QUALITY ACCOUNT 2014/2015 | 19
S ect
i on
1
QUALITY ACCOUNT
What is a Quality Account?
All providers of NHS services in England have a statutory duty to produce an annual report to
the public about the quality of services they deliver. This is called the Quality Account. Its aim
is to increase public accountability and drive quality improvement within NHS organisations.
They do this by getting organisations to review their performance over the previous year,
identify areas for improvement, and publish that information, along with a commitment
about how those improvements will be made and monitored over the next year.
Quality consists of three areas which are key to the delivery of high quality services:
• Patient safety
• Clinical effectiveness - how well the care provided works
• Patient experience - how patients experience the care they receive
20 | QUALITY ACCOUNT 2014/15
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Q U A L I T Yand A
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Part 1: Chief Executive’s
Further details are available in the Annual
statement
Report section entitled Strategic Report under
I am pleased to introduce this account
detailing the quality of care provided to
patients in our Trust for the year April 2014
to March 2015. The document aims to
provide readers with a summary of what
we have done during the year to improve
the quality of care provided to our patients
together with the areas where further work is
required.
During this year, the Trust has ensured that it
has kept quality of patient care as its primary
focus, with an emphasis on continuous
quality improvements in patient safety, clinical
effectiveness and patient experience. All
plans proposed as a part of the Trust’s Cost
Improvement Programme undergo a Quality
Impact Assessment process overseen by
the Medical Director and Chief Nurse. This
provides assurance to the Trust Board around
ensuring that quality of care is not negatively
impacted by financial savings schemes.
The Trust has experienced a challenging
year. Levels of staffing have been a concern
in all areas, leading to higher than expected
agency and locum expenditure. However
despite the national situation around the
shortage of clinical staff and the loss of the
MoD staff, the Trust has continued to recruit
both at home and abroad therefore we have
more staff at the end of the year than at the
beginning.
Alongside ongoing intense scrutiny around
our financial position and our clinical
and operational functions, we have also
experienced increases in emergency activity
significantly above the level of our contract
with our commissions. This has led to
further pressure on bed capacity which has
had an impact on timeliness of care and
admission for both emergency and elective
patients and regrettably, cancelled planned
operations. Despite this, our Friends and
Family Test results remain above the national
operational performance.
Our Falls Prevention Specialist Nurse, Teresa Stratton
(pictured right), has been working with the nursing teams
across the Trust in 2014/15 to reduce the number and
frequency of falls by patients in hospital.
The Trust recorded 143 fewer falls among inpatients in
2014/15 than the previous year.
During the year the Quality Assurance
Committee led a review of the effectiveness
of our Quality Governance Framework
using the Monitor self-assessment tool.
This Framework sets out the systems and
processes that assist Trust Board members in
meeting their responsibilities for the quality
of care provided to all those who use our
services. ‘Board to ward’ activities have
included participation in a Trust wide 15
Steps Challenge, night visits, patient safety
walkabouts and CEO and Chief Nurse weekly
visits to patient care areas.
This report gives details of where quality has
been improved for patients during 2014/15,
for example:
• An 8.1% reduction in patient falls in
hospital
• An 11% reduction in the number of
patients who fall more than once
It also reports on areas where we have
further work to do to improve patient care
outcomes, for example, despite great efforts
QUALITY ACCOUNT 2014/15 | 21
by many staff it is disappointing to report that
we did not achieve some targets, especially:
• Reducing the number of Clostridium
difficile infections
• Eliminating pressure ulcers (Grade 3 and
above)
In March 2014 the Trust was visited by the
Care Quality Commission (CQC) as part of
Phase 2 of the new style hospital inspections.
An overarching rating of ‘requires
improvement’ was given to the Trust; six of
the eight clinical streams at Peterborough
City Hospital were rated ‘good’ and Stamford
Hospital was rated ‘good’ throughout.
All essential standards were found to be
compliant in the March 2014 inspection.
There were no recommendations made
where the CQC directed the Trust MUST act;
11 areas for improvement were highlighted
stating that the Trust SHOULD improve. A
comprehensive action plan was compiled
to capture all the improvements needed
including the individual Clinical Directorate
quality improvements which were identified
during the inspection.
The content of the Quality Account has
been subject to review at a stakeholder
meeting and other key Trust meetings. The
participants met to review the document
and to scrutinise the content, data collection
method and narrative, and included
representatives from the Board of Directors
(including Non-Executive Director members
of the Audit Committee), the Council of
Governors, Clinical Commissioning Groups
(Cambridge and Peterborough, and South
Lincolnshire), Healthwatch and Overview and
Scrutiny Committee representatives from
Peterborough and Lincolnshire.
To the best of my knowledge, the information
contained in this Quality Account is accurate.
While it is not possible to guarantee the
totality of data collection and incident
reporting, it is noteworthy that the Trust
continues to be in the top reporting group
for medium acute Trusts. This is regarded as
being an indicator of a positive patient safety
culture.
I would like to thank all our patients, their
carers, our volunteers, other stakeholders
and our staff for their leadership, ideas and
comments which have been used to plan
the Trust’s quality improvement programme
for 2015/16. Our staff continue to drive the
delivery of high quality of care to patients
and on behalf of the Board I thank them
all for their hard work, professionalism and
compassion.
Stephen Graves, Chief Executive
Quality Account 2014/15
“
I had my hip replaced at PCH and
from the moment I went in I was
treated so well. The staff were
lovely and everybody helped me
whenever I needed it. I had hardly
any pain and cannot thank enough
the nurses on B7 and my surgeon.
This has given me back my life.
“
Priorities for quality improvement during
2015/16 are also reported and these reflect
national and local priorities across the
domains of safety, effectiveness and patient
experience and assist staff to realise the
Trust’s strategic vision of:
‘Delivering excellence in care; in the most
efficient way; in hospitals where it is great to
work’ and providing Right Care; First Time;
Every Time.
Joanne Bennis was appointed
to the role of Chief Nurse on
1 February 2015. Jo was
previously the Trust’s
Deputy Chief Nurse and has
been nursing for 30 years,
working in a variety of key
areas including intensive care
and practice development.
Jo took over from Chris
Wilkinson, who retired at the
end of January 2015 after
13 years in the role.
22 | QUALITY ACCOUNT 2014/15
Part 2: Priorities for improvement and statements of
assurance from the Board
Priorities for improvement identified for 2014/15
The following section summarises progress made during the year. The report should be read
within the context of the work completed by the Trust over the year, including care delivered
to our patients, numbers of which are in the table below.
2014/15
2013/14
52,238
50,698
Inpatients
45,229
43,045
Emergency admissions
93,500
90,475
Patients seen in the Emergency
Department
402,808
391,401
Outpatients
34,208
34,198
Day case patients
4,939
4,827
Newly delivered babies and their mothers
See the glossary at the end of this report for a key to the abbreviations.
Priorities results at a glance
Priority
Name
Goal 1a
1. Reduce the overall number of falls
2. Reduce number of patient falling more than
once
3. Zero tolerance for falls with harm (i.e. grade
3 and above)
Goal 1b
50% reduction of avoidable hospital acquired
pressure ulcers (Grades 2, 3 and 4)
Goal 1c
Reduction in catheter associated urinary tract
infection (CAUTI)
Goal 1d
Reduction in the number of avoidable
Clostridium difficile infections acquired in
hospital
Goal 1e
Improve outcomes for deteriorating patients:
introduction of National Early Warning Score
(NEWS)
Goal 2a
Reduce mortality rate: focus on respiratory
diagnosis groups
Goal 2b
1. Achieve 95% for waiting times in ED
2. Reduce number of non-clinical internal
transfers
3. Reduce number of cancelled elective
operations for non-clinical reasons
Goal 2c
Ensuring appropriate staffing levels and skill mix
Goal 3a
Improve response rate and satisfaction levels as
recorded by the Friends and Family Test (FFT)
Goal 3b
Increase the responses to questions in the
National Patient Survey (NPS) in the ‘best
performing’ category.
Goal 3c
1. Improve user satisfaction with complaints
process
2. Ensure lessons are learned
Goal Met
Goal Partially Met Goal Not Met
QUALITY ACCOUNT 2014/15 | 23
Patient Safety domain
Priority 1 – Improve the number of patients who are harm free whilst under the care of the Trust
Goal 1a
Outcome
summary
Information
Reason for
prioritisation
Baseline
Action taken
1. Reduce the overall number of falls
2. Reduce the number of patients falling more than once
3. Zero tolerance for falls with harm (i.e. grade 3 and above)
1.Goal Met
2.Goal Met
3.Goal Not Met
The Trust has successfully reduced the overall number of falls by 8.1% in
2014/15 compared to 2013/14. Patients who fall remain a real
concern for the Trust and the staff who care for them. Continuous
innovation, planning and care aim to further reduce the rate at which
patients fall and to focus on reducing the number of patients who are injured as they fall.
The Trust had a 4% reduction in falls in 2013/14
Risk of harm increased in patients falling more than once
Dignity campaign
A total number of 1786 falls were reported in 2013/14
The number of falls with serious injuries in 2013/14 (39 patients)
• Falls Steering Group with annual strategy
• Regular updates to front line staff with falls information and key
messages for practice
• The Trust has reviewed actions taken by other Trusts to gain
informationfrom what others have learnt
• Root Cause Analysis (RCA) of falls where serious harm is sustained.
Review at scrutiny panel and action planning
• ‘Being Open’ meetings with patients/families where serious harm has
been sustained
• Introduction of post falls management checklist for nurses to ensure best
treatment of any injuries and prevention of further falls
• Continued use and purchase of additional motion sensors
• Updated risk assessment and care planning documentation
• Review and update of Falls Policy
• The Trust has invested in 30 new, additional low rise beds to support
patients who are at risk of falling
• Increase in use of one to one care and cohorting of patients requiring
additional attention
• Training and awareness raising across the Trust with focus on ‘Making
Specialing Special’
• Falls Summit in November 2014 with work steams agreed: do not move
list, apprenticeship scheme, Matron audits of compliance with risk
assessment and planning
• Appointment of Dementia Nurse Specialist
24 | QUALITY ACCOUNT 2014/15
Outcome
details
1. Decrease in the number of patient falls by 8.1%. This is compared to a
4% decrease in 2013/14. The total number of falls in 2014/15 was 1640
(compared to 1784 in 2013/14).
The graph below demonstrates the reduction in the overall number of
patient falls in 2014/15. The cumulative figures for 2014/15 are consistently
below those for 2013/14.
The NHS Safety Thermometer is a monthly survey on one day of
all relevant patients* to collect data on four harms, pressure ulcers,
falls (within the last 72 hours), urinary tract infection in patients with
indwelling urinary catheters (within the preceding 72 hours) and Venous
Thromboembolism (VTE). The aim nationally is to deliver 95% harm free
care across the whole health economy.
*Relevant patients are all admitted inpatients except day cases, outpatients, ED
attendances, well babies, renal dialysis patients, regular day attenders such as
chemotherapy patients.
The graph below shows the percentage of patients who have fallen in
the Trust from the NHS Safety Thermometer data. The blue line shows
our Trust figures and is compared to the national average (purple line)
and the average from a cluster of 13 Trusts, peer group, with whom we
are benchmarking results (green line).The red line evens out fluctuations
and shows the overall trend for the Trust.
QUALITY ACCOUNT 2014/15 | 25
2.The number of patients who have fallen more than once has decreased
by 11% in 2014/15 compared to 2013/14.
3.The number of falls with serious injuries has increased to 50 from 39.
The graph below shows the percentage of patients who sustained harm,
from a fall in the Trust from the NHS Safety Thermometer data. Towards
the end of 2014/15 the Trust had a higher proportion of falls with harm
than both the peer group (green line) and the national average (purple
line). The peak in January 2015 is equal to 12 patients who sustained
harm during the time measured by this point prevalence study.
Next steps
• Strategy for 2015/16 in place with the campaign to;
‘Give your attention to falls prevention!’
• Continued regular reports to front line staff
• Continue to offer ‘Being Open’ meetings with patients/families where
serious harm has been sustained
• Continue Falls Steering Group with scrutiny panels
• Implementation of post falls management checklist for medical staff
• Trial and implementation of wrist bands
I have fallen before. Please help me stay safe
as an immediate visual sign that a patient has fallen before and is at risk
of further falls
• Increase links and joint activities with the Dementia Nurse Specialist
especially around the environment
• Introduction of the wellbeing apprenticeship scheme
• Increase working with community partners to prevent falls at home and
so reduce admissions
• Review of grading of falls in line with national recommendations
• Work closely with the pharmacy staff to review patients’ medications as
polypharmacy can often be the cause of patients falling
26 | QUALITY ACCOUNT 2014/15
Goal 1b
50% reduction of avoidable hospital acquired pressure ulcers
(Grades 2, 3 and 4)
Outcome
summary
Information
Goal Not Met
Reason for
prioritisation
Baseline
Action taken
Pressure ulcers, also known as bedsores or pressure sores, are a type of
injury that affects areas of the skin and underlying tissue. Pressure ulcers
can range in severity from discoloured skin to open wounds that expose
the underlying bone or muscle and are graded from grade 1 to grade 4,
with grade 4 being the most severe. Older people with reduced mobility are
particularly at risk of developing pressure ulcers as are those with conditions
such as type 2 Diabetes.
Pressure ulcers are recorded as avoidable or unavoidable;
• Avoidable = where the required documented care planning,
implementation, monitoring and evaluation were not in place at all times.
• Unavoidable = where despite all documented care planning,
implementation, monitoring and evaluation, a patient develops a pressure
ulcer usually as their underlying medical condition makes them extremely
vulnerable or that they were unable to adhere to advice.
Dignity campaign
Safeguarding cases
CQUIN scheme
In 2013/14 the Trust reported 129 grade 2, 13 grade 3 and no grade 4
hospital associated pressure ulcers
• A new full time Tissue Viability Nurse came into post from December
2014 to replace a colleague who had a change of role within the Trust
• 30 hours support nurse in post from March 2015
• Sustained ‘Stop the Pressure’ Campaign throughout 2014/15
• Tissue Viability multidisciplinary group and scrutiny panels for all hospital
associated pressure ulcers with grade 3 and above reviewed by the Chief
Nurse
• Monitoring of pressure ulcer free days – 3 wards have over 700 days of
pressure ulcer free days
• Update of Intentional Rounding to ‘Rounding with a Reason’ with
embedded SSKIN module and monitoring of compliance
• Deep dive investigation into grade 3 and 4 hospital associated pressure
ulcers in December 2014 and January 2015 with report and action plan
• The Trust is reviewing the heel protection used and running trials to find
an effective aid that patients find more comfortable
• Joint Link Nurse sessions with community partners
QUALITY ACCOUNT 2014/ww15 | 27
Outcome
details
There has been an increase in the grade 1 hospital associated pressure
ulcers, reporting of this skin redness at this early stage is encouraged.
There has been an increase in grade 2 hospital associated pressure ulcers to
195 in 2014/15. 49% agreed as unavoidable.
There has been an increase in grade 3 hospital associated pressure ulcers to
26 in 2014/15. 38% agreed as unavoidable.
There has been an increase in grade 4 hospital associated pressure ulcers to
2 in 2014/15. 100% agreed as avoidable.
(There remain some outstanding reviews from 2014/15)
The overall increase in pressure ulcers should be considered in relation to
the increased acuity and dependency of our inpatients as recorded in the
Safer Nursing Care Tool (SNCT) surveys undertaken every 6 months in the
Trust.
The graph below shows the NHS Safety Thermometer data regarding the
percentage of patients who have developed a hospital associated grade 2,
3 or 4 pressure ulcer. The NHS Safety Thermometer does not monitor grade
1 pressure ulcers. The Trust (blue line) is benchmarked with other Trusts and
as seen in the graph below we are in the main, below the national average
(purple line) and the Trust remains consistently below the peer group
(green line).
28 | QUALITY ACCOUNT 2014/15
Next steps
• New ‘6 STEPS’ campaign for 2015/16 launched on 6 May 2015 with the
aim of a reduction in the overall number of grade 2, 3 and 4 pressure
ulcers, a reduction in the number of patients who have more than
one pressure ulcer and a reduction in the number of pressure ulcers
developing on heels
• Monthly multidisciplinary team meetings
• Root Cause Analysis (RCA) and scrutiny panels review
• Update formulary so that the Trust provide the most appropriate
dressings for patients with pressure ulcers
• Review arrangements for providing topical negative therapy
(VAC pumps)
• Work closely with community partners to reduce the number of pressure
ulcers developing in the community
• Increase link between nutrition and hydration and skin integrity by
holding joint Link Nurse session
• Information for Agency staff to ensure they are aware of Trust
expectations with regard to tissue viability
• Embed pink entry and exit stickers to record skin integrity on each ward
into single episode documentation
• Robust completion of nursing documentation – monthly audits of
compliance and further education and training sessions
Goal 1c
Reduction in catheter associated urinary tract infection (CAUTI)
Outcome
summary
Information
Goal Met
Reason for
prioritisation
Baseline
The only downside in the whole experience was the waiting
times, but we realise that as an emergency patient, and with
the pressures on that department, that it will take a miracle
to cure that issue and we fully understood why there were
long delays in being seen. Well done to all concerned.
“
“
The use of a hollow tube to drain urine from the bladder is a common
intervention and appropriate in many cases such as to measure the output
of urine, following surgery, when having an epidural or spinal anaesthetic
or when the bladder cannot empty (retention of urine). The presence of a
catheter increases the risk of infection which may increase patient’s length
of stay, require antibiotic treatment and in the worst cases cause severe
illness. The most reliable method of reducing the risk and outcomes of
catheter associated infections is to remove the catheter as soon as this is
clinically appropriate.
CQUIN scheme
Prevention of infection
During 2013/14, an average of 21.8% of inpatients had an indwelling
urinary catheter (data from NHS Safety Thermometer, which includes very
short time catheters used in theatres and post natal mothers, lifelong
catheters and others in place from the community as well as those put in
whilst an inpatient in the Trust).
QUALITY ACCOUNT 2014/15 | 29
Action taken
• Monthly multidisciplinary team meetings
• Monthly scrutiny panels for patients who develop a catheter associated
bacteraemia (presence of bacteria in the blood) with reports and key
messages
• Monthly scrutiny panels with community partners for patients who
attend ED with a catheter problem (e.g. blocked catheter or infection
following a catheter change) to reduce such attendances, with reports
and key messages
• Monitoring of compliance with care bundles, care bundle completion,
ensuring appropriate reason for insertion and prompt removal of
catheters
• Continence Specialist Nurse gained a place on the Quality Improvement
Fellows (QIF) programme to inform our work on lifelong catheters
• Joint sharing best practice event on 4 September 2014 for Trust and
community Link Nurses
Outcome
details
The graph below shows the percentage of patients with an indwelling
urinary catheter (not suprapubic) demonstrating that the Trust’s rolling
average (red line) was below the 20% average for the peer group (green
line) throughout 2014/15 with the exception of April 2014.
The Trust has shown a consistent reduction in the percentage of patients
with an indwelling urinary catheter (not suprapubic) who are recorded as
having a new urinary tract infection where treatment starts in hospital. For
many patients the infection was not hospital associated as the treatment
started within 72 hours of being in hospital and they already had a catheter
in place.
Unfortunately my health dictates a
spell in with you guys. As hospitals go,
fantastic treatment, food & staff #psh
30 | QUALITY ACCOUNT 2014/15
Next Steps
• Robust documentation on admission
• Monthly multidisciplinary team meetings
• Monthly scrutiny panels for patients who develop a catheter associated
bacteraemia (presence of bacteria in the blood) with reports and key
messages
• Monthly scrutiny panels with community partners for patients who
attend ED with a catheter problem (e.g blocked catheter, infection
following a catheter change) to reduce such attendance with reports and
key messages
• Monthly monitoring of compliance:- with reasons for insertion, prompt
removal and catheter and care bundle completion
• Joint networking day with community partners in September 2016
• Secondment to Independent Prescriber community post for Continence
Nurse Specialist. The QIF project work has moved with the post to the
community where she is supporting our patients with lifelong catheters.
This post has been backfilled by a seconded post
• Work with community colleagues to improve catheter use prior to
admission and improve patient pathways once discharged
• Embed new culture in Trust for ‘lifelong catheters’ rather than the phrase
long term catheters
Goal 1d
Reduction in the number of avoidable Clostridium difficile
infections acquired in hospital
Goal Not Met
Outcome
summary
Information
Clostridium difficile (also known as ‘C. difficile’ or ‘C. diff’) is a
bacterium that can be found in people’s intestines (their ‘digestive tract’ or
‘gut’). However, it does not cause disease by its presence alone it can be
found in healthy people, about 3% of adults and two thirds of babies, with
no symptoms. It causes disease when the normal bacteria in the gut, with
which C. difficile competes, are disadvantaged, usually by someone taking
antibiotics, allowing the C. difficile bacteria to grow to unusually high
levels. This allows the toxin they produce to reach levels where it attacks
the intestine and causes symptoms of disease. Testing for C. difficile is
regulated by a policy, however the Trust does test a high level of samples.
(Public Health England , 2013. Summary points on Clostridium difficile infection (CDI).
London: Public Health England).
Reason for
prioritisation
Baseline
National Performance Targets – 31 for 2014/15
Dignity campaign
Benchmarking data
External review
38 (0.075% of admissions) cases were recorded in 2013/14.
QUALITY ACCOUNT 2014/15 | 31
Action taken
Outcome
details
Next steps
• A monthly trajectory was set for the year
• Root Cause Analysis (RCA) Monthly review of cases with Trust and
external scrutiny by CCG, areas for improvement identified and action
plans developed
• Monitoring of regular cleaning in all clinical areas
• Deep cleans following outbreaks of infection
• Review of cleaning on ward areas to align with national
recommendations, trial of increased hours and change of hours to
facilitate exit cleans
• Significant investment in cleaning programmes providing an extra 3hrs of
cleaning time
• New foamy soap dispensers fitted
• Continue to educate around when samples should be taken for
C.difficile testing
• Business case for ultra violet light deep cleaning for cleans following
outbreaks and planned Trust wide deep clean programme
• The Trust invited an external peer review which took place in March
2015 with immediate verbal feedback and written report. Action plan
developed in response linked with overall Infection Control Strategy for
2015/16
• Antibiotic stewardship including regular monthly and annual antibiotic
audits and feedback to Clinicians in ward areas
41 (0.078% of admissions) cases recorded 63% agreed
unavoidable. Three non-sanctioned cases (i.e. no lapses in care) removed
from the local quality schedule target
• National target for Clostridium difficile is 29 for 2015/16, trajectory in
place for each month
• Embedding of good infection control practice into every clinical area
• Infection Control Strategy in place for 2015/16
• Clostridium difficile scrutiny panel for each hospital associated case
• Increase critical analysis of antibiotic treatment at scrutiny panels
• Increase ownership of Clostridium difficile in Clinical Directorates with
completion of RCAs, attendance at scrutiny panels, role modelling and
improved antibiotic stewardship by front line staff. This should be led by
the Clinical Director and General Manager for the Directorate
• Review and reinvestment in the infection control team
• Continue training of clinical and non-clinical staff
• Monthly Infection Control Team Meetings with review of figures
and cases and quarterly multidisciplinary Hospital Infection Control
Committee
• Continue planned antibiotics audits including yearly point prevalence
audits in response to periods of increased incidence and outbreaks
• Implement and monitor new cleaning hours across the Trust and assess
the effectiveness of the planned UV-C deep cleaning programme
• Continue Link Nurse /Practitioner sessions
• Review of Infection Control team structure and establishment
32 | QUALITY ACCOUNT 2014/15
Goal 1e
Improve outcomes for deteriorating patients: introduction of National Early
Warning Score (NEWS)
Outcome
summary
Information
Goal Met
Reason for
prioritisation
Baseline
Action taken
A number of EWS (Early Warning Score) systems are currently in use
across the NHS, however, the approach is not standardised. This variation
in methodology and approach can result in a lack of familiarity with local
systems when staff move between clinical areas/hospitals – the various EWS
systems are not necessarily equivalent or interchangeable. When assessing
acutely ill patients using these various scores, we are not speaking the
same language and this can lead to a lack of consistency in the approach
to detection and response to acute illness. The Royal College of Physicians
recommendation is to move to a National Early Warning Score (NEWS)
and this was completed by 01/09/2014. The Trust’s Nursing and Midwifery
Advisory Group also recommend that physiological observations should
only be undertaken by Registered Practitioners (i.e Registered Nurses and
Therapists)
Clinical audit
MBSC
Serious incidents
Physiological observations audit in 2013 indicated that not all parameters
were completed accurately or that the appropriate escalation was
undertaken.
• Three hour training session for Registered Nurses and Therapists
• Trial wards with feedback from February 2014 with roll out to the rest of
the Trust
• NEWS in place by Registered Practitioners to all inpatient areas and the
Emergency Department by 01/09/2014
• Repeat audit in October 2014. This was presented at Joint Ward
Managers Meeting (JWMM) and the Nursing and Midwifery Advisory
Group (NMAG)
• Qualitative audit to assess the impact of change to Registered Practitioner
observations
Having been discharged from A4 in
PCH today, I have nothing for praise
for your staff, many thanks to all.
QUALITY ACCOUNT 2014/15 | 33
Outcome
details
The results of the audit in October 2014 were mixed, some elements such
as frequency of observations and implementing a fluid balance chart,
critical elements of the assessment had improved, whilst other such as
observations being undertaken a minimum of 12 hourly and the time and
date being recorded were less good. Each clinical area had an individual
report and developed a plan for any improvements required
A way to demonstrate the benefit to patient care, other than by audit, is
to recognise and respond to signs of patient deterioration. The number
of cardiac arrests (defined as those requiring external cardiac compression
or defibrillation) has shown a decline in numbers since the introduction of
NEWS.
The number of actual cardiac arrests should reduce as patients are escalated
earlier. Staff are encouraged to put out a 2222 call in the peri-arrest phase
as part of the escalation process.
• E observation technology is a paperless method of recording physiological
observations to assess ill patients and recognise and respond to the
deteriorating patient. The observations are entered into a hand held
device which calculates the NEWS and saves the results
• The Trust is currently undertaking a tender process for preferred bidder
for the various technologies and will evaluate this in the coming months
• The Trust applied for significant amounts of Nursing Tech Fund monies
and having been successful in our bid, the money has been allocated to
implement roll out in Q4 of 2015/16
• Alongside this work will be the development of the band 1-4 role within
the Trust
Next steps
Can’t compliment staff at A10 Renal
ward @psh_nhstrust for looking after
my Dad, enough. Thankyou & for
arranging the aftercare.#supportnhs
“
“
I have been treated by the Dermatology department as an
outpatient for nearly two years. My previous hospital, which
I had attended since 1970, cannot hold a candle to this one.
Appointments are made with ease and always run to time
(in my experience). I appreciate the friendly yet very professional
way in which I am treated and particularly the caring way in which
my condition, which I find very embarrassing, is dealt with. The
recommended treatment has, for the first time in 40 years,
been effective. Many thanks to my doctor.
34 | QUALITY ACCOUNT 2014/15
Effectiveness domain
Priority 2 – Ensure effective and responsive care: Right Care; First Time; Every Time
Goal 2a
Outcome
summary
Information
Reason for
prioritisation
Baseline
Action taken
Outcomes
Reduce mortality rate: focus on respiratory diagnosis groups
Goal Not Met
Through Dr Foster reporting, the Trust has been in the top 25% for low
mortality rates, despite this the respiratory condition groups have continued
to alert for some of the months as being a higher risk of mortality than
would be expected.
This is reflective of the catchment area demographics i.e. increased elderly
population, large number of migrant workers, high level of deprivation.
The mortality rate, especially for the respiratory diagnosis groups, has
been affected by the type of patient cases that we have in hospital. As the
acuity and age of patients’ increases, a higher number of in hospital patient
deaths are attributed to a respiratory condition.
Keogh report
Adverse events
Clinical audit
Dr Foster Intelligence
Relative Risk (Respiratory):
April 2013 to Mar 2014 = 101.68
• A review of respiratory diagnosis groups was reported through to the
Quality Assurance Committee and Hospital Mortality Group
• Respiratory alerts (as defined by Dr Foster methodology, relative risk over
100) are constantly reviewed
• Hospital Mortality Review Group (HMRG) invited a GP to be part of its
membership to assist with the understanding of these types of mortalities
especially when the SHMI results (which include 30 days post discharge
mortality) have shown persistent alerts around respiratory conditions
• Dr Foster representatives have met with the respiratory team clinicians to
review the codes that each respiratory condition / disease aligns to when
documenting the patients’ reason for admission. This has enabled better,
clearer documentation of diagnosis coding
• Improved education and training around coding
Relative Risk (Respiratory):
April 2014 to Dec 2014 (most recent data available at time of report) =
106.46
Latest investigations have shown that 40% of the cases are related to the
demographics of the Trust catchment area and 60% of the cases are linked
to clinical codes used on the initial clinical documentation.
QUALITY ACCOUNT 2014/15 | 35
Next steps
• There is a link to patients being treated on the correct speciality ward
if they require an inpatient stay and mortality rates. Therefore the Trust
is continuing its capacity management work across the Trust to ensure
Right Care; First Time; Every Time
• A new process for reviewing hospital deaths is being drafted to better
understand the themes. This will be led and trialled by a Respiratory
Consultant who is also the Chair of the HMRG and Associate Medical
Director of the Effectiveness Stream in the Care Quality Directorate
• Work continues with the Clinical Coding team who are a proactive part
of the HMRG
• To work collaboratively with the community to understand the burden of
illness and the support and provision available for respiratory and other
patients with long term conditions prior to their hospital admission
Goal 2b
Improve patient flow and clinical outcomes:
1. Achieve 95% for waiting times in ED
2. Reduce number of non-clinical internal transfers
3. Reduce number of cancelled elective operations for non-clinical reasons
Outcome
summary
1.Goal Not Met
2.Goal Met
3.Goal Met
The Trust was consistently failing to meet the waiting times for ED and the
patient flow through the Trust needed review. This was thought to impact
on the number of non-clinical transfers and the number of cancelled
elective operations
Information
Reason for
prioritisation
During 2014/15, the health economy agreed that there would be a
reduction of approximately 8% of patients attending the ED. Unfortunately,
this reduction was not seen and there has been more than 11% increase in
emergency activity since the hospital opened in 2010. This has impacted on
the ability of the organisation to meet the 95% targets.
ECIST report
Creating Capacity Week findings
March 2014 NHS England Medical Director
Complaints
CCG visits
36 | QUALITY ACCOUNT 2014/15
Baseline
1. 2013/14 Percentage performance for waiting times in ED
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
85.8
94.46
95.23
93.96
93.19
94.13
93.61
95.44
95.96
94.05
90.25
83.38
2. Inpatient transfers rose towards the end of 2013/14 to over 250
transfers a month. There were also high numbers of patients who
transferred five times or more.
It is important to note that the first transfer is captured as a move from ED
to an inpatient area and that a Consultant to Consultant transfer is also
captured as a transfer but may not mean the patient has an additional bed
move.
3.2013/14 cancelled elective operations for non-clinical reasons
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Total
79
29
47
45
23
69
63
45
62
69
82
87
700
I would like to say a big thank you to the
Breast Unit team for their excellent treatment
when I visited The Breast Outpatients Clinic.
They all made me feel less scared with their
kindness and answering all my questions.
I would highly recommend this hospital.
“
“
Apr
Big thanks to the nurses at #NHS
Stamford Hospital. Super-efficient
and friendly
QUALITY ACCOUNT 2014/15 | 37
Action taken
• A daily control room was set up in 2014 to monitor performance
throughout the Trust. Length of stay, patient flow and inpatient transfers
were discussed and actions decided to make improvements
• Cancelled elective operations were investigated, it was thought they
were cancelled due to capacity however this was a rare occurrence and
operations were cancelled for process issues e.g. patient unfit for surgery,
patient did not attend and procedure no longer required
• The work and footfall through the Ambulatory Care Unit was increased
and continues to support patient pathways
• Ward Trackers have been employed to support staff in the various
processes involved in patient discharge
• New whiteboards have been put in place to improve patient care
pathways and discharge
• Two creating capacity weeks took place which provided some relief and
lessons learnt but did not create a sustainable improvement
• Work with surgical teams on their Pre-operative processes to achieve less
cancelled operations
• To create more theatre time, some operations were moved from day
cases in theatres to procedure rooms, such as carpal tunnel operations
• Appointment of additional nursing and medical staff
• Use of temporary staff over agreed establishment to manage the
increased patient attendance and admission to the ED and ward areas
• Introduction and utilisation of Red Cross to assist with patient experience
within the ED
Seeing some excellent approaches to
care @psh_nhstrust, the white board
rounds allow the whole team to get
updates and check progress!
“
“
My elderly mother was taken to A&E last
week after a nasty fall. I followed in my car
and was surprised and delighted to see her
already in a cubicle having already started her
treatment when I got there. Both my mother
and myself have nothing but the most respect
and gratitude to the doctor and various nurses
who cared for her. Peterborough hospital is an
excellent example of the NHS at its very best.
38 | QUALITY ACCOUNT 2014/15
Outcome
details
1. 2014/15 Percentage performance for waiting times in ED
Apr
May
93.02 81.8
June
July
Aug
Sept
Oct
Nov
Dec
Jan
85.93
86.63
92.37
84.58
79.57
85.78
84.39
80.77
Feb
85.2
Mar
86.39
2. Inpatient transfers have dropped to under 200 transfers a
month. The greatest improvement is that the patients who had
five transfers or more dropped to 10 in total for the year 2014/15
3. 2014/15 cancelled elective operations for non-clinical reasons
Next steps
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Total
14
71
56
37
12
25
37
40
50
33
15
28
418
• To avoid breaches in Minors, there is now a dedicated team of staff
• GPs will be in ED out of hours at weekends to support inappropriate
patients who are using the service
• Breaking the cycle three weeks in preparation for the opening of a
Medical Assessment Unit
• Working with community colleagues to reduce the number of patients
staying in the hospital once they are fit to go home
• Planning for the booking of elective surgery will be reviewed and
actioned in 2015/16
• The Trust has a 10 point plan which involves the whole Health Economy
playing their part in giving patients the best care leading to a safe and
timely discharge
• Review paperwork in ED
• Review and cleanse the method of data collection for patient transfers
within the Trust
QUALITY ACCOUNT 2014/15 | 39
Goal 2c
Ensuring appropriate staffing levels and skill mix
Outcome
summary
Information
Goal Met
Reason for
prioritisation
Baseline
Action taken
Expectation 7 (National Quality Board, 2013) details the need for
openness and transparency for patients and public around safe staffing levels. There is clear guidance on requirements for publishing and for reporting
to the Board monthly. During 2014/15 there has been a national picture of
a shortage of appropriately trained nursing staff, with a specific shortage in
the East of England. The Ministry of Defence Hospital Unit (MDHU) staff left
the Trust, which has further impacted on the number of nurses required.
With the publication of NICE guidance for staffing levels, the Trust invested
in increasing nursing establishments to ensure that each area was staffed
to ‘appropriate / safe’ levels. As a Trust we have increased the substantive
number of staff overall, largely in clinical posts.
Francis report
NHSE National Quality Board (2013)
CQC requirements
Nurse vacancy levels at 16%
External review and use of Hurst tool to identify appropriate staffing levels
Agreed appropriate staffing levels for each area, including the Ward
Managers being made a supervisory post – finance agreed and wards
established and levels published and reviewed daily
• Ward RAG ratings displayed in each area – planned versus actual
• NICE guidance (2014) ‘Safe staffing for adult inpatients’ published.
Reports to the Board submitted monthly; registered nurse to patient
ratios identified; uploads of staffing levels to UNIFY and NHS Choices;
data published and available on Trust internet and linked to NHS Choices;
6 monthly acuity / dependency data capture undertaken and reported to
the Board
• Staffing scrutiny panels set up for wards that alert for 3 consecutive
months as having a fill rate of less than 90% for registered nurses.
Action plans developed and monitored through the Quality Assurance
Committee
• Investment appraisal to purchase Healthroster Live to enable acuity /
dependency levels to be captured daily and to calculate nursing hours per
patient day required
• Reviewed staffing establishments as and when services and pathways
have changed
• Standardised shifts introduced and rolled out
40 | QUALITY ACCOUNT 2014/15
Outcome
details
Next steps
Nurse vacancy levels have reduced from 16% to 8% despite the national
shortage
Successful overseas recruitment of 69 nurses from within the EU with a
retention rate of approximately 96%
Greater scrutiny and challenge of staffing levels
Triangulation of staffing levels with the acuity and dependency of patient
groups
Public facing reporting
Greater depth and understanding of staffing levels to assist with pathway
and service changes
Retention programme in place
Recruitment action plan in place
Recruitment of student groups 6 months prior to qualifying.
Monthly reporting through the Workforce Board report
Compliant with recommendations within NICE guidance
• Implement recommendations within Department of Health (DoH) ‘Care
contact time’ (2014) document
• Continue to review and identify gaps within the Maternity Safe Staffing
Guidance (March 2015)
• Await NICE guidance on Safe Staffing for ED
• Implement Healthroster Live module for daily acuity / dependency
monitoring and identification of nursing hours per patient days required
(NHPPD), this programme will benefit patients by reducing money spent
on agency and temporary staffing costs
• New mentoring system for students to be implemented with local
University
Patient Experience domain
Priority 3 - Increase the satisfaction levels reported by patients.
Goal 3a
Outcome
summary
Information
Reason for
prioritisation
Improve response rate and satisfaction levels as recorded by the Friends and
Family Test (FFT)
Goal Met
There is a continued focus on embedding FFT across the whole health
economy. GPs and community services have now been issued guidance on
completing FFT and in acute Trusts there is now a requirement to ensure
it is rolled out across all outpatient areas as well as involving children in
completing FFT.
Trust Objectives
National Requirement
CQUIN
QUALITY ACCOUNT 2014/15 | 41
Baseline
Action taken
Outcome
details
In April 2014 the inpatient participation rate was 33% and ED participation
rate was 13.4%
In April 2014 the satisfaction levels were measured by the Net Promoter
Score. However, this changed in October 2014 to a ‘% satisfied score’
which makes it very difficult to compare satisfaction levels across the whole
year.
• Staff were reminded through Joint Ward Manager Meetings about the
necessity of undertaking the FFT and the positive impact comments can
make on staff and the development of both staff and services
• Volunteers continued to visit wards and departments to encourage
patients to participate
• Additional signage was put into place around the Trust encouraging
patients to complete an FFT form
• FFT scores were used as a nurse sensitive metric for wards alerting on the
staffing report
• Areas such as outpatients, Ambulatory Care Unit and Diagnostic Imaging
were brought online with FFT prior to the April 2015 deadline
• All comments from FFT are used to develop locally owned action plans so
as to address feedback such as Amazon ward who have a ‘you said we
did’ board
Response rates for FFT inpatients have improved over the course of the year.
The Trust has struggled with the ED response rates. In the last few months
of the financial year a dedicated member of staff has been allocated to
work in ED to improve participation rates. Our overall participation rates
have increased with the rise in figures in the latter months increasing the
annual participation rates in ED.
In March 2015 the inpatient participation rate was 40.4% and ED
participation rate was 16.2%
Our satisfaction rates have consistently been above national average for
ED and have either been equal to or above national average for inpatients.
Our satisfaction rates for both inpatients and ED are very good with
approximately 98% of inpatients saying they would recommend inpatient
services from the Trust and approximately 95% of patients saying they
would recommend the Emergency Department.
In March 2015 the inpatient recommended score was 97.1% and 92.8%
for ED. This has been consistently above the national average.
Next steps
• Continue roll out of FFT to all areas
• Involvement with patients who are children completing FFT once details
are published
• Continued use of FFT data to make local improvements
• ED to devise pathway that ensures FFT is seen as integral to a patient’s
discharge, thereby improving further their participation rates
• Continued use of FFT data to influence Matrons and Ward Manager’s
action plans
• Qualitative feedback is used by the Ward Managers as an accolade for
staff or to raise actions and develop improvements where required
42 | QUALITY ACCOUNT 2014/15
Goal 3b
Increase the responses to questions in the National Patient Survey (NPS) in
the ‘best performing’ category.
Goal Met
Outcome
summary
Information
Reason for
prioritisation
Baseline
Action taken
Outcome
details
Next steps
The National Patient Survey referred to is an Inpatient Survey which is a
mandatory requirement of the Care Quality Commission (CQC) as is the
National Cancer Patient Survey and the Emergency Department Survey
although this is not undertaken annually. These are undertaken to gather
the views of patients about their care and treatment during their stay
in hospital and forms part of the data supplied by the CQC’s Intelligent
Monitoring Tool. By using this as one measure it supports Trusts to improve
the quality of services provided.
Review of 2013/14 results
Complaints
The 2013 Inpatient Survey showed the Trust achieving ‘best performing’
category for two questions
The 2013 Cancer Survey showed the Trust achieving ‘best performing’
category for six questions
There was no ED survey undertaken in 2013
• Action plan based on the findings of all of the surveys undertaken in
2013 was compiled and completed during 2014/15
• This was monitored by the QAC and by the local Clinical
Commissioning Groups
The Trust achieved the following results for 2014/15 – National Inpatient
Survey http://www.cqc.org.uk/content/surveys
(awaiting results, embargoed by CQC until 21/05/15)
The results of the 2014 National Patient Cancer Survey showed the Trust
to be in the top 5 Trusts for cancer care and treatment in the country
– 12 questions rated as ‘best performing 20% of Trusts’. No questions
responded to as ‘lowest 20% of Trusts’.
The results for the 2014 Emergency Department Survey showed the Trust
to be average in all questions when benchmarked in the CQC report –
many questions rated as improving from previous years however there
were no questions in the ‘best performing’ category nor in the ‘worst
performing’ category.
• Continue to use the results to formulate action plans in all specialities
• Aim to improve all surveys to feature in more of the best performing
category
Very proud of the team from
fracture clinic @psh_nhstrust
shortlisted for placement of the
year @StudentNTAwards
QUALITY ACCOUNT 2014/15 | 43
Goal 3c
Outcome
summary
Information
Reason for
prioritisation
Baseline
Action taken
1. Improve user satisfaction with complaints process
2. Ensure lessons are learned
1.Goal Partially Met
2.Goal Met
The complaints services this year has undergone a reconfiguration and
investment made in staffing. The establishment levels have increased and
the expertise of staff has improved following an increase in the number
of senior posts. We continue to work with Healthwatch Peterborough
regarding evaluating the satisfaction levels of complainants.
Complaints continue to remain a high priority for all agencies with reports
being published by the Care Quality Commission, NHS England/Healthwatch and the Parliamentary Health Service Ombudsman.
Annual Objective
First year for monitoring the survey results
• Feedback from the Complaints Process questionnaire has framed the
revision of the complaints policy and the process by which complaints are
managed
• A Complaints Review (task and finish) Group has been established
that has been led by a Non-Executive Director (NED) and includes
representation from Healthwatch. This has resulted in process changes
and highlighted the importance of NED reviews which have been taking
place for some time
• Additional resources have been placed in the Complaints Department
to ensure a more robust approach to scrutiny of responses and record
keeping
• Increased focus on chasing complaint responses that are approaching
due dates
• Continued and improved working with Healthwatch and CCGs regarding
complaints
• Complaints training has been implemented for those staff who complete
responses and those who undertake investigations and are involved in
early resolution at ward level
• The Complaints Team attend the Chief Nurse Rapid Review Meetings to
discuss complaints received, identify trends and review risk ratings on a
weekly basis
• Increased focus on partnership working with the Safeguarding Team, Risk
Management and the Complaints Department
• Development of Key Performance Indicators (KPIs) at Complaints Review
Group
44 | QUALITY ACCOUNT 2014/15
Outcomes
Next steps
Report from Healthwatch Peterborough Aug – Nov 2014 demonstrated
that the Trust had an average level of complainant satisfaction with the
complaints process. The second report Nov 2014 – Feb 2015 demonstrated
a decrease in satisfaction levels. However it should be noted that the
sample size was low in relation to the number of complainants. The Trust is
utilising this feedback to develop the service further.
The Trust has put in place various areas for lessons to be learned. Regular
feedback to Sharing Lessons Events. Clear detail in audit forms are fed
back to staff following a complaint. Lessons learnt are a part of the
CLAEP report. This has heightened staff awareness and promoted quality
improvements.
• Continue to monitor complaints resolution via KPIs as agreed by
Complaints Review Group
• Continue with rolling training programme for staff re complaints
handling
• Undertake the CCG Complaints Review and take appropriate action once
report is received
• Continue the NED undertaking a review and feedback report of a sample
of complaints
• Continue to evaluate user satisfaction around the complaints process
• Continue to ensure that lessons learned from complaints are shared at
Sharing Lessons Events, CLAEP reports and staff feedback following a
complaint
• Re-launch the Complaints Newsletter to emphasise lessons learnt
continue
• Development of a questionnaire internally to capture the information
previously reported by Healthwatch Peterborough on satisfaction with
the complaints process
Some of the many continuous quality improvement initiatives during 2014/15 have included:• The development of the Dementia Specialist Nurse role and the training, raised
awareness and care for families and patients who have dementia
• The purchase of two UV-C cleaning machines and the roll out of the deep clean
programme to support the reduction in the risk of infections and possible outbreaks of diarrhoea based illnesses such as Norovirus
• The Trust is developing a paper light system using an electronic documentation scheme, EDM, which will reduce the use of old paper records and improve accessing notes for patient review and audit making it a much quicker process
• The chaplaincy service has developed a ‘sitting’ service for those patients who are at end of life to enable family and friends to take a break away from the bedside confident that their loved ones are not alone
• The Practice Development Team (PDT) have employed two pre-reg educators to work
with students and their mentors within the Trust. Two overseas educators assist with recruitment and retention of these groups of staff
• Internal audit reports for the Quality Directorate demonstrated 4 out of 5 rated as Substantial
QUALITY ACCOUNT 2014/15 | 45
Priorities for 2015/16
The Trust is continuing to develop the support and resources available to both patients with dementia and their carers.
Some of our hospital volunteers, as well as members of staff have received dementia awareness training. Alongside this,
there are trained dementia champions in each speciality, who are available as an additional support to nursing staff.
Our Dementia Specialist Nurse visits all wards and departments to screen and support patients, carers and staff.
The table on the following pages identifies
priority areas for quality improvement during
2015/16 across the domains of patient safety,
effectiveness of care and patient experience.
In order to ensure that our priorities for
quality improvement in 2015/16 are set
in line with local needs as well as national
requirements we have included priorities from
the Trust Annual Plan. The priorities have
been chosen by the Trust Board of Directors
and shared with our stakeholders at an event
involving representatives from the Council of
Governors, Clinical Commissioning Groups
(Cambridge and Peterborough and South
Lincolnshire), Healthwatch and Overview and
Scrutiny Committee representatives from
both Peterborough and Lincolnshire; and at
the Quality Assurance Committee and Audit
Committee.
There is a strong alignment with national
priorities including contractual requirements,
regular review of the Care Quality
Commission’s Intelligent Monitoring Tool
and from our performance against national
targets measured by the NHS Safety
Thermometer. New recommendations have
been implemented such as, the requirement
that the name of the nurse caring for the
patient and the responsible consultant are
written above the patient’s bed. However,
local information has also influenced our
selection of priorities, for example, themes
emerging from patient complaints or adverse
events reported by staff, from information
collected by Healthwatch Peterborough and
Lincolnshire and from observations made
during visits by our Clinical Commissioning
Groups.
In addition there are many other quality
improvement initiatives in place across the
Trust, including National CQUIN schemes
aimed at improving care for patients who
are screened and treated for sepsis and with
acute kidney injury. New innovations such
as an agreed annual deep clean programme
with the Trust’s Ultra Violet Light programme
to decrease the risk of infection outbreaks
will make a difference both to the safety of
46 | QUALITY ACCOUNT 2014/15
our vulnerable patients and the wellbeing of
our staff. Priorities identified in previous years
will continue to be monitored and progress
recorded. All the priorities are also influenced
by the Trust’s Quality Strategy and the vision
statement of: Right Care; First Time;
Every Time.
We will continue to focus on improving care
of older and vulnerable patients in the Trust
including monitoring and reducing nonclinical inpatient transfers, continuing our
work to improve the environment and care
for patients with Dementia and those that
require 1-1 support. Improvements in the
management and treatment for our older
patients and increasing our support to carers
will have an impact on the whole health and
social care economy as well as the Trust’s own
effectiveness and productivity.
Our staff remain central to delivering
improved quality of care year on year. In
line with the National Quality Board’s (2014)
requirements, the Board of Directors receive
I had the unfortunate occasion to visit the
hospital recently with my daughter, with all the
recent press reports I was expecting a rough ride
at A and E on a Saturday evening. Yes it was
busy, however the care and attention was way
above what I had expected. It was not chaos and
organisation was apparent. The speed of being
seen, the treatment and kindness from all team
members, including the very entertaining porter
who had been at the hospital for over 20 years,
made what is always a worrying experience a
little bit better. We were admitted and spent two
days the children’s ward – again the care and
kindness was way above expectations.
“
“
monthly reports that review nursing and
midwifery staffing for adult inpatient areas
and six monthly papers detailing the acuity
and dependency of patients. Figures for
planned and actual staff on duty for each
shift and in every ward are now displayed in
ward areas and monthly reports are provided
to Board members in the public meetings.
During this time of acknowledged national
shortages of qualified and experienced staff,
the recruitment of nursing and medical staff
is ongoing. Our early recruitment and support
of student nurses and midwives and the
excellent retention of nurses from overseas
continues to provide a very positive addition
to the Trust’s workforce.
The table overleaf indicates the priority areas,
the reasons the priorities have been selected
and information reviewed, the measures
that will be used in year to track progress
and the groups identified to lead the actions
required and monitor progress. A summary
of progress will be reported to the Board of
Directors and the commissioners within the
monthly Quality Report.
QUALITY ACCOUNT 2014/15 | 47
Table to show priorities for quality improvements in 2015/16
Reason for
Measure
Monitoring
prioritisation
NHS Outcomes Framework Domain 5: Treating and caring for people in a safe environment and
protecting them from avoidable harm
Falls
1. 8.2% reduction 1. NHS Safety
Falls Group
1. Overall
in 2014/15.
Thermometer data Scrutiny panel
reduction in
for all grade 3 and
patient falls by
2. Risk of harm
2. Reduced
above falls and
10%.
increased in
number of
frequent
patients falling
patients falling
fallers.
2. Reduce the
more than once
more than once
number of patients
and those with
PSC
who fall three
3. Serious harm
head injuries
times or more by
sustained in
associated with
QAC
50%.
2014/15
anticoagulation
(49 patients)
from baseline
3. Reduce the
2014/15
number of patients 4. Dignity
figures.
with serious
campaign
head injuries
3. Monthly
internal data
Improve the associated with
capture
percentage anticoagulation
of patients issues by 50%
who are
4.100% of patients
harm
free whilst with serious head
injuries have timely
under
the care of CT scan in line
the hospital with policy
SAFETY
Domain
Priority
5.100% patients
with serious injury
are case reviewed
at Scrutiny Panel
Pressure Ulcers
1. Reduce
avoidable
hospital acquired
grade 3 pressure
ulcers by 50%
1. 11 avoidable
grade 3 or above
pressure ulcers in
2014/15
2. Dignity
campaign
2. Reduce
avoidable pressure 3. Safeguarding
ulcers deteriorating cases
after admission to
hospital by 50%
3. No avoidable
grade 4 pressure
ulcers
1. Number of
avoidable hospital
acquired pressure
ulcers reported by
grade (2, 3 and 4)
and by ward
2. Monthly
internal data
capture
Tissue
Viability Group
Pressure ulcer
scrutiny panels
PSC
QAC
48 | QUALITY ACCOUNT 2014/15
VTE
1. Only achieved
1. Reduce potential 95% target 7/12
preventable or
months in 2014/15
preventable VTE
as determined at
scrutiny panel by
50%
1. NHS Safety
Thermometer data
2. Monthly
internal data
capture
VTE scrutiny panel
QAC
2. 95% target for
risk assessment
achieved monthly
3. 100% of
appropriate
patients receive
written information
on VTE
4. 100% hospital
associated VTE
reviewed at
scrutiny panel
Early detection of
the deteriorating
patient
1. Reduction
in year in the
number of cardiac
arrests where the
cause is identified
as omitted or
miscalculated
NEWS score or a
failure to escalate
deterioration in
patient condition
early.
2. Improvement
in physiological
observations
as measured in
annual audit
3. Introduction of
e-observations by
Q4
1. Introduction
of National Early
Warning Score
(NEWS) during
2014/15
2. Roll out
programme, as
part of the drive to
improve accuracy
in observations.
Preparing nurses
for the future in
using
electronic tools
and IMT.
1. Cardiac Arrest
Scrutiny Panel
Resuscitation/
Sepsis Group
2. Audit of
Cardiac Arrest
Audit Form
Matrons
3. MBSC
4. Repeat NEWS
audit
5. Monthly
e-observations
monitoring via a
dashboard
NHS England
QUALITY ACCOUNT 2014/15 | 49
EFFECTIVENESS
Domain
Priority
Reason for
prioritisation
Measure
Monitoring
NHS Outcomes Framework
Domain 1: Preventing people from dying prematurely
Domain 2: Enhancing quality of life for people with long-term conditions
Domain 3: Helping people to recover from episodes of ill health or following injury
Further
1. Trust Annual
1. Consultant led
Hospital Mortality
improvement in
Plan
review of at least
Group
mortality rates
50% of all hospital
1. Introduce new
2. Clinical audit
deaths
QGOC
mortality review
system
3. Dr Foster
2. Respond to Dr
QAC
Intelligence
Foster alerts within
2. Improve
45 days of them
response rates to
being raised
Dr Foster mortality
alerts
Safe Staffing
1. Francis report
1. NICE safe
NMAG
Levels
staffing guidance
1. 85% of adult
2. NHSE National
(2014) – Adult
TMB
Ensure
inpatient
wards
Quality
Board
Inpatient
Areas
effective and
QAC
responsive have a minimum
90%
registered
3.
CQC
2.
UNIFY
care
nurse fill rate on
requirements
submissions
Board
days and nights
3. NICE Safe
2. Paediatric
Staffing for
inpatient areas
Maternity Settings
have a minimum
(2015)
90% registered
nurse fill rate per
4. NICE Safe
month
Staffing Guidance
for A&Es(2015)
3. Gaps analysis for
maternity staffing
5. Care Contact
Time (DoH, 2014)
4. Gaps analysis
for Emergency
Department (ED)
staffing
5. Implement
Healthroster Live
module
PATIENT EXPERIENCE
50 | QUALITY ACCOUNT 2014/15
NHS Outcomes Framework Domain 4: Ensuring that people have a positive experience of care
Complaints
1. Increase the
1. Francis Report
1. No final
QAC
response rate to a
response rate
minimum of 90% 2. CQC
longer than 30
QGOC
of complaints
days without
being responded
3. Healthwatch
complainant
CLAEP
to within the 30
Peterborough
agreement
day timescale
feedback
NMAG
unless agreed with
2. Monthly KPIs
the complainant
Complaints Review
3. Quarterly
Group
2. Ensure that
internal report
all complainants
(100%) receive an
Increase the acknowledgement
letter within 3 days
satisfaction
of receipt of the
levels
reported by complaint
patients
3. 80% of
complainants
‘extremely
satisfied’ or
‘satisfied’ with
their complaint
response
Complaints
1. Ensure lessons
are learned and
disseminated and
embedded across
the Trust
National Patient
Survey
1. Increase the
responses to
questions in the
inpatient National
Patient Survey
(NPS) in the ‘best
performing’
category
1. Francis report
2. CQC
3. Healthwatch
Peterborough
feedback
1. Review of
2014/15 results
1. Increase
monitoring of
lessons learned as
part of complaints
reconfiguration
1. Increase
the number of
responses rated by
patients surveyed
in the best
performing Trusts
category from 2 to
6
Sharing lessons
sessions
Directorate
governance
meetings
Patient satisfaction
steering group
In addition to these priorities there are many quality initiatives that will be rolled forward
from previous years to ensure they are sustained and embedded to continue quality care
improvements. There are also Trust initiatives which are National CQUINs in 2015/16 such as
work around Sepsis and Acute Kidney Injury.
QUALITY ACCOUNT 2014/15 | 51
Statements of Assurance
from the Board
Review of services
During the year April 2014 to March 2015
Peterborough and Stamford Hospitals NHS
Foundation Trust provided 48 NHS services
and specialities across six Clinical Directorates.
in 94% (30/32) national clinical audits and
100% (4/4) national confidential enquiries
of the national clinical audits and national
confidential enquiries which it was eligible
to participate in. The Trust did not submit
data for two of the national audits which we
were eligible to participate in due to clinical
decisions.
The Trust has reviewed all the data available
to them on the quality of care in 100% of
these NHS services.
The national clinical audits and national
confidential enquiries that Peterborough and
Stamford Hospitals NHS Foundation Trust was
eligible to participate in during 2014/15 are
detailed in column 2 of the table below.
The income generated by the NHS services
reviewed in 2014/15 represents 100% of the
total income generated from the provision
of NHS services by the Peterborough and
Stamford Hospital’s NHS Foundation Trust for
2014/15.
The national clinical audits and national
confidential enquiries that Peterborough and
Stamford Hospitals NHS Foundation Trust
participated in during 2014/15 are detailed in
column 3 of the table below.
Participation in clinical audits
During the year April 2014 to March 2015
30 national clinical audits and 4 national
confidential enquiries covered NHS services
that Peterborough and Stamford Hospitals
NHS Foundation Trust provides.
During 2014/15 Peterborough and Stamford
Hospitals NHS Foundation Trust participated
The national clinical audits and national
confidential enquiries that Peterborough
and Stamford Hospitals NHS Foundation
Trust participated in, and for which data
collection was completed during 2014/15,
are listed below alongside the number of
cases submitted to each audit or enquiry as a
percentage of the number of registered cases
required by the terms of that audit or enquiry.
Eligible
Participated
Comments on Progress
& Outcome
1
NCEPOD Sepsis,
yes
yes
Data submitted for two sites,
330
89%
71
71
100%
307
216
70%
yes
307
293
95%
yes
390
258
66%
GI Haemorrhage, Lower limb
amputation, Tracheostomy Studies
Sample
Requested
Participation
Rate
Project Title
Sample
Submitted
ID
Participation: See below table.
2
RCS Prostate Cancer Audit (NPCA)
yes
yes
294
3
BTS Pleural Procedures
yes
no
4
CEM Older People (Care in Emergency
Departments)
yes
yes
5
TARN Severe Trauma (Trauma Audit &
Research Network)
yes
yes
6
Cardiac Arrhythmia (CRM)
yes
7
National Heart Failure Audit
yes
8
Parkinson’s Disease National Audit
yes
yes
On-going
9
Renal Replacement Therapy
(Renal Registry)
yes
yes
On-going. Data submitted by Leicester.
Clinical Lead; Missed deadline/Clinical decision
Data up to Dec14.
52 | QUALITY ACCOUNT 2014/15
10
Sentinel Stroke National Audit
Programme (SSNAP)
yes
yes
513
513
100%
11
National Lung Cancer Audit (NLCA)
yes
yes
171
171
100%
12
Elective Surgery (National PROMs
Programme)
yes
yes
754
411
55%
13
National Vascular Registry (NVR)
yes
yes
178
178
100 %
14
Colorectal Bowel Cancer (NBOCAP)
yes
yes
214
203
95%
15
National Joint Registry (NJR)
yes
yes
1011
748
74%
16
RCP Falls and Fragility Fractures Audit
Programme(FFFAP)
yes
yes
420
420
100%
17
BSR Rheumatoid and Early
Inflammatory Arthritis(1 yr)
yes
yes
18
National Emergency Laparotomy
Audit (NELA) 2yr
yes
yes
208
206
99%
19
Chronic Obstructive Pulmonary
Disease RCP/BTS_COPD
yes
yes
92
48
52%
20
Case Mix Programme Intensive
Care - Adult Critical Care (ICNARC)
yes
yes
728
728
100%
21
CEM Mental Health (Care in
Emergency Departments)
yes
yes
50
50
100%
22
Epilepsy 12 Audit-Round 2 (Childhood yes
Epilepsy)
yes
118
118
100%
23
Neonatal Intensive and Special Care
(NNAP)
yes
yes
257
257
100%
24
RCPCH National Paediatric Diabetes
Audit (NPDA)
yes
yes
213
213
100%
25
National Cardiac Arrest Audit (NCAA)
yes
yes
136
136
100%
26
National Audit of Ulnar Neuropathy at
Elbow testing ( BSCN & ANS)
yes
no
27
Inflammatory Bowel Disease (IBD)
yes
yes
39
39
100%
28
Maternal, infant and new born
programme (MBRRACE-UK)
yes
yes
36
36
100%
29
National Comparative Audit of Blood
Transfusion Programme
-Anti D
-Consent
yes
yes
70
70
100%
30
Acute Coronary syndrome or Acute
Myocardial Infarction (MINAP)
yes
yes
363
323
89%
31
BTS Adult Community Acquired
Pneumonia (CAP)
yes
yes
32
CEM-Initial management of the fitting
child.
yes
yes
50
50
100%
Data for 2014
On-going
Clinical Lead; Missed deadline/Clinical decision.
Patient Blood
Management in
scheduled surgery,
On-going.
On-going
Not Eligible and did not run in 2014/15
33
Head and Neck Oncology (DAHNO)
no
no
Data Submitted by Addenbrookes
34
Oesophago-gastric Cancer (NAOG)
no
no
Data Submitted by Addenbrookes
35
National Audit of diabetic retinopathy
and age-related macular degeneration
(rcophth)
no
no
Not Running in 2014/15
36
BTS Non-Invasive Ventilation (NIV) Adults
no
no
Not Running in 2014/15
37
National Diabetes Inpatient Audit
(NADIA)
no
no
Not Running in 2014/15
38
Pulmonary Hypertension (Pulmonary
Hypertension Audit)
no
no
Not Eligible.
QUALITY ACCOUNT 2014/15 | 53
39
Mental Health clinical outcome review
Programme: National Confidential
Inquiry into Suicide and Homicide for
People with Mental Illness (NCISH)
no
no
Not Eligible.
40
National Audit of Intermediate Care
no
no
Not Eligible.
41
Adult Cardiac Surgery Audit
no
no
Not Eligible.
42
Chronic Kidney Disease in Primary
Care
no
no
Not Eligible.
43
Congenital Heart Disease (Paediatric
Cardiac Surgery)
no
no
Not Eligible.
44
Coronary Angioplasty
no
no
Not Eligible.
45
Paediatric Intensive Care (PICANet)
no
no
Not Eligible.
46
Prescribing Observatory for Mental
Health (POMH)
no
no
Not Eligible.
47
Specialist Rehabilitation for patients
with complex needs
no
no
Not Eligible.
48
RCPSYCH National Audit of Dementia
(NAD)
no
no
Not Running in 2014/15, TBC announcement due July 2015.
Submitted our intention to participate in Nov14.
49
BTS Adult Bronchiectasis
no
no
Not Running in 2014/15
Tracheostomy Care
Lower Limb Amputation
Gastrointestinal Haemorrhage
Participation
Sepsis
Participated
Sample
Submitted
National Confidential Enquiry title
Sample
requested
During 2014/15 Peterborough and Stamford Hospitals NHS Foundation Trust participated in
the following studies as confirmed by NCEPOD.
ü
ü
5
5
100%
ü
ü
5
5
100%
ü
ü
7
7
100%
ü
ü
2
2
100%
Eligible
Reviewing reports of national clinical audits
The reports of 17 national clinical audits and 3 national confidential enquiry reports were
reviewed by the provider in 2014/15 and Peterborough and Stamford Hospitals NHS
Foundation Trust intends to take the following actions to improve the quality of healthcare
provided. Examples of national clinical audits completed are given overleaf.
“
“
Thank you to the Urology Nurse and her
team for the excellent care on my recent
visit. To have complete confidence in her
and her team means a great deal to me.
Thank you.
54 | QUALITY ACCOUNT 2014/15
National Clinical Audit and Confidential Enquiries
Lower Limb Amputation Study
Actions Taken during 2014/15
• Work with the regional vascular reconfiguration team
•
•
•
•
Renal Replacement Therapy (Renal Registry)
on the future of the Trust service.
Once the vascular reconfiguration occurs,
Peterborough is expecting to have a visiting vascular
surgeon on three days during the working week.
Scope to increase age range review for the medical
care of amputees depending on funding and medical
input
More coordination between the vascular unit and the
anaesthetic department
Measures were put in place to reduce the risk of a
subsequent fall during the in-patient stay through
dissemination of knowledge to all the wards caring
for amputation patients.
• Data presented locally and regionally as our audit is
the sum of all dialysis units under UHL.
• Regional collaboration through the attendance of
regional meeting to discuss outcomes.
RCS Prostate Cancer Audit (NPCA)
• Extra funding has been acquired for a third Prostate
Cancer UK funded post .Additional funding for a full
time CNS.
Regular review of outcome of this ongoing audit
CEM Older People (Care in Emergency
Departments)
•
• More teaching to junior clinicians to ensure better
•
•
communication and assessments of cognitive
impairment.
Review the design of the clinical notes to include a
tick box of review completion
More nursing education.
Reviewing reports of local clinical audits
The reports of 143 local clinical audits were reviewed by the provider in 2014/15 and
Peterborough and Stamford Hospitals NHS Foundation Trust intends to take actions to
improve the quality of healthcare provided as detailed in a document available from the
Quality Governance and Compliance Team. Examples of some local clinical audits are given
below.
Local Clinical Audit
Shoulder Dystocia Audit
Actions during 2014/15
• Process review: Staff on delivery suite to ensure that
•
•
•
Management of Multiple Sclerosis Audit
the correct paperwork has been completed and that
the neonatologist is called to attend to check the
baby after birth as soon as possible.
Improve documentation of brachial plexus injuries
RCOG proforma amended in the Trust.
Improved Information dissemination using emails
and newsletters
• Organise a feedback meeting for neuro-outpatient
therapy team.
• In-service training
• Identify and agree on new standards in relation to
•
mobility assessments.
Re-audit.
QUALITY ACCOUNT 2014/15 | 55
Local Clinical Audit
Actions during 2014/15
Think Delirium Audit
• Expand the remit of the audit and pilot on medical
wards
• Author hospital guide
• Author/adopt learning modules for hospital use
• Author/adopt information leaflet for inpatients use
Audit of Constipation in Children and Young People
• Ensure required leaflets are available in the right
areas
• Add to the hospital drug stock list
• Re-audit
Participation in clinical research
Peterborough and Stamford Hospitals NHS
Foundation Trust is actively participating
in clinical research across many specialties.
As part of the five year Research and
Development strategy a project has been
undertaken during 2014/15 to open up
new specialities to research, giving more of
our patients the opportunity to participate
in clinical trials and have access to the
development of new treatments. The
core areas of research within the Trust are
oncology, cardiology, stroke, dementias
and neurodegenerative disease, surgery,
paediatrics and critical care. New specialties
embarking on research during 2014/15 were
musculoskeletal, respiratory and anaesthetics.
We are committed to establishing our Trust
as an internationally recognised centre of
excellence through supporting and training
our staff, working in world class facilities and
conducting research focused on the needs of
our patients.
As part of our commitment to our patients
to offer the best possible care, we have
appointed patient research ambassadors that
will enhance our patient voice and increase
the access our patients have to participate
in clinical trials. We hosted a successful
Research and Development symposium where
two research participants came to share
their research experiences with our staff,
enhancing, patient-clinician relationships.
During the period of 2014/15 122 Trust
clinical staff participated in research approved
by a Research Ethics Committee. These staff
have been involved in conducting 129 clinical
research studies (studies open to recruitment
during this period) in 2014/15, of which 109
(85%) were National Institute for Health
Research (NIHR) Portfolio studies. The Trust
sponsors 5 active research studies, where the
clinical trials are set up and managed from
within the Trust and a further 11 studies have
been approved by the R&D committee as
service evaluations.. Within these studies the
number of patients receiving NHS services
provided or sub-contracted by the Trust
in 2014/15 that were recruited during this
period to participate in research approved by
a research ethics committee was 646 (a 23%
increase from the 2013/14 financial year),
of this 497* (77%) were recruited to NIHR
portfolio studies.
In the year 2014/15, 67 publications in a
number of different specialties have resulted
from studies at the Trust, which shows our
commitment to transparency and desire to
improve patient’s outcomes and experience
across the NHS.
* These figures are taken from the Trust database
Seeing some excellent
approaches to care @psh_
nhstrust, the white board rounds
allow the whole team to get
updates and check progress!
56 | QUALITY ACCOUNT 2014/15
Number of patients recruited to clinical trials within PSHFT during 2014/15 by speciality
Use of the CQUIN payment framework
A proportion of the Peterborough and
Stamford Hospitals NHS Foundation
Trust’s income in 2014/15 was conditional
on achieving quality improvement
and innovation goals agreed between
Peterborough and Stamford Hospitals NHS
Foundation Trust and its commissioners
through the CQUIN (Commissioning for
Quality and Innovation) payment framework.
sign-off for Quarter 1 to 3 for the milestones
delivered. The quarter 4 targets will be
shared with commissioners at the end of April
but final confirmation is not expected until
the end of May.
For 2014/15 the baseline value of CQUIN
was 2.5% of the contract value (based on
the indicative activity plan April 2014 as
£199.1m). If the agreed milestones were not
achieved during the year payment would not
be made. There were partial payment targets
set for some CQUIN schemes attributable to
only quarter 4 targets. The Trust has received
CQUIN payments are based on final outturn
of contracted activity, £207.3m, of which
£3.6m relates to the income achieved from
the CQUIN programme. The Trust achieved
78% of its CQUIN goals with the main
commissioners and 92% of its CQUIN goals
with the specialist commissioners (NHS
England).
From arrival to discharge I was looked after
in every way. Staff worked hard to ensure
patient care was a priority. All the current
political “stuff” about the NHS is absolute
rubbish. With the available resources the staff
did a great job. Members of the public need
to be patient and realise a priority system is in
place. Please pass on my thanks to Ward A8
and A2 - absolutely top job.
“
“
Further details of the agreed goals for
2014/15 and for the following twelve month
period are available electronically at
annette.parker@pbh-tr.nhs.uk.
QUALITY ACCOUNT 2014/15 | 57
Indicator Name
Description of Goal
Total CCGs
Potential Financial
Value
FFT - Implementation of Staff
FFT
Provider to demonstrate FFT has been delivered across all £63,547.02
staff groups as outlined in the guidance
FFT- Early implementation
Full delivery of FFT across all services delivered by the
provider as outlined in guidance
£31,773.51
FFT - Increased or
maintained response rate
A response rate for Quarter 4 that is at least 20% for
A&E Services and at least 30% for inpatient services
£31,773.51
FFT - Increased response rate
in acute inpatient
A response rate of 40% (or more) for the month of
March 2015
£84,729.36
NHS Safety Thermometer –
S Lincolnshire
Median of five consecutive monthly data points up
to 31 March 2015. For this median value to count as
improvement the five consecutive monthly data points
have to be below the baseline median value
£68,773.26
NHS Safety Thermometer C&PCCG
50% reduction from Grade 2,3 and 4 PUs on Safety
Thermometer Day
£143,050.13
Dementia - Find, Assess,
Investigate and Refer
The proportion of patients aged 75 and over to whom
case finding is applied following emergency admission,
the proportion of those identified as potentially having
dementia who are appropriately assessed, and the
number referred on to specialist services
£127,094.03
Dementia - clinical
leadership
Provider must confirm named lead clinician and delivery
of planned training programme for dementia for the
year
£21,182.34
Dementia – Supporting carers
of people with dementia
Provider must demonstrate they have undertaken
a monthly audit of carers of people with dementia to
test whether they feel supported and reported the
results to the Trust Board
£63,547.02
7 Day Working - Time to first
consultant review
All emergency medical and surgical admissions to ESS
Ward (including EMU) to be seen by a suitable
consultant within 14 hours of admission
£635,470.17
7 Day Working - Access to
diagnostics
All inpatients to have access to 7 day scheduled
diagnostic services, to include X-ray, ultrasound, CT, MRI
and pathology, to include completed reporting
£423,646.78
7 Day Working - Fracture
neck of femur supporting
early discharge
To deliver a new pathway to improve care of patients
with Fractured NOF including seven day early
intervention enabling improved rehabilitation and
discharge
£423,646.78
7 Day Working - ACU
pathway development and
notification to GP practices
patient are on an ACU
pathway
Trust to present pathways and programme of development of new ACU pathways to both commissioners to
explore how primary care provision could be utilised to
enable more effective use of resources across primary
and secondary care. ACU notification to be
dispatched electronically same day as the decision to
treat/investigate is made.
£354,873.52
Medicines Safety
Thermometer - medicines
reconciliation
% of eligible patients who have received a pharmacist
led medicines reconciliation within 24 hours of
admission
£572,473.52
Medicines Safety
Thermometer - Steps 1 and 2
Introduce Steps 1 and 2 of The National Medicines
Safety Thermometer Tool’ in 6 inpatient wards.
£601,083.54
58 | QUALITY ACCOUNT 2014/2015
Improved Catheter
Care- Aiming to reduce
length of time catheters
remain in situ
All patients who have a catheter inserted must have
reason for insertion clearly documented. Catheters
inserted for output monitoring should have predicted
date of removal at time of insertion. Through education
of clinical staff aim to reduce the number of catheters
inserted
£256,389.51
Improved Catheter
The development of joint working between community
Care - prevention of
and hospital to improve care for those patients with
unplanned ED attendances by Long Term Catheter (LTC)
patients with (LTC)
£127,094.03
End of Life
Establishment of a new End of Life care plan for use by
clinical staff at PSHFT. Train all relevant nursing staff in
relation to the new care plan to improve the quality of
care provided to each service user.
£68,773.26
Cultural Barometer - Increased Response Rate and
effective monitoring of the
Trust’s Action Plan
Assess organisational culture, review areas of concern,
develop an action plan to address those areas and then
implement actions each quarter
£68,773.26
Improving the Quality of
Discharge
Communications
To improve the quality of all Inpatient and Emergency
£68,773.26
Department (including ACU) discharge letters. Discharge
letters to be sent to the patient’s GP within 48 hours of
the patient being discharged from hospital (timescale at
48 hours to allow for patient discharged on a Saturday /
Sunday/Bank Holiday).
Total Potential Value
Indicator Name NHS England
£4,236,467.82
NHS
England
Indicator
Weighting
NHSE
Potential
Financial
Value
FFT - Implementation of Staff
FFT
Provider to demonstrate to commissioner staff
FFT has been delivered across all staff groups as
outlined in the guidance
1.50%
£5,781.98
FFT- Early Implementation
Full delivery of FFT across all services delivered by
the provider as outlined in guidance
0.75%
£2,890.99
FFT - Increased or Maintained A response rate for Quarter 4 that is at least 20%
Response Rate
for A&E Services and at least 30% for inpatient
services
0.75%
£2,890.99
FFT - Increased Response
Rate In Acute Inpatients
Services
A response rate of 40% (or more) for the month
of March 2015
2.00%
£7,709.31
NHS Safety Thermometer - S
Lincs
Median of five consecutive monthly data points up
to 31 March 2015. For this median value to count
as improvement the five consecutive monthly data
points have to be below the baseline median value
5.00%
£19,273.27
NHS Safety Thermometer C&PCCG
50% reduction from Grade 2,3 and 4 PUs on
Safety Thermometer Day
0.00%
£0.00
Dementia - Find, Assess,
Investigate and Refer
The proportion of patients aged 75 and over to
whom case finding is applied following emergency
admission, the proportion of those identified as
potentially having dementia who are appropriately
assessed, and the number referred on to specialist
services
3.00%
£11,563.96
QUALITY ACCOUNT 2014/15 | 59
Dementia - Clinical
Leadership
Provider must confirm named lead clinician and
delivery of planned training programme for
dementia for the year
0.50%
£1,927.33
Dementia – Supporting
Carers of People with
Dementia
Provider must demonstrate they have undertaken a
monthly audit of carers of people with dementia to
test whether they feel supported and reported the
results to the Trust Board
1.50%
£5,781.98
NHSE Agree schemes to
take forward
Submit detailed action plans for improvements
each quarter for various specialist areas:
Expanding of the Outreach Service for NICU
(Neonatal Intensive Care Unit)
Introduction of Telemedicine for cancer patients
Ensuring cost effective prescribing and medicines
use reduction 70% of patients having a single
fraction of radiotherapy
45.00% £173,459.43
NHSE Delivery Schemes
Evidence action plans and targets achieved for
each area (NICU, Telemedicine, Pharmacy and
Radiotherapy) for Quarters 2-4.
40.00% £154,186.16
Total Potential Value
100% £385,465.39
Statements from the Care Quality
Commission
Peterborough and Stamford Hospitals NHS
Foundation Trust is required to register with
the Care Quality Commission and its current
registration status is unconditional for all
regulated activities.
The Care Quality Commission has not taken
any enforcement action against Peterborough
and Stamford Hospitals NHS Foundation Trust
during 2014/15.
Peterborough and Stamford Hospitals NHS
Foundation Trust has not participated in
special reviews or investigations by the Care
Quality Commission during 2014/15.
In March 2014 the Trust was inspected by
the CQC, as part of phase two of the new
style hospital inspections, with an overarching
rating of ‘requires improvement’. Following
the publication of the report in May 2014
the Trust wrote an action plan based on
the 11 areas highlighted as those that the
Trust ‘Should’ aim to improve. The Clinical
Directorates also highlighted other areas from
the report where positive changes and quality
improvements could be made. The action
plan was completed in April 2015 and sent to
the CQC as part of the preparation for a
re-inspection planned for May 2015.
To ensure sustainability and progress with
the action plan a series of peer review visits
to all areas of the Trust were planned; the
visits were undertaken by the Matrons, NonExecutive Directors, Senior Nursing staff and
the Chief Nurse.
The quarterly publication Intelligent
Monitoring Tool from the Care Quality
Commission has been reviewed during the
year. Clinical and Corporate Directorates are
required to use the data provided to inform
and confirm their quality improvement
activities. Results have informed the priorities
for 2015/16.
60 | QUALITY ACCOUNT 2014/15
Data quality (as at 14th April 2015, up to
month 10)
Peterborough and Stamford Hospitals NHS
Foundation Trust submitted records during
2014/15 to the Secondary Uses Services
(SUS) for inclusion in the Hospital Episode
Statistics (HES) which are included in the
latest published data. The percentage of
records in the published data which included
the patient’s valid NHS Number was: 99.7%
for admitted patient care (99.2% national);
99.8% for out-patient care (99.3% national);
and 99.9% for accident and emergency care
(95.2% national)
The percentage of records in the published
data which included the patient’s valid
General Practitioner Registration Code was:
100% for admitted patient care (99.9%
national); 100% for out-patient care (99.9%
national); and 100% for accident and
emergency care (99.2% national).
Information Governance Toolkit
attainment levels
Peterborough and Stamford Hospitals NHS
Foundation Trust Information Governance
Assessment Report overall score for
2014/15 was 71% and was graded green
(satisfactory). There were no serious breaches
of the Data Protection Act (level 2 reportable)
in 2014/15 which required reporting to the
Information Commissioners Office.
Clinical coding error rate
Clinical coding is the translation of medical
terminology that describes a patient’s
complaint, problem diagnosis, treatment or
other reason for seeking medical attention
into codes that can easily be tabulated,
aggregated and sorted for statistical analysis
in an efficient and meaningful manner.
Peterborough and Stamford Hospitals NHS
Foundation Trust was not subject to the
Payment by Results clinical coding audit
during 2014/15 by the Audit Commission but
was subject to an Information Governance
Audit to comply with Information
Governance Toolkit (IGT) requirement number
11-505. An audit of clinical coding, based on
national standards, has been undertaken by a
NHS Classifications Service Approved clinical
coding auditor within the last 12 months.
Data Quality audit, focused on clinical coding,
is a crucial part of the robust assurance
framework required for both Payment by
Results (PbR) and the development of the
NHS Care Records Service (NHS CRS).
The Information Governance audit and these
results are based on a 200 episode audit
from a random selection of all specialties
for patients discharged between July and
September 2014.
The NHS Classifications Service recommends
the following percentage scores measured by
procedure and diagnosis error rates as
targets:
Attainment Level for Information Governance Purposes
Level 2
Level 3
Primary diagnosis
>= 90%
>= 95%
Secondary diagnosis
>= 80%
>= 90%
Primary procedure
>= 90%
>= 95%
Secondary procedure
>= 80%
>= 90%
Audit results: The figures exceed the recommended 95% accuracy score for primary
diagnoses and procedures and are well above the 90% accuracy for secondary diagnoses and
procedures required for Information Governance purposes at Level 3.
QUALITY ACCOUNT 2014/15 | 61
Primary diagnosis correct
Secondary diagnosis
correct
Primary procedures
correct
95.50%
94.14%
96.43%
The figures for primary diagnosis and primary
procedure fell short of the recommended
percentage scores for Level 2 as stated in the
Information Governance Toolkit 11-505. The
figures for secondary diagnosis and secondary
procedures met the recommended Level 2.
Achievement of this standard is linked
to independent audit outcomes and as
improvements were noted as required in this
audit, an action plan has been put in place
with actions complete (but not audited). It
was proposed that the attainment level is set
at Level 2 compared to Level 3 in 2013/14.
This proposal was approved at Trust
Management Board In March 2015 taking
into consideration the audit results and the
action plan in place.
It should be noted that these results should
not be extrapolated further than the actual
Secondary
procedures
correct
97.55%
sample that was audited (i.e. 200 episode
audit).
Data quality improvements
Peterborough and Stamford Hospitals NHS
Foundation Trust will be taking the following
actions to improve data quality:
• Ongoing validation of 18 week pathways
and regular reports to sample check a
selection of pathways from all/any specialty.
• Ongoing sample audits of PAS episode data
for inpatient, out-patient and emergency
department as well as waiting list entries
validated against the case note information
to check for accuracy.
• Spot check audits to ensure demographic
data is being checked with the patient and
updated on PAS.
• Internal audit reports and level of
assurance.
Auditable Area
Assurance Framework and Risk
Management
Theatre Visits
Assurance Result
Substantial
Detail
Limited
WHO checklist and High
Impact Interventions were
highlighted. Action plans in
place
Job Planning
Clinical Audit Governance
Process
Substantial
Substantial
Quality indicators
For the majority of the Quality indicators
the data is made available to the NHS
Foundation Trusts by the Health and Social
Care Information Centre for the reporting
period 2014/15.The Health and Social Care
Information Centre was accessed on 24 April
2015 with the most recent data available
at that time reported. This is a National
reporting database which collates data for
many different parameters. These are not
always the figures that the Trust use to report
data so figures may appear different in other
reports.
Percentage of
patient deaths
with palliative
care coded at
either diagnosis or
speciality level
1.00
0.541
1.198
28%
24.77%
49%
0.00%
Data from HSCIC July 2013 – June 2014 published
in January 2015
Band 2
1.001
Data from HSCIC July 2013 – June 2014 published
in January 2015
Lowest
performer
SHMI value and
banding
Highest
performer
2014/15
Indicator
National
Average
Quality Indicators - performance table
1.01
2013/14
In 2015/16 we intend to: continue the level of scrutiny and
triangulation to ensure appropriate use of specialist palliative care
team resources and subsequent clinical coding.
Peterborough and Stamford Hospitals NHSFT has taken the
following actions to improve the percentage, and so the quality of
its services, by: As part of our quality improvement programme for
patients near or at the end of life, we have rolled out the Amber
Care bundle, a care plan for those who are likely to die in the next
year. Also a Personalised Care Plan for the End of Life has been
devised, rolled out and audited within the Trust.
Peterborough and Stamford Hospitals NHSFT considers that data is
as described for the following reasons: when patients are referred
to the specialist palliative care team, a sticker is placed in their
medical records. This is then used by the clinical coding team to
triangulate and calculate data. Regular review of palliative care
coding is undertaken by the hospital mortality group.
In 2015/16 we intend to: continue the level of scrutiny and action.
Jul 12
Jun 13
26.3%
Sept 14
26.3%
Band 2
1.01
2012/13
Oct 13
Peterborough and Stamford Hospitals NHSFT has taken the
Band 2
following actions to improve the indicator and percentage, and so
the quality of its services, by: review of mortality statistics, deep dive
audits with external
scrutiny, and implementation of clinical change as required.
Peterborough and Stamford Hospitals NHSFT considers that this
data is as described for the following reasons: the data shows
the Trust results to be in the banding ‘as expected’. The hospital
mortality group continues to monitor closely data relating to
mortality and identifying areas for further development and
improvement.
Trust Statement
62 | QUALITY ACCOUNT 2014/15
Data not
available
Data not available from HSCIC website
(iv) knee replacement surgery
The percentage of
patients aged
(i) 0-15
(ii) 16 or over
readmitted to a
hospital which
forms part of
the Trust within
28 days of being
discharged from
a hospital which
forms part of the
Trust
(Data
source,
Trust IT
systems)
(i)
12.2%
(ii)
18.5%
Data not
available
0.326
0.442
0.394
0.501
0.142
(iii) hip replacement surgery
0.100
Data not
available
0.125
(ii) varicose vein
surgery
0.081
Highest
performer
0.114
6mth
Data
Apr14 Sept 14
Patient reported
outcome scores
for:
National
Average
(i) groin hernia
surgery
2014/15
Indicator
0.249
0.35
0.054
0.009
Lowest
performer
Please note the data is being recorded using different
parameters which explains the very different figures for 2012/13
In 2015/16 The Trust have an Urgent Care Recovery plan which by
working with our community partners will lead to safe and effective
discharge.
Peterborough and Stamford Hospitals NHSFT has taken the following actions to improve this percentage, and so the
quality of its services, by: reviewing patient pathways and ensuring
multidisciplinary team discharge planning.
Peterborough and Stamford Hospitals NHSFT considers that these
percentages are as described for the following reasons:
In common with many Trusts a large number of readmissions are
unrelated to the previous episode
In 2015/16 we intend to: increase further patient participation rate
in the PROMs scheme, and use the patient level data to inform any
pathway redesign or improvements required.
Peterborough and Stamford Hospitals NHSFT has taken the following actions to improve the indicator, and so the quality of its
services, by: ensuring individualised patient assessment for appropriate surgical procedures. Pre-operative assessment has improved
identification of patients with co-morbidities enabling early intervention required for positive impact on outcomes.
Patient Related Outcome Measures (PROMs) are a tool used to
evaluate the outcome of the procedures outlined. The patient is
surveyed at pre-assessment and then again three or six months
later depending on the procedure undertaken. Peterborough and
Stamford Hospitals NHSFT considers that the outcome scores are
as described for the following reasons: Trust staff continue to work
towards ensuring the optimum level of participation in PROMs
responses therefore ensuring the sample size is statistically valid.
Trust Statement
(i)
11.8%
(ii)
17.8%
0.296
Data not
available
Data not
available
0.131
6mth
Data
Apr 13
Sept 13
2013/14
(i)
2.6%
(ii)
8.8%
0.332
0.416
Small
sample
size 9
0.084
0.131
9mth
Data
Apr 12
Dec12
2012/13
QUALITY ACCOUNT 2014/15 | 63
Lowest
performer
Trust Statement
The percentage of 2014
staff employed by,
or under contract
to, the Trust who
would recommend
the Trust as a
60%
provider of care
to their family or
friends.
2014
89%
2014
65%
38%
2014
In 2015/16 we intend to: continue quarterly cultural barometer and
progress action plans
Peterborough and Stamford Hospitals NHSFT has taken the
following actions to improve this percentage, and so the
quality of its services, by: giving staff confidence and
improving their perceptions of the Trust in such areas as staffing,
patient pathways and bed pressures within the Trust. All these
issues continue to be of high importance.
Leadership training continues and is available at all levels to place
patients at the heart of everything we do. Using the cultural
barometer, we have developed local action plans across all areas of
the Trust relating to the staff survey results, including this indicator
with regular monitoring and review.
Peterborough and Stamford Hospitals NHSFT considers that this
percentage is as described for the following reasons: The Trust has
increased activity levels and although demonstrates an improving
staff vacancy rate there is still use of locum and agency staff.
Enhanced communication and engagement with staff to ensure
they feel informed of the key Trust issues and motivated and
engaged to deliver Right Care; First Time; Every Time.
In 2015/16 we intend to: continue focus on safe and effective
discharge through our ten point plan and to develop the band 1-4
workforce.
Peterborough and Stamford Hospitals NHSFT has taken the
following actions to improve the indicator and percentage, and
so the quality of its services, by: a focus on improving our call bell
response times A more multi-disciplinary approach to ensure that
ward rounds improve communication both between disciplines and
also with patients, relatives and/or carers has been developed.
Most recent data available on HSCIC website August Score is a composite of five of the domains for the inpatient survey
2014
commissioned by the CQC each year. Peterborough and Stamford
Hospitals NHSFT considers that this data is as described for the
following reasons: The Trust’s composite score has improved to
just above National average. Many actions have been put in place
77.3
76.9
88.2
59.0
to achieve this including, volunteers to help at meal times and
an ongoing commitment to receiving and acting upon patient
feedback
Highest
performer
The Trust’s responsiveness to the
personal needs of
its patients
National
Average
2014/15
Indicator
68.2
67.2
2013/14
58
67.2
2012/13
64 | QUALITY ACCOUNT 2014/15
96%
95%
100%
Oct – Dec
Q3
Highest
performer
77.7%
Oct – Dec
Q3
Lowest
performer
The rate per 100,000 Most recent data available on HSCIC website
bed days of cases of 2013/14
C.difficile infection
reported within the
Trust amongst
18.9
14.7
0.0
37.1
patients aged 2 or
over
Oct – Dec
Q3
Oct – Dec
Q3
The percentage of
patients who were
admitted to hospital
and who were risk
assessed for venous
thromboembolism
National
Average
2014/15
Indicator
In 2015/16 we intend to: continue the ongoing surveillance,
teaching and audit activities to ensure any lessons to be learned
are identified and practice is consistently aligned with policy.
Address recommendations made by external reviewers (March
2015)
Peterborough and Stamford Hospitals NHSFT has taken the
following actions to improve the indicator and percentage, and
so the quality of its services, by: Rolling antibiotic treatment
audits with feedback to staff. Cleaning audits and root cause
analyses of all infections, scrutinised by a multi-disciplinary team
including external input
Peterborough and Stamford Hospitals NHSFT considers that this
rate is as described for the following reasons: each infection
is scrutinised and of the 41 infections reported in 2014/15,
22 were found to be unavoidable (i.e. Appropriate care and
preventative measures were in place).
In 2015/16 we intend to: continue embedded practices and
audit of compliance
Peterborough and Stamford Hospitals NHSFT has taken the
following actions to improve this percentage, and so the
quality of its services, by: Reviewing care in relation to the
NICE Guidance and including any changes in policy, education
initiatives and audit processes. All cases of blood clots
associated with a hospital stay were identified and investigated
and information was provided for patients who decline the
recommended treatment.
The results shown are for Q3, that is, October to December of
the given years. Peterborough and Stamford Hospitals NHSFT
considers that this percentage is as described for the following
reasons: electronic data capture of risk assessment results and
display of compliance. Audit of compliance with the policy and
feedback to teams of results and further action required. Root
cause analysis of any hospital acquired thrombosis.
Trust Statement
17.4
95.9%
2013/14
17.4
96.3%
2012/13
QUALITY ACCOUNT 2014/15 | 65
Peterborough and Stamford Hospitals NHSFT has taken the
following actions to improve the indicator and percentage,
and so the quality of its services, by: Quarterly reporting of
adverse events, complaints, litigation and PALS data with
wide distribution demonstrating the importance of reviewing
and learning from all these reporting mechanisms to protect
patients.
The data below is for this Trust and for the cluster classified as
‘medium acute Trusts’. Peterborough and Stamford Hospitals
NHSFT considers that this rate is as described for the following
reasons: The Trust is a high reporting organisation indicating a
positive patient safety culture
Trust Statement
Number
(incidents
involving
severe harm
or death) – 3
In 2015/16 we intend to: continue to emphasise our patient
0.05%
safety culture and the importance of openness and transparency
Rate 16.8
Hospital B)
Number
(patient
safety
incidents
reported) 5,495
Oct 13 –
Mar 14
Lowest
performer
Despite the fact that
Hospital A is in the
‘highest performer’
bracket for incidents
reported, their severe
harm or death rate is
significantly higher,
making them one of
the lower performers;
Hospital B however is
obviously a high reporting
Trust, however has a very
low rate of severe harm or
death, therefore making
them one of the highest
performers.
Number
(incidents
involving
severe
harm or
death) - 22
2.0%
Number
(incidents
involving
severe
harm or
death) - 14
0.34%
Rate 2.4
Oct 13 –
Mar 14
Rate - 9.5
Data not
available
Highest
performer
Hospital A)
Number
(patient
safety
incidents
reported) 1,048
Oct 13 –
Mar 14
The number and,
where available, rate
of patient safety
incidents reported
within the Trust
and the number
and percentage
of such patient
safety incidents that
resulted in severe
harm or death.
National
Average
Number
(patient
safety
incidents
reported) 4,089
2014/15
Indicator
Number
4,109
Rate 10
Oct –
Mar
2013
2013/14
Rate 9.53
Apr –
Sep 2012
2012/13
66 | QUALITY ACCOUNT 2014/15
Never events
Peri-operative
safety
checklist
MRSA
bacteraemia
cases
Trust Datix
system
Point
prevalence
MBSC
Audit
Pathology
system
Quality subject Data source
3
98.1%
1
2011/12
2
99.2%
1
2012/13
1
98.7%
0
2013/14
Part 3 – Review of Quality performance
Patient safety
0
100%
0
Target
2014/15
2
99.5%
0
Performance
2014/15
0
100%
0
Target
2015/16
Investigations and resulting
action plans completed. The
patients involved have been
kept informed. Cases have
been presented at ‘Sharing
Lessons Learned’ events
One incident (retained object
following surgery) resulted
from human error and system
weakness. The second incident (wrong
site surgery) resulted from
human error and the failure
to follow procedures.
Overall number of theatre
audits undertaken in 2014/15
- 752 patients in main theatre
excluding Trauma and
Emergency but including
obstetrics. This represents
5.3% audited of the whole
Target achieved
Comments
QUALITY ACCOUNT 2014/15 | 67
Evolution
Monthly
Stroke metrics
Post- partum
haemorrhage
>2 litres
Stroke care
Completion of MBSC
nutritional risk
assessment
and food
intake
monitoring
Data source
Quality
subject
93%
Achieved 6
out of 12
months.
Average for
year
calculated in
days 79.7%
0.72%%
2011/12
Clinical effectiveness
96.1%
Achieved
6 out of12
months.
Average for
year
calculated in
minutes as
78.1%
1.18%
2012/13
98.2%
Achieved 7
out of 12
months.
Average for
year calculated in minutes
as 77.8%
1.08%
2013/14
Performance
2014/15
Increase
completion
rates
80% of
patients spend
90% of time
on stroke unit
94.7%
Achieved 6
out of 12
months. Only
2 months
were below
80%
Average for
year calculated in minutes
as 86.3%
Reduce the % 1.4%
rate of PPH >2
litres
Target
2014/15
Comments
100%
National
target 80% of
patients spend
90% of time
on stroke unit
Completion of the MUST
score has been poor
throughout the year. This
has led to increased ward
based teaching and training
by the specialist nurse and
the dietetic team. Random
audits of 10 sets of notes
are completed monthly on 6
-7 wards. The results are fed
back to the ward managers
to create action plans and
work with their staff.
Due to the number of stroke
patients it is not always possible to place the patients
on the correct ward or the
extra 7 beds allocated on
another ward. The plan for
2015/16 is to create more
stroke bed capacity and
work with the community
to decrease patient length
of stay.
Reduce the % Root cause analysis is
rate of PPH >2 undertaken on all PPHs over
litres
2Ls. Further work to reduce
PPHs being undertaken
using Human Factor
Approach. This quality
indicator has not been
achieved.
Target
2015/16
68 | QUALITY ACCOUNT 2014/15
5.2%
2011
Q46 8.6
Q47 9.5
Q73 8.8
Total of20
breaches
reported
Web-based
IT functions
(PAS)
Complaints
statistics
Response to
national
inpatient
survey
Mixed sex
accommodation breaches
Reduction in
out-patient
clinic
cancellation
rates
Improve
complaint
response
times
Patient’s
privacy and
dignity
53 days
2011/12
Quality subject Data source
Patient experience
Total of 69
breaches
reported
2012
Q36 8.8
Q37 9.6
Q67 8.9
49 days
3.81%
2012/13
4%
Performance
2014/15
To continue to
improve privacy and dignity
issues within
the Trust
Zero
2014
Q37 X
Q38 X
Q66 X
30 days unless 36 days
otherwise
agreed with
the
complainant
Below 5% of
total clinics
cancelled
Target
2014/15
April 2013 – 7 Zero
June 2013 - 3
Dec 2013
– 15
Total - 25
2013
Q36 8.8
Q37 9.5
Q67 8.9
44 days
2.9%
2013/14
Zero
To improve
privacy and
dignity issues
within the
Trust
30 days
unless
otherwise
agreed with
the
complainant
Below 5% of
total clinics
cancelled
Target
2015/16
The Trust has avoided any
mixed sex accommodation
breaches during 2014/15 but
will continue to ensure that
every patient is nursed in a
dignified and caring
environment.
Work continues in respect
of privacy and dignity issues.
For example work is ongoing
to ensure rooms are available
for speaking to relatives and
breaking bad news.Results
have been embargoed by the
CQC until 21/05/15
Additional work is now
being undertaken in Clinical
Directorates to support them
to achieve the 30 day target.
This continues to be
monitored through the
weekly reports and the
Outpatient Management
Group with a focus on
the number of patients
affected by these
cancellations. Directorates
are ensuring that robust
measures are in place for
authorising short notice
cancellations. Continued use
of the partial booking system
for follow up appointments
is ensuring that fewer
patients are affected by
cancellations.
Comments
QUALITY ACCOUNT 2014/15 | 69
70 | QUALITY ACCOUNT 2014/15
Our maternity department has been working hard this year to implement a new electronic system to track the progress of
labour and delivery women and babies. This will be rolled out throughout all aspects of maternity services in 2015/16.
Performers from the Starlight Children’s Foundation are
regular visitors to our children’s ward, Amazon, where
they help keep youngsters entertained with their
captivating performances. They visited during a warm
spell in July 2014 which meant that our young patients
could enjoy outdoor entertainment.
“
“
This is my 4th pregnancy but 1st at
this hospital. Was amazed at how
thorough, reassuring and brilliant
the staff were. Made me feel so
much better and had so much
time and patience despite it being
relatively busy. Looking forward to
the birth of my baby here.
Our annual programme of vaccinating staff against the
flu begins every autumn and continues through to early
new year. By arming our staff against the flu we can help
halt the spread of the virus and ensure frontline health
workers don’t fall victim to the bug so they can continue
to care for patients. In 2014/15 71% of Trust staff
received their vaccination.
QUALITY ACCOUNT 2014/15 | 71
Overview of performance against the key national
targets
National target / Regulatory requirement
MRSA screening for all elective inpatients
2011/12 2013/14 2014/15
Target
100%
100%
100%
Actual
100%
100%
108.2%
MRSA screening for all emergency
inpatients
Target
100%
100%
100%
Actual
91%
91.1%
93.7%
VTE risk assessment
Target
95%
95%
95%
Actual
96%
96.5%
95.2%
18 week referral to treatment time –
Admitted patients
Target
90%
90%
90%
Actual
91.15%
89.9%
89.6%
18 week referral to treatment time –
Non admitted patients
Target
95%
95%
95%
Actual
97.29%
97.1%
96%
18 week referral to treatment time –
Incomplete pathways within 18 weeks
Target
0
92%
92%
Actual
0
97.8%
97%
Diagnostic 6 week waits (% waiting)
Target
0
1%
1%
Actual
439
0.30%
0.1%
Target
93%
93%
93%
Actual
96.50%
97.4%
96.8%
*
Target
Actual
96%
99.50%
96%
99.8%
96%
99.6%
*
Target
85%
85%
85%
Actual
89%
89.5%
89%
Target
90%
90%
90%
Actual
95.60%
96.2%
93.9%
Target
90%
90%
90%
Actual
94.50%
92.8%
95.4%
Target
98%
98%
98%
Actual
99.70%
100%
100%
Target
94%
94%
94%
Actual
99.0%
98.8%
98.9%
Cancer subsequent treatment Radiotherapy
Target
94%
94%
100%
Actual
97%
99.7%
99%
Cancer subsequent treatment –
All treatment types
Target
96%
96%
100%
Actual
98.70%
99.8%
99.4%
Breast symptomatic referral within 2 weeks
Target
93%
93%
93%
Actual
97.30%
97.9%
96.9%
Total time in A&E 4 hours or less – Local health
economy
Target
95%
95%
95%
Actual
93.15%
92.40%
85.5%
% elective operations cancelled for non-clinical
reasons
Target
1%
1%
1%
Actual
1.70%
1.64%
1%
All cancers 2 week wait from referral
All cancers – 31 days from decision to admit
All cancers – 62 days from referral to treatment
All cancers – consultant upgrades
62 days from screening to treatment
Cancer subsequent treatment – Drugs
Cancer subsequent treatment – Surgery
* Cancer information is provisional
*
*
*
*
*
*
*
*
72 | QUALITY ACCOUNT 2014/15
Annex: Statement from
key stakeholders
Council of Governors, Peterborough and
Stamford Hospitals NHS Foundation Trust.
The Council of Governors is pleased to
comment on the detailed Quality Account
that shows progress throughout the year. The progress provided by monthly quality
reports ensures that the Governors are kept
up to date with issues throughout the year
and assurance is further enhanced by having
a Governor on the Trust’s Quality Assurance
Committee. Our involvement enables us to
focus on issues of concern throughout the
year. We look forward to this progress being
continued throughout the coming year. The
Council of Governors continue to be satisfied
that quality and safety is at the heart of the
Trust. Mark Bush
Vice Chairman/Lead Governor
Tobias Payne
Governor Representative Quality
Assurance Committee
South Lincolnshire CCG has reviewed the
Quality Account produced by Peterborough
and Stamford Hospitals NHS Foundation Trust
(PSHFT) for 2014/15
impact on timeliness of care and admission
for both emergency and elective patients
and cancelled planned operations. SLCCG
notes however that quality has improved for
patients in some areas during 2014/15, for
example:
• A reduction in patient falls in hospital by
8.2%
• An 11% reduction in the number of
patients who fall more than once
Further, the Trust is applauded for the
application of safe staffing principles, where
nurse vacancy levels have reduced from 16%
to 8%, despite the national shortage.
There has been successful overseas
recruitment of 69 nurses from within the EU
with a retention rate of approximately 96%.
The Trust has ensured greater scrutiny and
challenge of staffing levels together with
triangulation of staffing levels with the acuity
and dependency of patient groups and public
facing reporting.
The CCG acknowledges that the Trust will
have to apply vigilance and focus in the
coming year with regard to a number of
areas where targets were not achieved, in
particular:
• Clostridium difficile infections
• Pressure Ulcers (Grade 3 and above)
Commissioning high quality, safe patient
services is South Lincolnshire CCG’s
highest priority and the areas identified for
improvement within the Quality Account will
enhance the patient experience and improve
patient safety and clinical outcomes.
The Trust’s performance in 2014/15 reflects
that the Trust has kept quality of patient care
as its primary focus, with an emphasis on
continuous quality improvements in patient
safety, clinical effectiveness and patient
experience, despite challenges in emergency
activity; financial challenges and significant
pressures on bed capacity which have had an
Trust staff joined the national launch of the Hello My Name
Is campaign in February 2015. The campaign, founded by
Dr Kate Granger following her being diagnosed with
terminal cancer, encourages NHS staff to build a connection
with patients by always ensuring they introduce themselves.
The initiative was supported throughout both our
hospitals – from ward to board level. Here, our board of
directors showed their support for the campaign.
QUALITY ACCOUNT 2014/15 | 73
There is a core set of quality indicators that
have been added to the statutory Quality
Account requirements together with
mandated statements and benchmarking.
The source for all the information in this
section is the Health and Social Care
Information Centre (HSCIC). Trusts are
required to report using the latest data
from this. South Lincolnshire CCG can verify
that the Trust has reported against all the
mandated statements within the Quality
Account where data is available.
The Trust is required to detail the number
of patient safety incidents reported and the
number and percentage of incidents that
result in severe harm or death. The Trust
is a high reporting organisation indicating
a positive patient safety culture and the
CCG encourages this level of openness and
transparency.
There have been two incidents reported
during 2014/15 which met the ‘Never Event’
criteria. The patients involved have been kept
informed. Cases have been presented at
‘Sharing Lessons Learned’ events.
In terms of performance against the 2014/15
CQUIN indicators for South Lincolnshire CCG,
the following indicators were achieved:
• End of Life
• Improving the Quality of Discharge
Communications
The following CQUIN indicators were partially
achieved:
• Friends and Family Test
• Dementia
• 7 Day Working
• Medicines Safety Thermometer
• Improved Catheter Care
• Cultural Barometer
The following CQUIN indicator was not
achieved:
• NHS Safety Thermometer
South Lincolnshire CCG notes that the
current CQC registration for the Trust is
unconditional for all regulated activities.
The Care Quality Commission has not taken
any enforcement action against Peterborough
and Stamford Hospitals NHS Foundation Trust
during 2014/15.
Peterborough and Stamford Hospitals NHS
Foundation Trust has not participated in
special reviews or investigations by the Care
Quality Commission during 2014/15.
Further, it is noted that the Trust was
inspected by the Care Quality Commission in
March 2014, as part of phase two of the new
style hospital inspections, with an overarching
rating of ‘requires improvement’. Following
the publication of the report in May 2014
the Trust wrote an action plan based on
the 11 areas highlighted as those that the
Trust should aim to improve. The Clinical
Directorates also highlighted other areas from
the report where positive changes and quality
improvements could be made. The action
plan was completed in April 2015 and sent to
the CQC as part of the preparation for a reinspection planned for May 2015. To ensure
sustainability and progress with the action
plan a series of peer review visits to all areas
of the Trust were planned; the visits were
undertaken by the Matrons, Non-Executive
Directors, Senior Nursing staff and the Chief
Nurse.
South Lincolnshire CCG therefore welcomes
the additional focus being placed on patient
safety by the Trust within its priorities for
2015/16:
• Reduce the number of patient falls harm
• Reduce the number of avoidable hospital
acquired pressure ulcers (Grades 3 and 4)
• Reduce the number of avoidable VTE
• Early detection of the deteriorating patient
• Further improvement in mortality rates
• Safe Staffing Levels
• Improve response to complaints and ensure
lessons are learned
74 | QUALITY ACCOUNT 2014/15
• Improved performance in National Patient
Survey
Additionally, the priorities identified by South
Lincolnshire CCG as CQUIN indicators for
2015/16 include:
• Acute Kidney Injury
• Sepsis
• Dementia and Delirium
• Urgent and Emergency Care
• Adolescent Transition Into Adult Care
• Falls and Apprenticeship scheme
• Medicines Safety Thermometer
• Support and identification to carers
South Lincolnshire CCG endorses the
accuracy of the information presented within
the Peterborough and Stamford Hospitals
NHS Foundation Trust Quality Account and
the overall quality programme performance
will be reviewed through the formal contract
quality review process.
Cambridgeshire and Peterborough Clinical
Commissioning Group (the CCG) has
reviewed the Quality Account produced by
Peterborough and Stamford Hospitals NHS
Foundation Trust (PSHFT) for 2014/15.
The CCG and PSHFT work closely together to
review performance against quality indicators
and ensure any concerns are addressed.
There is a structure of regular meetings in
place between the CCG, PSHFT and other
appropriate stakeholders to ensure the quality
of PSHFT services is reviewed continuously
with the commissioner throughout the year.
In addition, the CCG has carried out visits to
PSHFT to observe practice and talk to staff
and patients about quality of care, feeding
back any concerns so the Trust can take
action where required.
The CCG and PSHFT have been working
closely to address concerns in the
Emergency Department (ED) as the Trust had
experienced increased activity in ED and did
not achieved the A&E 4 hour waiting time
target throughout 2014/15. The Trust has
implemented a range of initiatives to address
this including daily review and capacity
weeks to focus on learning. A clinical audit of
quality in the ED was carried out which found
there had been no significant decrease in the
quality of care as measured by such indicators
as complaints, incidents and documentation.
The CCG visited the ED in November 2014
to review quality of care and see the newly
opened frail, elderly assessment unit. The
Trust is championing a Breaking the cycle
initiative in 2015/16 aimed at reducing
capacity in the ED.
Concern in relation to the percentage of staff
who had up-to-date appraisals was raised in
2013/14 and this continued into 2014/15.
Appraisal rates have improved slightly but
the CCG expect the Trust to continue to look
for actions that will improve this indicator.
Similarly, the percentage of staff
up-to-date with mandatory training has not
shown significant improvement in 2014/15.
Both indicators are important not only to
support quality of care, but also as a gauge
of the Trust’s approach to staff health and
well-being. Further indication of the need
to focus on this area is given by the result
for overall staff engagement in the 2014
national NHS staff survey for PSHFT which
fell to a below average score when compared
with comparator trusts. On a more positive
note, the latest staff Friends and Family
test (where staff are asked whether they
would recommend the Trust as a place to
work) has moved to a slightly above average
percentage.
One of the Trust’s priorities for 2014/15 was
a focus on ensuring appropriate staffing
levels and skill mix, following concerns raised
by the Francis report. The requirement to
report staffing ratios on wards and carry out
regular workforce establishment reviews
was introduced in 2014, and PSHFT has
implemented these requirements, setting
QUALITY ACCOUNT 2014/15 | 75
up a system of monitoring and escalation to
ensure safe staffing. The nurse vacancy levels
have improved significantly in 2014/15 and
retention rates remain high. However, this
increase in workforce puts pressure on the
systems in place to support staff, and the
Trust must ensure these are strengthened
further in 2015/16. The CCG would expect
to see this included in the priorities to ensure
effective and responsive care.
Other concerns raised by the CCG during
2014/15 include the percentage of staff
up-to-date with Safeguarding Adults and
Safeguarding Children training, The Trust
has a comprehensive action plan in place
which should ensure these rates improve.
There have also been issues relating to the
management of complaints and this area is
identified as a priority for improvement for
PSHFT in 2015/16. The CCG will continue to
monitor all these quality plans throughout
2015/16.
PSHFT is monitored by both the Care
Quality Commission (CQC) and Monitor, the
independent regulator of NHS Foundation
Trusts. The CQC inspected the Trust in
March 2014 and gave an overall rating of
Requires Improvement. The Trust developed
and implemented action plans to address
concerns, and the CQC will be carrying
out a follow-up inspection in May 2015 to
determine if PSHFT now meet the standards.
PSHFT is also subject to enforcement action
by Monitor, and has a material level of
financial risk. The CCG has been working
with PSHFT to drive improvements and
continues to monitor how the Trust is
addressing the issues raised by the national
regulators.
The Trust achieved two-thirds of the goals
set as part of the 2014/15 priorities. There
were issues around infection prevention and
control (IP&C), with PSHFT again exceeding
the agreed ceiling for levels of the healthcare
acquired infection Clostridium Difficile.
There have been problems with both IP&C
screening and the decolonisation pathway,
and cleaning in the hospital. The Trust is
investing in new cleaning machines and
improving its deep cleaning programme. The
CCG has been working with PSHFT to drive
improvements and continues to monitor
how the Trust is addressing the required
improvements in its IP&C systems.
The priorities for 2015/16 take forward and
extend the 2014/15 priorities, although some
of the previous work has been removed from
the priorities. This includes improvement
in A&E waiting times and reduction in
Clostridium difficile levels which will
continue to be monitored and action required
assessed. The priorities for patient experience
build on the work to improve the complaints
system and also focus on the national NHS
Inpatient survey. The Quality Account does
not include detail of local patient surveys or
patient involvement initiatives, and the CCG
will work with the Trust to ensure a strong
focus on patient experience and involvement.
Quality Accounts offer a transparent way for
trusts to report on innovation and research,
and PSHFT’s account shows the importance
of research to the Trust. There are examples
of the way the Trust has used its Clinical
Audit programme to drive improvement.
However, the Quality Account gives very little
detail of the way the Trust learns from patient
and staff feedback, and its positive level of
incident reporting. Further analysis would be
useful to show how PSHFT is using learning
to improve patient care.
The PSHFT Quality Account is presented in
an understandable and consistent format.
The Trust is open about the problems it had
faced, the challenges going forward, and the
importance of maintaining quality throughout
this period. The priorities for the Trust are set
out clearly, with rationale for inclusion for
the 15/6 goals. The report includes all the
nationally mandated sections. However, a list
of services and specialties provided by the
Trust is not given or signposted. The CCG has
reviewed the data presented in the Quality
Account and this appears to be in line with
76 | QUALITY ACCOUNT 2014/15
other data published.
Healthwatch Peterborough: Response to
Peterborough and Stamford Hospitals NHS
Foundation Trust (PSHFT) Quality Account
2014/15
Healthwatch Peterborough agrees and
supports the key priorities listed for 2015/16
and welcomes and acknowledges the
proposed improvement initiatives across
services.
Emergency Department We specifically
welcome the ongoing work to improve and
meet targets in the Emergency Department
(A&E) following disappointing performance
during this period. Following numerous
communications to utilise the voluntary
sector (specifically British Red Cross) for
over two year, we welcome the Trust’s
commitment to work with such organisations
to improve patient and carer experience in
this department.
Patient Engagement We welcome the
commitment to attend, contribute and
respond to issues raised at our monthly public
community meetings by Peterborough and
Stamford Hospitals NHS Foundation Trust
(PSHFT). Representation has been provided
almost every month throughout
2014/15.
We also welcome the Trust’s request
for support to provide patient and carer
representation from our volunteers on a
number of internal boards and committees.
This is to both challenge and provide a public
insight to the development and delivery of
services.
Healthwatch Peterborough staff and trained
volunteers, took part in the innovative
Trust-wide 15 Step Challenge. Findings
from this activity carried out in November
2014, formed part of the intelligence when
developing our multi-local Healthwatch Enter
and View at the site in March 2015.
Further, Healthwatch Peterborough staff and
trained volunteers, provided the patients
to take part in the Patient-Led Assessment
of the Care Environment (PLACE) at the
Peterborough City Hospital and Stamford
Hospital. Healthwatch Peterborough
welcomed the range of representation.
Feedback was acknowledged and used to
inform the action plan following this audit,
ensuring that patient’s views have an impact.
Healthwatch Peterborough continues to raise
awareness of where the Trust can work better
with the local community, voluntary groups
and other stakeholders.
Complaints Handling Healthwatch
Peterborough welcomes complaint handling
being a priority for 2015/16. We have worked
extensively with the Trust to improve this
area where there were ongoing concerns. As
a member of the Trust’s Complaints Review
Group, we welcome this range of evaluation
and data to improve this area and maintain
progress made.
Healthwatch Peterborough created a
complaint handling questionnaire which was
sent to all formal complainants since August
2014. Returned directly and anonymously
to us to collate and analyse to provided
independent reports on a quarterly basis.
(Reports can be found on our website
www.healthatchpeterborough.co.uk).
The first report showed a balanced and
reasonable level of satisfaction. The
subsequent report (for the period November
2014-January 2015) showed a marked
reduction in the level of satisfaction, and
it was felt that due to numerous negative
comments submitted by patients and carers,
this concern was highlighted with CQC,
Commissioners and directly with the Chief
Executive of the Trust.
We welcomed the detailed and
comprehensive response from the Chief
Executive, and saw an increase in level
of satisfaction in the following report,
from January to April 2015. However, we
are disappointed that the Trust is going
QUALITY ACCOUNT 2014/15 | 77
We look forward to the Trust developing
ways to demonstrate that ‘lessons are learnt’
so that patients and carers have confidence
that complaints are being used as the rich
source of insight and information, that comes
directly from the service user.
Following our recommendation, we welcome
that the Trust is now responding to patient
and carers comments on the NHS Choices
website.
Non-clinical Cancer Services Healthwatch
Peterborough has for nearly three years
highlighted a lack of non-clinical cancer
provision in Peterborough. We gathered
evidence and demonstrated under utilisation
of the Robert Horrell Macmillan Centre,
situated at the Peterborough City Hospital
site. We provided the Trust with patientcentred report with evidence to demonstrate
demand for and gaps in services. (Report can
be found on our website:
www.healthatchpeterborough.co.uk).
We supported the Trust with its proposal to
re-launch the centre and provide a wider
range of holistic and innovative provisions
to those living with and caring for someone
with cancer. Healthwatch Peterborough are
“
delighted with the work already done in
this area by the Trust and look forward to
continuing to support the Trust to engage
with local stakeholders, patients and carers.
Enter and View On 25th March 2015
Healthwatch Peterborough facilitated and
organised a joint local Healthwatch Enter and View visit at Peterborough City
Hospital. The staff and volunteers reviewed
three primary areas including:
i. Reviewing availability of information to patients, carers and visitors at ward level (notice boards etc)
ii. Shadowing Dementia Nurse/review activity/access/awareness and training
iii. Patient interviews on wards
Participating Healthwatchs included:
Healthwatch Cambridgeshire; Healthwatch
Lincolnshire; Healthwatch Northamptonshire;
Healthwatch Peterborough and Healthwatch
Rutland.
The report will be available on
www.healthwatchpeterborough.co.uk
website (and Healthwatchs noted above)
from mid-June 2015.
Healthwatch Peterborough
16-17 St Marks Street
Peterborough
PE1 2TU
www.healthwatchpeterborough.co.uk
03451 20 20 64 (new local rate number)
On both occasions I have been an inpatient staff
were attentive, even during the night shift, and
answered buzzers quickly. I observed how caring
they all were with some elderly patients, too. I was
discharged the next day via the Discharge Lounge
where the staff were very kind. There appeared
to be quite a lot of continuity of staffing in CCU
which must surely help. This included the catering
staff and cleaners. Special thanks to the doctors.
“
to terminate the use of our independent
questionnaire, but provide an internal
method (partly using our format/design).
However, we welcome a continuation of
some form of satisfaction monitoring.
78 | QUALITY ACCOUNT 2014/15
Appendix 1: Statement of directors’ responsibilities
in respect of the quality account
The directors are required under the Health
Act 2009 and the National Health Service
(Quality Accounts) Regulations 2010 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 NHS
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
2014/15 and supporting guidance
• 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 2014 to May 2015
papers relating to Quality reported to the
board over the period April 2014 to May
2015
feedback from the commissioners dated
15/05/2015
feedback from governors dated 13/05/2015
feedback from local Healthwatch
organisations dated 15/05/2015
the Trust’s complaints report published
under regulation 18 of the Local Authority
Social Services and NHS Complaints
Regulations 2009, dated 01/05/2015
the 2014 national patient survey, dated
01/05/2015
the 2014 national staff survey, dated
24/02/2015
the Head of Internal Audit’s annual opinion
over the Trust’s control environment dated
01/05/2014
Care Quality Commission Intelligent
Monitoring report dated October 2013,
March 2014 and December 2014
• 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 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.monitor.gov.uk/
annualreportingmanual) as well as the
standards to support data quality for
the preparation of the Quality Report
(available at www.monitor.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
27 May 2015
Rob Hughes, Chairman
27 May 2015 Stephen Graves, Chief Executive
QUALITY ACCOUNT 2014/15 | 79
Appendix 2: Independent Auditor’s Report to
the Council of Governors of Peterborough and
Stamford Hospitals NHS Foundation Trust on the
Quality Report
We have been engaged by the Council of
Governors of Peterborough and Stamford
NHS Foundation Trust to perform an
independent assurance engagement in
respect of Peterborough and Stamford NHS
Foundation Trust’s Quality Report for the year
ended 31 March 2015 (the ‘Quality Report’)
and certain performance indicators contained
therein.
Scope and subject matter
The indicators for the year ended 31 March
2015 subject to limited assurance consist of
the following two national priority indicators:
• Percentage of incomplete pathways within
18 weeks for patients on incomplete
pathways.
• Emergency readmissions within 28 days of
discharge from hospital
The Trust uses eTrack to manage its Patient
waiting lists and provide the data to calculate
the indicator ‘Percentage of incomplete
pathways within 18 weeks for patients on
incomplete pathways’. This is a dynamic
online system and information on the
reason for all pathway amendments is not
maintained.
We have not been able to complete testing
in relation to this indicator and have excluded
the provision of assurance in relation to the
percentage of incomplete pathways within 18
weeks for patients on incomplete pathways
from the scope of our work.
In this opinion all references to the ‘indicator’
refer to the national priority indicator:
Emergency readmissions within 28 days of
discharge from hospital.
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 Monitor.
Our responsibility is to form a conclusion,
based on limited assurance procedures, on
whether anything has come to our attention
that causes us to believe that:
• 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 the Detailed Guidance for External
Assurance on Quality Reports 2014/15
(‘the Guidance’); and
• the indicator 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 Guidance.
We read the Quality Report and consider
whether it addresses the content
requirements of the NHS Foundation Trust
Annual Reporting Manual and consider the
implications for our report if we become
aware of any material omissions.
We read the other information contained in
the Quality Report and consider whether it is
materially inconsistent with:
• the content of the Quality Report meets
the requirements set out in the NHS
Foundation Trust Annual Reporting Manual
80 | QUALITY ACCOUNT 2014/15
2014/15 and supporting guidance
• 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 2014 to May 2015
papers relating to Quality reported to the
board over the period April 2014 to May
2015
feedback from the commissioners dated
15/05/2015
feedback from governors dated
13/05/2015
feedback from local Healthwatch
organisations dated 15/05/2015
the Trust’s complaints report published
under regulation 18 of the Local Authority
Social Services and NHS Complaints
Regulations 2009, dated 01/05/2015
the 2014 national patient survey, dated
01/05/2015
the 2014 national staff survey, dated
24/02/2015
the Head of Internal Audit’s annual opinion
over the Trust’s control environment dated
01/05/2014
Care Quality Commission Intelligent
Monitoring report dated October 2013,
March 2014 and December 2014
We consider the implications for our report
if we become aware of any apparent
misstatements or material inconsistencies
with those documents (collectively, the
‘documents’). Our responsibilities do not
extend to any other information.
We are in compliance with the applicable
independence and competency requirements
of the Institute of Chartered Accountants in
England and Wales (ICAEW) Code of Ethics.
Our team comprised assurance practitioners
and relevant subject matter experts.
This report, including the conclusion, has
been prepared solely for the Council of
Governors of Peterborough and Stamford
NHS Foundation Trust as a body, to assist
the Council of Governors in reporting the
NHS Foundation Trust’s quality agenda,
performance and activities. We permit the
disclosure of this report within the Annual
Report for the year ended 31 March 2015,
to enable the Council of Governors to
demonstrate they have discharged their
governance responsibilities by commissioning
an independent assurance report in
connection with the indicator. To the fullest
extent permitted by law, we do not accept
or assume responsibility to anyone other
than the Council of Governors as a body and
Peterborough and Stamford NHS Foundation
Trust for our work or this report, except
where terms are expressly agreed and with
our prior consent in writing.
Assurance work performed
We 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’). Our limited assurance
procedures included:
• evaluating the design and
implementation of the key processes and
controls for managing and reporting the
indicator
• making enquiries of management
• testing key management controls
• limited testing, on a selective basis, of the
data used to calculate the indicator back to
supporting documentation
• comparing the content requirements
of the NHS Foundation Trust Annual
Reporting Manual to the categories
reported in the Quality Report.
• reading the documents.
A limited assurance engagement is smaller
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.
QUALITY ACCOUNT 2014/15 | 81
Non-financial performance information is
subject to more inherent limitations than
financial information, given the characteristics
of the subject matter and the methods used
for determining such information.
The absence of a significant body of
established practice on which to draw allows
for the selection of different, but acceptable
measurement techniques which can result
in materially different measurements and
can affect comparability. The precision of
different measurement techniques may also
vary. Furthermore, the nature and methods
used to determine such information, as well
as the measurement criteria and the precision
of these criteria, may change over time. It is
important to read the quality report in the
context of the criteria set out in the NHS
Foundation Trust Annual Reporting Manual.
The scope of our assurance work has not
included governance over quality or nonmandated indicator, which have been
determined locally by Peterborough and
Stamford NHS Foundation Trust.
Conclusion
Based on the results of our procedures,
nothing has come to our attention that
causes us to believe that, for the year ended
31 March 2015:
• 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 the Guidance; and
• the indicator in the Quality Report
subject to limited assurance has not been
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
Guidance.
KPMG LLP, Statutory Auditor
Chartered Accountants
15 Canada Square
Canary Wharf
London E14 5GL
Date: 27 May 2015
Children and young people attending the Emergency Department at the City Hospital are now treated in a separate area
designed specifically with them in mind by a dedicated team of children’s nurses and doctors. The décor for the department
has been funded by the charity For Lucie. We are extremely grateful to the For Lucie charity for their support in decorating
the rooms, as it makes a real difference to how the clinical areas look.
Innovative senior radiographers at Peterborough City Hospital have improved the diagnostic pathway for patients requiring
investigation for suspected bowel cancers, polyps and diverticular disease. They have changed the way in which patients are
referred for CT colonography, which uses a CT scanner to take pictures of the large bowel.
“The new pathway is a major improvement for patients requiring investigation for colorectal cancer, resulting in the vast
majority having their CT colonography examination undertaken and reported within a week of their initial out-patient
appointment” said Liam Gale, Senior Radiographer. “It has also led to a significant number of patients, in whom colorectal
cancer has been identified during their CT colonography examination, having their treatment planning discussed within the
same week as their initial outpatient’s appointment”.