust (SWFT) in April 2011
and vertical collaboration in the North of the County, SWFT aims to reduce the overlap between hospital and community
services and strengthen collaborative working with Primary Care.
Through integration, supported by an owned transformation programme, SWFT will demonstrate how effective such
integration can be to deliver quality, productivity and financial benefits.
There are currently 7 areas being reviewed and developed within the Transformation Programme as detailed below:
Transformation Programme Structure
Transformation
Transformation
Programme
Board
Programme Board
Transformation
Transformation
Programme Manager
Manager
Programme
Care of Older
Care
People of
Older
People
Long Term
Long Term
Conditions
Conditions
MSK
MSK
Stroke
Rehab
Transformation
Transformation
Programme
Office
Programme
Office
Technology
Ambulatory
Stroke
Workforce
Ambulatory
and Workforce
Care
Technology
and
Rehab
Integration
Care
Communications
Pathways
What have we done?
A number of our pathways have been redesigned which has
integrated the teams based in the hospital and those out in
the community. For patients this will improve the way that
they move through the system.
For our older patients and for those who have long term
conditions, the continued development of services both
in hospital and in the community will mean that they
should only need to come in to hospital if it is identified
that hospital is the best place to be, and that as soon as
they are well enough to be discharged, there are services
in the community to support them in their usual place of
residence and maintain their independence. Similar work is
now underway for Stroke Services.
Work has taken place to develop Emergency Ambulatory
Clinics for patients who require a review and/or treatment,
but do not need to stay in hospital. This may include
diagnosis, observation, treatment and rehabilitation.
For patients who need to access care for pain in their
knees, hips, shoulders, feet and ankles (MSK project) a
review of how patients are able to access treatment options
Communications
Integration
Pathways
has taken place. GPs, Consultants and clinical staff have
worked together to refine the way care is delivered to
minimise inconsistencies in referrals to the service, remove
duplication of diagnostics tests and reduce the waiting
times for both outpatients and diagnostic tests.
The changes to patient pathways through the
transformation work streams will create different
requirements for community and hospital based staff,
leading to different ways of working. The aim of the
Workforce Integration Project is to allow us to deliver
community services that are universal, integrated and easier
to access, coupled with this the implementation of mobile
working solutions will free-up more capacity.
Next steps
Each of the projects is monitored through a robust
governance structure, with a dashboard to report on
progress against key milestones and identified benefits to
keep the Programme on track. Building on the successful
integration of Community Services in to SWFT, as further
areas for development and improvement are identified, they
will be added to the Transformation Programme.
47
Virtual Wards
Virtual Wards are now operational in, Leamington, Nuneaton and Bedworth North Warwickshire, Rugby and Alcester.
The key performance indicators for the Virtual Wards have focused on managing patients with one or multiple long
term conditions in the community through an integrated health care pathway. This has prevented unnecessary hospital
admissions (Charts 1 and 2) and has also enabled the safe and timely discharge of patients from acute hospitals.
All of the Virtual Wards have seen an increase in activity
as they have evolved and responded to develop new
service models of care. Following the closure of Bramcote
Community hospital in 2011, the North Virtual Ward
has been involved in facilitating the early discharge of
patients, working closely with the George Eliot Hospital,
the Intermediate Care Team and other health and social
providers to look at opportunities for re-enabling those
patients to return home. The team has become engaged
in the development of a self care model of health through
the “Simple Telehealth pilot”. This allows individuals to
monitor their own health care status but when there is a
significant exacerbation of their symptoms the team are
able to respond quickly and provide a clinical management
plan to treat the patient in their own home, leading to better
outcomes for patients. The results of patient satisfaction
surveys indicate the difference the Virtual Wards have made
to the patients’ quality of life outcomes in terms of their
experience of accessing the Virtual Ward and being able to
have some control over the management of their long term
condition.
Virtual Wards Admissions Avoidance
April 2010 - March 2011
VW North
VW South
VW Rugby
[Figure 34]
Patient Satisfaction Survey
Yes
No
Unsure / Left Bank
Do you feel the Virtual Ward Service has benefitted you?
94%
Did you receive a Welcome leaflet and appointment on your first
visit?
83%
Were you involved in the planning of you care?
11%
2% 6%
94%
Do you feel more confident / able to manage your condition /
illness?
4% 2%
87%
Do you feel more knowledgeable about your condition / illness
2%
92%
Do you feel the VW service has helped with your general health
and peace of mind?
10%
4% 5%
4% 2%
94%
Do you know how to contact the VW team if your condition
changes following discharge?
Overall, do you think you have spent less nights in hospital
6%
92%
Do you feel all of your care needs have been met?
Have you been admitted to hospital whilst in the care of the
Virtual Ward
3% 3%
4%
79%
30%
5%
66%
67%
17%
1%
32%
[Figure 35]
48
Increasing Breast Feeding Rates
What We Have Done
A significant number of staff in the hospital and community have received comprehensive training in breast feeding.
Both the acute and community service achieved level 1 accreditation during 2011-12 and the trust is now working towards
level 2 assessment. Audits are being undertaken to ensure that staff have required knowledge and skills to support
successful breast feeding in preparation for the Level 2 assessment which will involve UNICEF BFI assessors visiting both
the hospital and community setting in the autumn to interview staff about their knowledge and skills.
In addition to this the staff working in the Special Care Baby Unit are participating in an exciting project that assesses staff
knowledge of breast milk expression, breastfeeding, kangaroo care and positive touch for premature babies.
This will provide a rapid and objective assessment of the knowl¬edge of the staff, enable the maternity department to
target educational and professional development programmes most effectively on the topics and on the staff that most
need it.
Energise for Excellence E4E
What We Are Doing
E4E is a national ‘Call to Action’ launched by the Department of Health in 2011, with the aim of providing a framework
and tools to re energise nurses and midwives to deliver high quality care. Five key areas for delivering excellence were
developed under the E4E umbrella:
The Trust used the launch of E4E as an opportunity to highlight the great work that different teams are doing under the E4E
umbrella, and, in November 2011, members of the Board went out to different areas across the Trust to support the work
that is going on:
49
Getting Staffing Right
Staff Experience
In 2011/12 the Trust continued to invest in getting staffing
levels right in all of its areas, in response to national
maternity and paediatric standards, and results from its
analysis of ward staffing levels, using the Association of UK
University Hospitals’ measuring tool. An electronic rostering
system and improved temporary-staff booking tool was also
introduced, which is moving the Trust towards increased
efficiency in staff cover, ensuring that there are always the
‘right staff, in the right place, at the right time’. The Trust
continued to respond to changes in the supply and demand
for staff through, for example, expanding its teams of
medical nurse practitioners and health visitors and providing
opportunities for staff to train as assistant practitioners.
Work continued in 2011/12 to enhance the experience of
staff working in the Trust, this included: staff engagement
workshops with the Chief Executive, an internal leadership
programme for senior managers, on site exercise
classes, psychology and occupation health services, self
development workshops, training opportunities, increased
parking spaces, child care vouchers, and flexible working.
Monthly monitoring and support in relation to sickness
absence and appraisals continued, with the annual Trust
sickness rate approximating 4.5%, and the appraisal rate
51%.
Deliver Care and Measure Impact
In 2011/12 the Trust continued in its work to deliver
excellent care to patients and measure its positive effects.
The key principles of the Productive Ward – ‘Releasing
Time to Care’ continued to be adopted in acute wards, and
community hospitals, with particular emphasis on improving
information about patient status, through the use of flat
screens, and efficient storage of ward stocks and delivery
of meals. Essence of Care, High Impact Actions and Nurses
Care Indicators are all audits and programmes that have
continued to be used to emphasise and measure the key
aspects of basic nursing care which include; pressure
ulcer care, nutrition, hydration, preventing falls, discharging
patients, promoting normal birth, choosing where to die,
preventing infections, administering medications, carrying
out observations, communication, record keeping, personal
hygiene, privacy and dignity, and protecting vulnerable
patients.
Patient Experience
Patient experience continued to be given a high priority
in 2011/12. Measurement of this was through; patient
surveys at the bedside, surveys by nursing staff, the Trust’s
catering contractors, and the Patients’ Forum; complaints
analysis and monthly reporting; departmental patient
surveys on discharge and the annual National Inpatient
Survey.
Also, a new format for collecting patient feedback was
introduced - the ‘Smiley Face’ postcards. Monthly reporting
of mixed sex accommodation is another measurement of
patient experience that continued in 2011/12 and patient
stories were heard at Board of Directors Meetings. Patient
experience was also used as a key part of redeveloping
services, such as the community wheel chair services,
through the process of ‘Experience Based Design’.
50
Positive staff experience was reflected in the 2011 National
NHS Staff Survey, which reported that: more SWFT staff
are satisfied with their job in comparison to the majority
of other Trusts in England; the Trust is among the best in
relation to staff feeling valued by colleagues; and an above
average number of staff agreed that they felt satisfied with
the quality of work and patient care that they were able to
deliver. Further analysis of the staff survey results can be
found in the Annual Report.
Staff Pledges
Staff Pledge 1 relates to clear roles and responsibilities and
rewarding jobs. 77% of our staff, responding to questions
in the national staff survey reported feeling satisfied with the
quality of work and patient care they were able to deliver.
This was a slight improvement on last year’s good score
and puts us in the “better than average” category. 93%
of our staff, responding to questions in the national staff
survey agreed that their role makes a difference to patients.
This was an improvement on last year’s good score and
puts us in the top 20% of Trusts.
There are 6 questions in the national staff survey which
relate to Staff Pledge 2. In 3 of the 6 the Trust scored in
the top 20% of Trusts. In only one was the result below
average. This related to percentage of staff who reported
having had an appraisal in the last year. In this category,
the Trust had increased its performance over the previous
year but, at 78%, was still below the average of 81%. This
continues to be a focus for the Trust and an action plan
is in place to support an improvement in the coming year.
However, the Trust was in the top 20% of acute Trusts
who support staff to develop their potential at work and
also in the top 20% of Trusts for staff receiving job relevant
training, learning or development within the last 12 months.
In addition, the Trust is identified as the top acute Trust
in the country for providing equal opportunities for career
progression or promotion.
In relation to Staff Pledge 3, the Trust’s scores were similar
to last year with the Trust in the best 20% in relation to staff
reporting suffering a work related injury or work related
stress in the last 12 months. Staff responses relating to
the impact of their health and wellbeing on their ability to
perform their work were also, similar to last year, and in the
best 20% category.
Planning and Developing the Workforce
Health and Wellbeing
The 7 key learning and development objectives set in March
2011 have been achieved. The creation of a Trust Learning
Board in February 2012 has provided both an operational
and strategic focus to achieving a co-ordinated approach to
the commissioning and delivery of Education, Learning and
Development to support delivery of the Trust objectives for
the development and delivery of services.
A Health and Well-being Group has been established to
oversee health and well-being initiatives across the Trust,
with membership from acute and community staff and
their representatives. The Group monitors training for staff
in managing stress, and has integrated revised sickness
and stress management policies for the new organisation,
and reviewed the results of the 2011 national staff survey.
Our Dignity at Work guidance has also been reviewed
and harmonised, in consultation with staff and their
representatives.
The Trust is one of 64% of acute hospitals in England and
38% of Community providers to
have achieved a green RAG rating for readiness for
revalidation of doctors.
Robust workforce planning supports the Trust’s strategy
with all new developments including a detailed workforce
plan which includes detail of numbers as well as required
skills.
During the past year, the Trust has implemented a new
system to support better utilisation of our temporary staff.
In addition, a project is in place to implement an electronic
rostering system which will ensure the most appropriate and
effective utilisation of our workforce.
Turnover, absence and vacancy information is monitored
on an ongoing basis to support a robust understanding
of where there are gaps so that appropriate action can be
taken.
During 2011 the Trust had two external quality assurance
visits from the West Midlands Deanery. These were for
Foundation Year and Emergency Medicine doctors. Both
reports were favourable.
Leadership
During the year, the Trust provided a Leadership
Development Programme for senior clinical and non clinical
staff. The programme, facilitated by Keele University,
focussed on the principles of leadership and involved
work on integrating the clinical and non clinical teams,
negotiation skills, creativity and quality metrics. Evaluation
from the programme was positive and the Trust will continue
to support the positive momentum generated, by arranging
further sessions later in the year to consolidate the learning.
The output from the 2011 Staff Engagement programme
and the results of the2011 staff survey will help to inform a
wider leadership programme which will be delivered to all
line managers during 2012. Further detail can be seen in the
Annual Report.
Undergraduate medical students from the University of
Warwick have continued to supply excellent feedback on
the teaching and support that they receive at the Trust.
Staff Engagement
The Trust places engagement with staff and partnership
working with our Trade Union and Staff Side
Representatives as a priority. Both the Joint Negotiating
and Consultative Committee and the Local Negotiating
Committee meet regularly, are chaired by the Chief
Executive, and provide a forum for formal negotiation,
consultation and communication. In the autumn of 2011
the Chief Executive led a programme of engagement events
with front line staff.
51
High Impact Actions (HIAs)
In 2010, eight HIAs were identified by frontline nurses and midwives across the country as key areas which have a major
impact on the quality and efficiency of patient care. During 2011, the Trust organised a training event which highlighted the
importance of these HIAs. Two of these HIAs are reported on separately in this quality report; pressure ulcers and falls, the
remaining HIAs are summarised below:
What We Are Doing
Keeping Nourished:
Over 90% of our patients, who need assistance with food and drink, reported that their experience of being assisted
was good or very good and over 90% of our patients were nutritionally assessed. Patients reported that they were
87% satisfied with the food that they were served. During 2011/12, we extended our visiting hours to encourage visitor
participation at meal times; and continued with initiatives to ensure that all of our patients were adequately nourished and
hydrated: protected mealtimes, red trays for patients who need help, mealtime volunteers, red jugs, dietician reviews,
improved fluid monitoring, improved thickeners, weekly weights, nutritional supplements for all patients who need them,
regular patient surveys and regular audits.
Promoting Normal Birth:
The Trust’s Caesarian section rate remained at or below the standard of 25%. The Trust has managed to achieve this
through following the Kings Fund Safer Birth Programme, continuing audits of all deliveries and the success of midwife led
‘vaginal birth after C section clinics’.
Dying in the Place of Your Choice:
A new version of the End of Life Care Pathway was introduced across the Trust, which includes an emphasis on working
with patients and their families to choose their place of death. A regional wide collaboration, to facilitate this choice,
continued its work in 2011/12, as did the Trust’s Palliative Care Team and MacMillan Nurses. Training about End of Life also
continued across the Trust.
Fit and Well:
The Trust scored very highly in the 2011 National Staff Survey and continues with its health and wellbeing programme
for staff. The Human Resources Team continued to support mangers to manage their staff with frequent and long term
sickness. The sickness absence rate was close to the Trust’s target of 4%. The Trust continued its monitoring process to
ensure safe staffing levels across the Trust and introduced new computer systems to improve the reporting, rostering and
efficiency of staffing.
Ready to Go:
Nurse led patient discharges continued to increase in 2011/12 through the increased number of nurse practitioners,
introduction of new ambulatory care pathways and community nurses starting to administer intravenous therapy to patients
at home. Improved communication about patients expected discharge dates and referrals related to discharge, through the
introduction of increased auditing and a new mobile phone and flat screen communication system – Hospital Heartbeat,
has also helped.
Reducing Urinary Tract Infections:
The Trust has addressed this HIA through reducing the use of urinary catheter rates, as this has a strong link with rates
of bladder infections. During 2011/12, the Trust increased its auditing of catheters, increased the profile of reducing
catheter rates, introduced a catheter care bundle to promote good practice and improved collaboration with its community
continence team and the acute wards. This has resulted in a decrease in the rate of catheter use from 24% to 12%.
52
Essence of Care
In 2011 SWFT recognised that there were three essential nursing areas that we were not benchmarking and were not
included in the essence of care. The purpose of benchmarking is to identify where education is needed and celebrate best
practice. It was for these reasons we decided to develop 3 new benchmarks: falls, safeguarding and safety in medications.
We wanted to ensure that clinical practice reflected policies and procedures and also mirrored best practice in the NHS.
Benchmarks are issued monthly and teams complete and return them to be issued with a RAG (Red, Amber and Green)
rating. Best practice is celebrated through a monthly newsletter and teams can share ideas on how to improve their
practice.
Compliance
Some areas with movement of staff have not completed all of the benchmarks for 2011 but they are being supported to
train new staff in how to complete the benchmarks.
Essence of Care Compliance 2011-12
120
80
60
40
20
Willoughby
Womens Unit
Victoris
Theatres
Swan
SCBU
Squire
Physiotherapy
Occupational Therapy
OPD
Oken
Nicholas
Nichol Unit Stratford
Mary
MIU Stratford
Malins
Machen
Macgregor
ITU
Labour
Guy
Hatton
GUM
Farries
Fairfax
Endoscopy
DSU
Colposcopy Unit
Charlcote
Castle
Coronary Care
Beaumont
Aylesford Unit
Avon
A&E + Obs
0
23 Hour Ward
Score Percentage
100
Departments
100% Compliance
70% - 90% Compliance
<70% Compliance
[Figure 36]
53
Care of our Older Patients
Objectives 2011-12
• To improve systems and processes to reduce mortality rates
• To improve the discharge pathway both in the Trust and with partner agencies
• To reduce the number of patients delayed in hospital when their need for a hospital environment is complete
• To redesign the process for emergency medical admissions leading to faster safer care
• To implement a pathway for the care of patients with dementia in hospital
What we have done?
Next steps
Initiatives:
1.Dementia Care Strategy
1.Cutting the Cost (human and financial) of
Frailty: the principles of the scheme are:
• Choose to admit
• Discharge to assess
• Old Age Specialist care in hospital
• Comprehensive Geriatric Assessment in
post-acute care
The pathway for care of our older patients
has been redesigned. New community
teams have been implemented in the
Stratford locality and are now rolling out to
the Warwick Leamington and Kenilworth
areas. These teams of nursing and therapy
staff help to review patients in a crisis in
the community to prevent admission to
hospital and help support early discharge
for patients in hospital; assess their needs
and support them at home in the early
days; continue their rehabilitation and aid
transition to independence or to ongoing
social care if that is needed. These teams
are supporting up to 20 patients per week
on admission prevention or early discharge
schemes at present; it is anticipated that
this will increase as systems develop.
2.Care of Patients with Dementia
A National Strategy drives enhancements
to care for patients with Dementia. The
trust has moved forward with local
implementation (update on last years).
The dementia pathway is under review
with plans for a redesigned pathway to
be implemented this year. (Matron leading
project is yet to be released from other
duties to address this).
Now, screening for dementia at first point
of contact in hospital for all patients over 75
years is being implemented and redesign of
the medical clerking proforma is agreed.
3.The Nicol unit
In 2011, the Nicol Unit at Stratford Hospital
implemented ‘The Freedom Project’. The
project was funded in conjunction with
the King’s Fund, London, Enhancing the
Healing Environment Programme and
through monies raised by the public.
Redevelopment of the unit has provided a
more conducive, caring environment and
atmosphere to support rehabilitation for
our older patients including those with a
dementia. They now have easy access to
the garden and to an expanded range of
social and functional activities.
The unit now comprises of 18 beds. Staffing
levels have been reviewed and enhanced,
and medical leadership is now provided by
a single GP practice; Rother House. This
has created a proactive multidisciplinary
team and focussed treatments and care
planning. Throughput has increased
by some 30 % for those admitted from
the community and by 17% for those
transferred from Warwick Hospital.
54
A local strategy is under
consideration including the
development of a dementia
ward or dementia friendly
enhancements to all wards
receiving older patients.
2.Stroke Care
The stroke pathway is under
review following a strategic
planning day in December
2011. The new pathway
aims to improve quality of
care, access and develop
early supported discharge
for patients with stroke.
3.Older People’s Care
The next stage of the
Cutting the Cost of Frailty
will be implemented in
2012. This includes ‘rightsizing’ our organisation
through reallocation of
duties so that our older
patients are cared for by
Elderly Care Physicians.
They will then receive an
assessment within 24 of
admission to provide a
comprehensive treatment
plan.
The Community Children’s Nursing
Team (CNN)
The service continues to grow as it responds to the increased need for delivery of skilled complex/technological nursing
care in any setting outside of the hospital. The objectives continue to focus on reducing hospital admissions, facilitating
early discharge from hospital for children with life changing and life limiting conditions, ensuring high quality safe care
for children with complex care needs and ensuring user involvement with the child young person and families. Through
successful partnership working with Coventry Universities Research Department, funding has been secured for three years
to run focus groups and explore patient experience. The two focus groups run thus far, have been very successful, we were
also able to organise a Christmas party for the children in both Coventry and Warwickshire CCN services and evaluation
was excellent.
In November 2011 we held our first celebration conference at Dunchurch Park, professionals from health, social care
and education were invited to the event which showcased the amount of innovative work carried out in the team. We
were fortunate to have Christine Humphreys from the Department of Health (DoH) as our keynote speaker, who was very
impressed with all the hard work currently being carried out by the team.
Due to a successful Department of Health (DH) Paediatric palliative care bid in 2011, our lead nurse and consultant have
raised the profile through working on an end of life national paediatric palliative care toolkit, which they have disseminated
across the West Midlands. The bid secured the development of a play specialist service within the team, which is already
paying huge dividends to care delivery. Through the development of the play service, we have alongside our allied health
professionals, been able to successfully support two rehabilitation packages in the community. This has emphasised the
significant savings to commissioning and demonstrated successful joint working with our colleagues in children’s services.
Partnership working continues with our colleagues in the local authority-integrated disability service. Following the
successful funding in 2010 of two of our support workers, the Integrated Disability Service (IDS) has funded a further two
band 3 support workers from the team to work alongside their staff, to deliver a short breaks service to children and young
people across Warwickshire.
Income generation continues with cross boundary working, supporting others with our skilled workforce to deliver safe
ventilated care packages in the home and in other care settings. This remains an area of continued growth for the team.
Family Nurse Partnership (FNP)
The Family Nurse Partnership was launched in Warwickshire in July 2010 and went live in October 2010. Four Family
Nurses are based in Children’s Centres and provide the programme to young people across Warwickshire. The Family
Nurse Supervisor and Administrative Assistant are based alongside the Early Intervention team in council premises at
Saltisford Office Park.
There have been a total of 108 clients enrolled to the service and caseloads are now full. Occasionally spaces arise in
case loads due to attrition and we target the youngest and most vulnerable to these places wherever possible. During the
recruitment phase of the programme, the target was to enrol 75% of eligible clients and the team achieved 76%.
90% of clients have additional needs such as mental health problems, leaving care, unstable living arrangements and
learning difficulties. So far 9 clients have left the programme – 5 have moved out of the area and 4 have become inactive
(decided to leave the programme). The fidelity goal for attrition is 40%; Warwickshire’s attrition rate is 9%. All the Family
Nurses are fully resourced and have completed the pregnancy and infancy training, motivational interviewing techniques
and post natal depression training. There is one further training day in March, 2012.
Learning from FNP has been shared with other services such as health visiting and school nursing; and client and agency
feedback about the service has been good.
The Annual Review of FNP took place on 27 January 2012. Two Service Development Leads from the FNP National Unit
and the DoH visited the FNP advisory board and reviewed licensing, governance and strategy requirements in respect of
programme delivery in Warwickshire and concluded that FNP was being delivered to a high standard. The action plans for
improving health outcomes were agreed and are currently being implemented.
55
School Nursing
Over the past year the Department of Health has been working on the development of a new framework for school nursing.
The Professional Lead for School Nursing has been a member of the Task Group. The framework is in line with the new
service model for health visitors and there is a desire to create a more seamless transition for children and families as
they enter education. The Healthy Child Programme 5-19 needs to be implemented and will be challenging to the current
service as currently school nurses work with children from the age of 5 to 16.
The school nurses have undertaken ‘Ages and Stages’ training on the evidence based developmental tools being used by
health visitors. It is hoped that the social and emotional tools will be used by school nurses when teachers or parents and
carers present with a concern about a child with regards to social skills and interaction with others.
A number of the school nursing teams have been involved in the Productive Community Services (PCS) project and as part
of the work an evaluation was completed around the health questionnaire for reception children. It was felt that the current
questionnaire lends itself more to a medical model. A working party will be looking at the questionnaire in more detail
with the hope of it being introduced from September 2012. The PCS project has enabled the school nurses to implement
several different and more efficient ways of working which they have passed on to other teams across Warwickshire.
School nurses offer smoking cessation to young people in schools and other venues where young people attend. It is a fact
that 450 young people aged under 18 start smoking every day. They have secured payment from the smoking cessation
services for the work they do. Monies gained will go towards buying resources for school nurses. These resources are
used in schools to educate children and young people on the harm and effects of smoking.
School nurses have recently been recognised by the CQC/Ofsted safeguarding inspect in the work they do around
performing health assessments on children who are entering the child protection arena. They visit the family or see the
young person with parental consent and complete a full holistic health assessment. This provides the chair of the child
protection case conference and other agencies with information on the child. A health assessment has always been
done before by school nurses, but not in this intense way. There are very few areas of the country where school nurses
undertake this assessment.
Funding has been secured from “Respect Yourself” to train six members of the school nurse team to undertake a sex and
relationship course. This course aims to help staff with the delivery of sex education in schools.
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Health Visiting (HV)
The Health Visiting Service in Warwickshire was successful in being selected to be an Early Implementer Site in March
2011. We were selected as one of 20 trusts nationally in taking the new HV Service Model forward by the end of March
2012. This is as cited in the DoH document ‘A Call to Action’ (Feb, 2011). We have worked very closely with the DoH and
met monthly to share ideas across sites and move the new vision forward. The outcome will be that by the end of March
2012 Warwickshire Health Visiting teams will be offering the new core offer to all families to include: Community, Universal,
Universal Plus and Universal Partnership Plus. We are on target to reach this aspiration.
As part of this work, we have increased Antenatal Promotional Interview home visits, implemented an up-to-date validated
development assessment tool and developed and launched an Early Years Health Directory for all Early Years settings in
Warwickshire during the last year.
By increasing the antenatal promotional visits we have increased not only coverage but also quality of service to families.
These visits have been shown to improve outcomes for children at two years of age. The most challenging piece of work
has been to communicate more effectively with our midwifery colleagues across the three acute trusts to enable these
visits to take place. We have been successful in obtaining the twenty week scan information from Warwick Hospital which
will help us with our ultimate aim of this being a universal offer. We have successfully increased this offer across the county
within the last year. We have also worked closely with our midwifery partners in developing a ‘Partnership Agreement’
between Midwives and Health Visitors to improve communication.
We have implemented the ‘Ages and Stages’ developmental assessment tool for both the nine month and two to two and
a half review as part of our Healthy Child Programme. This was initially piloted and rolled out universally from 1 November
2011.We have collected over 2000 evaluations from parents regarding the tool, which have been very positive. Other
regions across West Midlands are planning to follow suit.
The Early Years Health Directory has required a great deal of partnership working and engagement with Early Years
settings. As a result we have an up to date, well regarded directory, which settings can access easily and will enable
standards to be consistent within settings across the county.
Families have been at the heart of the developments within Health Visiting during this time. This has included focus
groups with parents to explain and translate the new core offer to all families. This information has been used to inform
the development of a new HV leaflet which has been positively evaluated by parents and now in the final edits. Social
marketing has also included the design of posters, both for the public and stakeholders, and various promotional materials
to raise awareness of the new service.
We are working closely with our commissioners in ensuring the growth of Health Visitors is reached as outlined in the
Operating Framework (2011). This will mean that we will have a further huge increase in the amount of HV students we
train. We have implemented a new model within Warwickshire with our Community Practice Teachers in ensuring that
quality is maintained as much as possible with the increase in educational commissions. Nevertheless, this will be our
biggest challenge within the next year, when we are expected to take over five times as many students this coming year.
Stakeholder involvement about these changes has been a key part of our work over the last year and this will continue to
be high profile. A national ministerial event is planned for the 30th April in which we will be celebrating the achievements of
the Early Implementer Sites nationally.
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Quality Overview
This section of our quality accounts provides information on our compliance with national standards and targets
and locally derived targets not covered elsewhere
NATIONAL KEY PERFORMANCE TARGETS
2011 - 2012 Financial Year Achievement
Target
Target
Actual
Cdiff (In-Hospital)
43
42
Achieved
MRSA (Post 48hr)
6
3
Achieved
surgery
94%
97.7%
Achieved
anti-cancer drug treatments
98%
100.0%
Achieved
Cancer 31-Day (all subsequent cancer treatments):
Cancer 62-Days National Screening Programme
90%
95.3%
Achieved
Cancer 62-Day (2WW Ref to treat, all cancers)
85%
86.9%
Achieved
23 weeks
22.6
Achieved
18.3 weeks
17.6
Achieved
96%
99.5%
Achieved
Referral to Treatment waiting times - admitted (95th percentile)
Referral to Treatment waiting times - non admitted (95th
percentile)
Cancer 31-Day (Diag to treat, all new cancers)
Cancer 2WW all cancers (Urgent GP Referral)
93%
97.5%
Achieved
Cancer 2WW (Symptomatic Breast)
93%
94.4%
Achieved
A&E 4-hour wait (95%)
95%
93.4%
Not Achieved
Compliant
Compliant
Achieved
Compliance with requirements regarding access to healthcare for
people with a learning difficulty
[Table J]
Data Quality
Statement on Relevance of Data Quality and Actions to Improve Data Quality
South Warwickshire NHS Foundation Trust will continue its work in improving data quality to ensure standards are
continually kept high which in turn will help the performance and management of the activities of the Trust. It is essential that
the Trust Data is complete, accurate and inputted in a timely manner to ensure support in providing patient care and helping
the Trust to achieve performance targets. Data is continually monitored internally on a daily/ weekly basis and by the use of
external dashboards provided by CHKS and The NHS Information Centre. The following taken from shows the percentage of
all patients seen in the trust during March 2012 who have a valid NHS Number and General Medical Practice Code.
The Audit Committee has reviewed data quality using the above sources and has identified some areas where improvements
are required. These include a need to provide greater assurance on data quality relating to A&E performance as well as an
apparent deterioration in overall Trust performance on data quality, reflected by the Audit Commission study on Payment by
Results Data Assurance.
% of records that include the patient’s
valid NHS Number
% of records that included the patient’s
valid General Medical Practice Code
99.9%
100%
Outpatient Attendances
99.9%
100%
A&E Attendances
99.1%
100%
Admitted Patient Care
Internal follow up audits have taken place to ensure that recommendations have been implemented within certain areas.
There are Data Quality Groups that meet regularly where issues and improvements are discussed. New processes are
continually being put into practice to ensure that data within the Trust is complete and of a high standard
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[Table K]
South Warwickshire NHS Foundation Trust submitted records during 2011/12 to the Secondary Uses service for inclusion
in the Hospital Episode Statistics which are included in the latest published date. The percentage of records in the
published data are shown in Table K.
South Warwickshire NHS Foundation Trust will be taking the following actions to improve data quality. It
recognises that good quality data is vital to the performance and management of the activities of the Trust. Data
quality is crucial and the availability of complete, accurate and timely data is importance in supporting patient
care, clinical governance and service provision. It also underpins the internal and external reporting of the Trust’s
performance targets and income. The Trust continues to monitor the timeliness of when data is input by the use of daily
and weekly reports that are shared with operational staff. The Trust provides a Data Quality Dashboard to the Finance
& Performance Committee each month covering both data completeness and timeliness together with a written report
highlighting any data quality issues that need to be addressed with each operational Division of the Trust. The Trust has
two Data Quality Groups – one for acute hospital staff and the other for community staff. It is the responsibility of these
groups to raise data quality issues to senior and/or executive level as well as ensuring that changes in processing and
recording data filter down to the appropriate operational staff. Internal audits have taken place for A&E attendances and
these have resulted in a series of actions to improve the timeliness and completeness of the Trust’s A&E activity data.
This in turn has improved the accuracy of data for patients starting on an emergency pathway and is used to support
changes to emergency flows and the way emergency care is delivered. The Trust’s Data Quality team has also played a
key role in implementing new procedures to ensure data is accurately recorded for patients whose care starts in hospital
but is then transferred to care in the community. This is important as the Trust needs to monitor outcomes, lengths
of stay in hospital and readmission prevention. South Warwickshire NHS Foundation Trust achieved a level 3 when
assessing its Data Quality for Information Governance.
Local Involvement
Network Statement
Warwickshire LINk appreciates the opportunity to provide comment on the quality of the services provided
by South Warwickshire Hospital NHS Trust.
Due to staff changes and the extremely challenging landscape that the Health Economy has experienced this year
engagement and dialogue between SWHFT and Warwickshire LINk has not been as meaningful as either partner would want
or expect in order to inform a thoughtful commentary to these Quality Accounts.
We note the contents and are delighted that quality is central to all work but do not propose to comment in any detail this
year. We are, however, putting actions in place to ensure that there is greater engagement and dialogue with all trusts in the
future.
Warwickshire LINk will be working with Health and Social Care Overview and Scrutiny Committee to develop an ongoing
partnership approach to this work.
Warwickshire LINk has not directly been involved in the Trust’s work regarding patient engagement and are hoping to
develop opportunities for joint work around engagement in the coming year.
59
Warwickshire County Council - Adult
Social Care and Health Overview and
Scrutiny Committee Commentary for
South Warwickshire Foundation Trust
Quality Account for 2011-12
A Task and Finish Group of the Adult Social Care and Health Overview and Scrutiny Committee considered
the draft Quality Account of the South Warwickshire Foundation Trust on 14 May 2012.
The Adult Social Care and Health Overview and Scrutiny Committee held a special meeting on 24 May 2012 to consider
Quality Accounts. At that meeting they agreed the points made by the Task and Finish Group in relation to the Quality
Account for South Warwickshire Foundation Trust as set out below.
The committee would wish the following points noted.
• The South Warwickshire NHS Foundation Trust Quality Report 2011-2012 was clear and easy to follow, but the final
document should include the following:
- table of contents
- reference to the Annual Account.
• Members acknowledged the difficulty in producing comparative data with the integration of the Warwickshire Community
Services into South Warwickshire Foundation Trust, and sought assurances that future Quality Account reports would
include benchmarking data.
• Members welcomed the priority “to ensure that there are no single sex accommodation breaches”, which was linked to
other work being carried out in the hospital, such as achieving A&E targets and reducing the number of moves between
wards.
• Members welcomed the work being done towards the programme of care “Delivering Excellence in Dementia Care in
Acute Hospitals”, which had been identified as a priority for the Hospital.
• The continued underperformance on Ambulance Handover was highlighted and the work being done to analyse the
reasons for the changing patterns of numbers presenting to A&E (particularly by ambulance and self-referrals) was noted.
• The challenge for the Hospital continued to be the increasing numbers of elderly and frail elderly. Members highlighted
the importance of health and social care working together to prevent inappropriate admissions and to shorten the length
of hospital stays through prevention and reablement services.
• There needed to be more detail given in relation to pressure ulcers, with a clear distinction between inherited and hospital
acquired ulcers, and giving patient numbers. The need for more emphasis to be placed on prevention of pressure ulcers
was also agreed.
• Members congratulated the Hospital on the reduction in the number of hospital acquired CDiff cases.
• The information provided on Staff Experience (Page 60 of 72) on sickness and appraisal rates should be expanded to a
table form to include target figures and national figures.
• Members agreed that the Quality Account should make reference to the role of Monitor in relation to performance
monitoring and the results of any inspections.
Councillor Les Caborn
Chair
60
Primary Care Trust Statement
Following our review of the Quality Account we consider that the document represents a true and very honest
summary of the work they have undertaken throughout 2011/12.
The Arden Cluster (comprising of NHS Coventry and NHS Warwickshire) have continued to work in partnership with SWFT
throughout the year to ensure that service users, carers and their families receive excellent care and treatment throughout
their healthcare experience.
This has been a year of significant change for the organisation with the integration of community services to South
Warwickshire Foundation Trust. We recognise that the integration of Community Services into SWFT has presented it’s
challenges but has been a smooth transition.
We have seen significant work to reduce patient falls, pressure sores and improvements to meet infection control targets.
These continue to challenge all our health care organisations for the coming year, especially with the regional aim of
eradicating attributable pressure sores in all health care organisations. SWFT have set targets for 2012/13 to meet this
challenge.
Eliminating mixed sex accommodation continued to be a challenge for the Trust and we have encouraged the Trust to
alter its wards environmental design to eradicate the mixing of men and women in order to ensure quality of the patient
experience overall. We expect to see no breaches in the coming year. We have been pleased to see the Trust link this work
with other work being carried out in the hospital relating to meeting A&E targets and reducing the number of moves between
wards.
We welcome the work in the programme of care ‘Delivering Excellence in Dementia Care in Acute Hospitals’ which has been
identified as a priority for the hospital. The Trust has worked on the timeliness of discharge from hospital an example being
programme ‘Home for Lunch’ pilot and actively encouraged support for patients who require help with eating, drinking and
increased interaction with staff through their ‘Lets do Lunch’ and Tea for Two’ projects. Commissioners also recognise the
work in developing care pathways for frail elderly patients, urgent care services and reducing delayed discharges.
The quality of care at SWFT, as discussed in monthly contractual quality meetings, is good and we have triangulated this
with data and walking the floor of the hospital to see the services in action for our own assurance. Information provided
within this account that does not form part Arden Cluster is assured that the account contains accurate data and information
where related to items contractually discussed throughout the year with commissioners.
We have been encouraged by the open and transparent staff attitude to quality monitoring during on site clinical reviews
of services. As commissioners we support SWFTs commitment to delivering safe services of a high quality standard and
further improving the patient’s experience. There is evidence in this account that quality is a key theme throughout all of the
strategic developments.
Trust Statement
We welcome the comments from Health Overview and Scrutiny Committee (HOSC), NHS Warwickshire (PCT) and
Local Involvement Network (LINk) on our Quality Report 2011/12.
We are particularly encouraged by the comments from our main commissioners about the areas where the Trust has
shown significant improvements. We have plans in place to face the challenges identified by our commissioners to make
improvements for patients, particularly around same sex accommodation standards and A&E performance.
Based on the feedback provided by HOSC we have made their suggested amendments to help people navigate the
document. We also hope to provide more comparative data next year for our community services to highlight the
improvements to quality.
We will seek to work with LINk’s to build a stronger partnership to enable more involvement in next year’s quality report.
Signed:
Date:
13
/
06
/
2012
Chief Executive
61
2011/12 Statement of Directors’
Responsibilities in Respect of the Quality Report
The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations
2010 to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust
boards on the form and content of annual Quality Reports (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 Report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that:
• The content of the Quality Report meets the
requirements set out in the NHS Foundation Trust Annual
Reporting Manual 2011-12 and that the content of the
Quality Report is not inconsistent with internal and
external sources of information including:
Board
minutes and papers for the period April 2011 to
June 2012
Papers
relating to Quality reported to the Board over
the period April 2011 to June 2012
Feedback
from the commissioners dated 01/06/12
Feedback
from governors dated 05/01/12 and
Feedback
from LINks dated 12/06/12
The
The
[latest] national outpatients survey January 2011
The
[latest] national inpatients survey January 2011
The
[latest] national staff survey March 2012
The
CQC
24/05/12
trust’s complaints report published under
regulation 18 of the Local Authority Social Services
and NHS Complaints Regulations 2009, dated
25/04/2011;
Head of Internal Audit’s annual opinion over the
trust’s control environment dated
quality and risk profiles dated March 2012
• The Quality Report presents a balanced picture of the
NHS foundation trust’s performance over the period
covered;
• The performance information reported in the Quality
Report is reliable and accurate;
• There are proper internal controls over the collection and
reporting of the measures of performance included in the
Quality Report, and these controls are subject to review
to confirm that they are working effectively in practice;
• The data underpinning the measures of performance
reported in the Quality Report is robust and reliable,
conforms to specified data quality standards and
prescribed 106 definitions, is subject to appropriate
scrutiny and review and the Quality Report has been
prepared in accordance with Monitor’s annual reporting
guidance (which incorporates the Quality Accounts
regulations) (published at www.monitornhsft.gov.
uk/annualreportingmanual) as well as the standards
to support data quality for the preparation of the
Quality Report (available at www.monitornhsft.gov.uk/
annualreportingmanual)).
The directors confirm to the best of their knowledge and
belief they have complied with the above requirements in
preparing the Quality Report - By order of the Board
Signed:
13 / 06
Date:
/
2012
Chairman
Signed:
Date:
62
13
/
06
/
2012
Chief Executive
Independent Assurance Report to the Council of Governors
of South Warwickshire NHS Foundation Trust on the Annual
Quality Report
I have been engaged by the Board of Governors of South Warwickshire NHS Foundation Trust to perform an
independent assurance engagement in respect of South Warwickshire NHS Foundation Trust’s Quality Report for
the year ended 31 March 2012 (the “Quality Report”) and certain performance indicators contained therein.
Scope and subject matter
• Care Quality Commission quality and risk profiles dated September,
October, November, December 2011, February and March 2012;
The indicators for the year ended 31 March 2012 subject to limited
assurance consist of the national priority indicators as mandated by
Monitor:
• The Head of Internal Audit’s annual opinion over the Trust’s control
environment dated April 2012; and
• 62 Day Wait, Cancer
• Any other information included in our review.
• Clostridium Difficile
I consider the implications for my report if I become aware of any
apparent misstatements or material inconsistencies with those
documents (collectively the “documents”). My responsibilities do not
extend to any other information.
I refer to these national priority indicators collectively as the
“indicators”.
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of
the Quality Report in accordance with the criteria set out in the NHS
Foundation Trust Annual Reporting Manual issued by the Independent
Regulator of NHS Foundation Trusts (“Monitor”).
My responsibility is to form a conclusion, based on limited assurance
procedures, on whether anything has come to my attention that causes
me to believe that:
• the Quality Report is not prepared in all material respects in line with
the criteria set out in the NHS Foundation Trust Annual Reporting
Manual;
• the Quality Report is not consistent in all material respects with the
sources specified in section 2.1 of Monitor’s Detailed Guidance for
External Assurance on Quality Reports 2011/12; and
• the indicators in the Quality Report identified as having been
the subject of limited assurance in the Quality Report are not
reasonably stated in all material respects in accordance with
the NHS Foundation Trust Annual Reporting Manual and the six
dimensions of data quality set out in the Detailed Guidance for
External Assurance on Quality Reports.
I read the Quality Report and consider whether it addresses the content
requirements of the NHS Foundation Trust Annual Reporting Manual,
and considered the implications for my report if I became aware of any
material omissions.
I read the other information contained in the Quality Report and
consider whether it is materially inconsistent with:
I am in compliance with the applicable independence and competency
requirements of the Chartered Institute of Public Finance and
Accountancy (CIPFA) Standard of Professional Practice My team
comprised assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the
Board of Governors of South Warwickshire NHS Foundation Trust as a
body, to assist the Board of Governors in reporting South Warwickshire
NHS Foundation Trust’s quality agenda, performance and activities.
I permit the disclosure of this report within the Annual Report for the
year ended 31 March 2012, to enable the Board of Governors to
demonstrate that it has discharged its governance responsibilities by
commissioning an independent assurance report in connection with
the indicators. To the fullest extent permitted by law, I do not accept
or assume responsibility to anyone other than the Board of Governors
as a body and South Warwickshire NHS Foundation Trust for my work
or this report save where terms are expressly agreed and with my prior
consent in writing.
Assurance work performed
I conducted this limited assurance engagement in accordance with
International Standard on Assurance Engagements 3000 (Revised) –
‘Assurance Engagements other than Audits or Reviews of Historical
Financial Information’ issued by the International Auditing and
Assurance Standards Board (‘ISAE 3000’). My limited assurance
procedures included:
• Evaluating the design and implementation of the key processes and
controls for managing and reporting the indicators;
• Making enquiries of management;
• Board minutes for the period April 2011 to June 2012;
• Testing key management controls;
• Papers relating to quality reported to the Board over the period April
2011 to June 2012;
• Limited testing, on a selective basis, of the data used to calculate
the indicator back to supporting documentation;
• Feedback from the Commissioners dated June 2012;
• Comparing the content requirements of the NHS Foundation Trust
Annual Reporting Manual to the categories reported in the Quality
Report; and
• Feedback from Governors dated June 2012;
• Feedback from LINks dated June 2012;
• The Trust’s complaints report published under regulation 18 of the
Local Authority Social Services and NHS Complaints Regulations
2009, dated April 2012;
• The latest national patient survey dated 2011;
• The latest national staff survey dated 2011;
• Reading the documents listed above under the respective
responsibilities of the Directors and auditors.
A limited assurance engagement is less in scope than a reasonable
assurance engagement. The nature, timing and extent of procedures for
gathering sufficient appropriate evidence are deliberately limited relative
to a reasonable assurance engagement.
Mark Stocks, Engagement Lead
Officer of the Audit Commission, 1st Floor, No. 1 Friars Gate, 1011 Stratford Road, Solihull, B90 4EB
27 June 2012
63
South Warwickshire NHS Foundation Trust
Warwick Hospital
Lakin Road
Warwick
CV34 5BW
Phone : 01926
495321
482603
www.swft.nhs.uk
Fax : 01926
To obtain a printed copy of the
Annual Report please email
communications@swft.nhs.uk
64