QUALITY ACCOUNTS REPORT 2014-15
‘Pride in Pennine – A Year of Change’
QUALITY ACCOUNTS REPORT 2014-15
Contents
PART 1
1.1 Statement on Quality on
Behalf of the Board . . . . . . . . . . . . . . . . . . 2
2.13 Priorities for Quality
Improvement 2015/16 . . . . . . . . . . . . . . . 35
2.13.1 Safety Priorities for 2015/16. . . . . . 35
1.2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . 5
2.13.2 Clinical Effectiveness Priorities
for 2015/16. . . . . . . . . . . . . . . . . . 38
1.3 Purpose of a Quality Account . . . . . . . . . . 5
2.13.3 Patient Experience Priorities
for 2015/16. . . . . . . . . . . . . . . . . . 40
1.4 How the Quality Account was produced . 5
1.5 About Us. . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.14 Review of Quality Performance
Priorities 2014/15 . . . . . . . . . . . . . . . . . . . 43
1.6 Our Services . . . . . . . . . . . . . . . . . . . . . . . . 6
2.15 Performance during 2014/15. . . . . . . . . . 44
1.7 Quality of Care . . . . . . . . . . . . . . . . . . . . . . 6
2.15.1 Hospital Mortality . . . . . . . . . . . . . 44
1.8 Our Vision & Values . . . . . . . . . . . . . . . . . . 7
2.15.2 Hospital Readmissions within
28 days of discharge. . . . . . . . . . . 46
1.9 Our Strategic Goals &
Corporate Objectives. . . . . . . . . . . . . . . . . 8
1.10 Commissioned Services. . . . . . . . . . . . . . . 10
2.15.3 Patient Reported Outcome
Measures (PROMs) . . . . . . . . . . . . 47
2.15.4 Patient Safety Incident Reporting. . 50
1.11 Quality & Performance. . . . . . . . . . . . . . . 11
2.15.5 Venous Thromboembolism (VTE). . 52
PART 2
2.15.6 Healthcare Acquired Infections . . . 53
2.1 Continual Quality Improvement. . . . . . . 12
2.15.8 NHS Staff Survey Results 2014. . . . 55
2.2 Meeting Quality Standards . . . . . . . . . . . 12
2.15.9 Friends & Family Test . . . . . . . . . . . 58
2.3 Quality Improvement Strategy . . . . . . . . 12
2.15.10 National Survey Programme – 2014
survey results . . . . . . . . . . . . . . . . 59
2.4 Transparency of Care: Open and
Honest Care . . . . . . . . . . . . . . . . . . . . . . . 13
2.5 Priorities and Proposed Initiatives
for 2015/16 . . . . . . . . . . . . . . . . . . . . . . . . 13
2.15.7 NHS Staff Friends and Family Test . 54
2.15.11 National Inpatient Survey . . . . . . . 62
2.15.12 A&E 4 hour Emergency Access
Standard. . . . . . . . . . . . . . . . . . . . 64
2.6 Research & Innovation. . . . . . . . . . . . . . . 14
2.15.13 Referral To Treatment (RTT) –
18 weeks. . . . . . . . . . . . . . . . . . . . 66
2.7 Participation in Clinical Audit . . . . . . . . . 15
2.15.14 Cancer standards. . . . . . . . . . . . . . 67
2.8
Participating in CQUINs. . . . . . . . . . . . . . 28
2.9 Data Quality. . . . . . . . . . . . . . . . . . . . . . . 30
PART 3
3.1 Keeping you safe . . . . . . . . . . . . . . . . . . . 70
2.10 Information Governance toolkit
attainment levels . . . . . . . . . . . . . . . . . . . 31
3.1.1
2.11 Clinical coding error rate. . . . . . . . . . . . . 31
3.1.2 Safe Staffing. . . . . . . . . . . . . . . . . 71
2.12 Care Quality Commission (CQC)
Registration Annual Review . . . . . . . . . . 31
Sign up to Safety –
Listen, Learn, Act . . . . . . . . . . . . . 70
3.1.3
Safeguarding Adults and Children. 73
3.1.4
Patient Health Records. . . . . . . . . . 75
PAGE 1
3.1.5
Electronic prescribing . . . . . . . . . . 76
3.5.4
3.1.6
Infection Control & Prevention . . . 76
Healthier Together (Greater
Manchester) . . . . . . . . . . . . . . . . . 97
3.2 Listening & Responding to you. . . . . . . . 77
3.6 Investing in our staff . . . . . . . . . . . . . . . . 98
3.2.1
Handover of Care Communication
(discharge summaries). . . . . . . . . . 78
3.6.1
Clinical service redesign at NMGH
A&E. . . . . . . . . . . . . . . . . . . . . . . . 98
3.2.2
Patient Communication . . . . . . . . 79
3.6.2
3.2.3
Patient Leaflets and
Public Information. . . . . . . . . . . . . 80
Divisional Operational Management
Triumvirate . . . . . . . . . . . . . . . . . . 99
3.2.4
Patient-Led Assessments of the
Care Environment (PLACE) 2014 . . 81
3.7.1
North East Sector NHS
Commissioner Response . . . . . . . . 99
3.2.5
New partial appointment
booking system . . . . . . . . . . . . . . 82
3.7.2
Joint Health Overview and
Scrutiny Committee (JHOSC) . . . . 101
3.2.6
Advice, Liaison and Complaints. . . 83
3.7.3
3.2.7
Hospital Car Parking . . . . . . . . . . . 84
Local Health Watch
organisations. . . . . . . . . . . . . . . . 101
3.2.8
Operation Hospital Food . . . . . . . . 84
3.2.9
#Hello my name is……… . . . . . . . 85
3.3 Improving Our Services/Your Care . . . . . 85
3.3.1
Improvements in A&E . . . . . . . . . . 85
3.3.2
Dementia Care. . . . . . . . . . . . . . . . 86
3.3.3
Oasis Dementia Medical Unit . . . . 86
3.3.4
New Hybrid Theatre at Oldham. . . 88
3.3.5
Physios Make Every Contact Count .88
3.3.6
Home Intravenous (IV)
Therapy Service. . . . . . . . . . . . . . . 89
3.3.7
New Doppler Scan Service at
Rochdale . . . . . . . . . . . . . . . . . . . 89
3.3.8
Learning and Organisational
Development . . . . . . . . . . . . . . . . 90
3.3.9
“3 Steps to Excellence” in
Nursing & Midwifery. . . . . . . . . . . 91
3.4 Meeting Standards. . . . . . . . . . . . . . . . . . 92
3.4.1
Nursing Care Indicators . . . . . . . . . 92
3.5 Working with our partners . . . . . . . . . . . 93
3.5.1
Integrated Health & Social Care. . . 92
3.5.2
HepatoBiliary Service (HPB) . . . . . . 96
3.5.3
Surgical Vitro-Retinal
(VR) Service. . . . . . . . . . . . . . . . . . 96
3.7 What others say about the Trust. . . . . . . 99
3.8 Statement of Director’s responsibilities
in respect of the Quality Account. . . . . 102
3.9 Independent auditors limited assurance
report to the Directors of PAHT on
the Quality Account. . . . . . . . . . . . . . . . 103
PAGE 2
QUALITY ACCOUNTS REPORT 2014-15
Part 1
1.1 Statement on Quality on Behalf of the Board
At the start of the year we
embarked on a major piece
of work using innovative
on-line technology to
Welcome to our
engage and involve all
Quality Account
of our staff across the
Trust in setting out
Report which sets out
a strategic vision for
the work this year under
the Trust – a clear
the theme of Pride in
vision of where we
Pennine – a year of
want to be in five
year’s time – supported
change.
by a Transformation
Map which sets out how
we will get there and all
underpinned by redefined values.
This work generated 27,000 contributions
from our staff and they were clear that our values
should be that we are Quality Driven, Responsible and
Compassionate.
The Board has taken time during the year to critically
review a wide range of the underpinning structural
and governance arrangements to ensure that the Trust
is fully quality focused. In particular the Board has:
●● Reviewed the Executive Director portfolios
confirming the respective responsibilities in
relation to quality standards, service delivery and
clinical governance;
●● Placed clinical leadership at the heart of our
management structure by establishing a
triumvirate structure at Divisional level with a
Divisional Director, Divisional Medical Director
and Divisional Nurse Director jointly accountable
for the delivery of services. The roll out of this
structure to Directorate level started in May 2015;
●● Reviewed the Board governance arrangements
and established a new Non-Executive chaired
Quality and Performance Committee;
●● Established a Safety programme to focus attention
on key quality and safety issues;
●● Commissioned an external review and received
a report on how the Trust’s Serious Untoward
Incident process operates and has agreed new
arrangements which will be leading edge in terms
of the recently published new national guidance
on managing serious incidents;
●● Reviewed Clinical Governance arrangements;
●● Implemented revised complaints management
arrangements which has seen a significant
reduction in the number of complainants stating
dis-satisfaction with the response to their
complaint;
●● Established and appointed to two new senior
posts focused on quality – a Director of Clinical
Governance and a Deputy Chief Nurse;
●● Agreed the establishment of new roles of Director
of Midwifery and Deputy Director of Midwifery to
bring increased focus on quality in this important
area;
●● Agreed to establish dedicated clinical governance
support posts in each Division;
●● Commissioned an external review of a number of
incidents in maternity services and acted on the
recommendations of the review;
●● Undertaken development sessions on the Duty of
Candour and the Well Led arrangements.
PAGE 3
Our Quality Account for 2014/15 reports on the progress made against our six main
Priorities for Quality Improvement. These were:
Mortality
To continue to effectively manage hospital mortality with a
specific focus on weekend mortality;
Hospital Readmissions
To build on the work commenced during 2013/14 to ensure
the outputs are embedded to support an ongoing reduction in
hospital admissions;
Nutrition
To improve compliance with the Malnutrition Universal Screening
Tool (MUST) and ensure individualized care plans are put in place
and implemented for patients who are nutritionally compromised;
Discharge Criteria
To work with partner agencies to ensure patients are discharged
in an appropriate and timely manner in line with the Trust’s
discharge policy;
Referral To Treatment (RTT)
To work with administration teams to achieve awareness
and understanding of the impact of RTT standards in clinical
management plans and on the patient experience;
Cancer pathways
To work with Clinical Commissioning Groups (CCGs) and Tertiary
Trusts to agree amendments to clinical pathways in order to help
improve efficiency, safety and quality of service for all cancer
pathways.
During 2014/15 we again made significant progress in meeting and improving on a
number of important key national and local clinical and patient experience performance
standards. Our mortality ratio continues to be the second lowest in the North West of
England, with a level of performance which means that statistically 20% fewer patients
than expected died in our hospitals in 2014/15. We have continued to deliver against
the 18 week referral to treatment target and the cancer targets.
Like many Trusts across the country we experienced a very difficult winter period with
high levels of A&E attendances and admissions and a longer length of stay as patients
were more acute at all our hospital’s A&E departments. However, North Manchester
General Hospital (NMGH) A&E department which sees around 100,000 patients a year
performed very well and it is the only hospital in Greater Manchester and only a small
Our mortality
ratio continues
to be the second
lowest in the
North West of
England
PAGE 4
QUALITY ACCOUNTS REPORT 2014-15
PART 1
number of Trusts
nationally to meet the
four hour national
access standard. We
established a Lloyds
pharmacy-led clinic
at NMGH as a pilot
this year and have also
introduced a new medical
model integrating local GPs
to the medical team.
In addition to our encouraging clinical
performance, during the year we have continued
to invest and develop services and facilities that will
improve patient care. These include investment in
making some of our wards and clinical areas more
suitable to meet the needs of patients with dementia.
Two major capital building works have been
completed at two of our A&E departments this year
at The Royal Oldham Hospital and at Fairfield General
Hospital. We have also opened a brand new Hybrid
Theatre following £5m investment which confirms our
commitment to The Royal Oldham Hospital remaining
a major centre for vascular services in Greater
Manchester.
During the year we placed a major focus on patient
pathways and improving our relationships and
communications with our colleagues in primary
care, including our local GPs. We have significantly
improved the processes to reduce the length of time
taken to provide letters to GPs following patient
attendance at outpatient appointments and discharge
from hospital.
We have also undertaken significant work on
strengthening our partnerships. A key element of
providing a quality service is making sure that patients
move swiftly through a single joined up pathway. We
must ensure that where patients transfer from service
to service or between providers that their care remains
uninterrupted and seamless. The changes that we
have made within the Trust have helped streamline
the patient journey and we are taking major steps
to improve joined up care with other NHS providers,
local authorities and the third sector. Fundamental to
this has been the establishment of a new Integrated
and Community Care Division which brings a focus to
this area and will build on the successful integrated
secondary and community care arrangements which
the Trust has managed in North Manchester for a
number of years. We have the exciting opportunity
in 2015 to further strengthen this as the Trust has
taken managerial responsibility for the adult social
care service in north Manchester. Other parts of
the system are watching these developments with
interest.
We continue to place patient safety and quality of
care at the heart of everything we do as we work
with our local NHS commissioners and partners to
transform our services, improve outcomes and meet
the financial challenges facing us.
The quality priorities reported have been measured
using our internal assurance structures such as
patient records, clinical audits and internal and
external inspections. We have used information
from participation in national NHS surveys and
conversations with patients to help us in writing our
Quality Account for 2014/15.
To the best of my knowledge, the information in this
document is accurate.
Best wishes,
Dr Gillian Fairfield
Chief Executive
PAGE 5
1.2Introduction
Quality Accounts are annual reports to the public
from providers of NHS healthcare services about
the quality and standard of services they provide.
They are required by the Government to help NHS
Trusts, including providers of hospital acute services,
community health services and mental health services,
maintain focus and improve the quality of care for
patients.
1.3 Purpose of a Quality Account
Quality Accounts have become an important tool
for strengthening accountability for quality within
NHS Trusts and for ensuring effective engagement of
Trust Board of directors in the quality improvement
agenda. By producing a Quality Account, Trusts are
able to demonstrate their commitment to continuous
evidence based quality improvement and to explain
their progress to patients and their families, the public
and those who have an interest in the services that
the Trust provides. This report is the sixth Quality
Account published by The Pennine Acute Hospitals
NHS Trust.
1.4 How the Quality Account was produced
To ensure that our staff, our external partners and
our patient representatives and local communities
were able to influence the content of this report, a
consultation exercise was undertaken to hear their
views. We invited suggestions on what our main
quality improvement priorities should be for this
year (2015-16) and what information should be
included in this year’s Quality Account report in
addition to the mandated content as set by
the Department of Health.
We welcomed the comments that
were received and have reflected this
information in this report. The report
has been overseen by our senior
clinicians and managers through our
Senior Management Team, chaired by
the Chief Executive, and the Trust’s
Quality and Performance Committee.
The final version of the Quality Account
report was approved and ratified by the
Trust Board of Directors on 28th May
2015.
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QUALITY ACCOUNTS REPORT 2014-15
PART 1
1.5 About Us
The main asset of our Trust is our highly committed, skilled and professional staff. We employ around 9,000
staff and serve a population of approximately 820,000 people, principally from within the communities of Bury,
Prestwich, North Manchester, Oldham, Heywood, Middleton, Rochdale and parts of East Lancashire.
Our population is spread across both urban and rural landscapes, is demographically diverse and faces some of
the greatest challenges, including significant areas of deprivation, health inequality and chronic disease.
As the largest non-teaching acute hospital Trust in the country, it is our responsibility to develop and deliver
high quality healthcare services around the needs of our patients, their families and the communities we serve.
1.6 Our Services
We run and provide healthcare services from North Manchester General Hospital in Crumpsall, Fairfield General
Hospital in Bury, The Royal Oldham Hospital, and Rochdale Infirmary. We also run the Floyd Unit (neurological
rehabilitation) at Birch Hill Hospital in Rochdale.
Although we are a hospital Trust, we also provide a range of community and integrated healthcare services
across the north part of the city of Manchester.
1.7 Quality of Care
The Trust’s mission statement is
“to provide the very best care to each
patient on every occasion.”
Our staff understand the importance of this pledge
and work hard to ensure this is delivered every
day to every patient that we care for. It
underpins everything we do.
PAGE 7
1.8 Our Vision & Values
The Trust Board of Directors approved our new corporate vision and values and five-year Strategic Plan at its
June public Board meeting on 26th June 2014. This followed a huge amount of work undertaken to involve and
hear the views of our staff through our Pride in Pennine online workshop and a Strategy Summit held in May
2014.
Our vision is to be:
‘A leading provider of joined up healthcare that will
support every person who needs our services, whether in
or out of hospital to achieve their fullest health potential.’
Our Values guide every action we take. They determine how we work and the promise we make to our patients,
their families, the public and each other as colleagues. Our vision is driven by three key Trust values. We are:
Quality Driven, Responsible, Compassionate.
Quality-driven
Responsible
Compassionate
We promise:
We promise:
We promise:
●● To provide excellent quality
safe, evidence-based patient
care that exceeds national
standards;
●● To be honest, open and
transparent in all our
commitments, actions and
results;
●● To treat you with empathy,
professionalism and a
positive, friendly attitude;
●● To push the boundaries of
care delivery and efficiency
by adopting best practice and
building on our clinical and
technical knowledge;
●● To be personally accountable
for the things we do, our
services and the Trust’s
reputation;
●● To individually be the best
we can in our actions and
interactions;
●● To work as one team with
both our colleagues and
partners to deliver the best
care both in and out of
hospital.
●● To be alert to the potential
for errors and always strive to
correct things that go wrong;
●● To acknowledge and celebrate
success;
●● To be resourceful and open
to new, innovative, evidencebased ideas.
●● To act with integrity and
respect at all times;
●● To listen to you, understand
your perspective, value
differences and be
approachable, sensitive and
considerate;
●● To organise our services
around the individual needs
of our patients and their
carers, creating the best
patient experience possible.
PAGE 8
QUALITY ACCOUNTS REPORT 2014-15
PART 1
1.9 Our Strategic Goals & Corporate Objectives
To support our Vision, we have developed Strategic
Goals along six domains. These are:
●● To provide excellent care in hospitals and the
community by building on our expertise and
exploring new business opportunities
●● To embrace and work with an innovative range of
partners, joint ventures and networks to achieve
the best outcomes for the communities we serve
●● Employer of choice. We will value and respect our
staff and nurture their skills and talents to provide
the best care
●● High quality, adaptable facilities – fit for now and
the future
●● A high performing, safe organisation, consistently
delivering excellent patient care and experience;
doing no harm
●● Clinically effective services that are financially
sustainable.
Our annual corporate objectives set the overall
direction for the Trust, both in terms of how our
services our delivered and the expectations on our
staff.
Quality of care and
patient safety is
the cornerstone of
everything we do
and everything our
staff believe in.
PAGE 9
Our ten Corporate Objectives for
2015/16 are set out below:
01
To provide high quality, evidence based,
safe services delivered in a personal and
compassionate way
02
To be a financially and clinically sustainable
organisation
03
To modernise, transform and integrate
services across our sites
04
To improve productivity and reduce variation
05
To engage and support patients, carers,
volunteers, staff, public and communities in
our work
06
To drive up quality and performance,
reaching all our targets
07
To develop and embed leadership and
personal responsibility across the Trust
08
To create an environment so staff choose to
work with us, sickness absence is reduced/
morale increased
09
To be an influential organisation working
in partnership with others across the health
and social care system to improve the health
of the population
10
To progress Foundation Trust status.
To continue to support the delivery of our mission statement and our core Trust
values, we have four key areas within our strategic corporate objectives which place
quality of care and clinical improvement as a key priority throughout the Trust.
● To improve clinical effectiveness and safety
● To reduce mortality
● To reduce harm
● To improve the patient experience
QUALITY ACCOUNTS REPORT 2014-15
PAGE 10
PART 1
1.10 Commissioned Services
We provide a range of secondary care acute and integrated services on behalf of our four local Clinical
Commissioning Groups (CCGs) - NHS Oldham, NHS Heywood, Middleton and Rochdale, NHS Bury and NHS
Manchester.
In the case of NHS Manchester, our services including acute secondary and community services relate to the
north of the city only. Our CCGs are led by local family doctors (General Practitioners) and commission services from healthcare
providers for their local populations. They are responsible for deciding what services are commissioned and how
local taxpayers’ money is spent on healthcare services.
We have three NHS contracts for acute, community and specialist services, which detail commissioning
requirements in terms of finance, activity, performance and quality. In addition, a number of specialist services
previously included in the acute contract continue to be migrated into the Trust’s contract with the North West
of England Specialised Commissioning Group. In 2014/15, The Pennine Acute Hospitals NHS Trust provided and/or subcontracted the following services:
Accident & Emergency,
Women and Children,
comprising:
comprising:
Community Services in North
Manchester, comprising:
●● Urgent Care
●● Gynaecology & Obstetrics
●● Active Case Management
●● Community Midwifery
●● Community Nutrition
Diagnostics, comprising:
●● Paediatric care
●● Continence
●● Anaesthetics
●● Neonatology
●● District Nursing
●● Pathology
●● Falls and Navigator
●● Radiology
Surgery, comprising:
●● Funded Nursing Care
●● Critical Care
●● Ear, Nose and Throat Surgery
●● Home Enteral Feeding
●● Clinical and Allied Healthcare
Professions
●● General Surgery
●● Intermediate Care
●● Ophthalmology
●● Macmillan Nursing & Therapy
●● Orthopaedics
●● Physiotherapy
Medicine, comprising:
●● Specialist Dental
●● Podiatry/Vascular Triage
●● Cardiology
●● Urology
●● Stroke
●● Elderly Care
●● Gastroenterology
●● Endocrinology and Diabetes
●● Vascular
●● Tissue Viability / Leg Ulcer
Service.
●● General Medicine
●● Oncology
Specialist services, comprising:
●● Palliative Care
●● HIV/ AIDS
●● Respiratory
●● Infectious diseases
●● Rheumatology
●● Sexual health
●● Acute Medicine
PAGE 11
1.11 Quality & Performance
The Trust has reviewed all the data available on the
quality of care in all of these NHS services as part of a
review of quality performance.
This includes:
●● Participation in relevant national audit
programmes (see section on participation in
clinical audit)
●● Local audit plans
●● CQUIN development schemes as agreed with
commissioners
●● National / Contractual / Local Key Performance
Indicators aligned to quality (outcomes)
●● Ongoing assurance monitoring, via internal
governance processes and external quality
meeting with Commissioners monthly.
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
Pennine Acute Hospitals NHS Trust for 2014/15.
Our vision is delivered in partnership with our partner
agencies and particularly our local commissioners
(Clinical Commissioning Groups) who purchase
our services
from us and with
whom we agree
each year areas of quality
improvement under the
contracting for quality process. These
areas of quality improvement payments are known
as Commissioning for Quality and Innovation or
CQUINs.
We continuously and routinely review data related
to the quality of our services to ensure we are
meeting high standards for our patients. We use our
integrated Performance Scorecard to demonstrate
this. Monthly reports to the Trust Board of Directors
and our Quality and Performance Committee all
include performance data and information relating
to the quality of services which are monitored and
scrutinised.
Progress against last year’s priorities for quality
improvements as set out in our Quality Account
Report 2013/14 have been monitored and reported
through our Quality and Performance Committee
and to the Trust Board of Directors.
PAGE 12
QUALITY ACCOUNTS REPORT 2014-15
Part 2
2.1 Continual Quality Improvement
Over the past year, we have continued to look at ways
to improve the quality of our services. This is achieved
through our doctors, nurses and healthcare staff in
collaboration with managers working hard to reduce
inefficiencies and reduce and eliminate variation in
clinical procedures, healthcare delivery and improving
patient outcomes and the patient experience, whilst
maintaining our focus on patient safety and quality.
We have also looked to redesign and transform a
number of our services by working closely with our
commissioners, local GPs and partner agencies to
improve patient pathways and the outcomes for
patients. These are highlighted in this report.
2.2 Meeting Quality Standards
In addition, we continue to focus on meeting and,
where possible, exceeding locally and nationally
determined standards of care. These include
standards that we understand are important to
patients and their families who choose to be treated
and cared for in our hospitals and by our community
services staff. For example, these quality standards
include A&E waiting times, cancer and surgery
appointment targets, reducing healthcare acquired
infections such as MRSA and Clostridium Difficile,
reducing incidence of pressure ulcers, and a further
reduction in our hospital mortality rate.
2.3 Quality Improvement Strategy
In August 2013, the Trust Board of Directors
approved a five year Quality Improvement Strategy
(2013-18). It sets out a number of ambitious but
important quality aspirations and priorities for our
staff to focus on and improve patient care and the
experiences and outcomes for our patients.
The strategy continues to be implemented across all
parts of the organisation and is intended to make
explicit our commitment to patient safety, clinical
effectiveness and patient experience through the
adoption of stretching goals that will demonstrate
our ambition to be the NHS Trust provider of choice
for our local communities.
PAGE 13
2.4 Transparency of Care:
Open and Honest Care
Since December 2013 we have continued to publish
a range of key performance data every month as part
of NHS England’s Transparency of Care programme.
This includes important data showing how we are
performing in relation to hospital acquired pressure
ulcers, falls in hospital, hospital infection figures,
patient and staff experience surveys, Friends and
Family Test scores, patient stories and our Safety
Thermometer. Our data can be found on our website
at www.pat.nhs.uk.
2.5 Priorities and Proposed Initiatives for 2015/16
A major component of our five year plan is outlined
within the Trust’s Quality Strategy. Outlined within
this is our long term aspiration that:
●● We will have no Never Events;
●● There will be no cases of Clostridium Difficile (C
Difficile) or Methicillin-resistant Staphylococcus
Aureus (MRSA);
●● There will be no Trust acquired harm in relation to
pressure sores, falls, venous thromboembolism or
catheter acquired infections;
●● There will be no harm resulting from medication
errors and patients who have unplanned returns
to theatres;
●● We will have a Trust wide Hospital Standardised
Mortality Ratio (HSMR) of 80;
●● We will communicate with our patients so that
their expectations of their treatment are absolutely
clear;
●● The Friends and Family Test will demonstrate that
patients would recommend our hospitals;
●● We will be in the top 10 percentile for all
indicators of clinical efficiency;
●● Our staff will want to work here and be treated
here if necessary;
●● We will put the patient first and work in a culture
of care, compassion, openness and transparency.
The quality priorities for 2015/16 are enablers for
delivery of the Trust’s long term quality strategy.
We have discussed our future priorities with
commissioning (CCG) colleagues. We have taken into
account the feedback received on the Quality Account
from the Joint Health & Overview Scrutiny Committee,
Bury CCG and Heywood, Middleton & Rochdale
CCGs, as well as all local Healthwatch groups when
developing our quality improvement priorities for
2015/16.
Our quality priorities for 2015/16 are listed and
explained in section 2.13 of this report on p35.
PAGE 14
QUALITY ACCOUNTS REPORT 2014-15
PART 2
2.6 Research & Innovation
We are committed to research and transformation as
a driver for improving the quality of care we provide
to our patients. It enables our staff and the wider
NHS, regionally and nationally, to improve the current
and future health outcomes of the people we serve.
Only by carrying out research into “what works” can
we continually improve treatment for patients, and
understand how to focus NHS resources where they
will be most effective.
‘Clinical research’ means research which has received
a favourable opinion from a research ethics committee
within the National Research Ethics Service (NRES).
Information about clinical research involving patients
is kept routinely as part of a patient’s record. We
currently support 382 research studies. Of these
studies, 75 are clinical trials involving medicinal
products. Our engagement with clinical research
demonstrates the Trust’s commitment to testing and
offering the latest medical treatments and techniques.
During 2014/15, we recruited patients to 108
National Institute for Health Research Clinical Research
Network (NIHR CRN) clinical research studies. The
number of patients receiving NHS services provided or
sub-contracted by The Pennine Acute Hospitals NHS
Trust in 2014/15 that were recruited to participate
in research that was approved by a research
ethics committee was 2250. This reflects an 18%
recruitment increase on the previous year.
Cancer research performance across the Trust has
been excellent this year. Indeed, 455 of our patients
diagnosed with cancer have participated in a high
quality NIHR CRN study. This level of participation in
cancer research means that approximately one out
of every four of our patients diagnosed with cancer
took part in a high quality study. Patient participation
in cancer research has increased enormously within
the Trust over recent years and we are committed to
providing patients with the opportunity to take part in
high quality cancer research studies.
The Trust has impressive research activity across a wide
range of clinical specialities. For instance, our research
activity within paediatrics has grown considerably
this year. Last year 170 children participated in a high
quality research study, whereas this year the level
of participation more than doubled to 345, which
highlights the commitment shown by our staff within
our paediatric services.
Participation in high quality diabetes and
cardiovascular research has also grown considerably
over the past 12 months. Indeed, during 2014/15,
over 300 patients participated in a high quality
diabetes and/or cardiovascular study. Additionally,
during 2014/15 there was a seven fold increase in
the number of patients recruited to high quality
respiratory studies and there were three times as
many patients recruited to studies looking at new
treatments for Infectious Diseases in comparison to
last year.
During 2014/15, we recruited patients to 26 NIHR
CRN industry studies. We are recruiting more patients
to NIHR CRN industry trials than ever before, thus
providing patients with an opportunity to participate
in state of the art research trials. In addition to the
above research, high quality research is also being
conducted within other clinical specialities, such
as: anaesthesia, gastroenterology, hepatology,
endocrinology, stroke, rheumatology, Parkinson’s
Disease, neurological disorders and surgery.
In October 2014, the Trust received national
recognition for demonstrating a commitment to
supporting high quality research and we were
extremely proud to be shortlisted for the highly
prestigious “Clinical Research Impact” award at the
2014 Health Service Journal Awards.
PAGE 15
Case study
In January 2015, the Trust was successful in recruiting the first patient in
the UK to a highly specialised research study looking at new treatments for
patients with inflammatory bowel disease.
Inflammatory Bowel Disease (IBD) is a condition that affects the digestive
system. Ulcerative Colitis and Crohn’s Disease are the most common
and main forms of IBD, which is a life-long condition, meaning that
patients have periods of relapse and remission of the condition. Started
in January, our clinical research team and Dr Jimmy Limdi, consultant
gastroenterologist, recruited a patient into the Hickory study which is part of
the Etrolizumab programme of five randomised controlled trials, which offer
new hope to patients with refractory IBD.
“This trial marks a
new era in medical
treatment of the
inflammatory bowel
disease and the
ability to offer such
novel therapy to
our patients is most
gratifying.”
Dr Jimmy Limdi,
consultant
gastroenterologist
The Trust is only one of six UK centres to be selected to run this important
trial, and only 24 UK patients will be randomised. The clinical trial is being
carried out at our research unit at Fairfield General Hospital on ward 20
where our research nurses are working closely with staff in our endoscopy
unit.
2.7 Participation in Clinical Audit
Clinical audit is a way of improving the quality of care
we provide to patients.
National clinical audits are largely funded by the
Department of Health and commissioned by the
Healthcare Quality Improvement Partnership (HQIP)
which manages the National Clinical Audit and
Patients’ Outcome Programme (NCAPOP). Most
other national audits are funded from subscriptions
paid by NHS provider organisations. Priorities for the
NCAPOP are set by the Department of Health with
advice from the National Clinical Audit Advisory
Group (NCAAG).
Involvement in the National Clinical Audit Programme
is high on the Trust’s clinical audit agenda and we
aim to participate in all applicable national clinical
audits which form part of the National Clinical Audit
and Patient Outcomes Programme.
During 2014/15, 45 national clinical audits and five
national confidential enquiries covered a variety of
NHS services with a total of 36 (80%) of the national
projects linked to the services the Trust provided
during this time period. In addition the Trust
participated in 100% of the national
clinical audits and 100% of the
national confidential enquiries
of the services it provides.
Patients participating
in clinical research
trials can now attend
their appointments
in a purpose built
research unit.
PAGE 16
QUALITY ACCOUNTS REPORT 2014-15
PART 2
The national clinical audits and national confidential enquiries that the Trust was eligible to participate in during
2014/15 are listed below alongside the number of cases submitted for each audit where data collection was
completed within the period.
Participation
Data collection
completed 14/15
% cases
submitted 14/15
Adult community acquired pneumonia (BTS)*
Yes
Yes
100
Case Mix Programme (CMPD)
Yes
Yes
continuous
Mental health care in emergency departments (CEM)*
Yes
Yes
100
National Emergency Laparotomy Audit (NELA)
Yes
Yes
100
National Joint Registry (NJR)
Yes
Yes
100
National Clinical Audit
Non-invasive Ventilation Audit (BTS)***
No
No
Na
Pleural procedure (BTS)*
Yes
Yes
100
Severe trauma – UK TARN
Yes
Yes
continuous
National Comparative Audit of Blood Transfusion
programme*
Yes
Yes
100
Bowel cancer (NBOCAP)
Yes
Yes
100
Head and neck oncology (DAHNO)
Yes
Yes
98
Lung cancer (NLCA)
Yes
Yes
100
Oesophago-gastric cancer (NAOGC)
Yes
Yes
100
Prostate Cancer*
Yes
Yes
100
Acute coronary syndrome or Acute myocardial
infarction (MINAP)
Yes
Yes
100
Cardiac Rhythm Management (CRM)
Yes
Yes
100
Coronary angioplasty (PCI)
Yes
Yes
100
National Cardiac Arrest Audit (NCAA)
Yes
Yes
100
National Heart Failure Audit
Yes
Yes
100
National Vascular Registry
Abdominal Aortic Anyserym
Peripheral vascular surgery/VSGBI Vascular Surgery
Yes
Yes
100
Diabetes (Adult)
Inpatient Audit (NADIA),
Diabetes care in pregnancy
Yes
Yes
100
Diabetes (Paediatric) (NPDA)
Yes
Yes
100
Inflammatory bowel disease (IBD) programme
Yes
Yes
100
National Chronic Obstructive Pulmonary Disease
(COPD) Audit Programme*
Yes
Yes
70
Rheumatoid and early inflammatory arthritis*
Yes
Falls and Fragility Fractures Audit Programme (FFFAP)
Yes
Yes
100
Older people (care in emergency departments)*
Yes
Yes
100
3 yr project
PAGE 17
Participation
Data collection
completed 14/15
% cases
submitted 14/15
Sentinel Stroke National Audit Programme (SSNAP)
Yes
Yes
100
Elective surgery (National PROMs Programme)***
Yes
Yes
??
National Audit of Intermediate Care
Yes
Yes
100
Adherence to British Society for Clinical
Neurophysiology (BSCN) and Association of
Neurophysiological Scientists (ANS) Standards for Ulnar
Neuropathy at Elbow (UNE) testing*
Yes
Yes
100
Epilepsy 12 audit - Childhood Epilepsy
Yes
Yes
100
Fitting child in emergency departments (CEM)*
Yes
Yes
100
Maternal, Newborn and Infant Clinical Outcome
Review Programme (MBRRACE-UK)
Yes
Yes
100
Elective surgery (National PROMs Programme)***
Yes
Yes
80
Neonatal intensive and special care (NNAP)
Yes
Yes
100
National Clinical Audit
*
The Trust has registered participation and is awaiting publication of the audit results
** The audit was included into the HQUIP Quality Accounts list for 2014/15. BTS decided not to undertake the audit at this
time.
*** PROMs (Patient Reported Outcome Measures) is a project that measures a patient’s health-related quality of life following
surgery using pre and post operative surveys. As patients can choose whether to participate in PROMs, the percentage
represents the take-up rate rather than the percentage of cases submitted by the Trust.
National confidential enquiry is a form of national clinical audit and is a method of assessing the quality of care
to help identify potentially avoidable factors associated with adverse outcomes.
Trust
Participation
Data collection
completed 14/15
% cases
submitted 14/15
Confidential Enquiry into Maternal and Child Health
(CMACH)
Yes
Continuous
100%
NCEPOD Lower Limb Amputation study
Yes
Yes
100%
NCEPOD Medical and surgical clinical outcome review
programme)
Yes
Yes
100%
NCEPOD Sepsis Study
Yes
Yes
60%
NCEPOD Gastrointestinal Haemorrhage (GIH) Study
Yes
Yes
100%
NCEPOD Trachostomy Care Study
Yes
Yes
100%
National confidential enquiry
The table above also notes the national clinical audits and national confidential enquiries that The Pennine
Acute Hospitals NHS Trust participated in during 2014/15, where the associated data collection was completed
during 2014/15, and the number of cases submitted to each audit or enquiry as a percentage of the number of
registered cases required by the terms of the audit or enquiry.
PAGE 18
QUALITY ACCOUNTS REPORT 2014-15
PART 2
The reports of 25 national clinical audits were reviewed by the provider in 2014. We intend to take the
following actions to improve the quality of healthcare provided.
National Audits
Reported in
2014/15
Improvements made or to be made as result of report
Bowel cancer
(NBOCAP)
Findings of the national report were sent to the Trust Cancer Lead and disseminated to
all of the Colorectal Consultants.
●● Discussion with the Cancer Lead identified that data was incomplete and not all
patients were submitted to the national database.
●● The Trust has reviewed the stoma care provided and has implemented a process of
listing patients with a temporary stoma within 12 months.
●● At present there is a review of mortality following 90 days of surgery and the Trust
has commissioned the Royal College of Surgeons to undertake an audit on this
cohort of patients. The review is to take place by the 30th September 2015.
●● The Clinical Audit Department has provided the Colorectal Consultants with their
data prior to uploading onto the national database for validation purposes. These
reports include patients diagnosed with colorectal cancer from 1st April 2013 to 31st
March 2014 with the first reports being sent in January 2014 prior to the deadline for
surgeon level reporting.
●● Quarterly reporting is underway.
Head & neck
oncology
(DAHNO)
Results have been received by the Cancer Lead and the Multi Disciplinary Team (MDT)
have developed a local action plan in response to the audit findings.
●● The national annual report is discussed at our MDT business meeting with reference
to our own entries and compare against other service providers.
●● A review in underway on the Trust systems were data can be collected in order to
ensure full data completeness.
●● 92.8% of head and neck cancer patients were discussed at MDT since then the
percentage of patients discussed at MDT has reached 99.7%.
●● 80% of T and N staging was recorded at MDT. Following a review T and N staging is
recorded live which has increased to 99.7%.
●● The Clinical Audit Department provide the Head & Neck Consultants with their data
prior to uploading onto the national database for validation and data completeness
purposes.
Oesophagogastric cancer
(NAOGC)
Findings of the national report were sent to the Trust Cancer Lead and will be discussed
with Pennine Acute Hospital NHS Trust MDT in conjunction with Salford Royal Hospitals
NHS Foundation Trust MDT.
The results of case ascertainment, M-staging after CT scan and planned intent continue
to be of good quality, meeting the audit excepted standards.
The patient pathways have continued to improve with the host Trust (Salford Royal
NHS Foundation Trust) and work is ongoing in ensuring these pathways develop into a
seamless service.
PAGE 19
National Audits
Reported in
2014/15
Improvements made or to be made as result of report
National Lung
Cancer Audit
The national report was received by the Trust in December 2014. Results have been sent
to the directorate team and local actions continue to be incorporated into the main Work
Programme / Action Plan for the Lung MDT. To date actions include:
●● Improving data collection and data validation.
●● Continue to work with CCGs to ensure appropriate referrals to 2ww clinics.
●● Continuing to undertake root cause analysis of all 62 day cancer breaches.
●● Continuing to develop nurse led follow up clinics for patients post radical treatment.
Falls and
Fragility
Fractures Audit
Programme
(FFFAP)
The national report was received into the Trust in September 2014 and the Directorate
has been requested to review the results and develop an action plan. Since the 2013
report the directorate has taken the following steps:
There remains however areas for improvement and additional focus. The Directorate has
two dedicated Orthopedic Surgeons who are the Clinical Leads for hip fractures across
both trauma sites. Hip fracture performance and outcomes remain central to the agenda
of the directorate with the following activity undertaken:
●● Monthly Multidisciplinary # NOF group
●● Clinical Validation of all patients who fail Best Practice Tariff and ongoing action log
●● Additional trauma sessions implemented on the The Royal Oldham Hospital (ROH)
sites
●● # NOF patient to be the first patient on every trauma list
●● # NOF integrated pathway that follows patient from Emergency Department (ED)
presentation to discharge, through to 30 day follow up
●● Specific Hip # Junior Doctor handbook and teaching for every medical rotation
●● Standing agenda item and performance update given at every Quality and
Performance meeting
●● Seven days a week trauma meeting at 7.45 am for all on call teams. Consultant,
Anaesthetists and Orthogeriatrician undertake a review of previous days hip fractures,
plan theatre lists and agree clinical management plans.
In addition the Directorate participates in the North West Advancing Quality Programme
(AQUA) submitting data on a monthly basis and since November 2014 they have been
submitting data on hip fracture patients. The programme provides the Directorate with
monthly reports measuring key standards of care which are linked to the national audit
criteria.
PAGE 20
QUALITY ACCOUNTS REPORT 2014-15
PART 2
National Audits
Reported in
2014/15
Improvements made or to be made as result of report
National Joint
Registry
Data submission to this project is continuous and the Orthopaedic Directorate reviewed
the results of the 11th annual report with the Trust submitting a total of 720 cases, an
increase of 18% since 2012/13.
The consent rate was 70%, this was below expectation and the Directorate sent a
directive to the Orthopaedic team highlighting the need to ensure that this criterion
is submitted to the national dataset. Since the directive the overall NJR consent has
increased to 98.7%.
The hip and knee revision rates are within the range of the national average. In addition
the Trust has been submitting data for shoulder, elbow and ankle replacement. At
present the numbers are too small, however when the twelfth annual report is published
the Directorate will compare the results against the national audit results.
National
Vascular Registry
Findings of the national reports were discussed by the directorate. The Trust’s data
submission and data completeness overall figures continue to be very good.
●● Trust performed and submitted more Carotid Endarterectomy data than any other
centre in the county. One of the main areas The Vascular and Stroke team have been
working together to improve the time from symptom to onset. The current national
guideline on stroke care recommends two weeks as the target time from symptom to
operation in order to minimise the chance of a high-risk patient developing a stroke.
●● The national result published in October 2014 displayed an improvement from
symptom onset to carotid surgery from 20 days to 12 days. Pennine Acute also
displayed an improvement from 14 days to eight days from symptom onset to
carotid surgery. The Vascular and Stoke teams across the Trust have worked tirelessly
together to develop a robust referral and treatment pathway.
●● The results continue to demonstrate that the Directorate mortality rates are within
the national expected rates:
• Abdominal Aortic Aneurysm (AAA) has a risk adjusted morality of 2.0% and this
is comparable with the national average.
• Carotid Endartectomy (CEA) has a risk adjusted morality of 1.1% compared to
the national average of 2.2%.
The results clearly show an improvement in our practice as our referral rates are now
below the national average.
PAGE 21
National Audits
Reported in
2014/15
Improvements made or to be made as result of report
Acute coronary
syndrome
or Acute
myocardial
infarction
(MINAP)
The findings of the Trust’s participation in this national report were discussed by the
directorate.
●● 96.2% of patients were seen by a cardiologist compared to the national average of
94.3%.
●● 71.9% of patients received an angiogram (either during hospital or post discharge)
compared to national average of 80.3%. The Directorate is working with the
Radiology Directorate on improved access.
●● 85.3% of secondary prevention patients received all indicated medications compared
to the national average of 84%.
●● 90.6% of patients with a STEMI (ST-elevation myocardial infarction) received cardiac
rehabilitation compared to the national average of 80.6%.
●● 87.9% of patients with a NSTEMI (non-ST-elevation myocardial infarction) received
cardiac rehabilitation compared to the national average of 82.3%).
During 2014/15 the Cardiology Team and the Clinical Audit Department have
implemented a robust system for data completeness and data validation.
National Heart
Failure Audit
The results of the audit form part of the Advancing Quality monthly monitoring process.
Cardiac Rhythm
Management
Audit (CRM)
The results of the audit were received by the Directorate in December 2014 and the team
is in the process of reviewing the information and developing an action plan.
Coronary
Angioplasty
Audit (PCI)
National Cardiac
Arrest Audit
(NCAA)
See “Advancing Quality”, Heart Failure Section of the report for details on actions taken
to improve treatment received by Heart Failure patients.
Results from the national audit report published in December 2014 have been reviewed
and the Trust is above the expected month on month.
There is on-going monitoring of the data, including Root Cause Analysis reviews and
feedback sessions to the Directorate team.
In October 2014 (risk-adjusted comparative hospital level reports) were received by the
Trust and the Resuscitation Officers are continuing:
●● To support the medical staff to complete the forms and in 2014/15 the number of
completed forms received was 85.7%.
●● To provide a Resuscitation training programme linked to the Resuscitation Council
(UK) which have quality standards for practice and training with a dedicated section
relating to acute care.
The results of the NCAA audit are used by the Trust to benchmark against other national
statistics relating to incidence of cardiac arrest, outcome and survival to discharge rates.
PAGE 22
QUALITY ACCOUNTS REPORT 2014-15
PART 2
National Audits
Reported in
2014/15
Improvements made or to be made as result of report
National
Diabetes
Inpatient Audit
Results have been received by the Trust and the directorate team reviewed the results.
●● The average prevalence of diabetes is 19.2% compared to 15.8% nationally.
●● The average percentage of medication errors for the Trust is 28.9% compared to
37% nationally.
●● The percentage of prescription errors at the time of publication was 11.6%
compared to 21.9% nationally.
●● The average percentage of patients who received a foot risk assessment within 24
hours of hospital admission was 35.7% compared to 36.3% nationally.
●● As part of the national audit, patients were asked about their overall experience in
the care they received, with 87% of Trust patients stating they were satisfied with
their overall experience compared to 86% nationally.
All actions to be taken via the Safety Programme Board with Diabetes being identified
as a primary area of focus and the two key areas that we will concentrate on in 2015/16
are:
●● Nursing staff education around genetic skills in diabetes care.
●● Mapping to the newly signed up “Advancing Quality Diabetes” Care bundle,
focusing on the following key areas:
Acute foot care, urgent hyperglycaemia and acute hypoglycaemia.
National
Diabetes in
Pregnancy Audit
Results have been received by the directorate team and they have reviewed the national
and regional audit results. The regional audit results were presented in November 2014,
Developments in Diabetes and Pregnancy in the North West, “Sharing Good Practice”.
The recommendations made in the National Summary report are for units to:
●● urgently develop a strategic focus on improving preparation for pregnancy, including
engaging with primary care teams locally to raise awareness and enhance pregnancy
planning
●● develop plans to incorporate training about pregnancy into patient education
programmes especially for women with Type 2 diabetes
●● focus on improving glycaemic control during pregnancy for women with both Type 1
and Type 2 diabetes to avoid late adverse fetal outcomes.
Since the publication of the national and regional audit reports the Trust has developed a
local action plan which includes:
●● The development of a strategic process on improving preparation for pregnancy
including engaging with primary care teams
●● Improvements on pre contraception care at the annual reviews and young person’s
clinics,
●● Closer focus on glycaemic control during pregnancy, involving regular HbA1c
measurements have been implemented.
PAGE 23
National Audits
Reported in
2014/15
Improvements made or to be made as result of report
National
Diabetes in
Paediatrics
Audit (NPDA)
Results have been sent to the Directorate Lead and they are in the process of compiling a
local action plan linked to the key recommendations and this is due to be completed by
30th June 2015.
Fourth Round
Inflammatory
bowel disease
(IBD)
Results have been received by the directorate team and they are required to develop a
local action plan in response to the audit findings and this is due to be completed by
30th June 2015.
Sentinel Stroke
National Audit
Programme
(SSNAP)
The results of the national audit are monitored with treatment continuing to be in line
with the RCP recommendations.
In addition the directorate participates in the North West Advancing Quality Programme
(AQUA) submitting data on a monthly basis and provide the directorate with monthly
reports measuring key standards of care.
Patient Reported See “Patient Survey / Experience”, PROMs section of the report.
Outcome
Measures
Programme
(PROMS)
National
Neonatal Audit
Programme
(NNAP)
Results have been received by the directorate team and as expected the results
demonstrate that the units within the Trust are comparable with the national results.
Case Mix
Programme
(CMP)
The data collected locally is validated by ICNARC, communicating closely with the
ICNARC data collection leads where necessary to ensure data is accurate and patient care
has been of a high standard.
The units will continue to submit data and monitor the results on a regular basis to
ensure that standards improve.
Data analysis reports received are circulated to site leads/consultants to highlight any
activity of concern with the opportunity to follow up a patient for specific indicators.
DAR’s compare the unit(s) to the national average in funnel plots to allow us to see areas
needing improvement
Epilepsy 12 audit
- Childhood
Epilepsy
The Trust received the second round audit report in November 2014. The Directorate is
in the process of reviewing the results and implemented a localised action plan linked to
the following areas for improvement:
●● Waiting areas don’t have facilities/activities suitable for their age.
●● Review of appointment system.
●● Review current information available regarding support groups.
●● Review current information regarding contact with other young people with epilepsy.
●● MRI scanning
●● Improve diagnosis
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QUALITY ACCOUNTS REPORT 2014-15
PART 2
National Audits
Reported in
2014/15
Improvements made or to be made as result of report
Maternal,
Newborn and
Infant Clinical
Outcome Review
Programme
(MBRRACE-UK)
The Trust received the report in December 2014 and the Obstetric Directorate are in the
process of reviewing the results and are in the process of formulating an action plan.
NCEPOD
Tracheostomy
Study
In June 2014 the Trust received the national report and upon review of the results the
Trust undertook the self assessment checklist linked to the report recommendations.
●● As a result of the outcome of the report a Task & Finish Group has been set up.
●● Medical training days for anaesthetists and ICU staff have been set up and delivered.
●● Speech & Language Therapy referrals and review process have been implemented.
●● Bespoke patient information leaflet specific to ICU
NCEPOD
Lower Limb
Amputation
Study
In November 2014 the Trust received the national report and upon review of the results
the Trust undertook the self assessment checklist linked to the report recommendations.
●● As a result of the report a Task & Finish Group has been set up.
●● Patient Pathway is in the process of being developed and will link into care in the
community setting.
Local Clinical Audit
The reports of 21 local clinical audits were reviewed
by the Trust in 20114/15. Actions planned and
undertaken in response to the audit findings will be
detailed in the Trust’s 2014/15 Clinical Audit Annual
Report.
The Pennine Acute Hospitals NHS Trust has taken the
following actions to improve the quality of healthcare
provided.
Annual Record Keeping Audits:
As a result of the annual recording keeping audits the
following has been implemented during 2014/15:
●● The Trust updated its Record Keeping Policy in
October 2014.
●● Knowledge of the policy was identified as a
‘must’ and has been included as part of the
mandatory requirements for those staffs who
record / document in healthcare records.
●● In addition, the e-learning and classroom delivery
has seen 36% of staff completing the training.
This is higher than the expected 30% planned.
DNAR - Do Not Attempt Resuscitation
The resuscitation team undertakes a regular review of
the compliance with the Trust DNACPR Policy.
●● Correct completion of forms must continue and
all sections completed as per Trust standard.
●● Details of patient’s capacity must be fully
documented on the DNACPR Form.
●● Discussion and communication with patients,
relatives, welfare attorneys and multi-disciplinary
teams must be improved.
●● Highlighting issues around DNACPR is part of the
medical staff induction.
●● DNACPR forms part of junior doctors’ teaching.
PAGE 25
Infection Control Audits:
The Infection Control Team continues to reiterate
cleaning responsibilities across a range of areas
including hand hygiene, ward kitchen areas, and the
overall environment with the nursing teams.
This result of these continuous audits has reduced
the risk of infection across the Trust in December
2014. The overall standard of compliance against the
set criteria was 89%.
The results of the audits are disseminated to the
clinical areas and where necessary are asked to
develop an action plan and provide evidence of its
implementation.
Admissions to the Medical Assessment
Unit (NMGH)
This was a newly designed audit and the standards
were taken from The Royal College of Physicians
(RCP) and Society for Acute Medicine (SAM), which
recommends that a consultant presence should be
maintained on the AMU for a minimum of 12 hours
per day, seven days a week.
Recent reports have highlighted the value of
consultant-delivered care in improving outcomes for
patients. Patient admissions to the North Manchester
General Hospital, Medical Assessment Unit (MAU)
over a one week period were audited to see if
patients were being reviewed by doctors within the
recommended timeframes outlined in the Society for
Acute Medicine.
The audit results reflect that the service is on target
with:
●● 95% of patients arriving on the MAU between
the hours of 08:00 - 18:00 were reviewed by a
consultant within eight hours, target 100%.
However, the audit highlighted areas for
improvement:
●● 92% of patients had their EWS recorded within
20 minutes of arrival on the MAU, target 100%.
●● 93% of patients admitted to the MAU were
assessed by a junior doctor within four hours,
target 100%.
●● 85% of patients were assessed by an appropriate
consultant within 14 hours of admittance to the
MAU, target 100%.
The action plan devised by the Senior Lead, Mr
Abuzour and Mr J Stewart implemented three key
actions;
●● The employment of four new consultants to cover
the needs of the service (Employed Jan 2015)
●● The implementation of an extra consultant to
cover Saturday and Sundays (implemented Oct 14)
●● A new clerking pro forma has been devised
to assist the ward clerks to record the time of
patient arrival on MAU.
Re-audit of third & fourth Degree Tears
The overall incident of obstetric anal sphincter injury
(third- and fourth-degree perineal tears) is 1% of all
vaginal deliveries and with increased awareness and
training delivered by the Trust, there appears to be
an increase in detection of anal sphincter injury.
The results of undertaking this re-audit have
identified the following:
●● Documentation appears to be an area for
improvement especially concerning
postnatal period including follow-up
and debriefing.
●● Re-emphasize the use of
Vicryl and or PDS sutures
and documentation of
operative procedure.
●● Staff grades should
document in the
notes:
• Patients’ written
consent
• Antibiotics/
laxatives/analgesia
• Counselling
• Provision of written
information
• Supervision during
procedure
PAGE 26
QUALITY ACCOUNTS REPORT 2014-15
PART 2
The following actions have been taken:
The following actions have been implemented:
●● Results of audit presented at Trust wide Obstetrics
& Gynaecology Audit Meeting in November
2014.
●● Every month cases in which there are lessons to
be learnt are discussed in Wednesday afternoon
teaching / MDT.
●● With the emphasis on documentation and
following the ’13 steps to good record keeping’
linked to the areas highlighted for improvement.
●● Trainees are made to present under senior
supervision.
●● In the process of designing a patient debrief
leaflet.
●● In the process of designing postnatal check list
which will be handed to the patient and also filed
in notes.
●● In addition enquiries are being made to assess if
there can be amendment / additional fields made
to E3 (the maternity electronic system).
Pregnancy of Unknown Location
Pregnancy of unknown location (PUL) identifies
pregnancy test is positive but there is no evidence of
the pregnancy on ultrasound scan or laparoscopy.
There are four possible outcomes; pregnancy
progresses to become a viable intrauterine
pregnancy, an ectopic pregnancy, a failed pregnancy
or remains to be a true pregnancy of unknown
location. Poor management may pose the risk of
missing an ectopic pregnancy or treating what could
potentially become a viable intra-uterine pregnancy.
Early senior involvement is necessary to ensure safe
management suitable for each individual patient.
As a result of this audit being undertaken it identified
that the following areas needed to be improved:
●● Need earlier consultant involvement, especially if
high risk i.e. b-HCG > 1500 or previous ectopic
pregnancy.
●● TV USS should be done as first line investigation
for all patients (not B-HCG level).
●● Senior medical staff are involved in decision
making at the earlier stage to avoid unnecessary
investigations/adverse outcomes.
●● Development of new guidelines to reflect the
decision making process.
VTE Prophylaxis: Audit of assessment
and prescription in acute surgical
admissions
The results of the audit showed that VTE prescription
did not reach NICE guideline standards with 41% of
patients not being prescribed VTE prophylaxis within
the initial 24 hours and 35% of patients not being
prescribed VTE prophylaxis whilst in hospital.
One of the actions to improve these statistics was to
organise an EPMA alert to be set up to prescribed
VTE prophylaxis and the doctor would have to
acknowledge this before continuing to prescribe.
Vitamin Prophylaxis
This was a Trust-wide audit undertaken by the
safeguarding team; the results of the audit showed
that 100% of patients were commenced on to the
alcohol integrated care pathway and whilst 93%
of patients meet the criteria for Pabrinex, 21%
of patients were not prescribed Pabrinex when
indicated. One of the recommendations was for the
liaison teams to devise a training structure and for
training packages to commence within a six month
time frame.
●● If treated conservatively, discharge when HCG
levels < 5 IU/L.
Cervical spine scanning in high-risk
stable and alert trauma patients
●● Better documentation of diagnosis in
Gynaecology Assessment Unit (GUA)
The radiological investigation of the cervical spine of
trauma patients is an area of much controversy. The
main debate stems from whether patients should
●● Doctors to document the diagnosis GAU book.
PAGE 27
receive plain X-rays prior to offering CT, or whether to
go straight to CT.
audit was undertaken to assess if the unified approach
was adopted comparing against national standards.
This was a single site audit looking at C-spines over
three month. The audit results showed that targeted
CT of abnormal areas is not happening in practice and
the whole c-spine is imaged. This is in keeping with
existing evidence to reduce the risk of missing any
injury and aid referral to tertiary. More patients will be
receiving CT of the C-spine in the coming years. Often
these patients have been exposed to radiation via
X-rays and scans of other body areas. It is, therefore,
important that we do not scan large sections of the
body unnecessarily.
●● The 2013 audit revealed total success rate of 68%
that included Weis procedure, skin and muscle
excision with LES and LES alone.
There is a need to increase awareness of the CT
scanning protocols in the Trust and since the
completion of this audit, copies of the protocols
have been printed off and placed within each of the
scanning areas.
Re-audit - Entropion surgeries in
Ophthalmology
This audit was the continuation of the 2013 audit of
entropion surgeries and as a result of this audit being
undertaken recommendations were made to adapt
a unified approach with best possible results. This re-
Criteria
2013
●● The 2014 audit has demonstrated an increase in
the success rate to 96.3%.
●● Part of this success rate has to be due to more
juniors trained in these procedures.
Re-audit - Adequacy of Op notes in
Orthopaedics
The table below demonstrates the improvement since
last audit undertaken in 2013.
As a result of undertaking this audit, the following
actions have been implemented:
●● New trauma operation pro-forma was
implemented in the department and forms part of
the patient medical records.
●● The senior and trauma ward staff have been made
aware of the new pro-forma.
●● The trauma coordinator ensures the pro-forma is
used and accompanies the patient to theatre.
2014 - TRAUMA
2014 - ELECTIVE
Legibility
92%
90%
97%
Immediate post-op instructions
100%
93%
100%
DVT prophylaxis
24%
90%
100%
Antibiotic cover
74%
70%
83%
Weight bearing status
64%
90%
88%
Mobilisation / Physio
78%
77%
87%
Cast removal
62%
89%
100%
Removal of clips / sutures
38%
87%
87%
Follow-up
38%
80%
97%
Signed by the surgeon
100%
93%
97%
Full name of the surgeon
100%
90%
90%
Grade of the surgeon
34%
37%
30%
PAGE 28
QUALITY ACCOUNTS REPORT 2014-15
PART 2
2.8
Participating in CQUINs
NHS Trusts (providers of services) are required to
make a proportion of their income conditional
on quality and innovation. This is carried out and
monitored through the Commissioning for Quality
and Innovation (CQUIN) payment framework.
A proportion of The Pennine Acute NHS Trust’s
income for 2014/15 was conditional on achieving
quality improvement and innovation goals agreed
between the Trust and any person or body we
entered into a contract, agreement or arrangement
with for the provision of NHS services. Further details
of the agreed goals for 2014-15 and the following
12 month period are available on request from the
Trust.
The CQUIN framework forms one part of the overall
approach on quality, which includes: defining
and measuring quality, publishing information,
recognising and rewarding quality, improving quality,
safeguarding quality and staying ahead. It is intended
to support and reinforce other elements of the
approach on quality and existing work in the NHS by
embedding the focus on improved quality of care in
commissioning and contract discussions.
CQUINs encourage and reward organisations that
focus on quality improvement and innovation in
commissioning discussions to improve quality for
patients and innovate. CQUINs build on, but not
replace, existing initiatives such as the Advancing
Quality (AQ) programme.
For 2014/15 there were acute contract CQUIN
indicators made up of 12 nationally defined
indicators, 11 regionally defined indicators
(Advancing Quality), eight NHS Greater Manchester
defined indicators and 19 locally agreed indicators,
with an associated value of approximately £11m.
These indicators, the percentage weighting assigned
to each and the approximate financial value
associated is detailed in the table below. As a result
of participation in the CQUIN framework, the Trust
continues to make significant improvements to both
patient experience and outcomes.
The Trust has a plan with its Commissioners for
2015/16 to recover £11.08million from CQUIN
payments. In 2014/15 the Trust recovered £10.92
from Commissioners for the achievement of CQUIN
schemes.
CQUIN %
Approx
Value
Friends & Family Test - Implementation of staff FFT
2.00%
£215,011
Friends & Family Test - Early implementation of patient FFT
(outpatients & day case)
1.00%
£107,505
National
Friends & Family Test - Increased and/or maintained response rates
(A&E and Inpatients)
1.00%
£107,505
National
Friends & Family Test - Increased response rates (Inpatients)
2.67%
£286,681
National
NHS Safety Thermometer - Prevalence of pressure sores
6.67%
£716,703
National
Dementia – Find, Assess, Investigate & Refer
4.00%
£430,022
National
Dementia – Clinical leadership
0.67%
£71,670
National
Dementia – Supporting carers of people with Dementia
2.00%
£215,011
Type
Name of Indicator
National
National
PAGE 29
CQUIN %
Approx
Value
Advancing Quality (AQ) - AMI (ACS score)
0.45%
£42,861
AQ
Advancing Quality (AQ) - Heart Failure (ACS score)
0.45%
£42,861
AQ
Advancing Quality (AQ) - Hip & Knee (ACS score)
0.45%
£42,861
AQ
Advancing Quality (AQ) - Pneumonia (ACS score)
0.45%
£42,861
AQ
Advancing Quality (AQ) - Stroke (ACS score)
0.45%
£42,861
AQ
Advancing Quality (AQ) - COPD (ACS score)
0.45%
£42,861
AQ
Advancing Quality (AQ) - Diabetes (ACS score)
0.45%
£42,861
AQ
Advancing Quality (AQ) - Hip Fracture (ACS score)
0.45%
£42,861
AQ
Advancing Quality (AQ) - Sepsis (ACS score)
0.45%
£42,861
AQ
Advancing Quality (AQ) - Acute Kidney Injury (ACS score)
0.45%
£42,861
AQ
Advancing Quality (AQ) - Alcoholic Liver Disease (ACS score)
0.45%
£42,861
GM
Reducing emergency admissions through integration
6.67%
£648,853
GM
Clinical effectiveness - improve care of the deteriorating patient
3.33%
£324,426
GM
Traffic Light Passport (TLP) - improving Learning Disability user
experience
5.00%
£486,639
GM
Lessons learned once
5.00%
£486,639
GM
Academic Health Science Network - Engagement
5.00%
£243,320
GM
Academic Health Science Network - Medication Safety
Thermometer
5.00%
£243,320
Local
Mortality reduction partnership
17.00%
£1,603,003
Local
Shared decision making - Outpatients
4.50%
£424,324
Local
Shared decision making - Birth options after caesarean section
4.50%
£424,324
Local
Shared decision making - COPD
4.50%
£424,324
Local
Shared decision making - Diabetes
4.50%
£424,324
Local
Optimising transition - child to adult
12.00%
£1,131,531
Local
Dementia training for consultants
3.00%
£282,883
Local
National Dashboard - HIV
3.33%
£33,925
Local
National Dashboard - Neonatal Intensive Care
3.33%
£33,925
Local
National Dashboard - Cardiology
3.33%
£33,925
Local
Improved access to maternal breast milk in preterm infants
17.50%
£356,216
Local
Orthopaedics (Adults) Network Development: regional audit &
governance, regional MDT for complex cases
17.50%
£356,216
Local
Consistent coding for oral surgery and Maxillo Facial surgery
procedures
17.10%
£51,875
Local
Phased expansion of implementation of FFT in all areas of Dental
services
17.10%
£51,875
Type
Name of Indicator
AQ
PAGE 30
QUALITY ACCOUNTS REPORT 2014-15
PART 2
CQUIN %
Approx
Value
Health Inequalities - Diabetic Retinal Screening (DRS) & Bowel
Screening
20.80%
£63,099
National
Friends & Family Test - Implementation of staff FFT (NM
Community Services)
3.00%
£5,106
National
Friends & Family Test - Early implementation of patient FFT (NM
Community Services)
4.00%
£6,808
National
Friends & Family Test - Phased expansion (NM Community Services)
3.00%
£5,106
National
NHS Safety Thermometer - Prevalence of pressure sores (NM
Community Services)
10.00%
£17,020
GM
Lessons learned once (NM Community Services)
8.00%
£11,961
Local
Pressure ulcer management improvement (NM Community
Services)
24.00%
£35,883
Local
Reduction of Heart Failure 1-4 days LOS (NM Community Services)
24.00%
£35,883
Local
Mental Capacity Act training (NM Community Services)
24.00%
£35,883
GM
Reducing emergency admissions through integration (Oldham
Respiratory Service)
25.00%
£4,137
Local
Member practice satisfaction with the responsiveness of cluster
based services (Oldham Respiratory Service)
25.00%
£4,137
Local
Cluster activity profiling (Oldham Respiratory Service)
25.00%
£4,137
380.00%
£10,916,609
Type
Name of Indicator
17.1
2.9 Data Quality
Good quality information underpins sound decision
making within the Trust and contributes to the
improvement of healthcare services. The Trust is
committed to improving data quality and has a Data
Quality Assurance Group in place to review related
reports and provide assessment and assurance
on data quality. We recognise the need to
have regular dialogue with our local
commissioners (CCGs) and data
quality is discussed on a regular
basis with them as part of
the contract challenge
programme for payment by
results (CQUINS).
The Pennine Acute
Hospitals NHS Trust
submitted records during 2014-15 to the Secondary
Uses Service for inclusion in the Hospital Episode
Statistics which are included in the latest published
data. The percentage of records in the published data
which included the patient’s valid NHS number was:
●● 99.8% for admitted patient care;
●● 99.8% for outpatient care; and
●● 98.9% for accident and emergency care.
The percentage of records in the published data
which included the patient’s valid General Medical
Practice Code was:
●● 100% for admitted patient care;
●● 100% for outpatient care; and
●● 100% for accident and emergency care.
PAGE 31
2.10 Information Governance toolkit attainment
levels
Information Governance is about how NHS and social care organisations and individuals handle information.
This can be personal/patient, sensitive and corporate information. The Pennine Acute Hospitals NHS Trust score
for 2014-15 for Information Quality and Records Management assessed using the Information Governance
Toolkit was 71% which is a ‘Satisfactory’ Green status – see table below:
Overall
Assessment
Version 12
(2014-2015)
Level Level Level Level Not
Stage
0
1
2
3
Relevant
Published 0
0
37
7
1
Total
Req’ts
45
Overall Self-assessed
Score
Grade 71%
Satisfactory
Reason for
Reviewed Change of
Grade Grade n/a
n/a
2.11 Clinical coding error rate
Monitor/Capita decide which NHS Trust is to be
audited for clinical coding. This year the Trust has
not been subject to a Clinical Coding Assurance
Framework Audit.
2.12 Care Quality Commission (CQC) Registration
Annual Review
The Pennine Acute Hospitals NHS Trust is required
to register with the Care Quality Commission
(CQC). The CQC is the independent national body
responsible for regulating the quality of care provided
by NHS Trusts, social services and independent care
providers.
Our current registration status is compliant with the
regulations. The CQC has not taken enforcement
action against The Pennine Acute Hospitals NHS Trust
during the period 2014/15, nor has the CQC taken
any enforcement action against The Pennine Acute
Hospitals NHS Trust since its inception. The Pennine
Acute Hospitals NHS Trust has not been required to
participate in any special reviews or investigations by
the CQC during the reporting period.
The CQC monitors, inspects and regulates hospitals,
care homes, dental and general practices and other
care services to provide people with safe, effective
and high-quality care, and encourage them to make
improvements where needed. It continually monitors
whether our Trust, and other care providers, are
meeting their essential standards of quality and
patient safety. Their particular focus is on patient
outcomes in terms of the delivery of a quality
experience of care.
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QUALITY ACCOUNTS REPORT 2014-15
PART 2
The CQC pays particular attention to what people
say about the service. The intelligence which is
used by the CQC to make an assessment upon the
Trust’s performance against the statutory standards
is obtained from external sources, including the
Parliamentary Health Service Ombudsman, service
users through a dedicated web site, mortality
alerts, national inpatient and staff surveys and
through Healthwatch, local charities and voluntary
organisations. The Trust also undertakes a rigorous
annual cycle of self-assessment, evidence production
and assurance against the quality standards.
Action was needed for Outcome 4 - Care and
welfare of service users. The CQC judged that this
had a minor impact on people using the service. The
Trust produced and submitted an action plan which
aimed to return the Trust to a compliance state by 31
March 2014. The detailed action plan addressed the
points raised by the CQC, these being:-
The CQC carries out a routine formal review of
services every year to audit and review service
outcomes against the essential standards for each
service location. The review includes unannounced
visits to the Trust premises so that teams of
CQC inspectors can speak with and observe the
interactions between patients and staff and the
quality of care being provided.
●● Individualised care plans to be in place for all
patients who are nutritionally compromised.
The CQC inspections are now focused on five key
lines of enquiry, determining whether services are:●● Safe
●● Effective
●● Caring
●● Responsive to people’s needs
●● Well-led
Inspections during the Year
The Trust was inspected by the CQC on 8th and
9th November 2013 as part of a routine inspection
to check that essential standards of quality and
safety were being met. Although this was a routine
inspection, it was unannounced.
The following outcomes were assessed and standards
met:Outcome 1 Respecting and involving people who
use services
Outcome 5 Meeting nutritional needs
Outcome 13Staffing
Outcome 16 Assessing and monitoring the quality
of service provision
●● Malnutrition Universal Screening Tool (MUST) to
be completed within 24 hours of admission.
●● MUST and rescreening to be completed as per
Trust guidelines.
●● Fluid balance and food charts to be completed.
North Manchester General Hospital was reinspected by the CQC on 26th June 2014. The Trust
subsequently received a compliance report from
the CQC which shows the standard with regard to
Outcome 4 – Care and welfare of users - was being
met.
Other than the above re-inspection, the Trust has
not been inspected during 2014/15. Future CQC
inspections will be in the form of Chief Inspector of
Hospitals’ visits.
Chief Inspector of Hospitals
One of the major outcomes from the Francis Inquiry
was the creation of a new Chief Inspector of
Hospitals post within the Care Quality Commission.
In 2013, Professor Sir Mike Richards introduced new
radical changes to the way hospitals in England are
inspected. These inspections started in August 2013
across acute hospitals and mental health Trusts.
These inspections are carried out by a panel of 20 or
more nurses, doctors, managers and CQC inspectors.
The Trust has not been notified of the timing of
its Chief Inspector of Hospital’s visit at the time of
producing this report. It is not included in the next
wave of Trusts to be inspected between April-June
2015.
PAGE 33
As part of the Trust’s preparation for our Chief
Inspector of Hospital’s visit, the Trust’s former
Governance Director led a series of mock peer-topeer inspections during 2014/15. The results of
these inspections were considered by the former
Clinical Governance & Quality Committee in the
summer of 2014.
including patient experience, staff experience and
statistical measures of performance. Each Trust is
banded into six bands - Band 1 is the highest level of
risk and band 6 is the lowest level of risk.
With the publication of the fundamental standards,
and the new inspection process, the Trust will be
reviewing its governance arrangements to ensure
they align to the new standards. This agenda will
be led by the newly appointed Director of Clinical
Governance and Deputy Chief Nurse, reporting to
the Chief Nurse. ●● October 2013 - band 3 (mid range)
This will include:
●● commissioning an external ‘mock Keogh’ review
inviting peer review from external Trusts
●● ensuring that the existing ward metrics are
aligned to the fundamental standards
●● that a safety walk round programme is put
in place, again aligned to the fundamental
standards and to further improve ward to Board
reporting
●● working to develop composite quality reporting
as part of our Integrated Performance Report. Intelligent Monitoring
Report (IMR)
The IMR is a surveillance model which sets out
a range of information held for each acute and
specialist Trust. The IMR is issued quarterly by the
Care Quality Commission (CQC) and subsequently
shared and discussed at the Quality & Performance
Committee. Summary level data is included in the
monthly Integrated Performance Report for the
Trust Board. The CQC surveillance model sets out
a range of information held for each acute and
specialist Trust. The information is based on over
150 indicators that look at a range of information
Since the CQC has been producing the Intelligent
Monitoring Report, the Trust’s bandings have been as
follows:●● March 2014 - band 6 – (lowest risk)
●● July 2014 – band 6
●● October 2014 – band 6
●● May 2015 – band 6
The CQC has taken the results of their intelligent
monitoring work and grouped the 160 acute NHS
Trusts into six priority bands for inspection based
on the likelihood that people may not be receiving
safe, effective, high quality care. The indicators
will be used to raise questions about the quality
of care but will not be used on their own to make
final judgements. The judgements will continue
to be based on a combination of what is found
at inspection, national surveillance data and local
information.
Maternity Outlier Alert For
Perinatal Mortality
The Trust received an outlier alert from the CQC on
13th October 2014 in relation to Perinatal Mortality.
The Trust’s response was submitted to the CQC on
21st November 2014. The response included the
context that the Trust previously had four in-patient
maternity services and four local neonatal units
(LNU) at The Royal Oldham Hospital (ROH), North
Manchester General Hospital (NMGH) Fairfield
General Hospital (FGI) and Rochdale Infirmary (RI).
During 2011-2012 as part of the reconfiguration
of maternity and neonatal services in Greater
Manchester and the Trust’s internal reconfiguration,
in-patient maternity and neonatal services were
PAGE 34
QUALITY ACCOUNTS REPORT 2014-15
PART 2
concentrated on two sites at ROH and NMGH. The
Neonatal Unit at ROH was significantly enlarged and
developed and was designated as one of Greater
Manchester’s three Neonatal Intensive Care Units
(NICU, Level 3). It began to operate as a fully-fledged
NICU in December 2012. The Unit has 37 cots in
total, including 18 intensive care/high dependency
cots, and provides the whole spectrum of medical
neonatal intensive care caring for the smallest and
sickest babies and accepts in-utero and post-natal
transfers from Greater Manchester and beyond.
Because of the increase in activity and complexity
of the patients there has been an anticipated rise in
neonatal deaths which would be expected to impact
on the “expected” number of neonatal deaths in
the Trust, and to a degree on stillbirths (because of
an increase in high risk pregnancies now managed
within the Trust).
The Trust cross referenced the data the CQC provided
with our own reporting systems and confirmed to
the CQC that all deaths had been reported and
appropriately investigated. The CQC recommended
an analysis of a random selection of at least 30
cases from April 2014 onwards. The Trust elected to
review all of the perinatal deaths within this period,
which is a total of 40 cases, to provide the Trust and
the CQC with a high level of assurance.
The detailed and comprehensive review of 28
stillbirth cases has revealed that there was only one
case where the baby was small and different care
may have affected the outcome.
In all the other cases the Trust has concluded that
there was no suboptimal care or where there was an
element of suboptimal care, the Trust’s investigation
concluded that different management would not
have altered the outcome.
The detailed analysis, when looking at all the cases
in the round, has indicated that the Intrauterine
Growth category could be improved. Accordingly
an Implementation Plan was developed for which
the Women & Children’s Divisional Quality and
Performance Committee is taking lead responsibility
for overseeing implementation of all the actions; this
committee reports upwards to the Trust’s overarching
Quality and Performance Committee, which is a
subcommittee of the Board.
Statement of Purpose
It is a statutory obligation of the Trust to notify the
CQC of any changes in our premises or the type of
services provided. The Statement of Purpose has
been updated in December 2014 and is next due for
review in June 2015 as part of its six-monthly review
cycle.
Nominated Individual
Since 1st April 2014, Mr Gavin Barclay, Assistant
Chief Executive/Board Secretary is the Nominated
Individual for the Trust’s CQC registration.
Regulatory Update
A number of new measures are being introduced
as part of the government’s response to the Francis
Inquiry’s recommendations. These are intended to
help improve the quality of care and transparency of
providers by ensuring that those responsible for poor
care can be held to account.
These include:●● New fundamental standards which will define the
basic standards of safety and quality that should
always be met, and introduce criminal penalties
for failing to meet some of them. These will
come into force in April 2015. The Trust’s Quality
& Performance Committee received a report on
this in December 2014.
●● A new fit and proper persons’ requirement means
that all Directors of NHS bodies must pass a test
proving they are fit and proper persons. The CQC
will be able to insist on the removal of Directors
that fail. This came into effect on 27 November
2014. The Board of Directors received a report
on this in November 2014.
PAGE 35
●● The Duty of Candour will require NHS bodies to
be open and transparent with service users about
their care and treatment, including when it goes
wrong. This came into effect on 27th November
2014. The Trust’s Quality & Performance
Committee received a report on this in December
2014.
2.13 Priorities for Quality Improvement 2015/16
2.13.1 Safety Priorities for
2015/16
1. Priority for Quality Improvement
Improve safety and patient experience
through reduction in avoidable harm to
patients, via monitoring of harm-free care and
internal monitoring of specific safety metrics
Rationale for selection for this priority Reducing the incidence of avoidable harm is a key
Trust objective. There are a number of indicators
that the Trust monitors on an ongoing basis to
ensure patient safety. This year, the Trust has selected
three specific areas to focus on as part of quality
monitoring.
Specific safety areas that have been chosen to
monitor reduction of avoidable harm are as follows:
●● Infection prevention;
●● Safety Thermometer and levels of harm-free
care across pressures ulcers, falls, catheterassociated urinary tract infections and venous
thromboembolism; and
●● Safer Surgery Checklist. How progress to achieve this priority
will be measured
Key performance indicators have been established
against each of these three key safety priorities,
which are as follows:
●● Meet all infection-prevention targets;
●● Be within the top 20% of the National Safety
Thermometer and with 98% hospital-acquired
harm-free care; and
●● Full implementation of the WHO Safer Surgery
Checklist and to achieve an audit standards
completion target of above 95%. Monitoring will
be in the form of auditing and incident reporting. How progress to achieve the priority
will be monitored Monthly data will be presented to the Board
of Directors as part of the Trust’s Integrated
Performance Report. Performance on this will also
be monitored through Trust and divisional Quality &
Performance Committees.
2. Priority for Quality Improvement
Reducing avoidable death/serious harm
related to severe sepsis targeting in particular
the Trust’s Emergency Departments in the
first year and subsequently incorporating
the Trust’s Acute Assessment units (Surgical,
Gynae and Medical) and surgical wards
Rationale for selection for this priority
Sepsis is a time-critical medical emergency, which
can occur as part of the body’s response to infection.
The resulting inflammatory response adversely affects
tissues and organs. Unless treated quickly, sepsis can
progress to severe sepsis, multi-organ failure, septic
shock and ultimately death. Septic shock has a 50%
mortality rate.
Sepsis is almost unique among acute conditions in
that it affects all age groups and can present in any
clinical area and health sector. Over 70% of cases
arise in the community. However, sepsis can be
treated through timely intervention and basic, costeffective therapies.
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QUALITY ACCOUNTS REPORT 2014-15
PART 2
Key to reducing harm/mortality due to sepsis is:
●● Timely recognition and diagnosis of sepsis;
●● Fast administration of intravenous antibiotics;
●● Quick involvement of experts including intensive
care specialists.
In order to achieve this, the Trust will:
●● Revise the Trust policy and care bundle for sepsis
management, implement and communicate to
staff;
●● Gather baseline information with regard to the
management of severe sepsis across all the ED
sites and acute assessment units with action
plans and improvement targets from audit data
and incident analysis;
●● Complete severe sepsis staff training across
EDs and acute assessment units with 80%
attendance;
●● Raise awareness across the Trust; and
●● Review the infrastructure to allow identification
of all patients diagnosed with sepsis within the
Trust.
How progress to achieve this priority
will be measured
We will measure compliance against the Advancing
Quality (AQ) audit standards for Sepsis (mirrored
by local sepsis Commissioning for Quality and
Innovation (CQUIN)), the nine key indicators being:
1. Early Warning Score recorded within 60 minutes
of hospital arrival
2. Evidence of two or more Systematic Inflammatory
Response Syndromes (SIRS) and documentation
of suspected source within two hours of hospital
arrival
5. Serum lactate taken within three hours of
hospital arrival
6. Second litre of Intravenous (IV) fluids commenced
within four hours of hospital arrival
7. Oxygen therapy administered within four hours
of hospital arrival
8. Fluid Balance Chart commenced within four
hours of hospital arrival
9. Senior Review or assessment by Critical Care
within four hours of hospital arrival
●● In addition to the above, we will identify
compliance via local audit for those patients
specifically with severe sepsis/septic shock and
implementation of action plans; and
●● Carry out a Mortality Review of all notes where
sepsis has been a contributing factor and Serious
Untoward Incident (SUI) monitoring.
How progress to achieve the priority
will be monitored A quarterly update, tracking progress against this
priority, will be given to the Trust’s Quality and
Performance Committee, via receipt of the Trust’s
newly developed Quality Report, and also an update
will be given to the Trust’s Safety Board, reporting to
the Trust Programmes Board.
3. Priority for Quality Improvement
Implement the Royal College of Physicians
(RCP) Fall Safe Care Bundle at PAT, with the
aim reduction in inpatient falls resulting in
severe harm or death. The Trust is aiming for
a reduction of 25% over a three-year period.
Rationale for selection for this priority
3. Blood cultures taken within three hours of
hospital arrival
There are 280,000 inpatient falls within UK hospitals
every year. Inpatient falls not only result in both
physical morbidity and mortality but have a marked
psychological impact on those who have fallen.
4. Antibiotics administered within three hours of
hospital arrival
The Royal College of Physicians (RCP) developed a
care bundle that specified a list of evidence-based
PAGE 37
elements that needed to be applied consistently in
order to holistically assess and reduce the risk of falls
in frail older adults.
Part A: The care bundle for all patients,
entails the following:
●● A history of previous falls and of fear of falling
taken at the time of admission
●● Urinalysis during admission (to consider the
possibility of infection causing falls and delirium)
●● Avoidance of prescriptions of night sedation
●● Ensuring that a call bell is in reach
●● Ensuring that appropriate footwear is available
and in use. Patients are encouraged to use
suitable footwear however the Trust can access
footwear if required
●● Immediate assessment for and provision of
walking aids
●● Clear communication of mobility status
●● Medication review for medication that can
increase the risk of falls
●● Observation, including bed position on the ward,
and toileting assessment and plan
●● Medical review of falls risk factors and
assessment for osteoporosis
●● Screen for depression
How progress to achieve this priority
will be measured
Revised falls policy document being approved,
including:
●● Actions after an inpatient fall
●● Safe use of bed-rails
●● Measure incidence of falls and perform an
investigation
●● New patient risk assessment tool to reduce the
incidence of falls
●● Personal items in reach
●● Creation of Steering groups
●● No trip or slip hazards
●● Recruitment and training of falls champions
Part B: The care bundle for older and more
vulnerable patients, entails the following:
●● Roll out of RCP care bundle to first wave of wards
●● A cognitive assessment (Abbreviated Mental
Test Score (AMTS) in all patients admitted aged
>65yrs
●● Sequential implementation of different facets of
the bundle;
●● Assessment of concordance with the different
elements of the bundle;
●● Testing for delirium (confusion assessment
method (CAM) in those at risk, as advised in the
National Institute for Health and Care Excellence
(NICE) guidelines
●● Comparison of incident analysis.
●● Bedrail risk – benefit assessment and/or
consideration of ultra low beds
A quarterly update, tracking progress against this
priority, will be given to the Trust’s Quality and
Performance Committee, via receipt of the Trust’s
newly developed Quality Report, and also an update
will be given to the Trust’s Safety Board, reporting to
the Trust Programmes Board.
●● Visual assessment (a basic check of ability to
recognise objects from the end of the bed as a
screen for severe eyesight problems, and fuller
assessment as required)
●● Lying and standing blood pressure to check for
orthostatic hypotension, and pulse taken by hand
to check for arrhythmias
How progress to achieve the priority
will be monitored PAGE 38
QUALITY ACCOUNTS REPORT 2014-15
PART 2
2.13.2 Clinical
Effectiveness Priorities for
2015/16
1. Priority for Quality Improvement
To Develop a Lessons Learned Framework
for the Trust, to ensure that the Trust moves
towards being a Learning Organisation.
Rationale for selection for this priority
When Sir Liam Donaldson, former Chief Medical
Officer in England, developed the Clinical
Governance Framework for the NHS, he stated: “To
err is human, to cover up is unforgivable, and to
fail to learn is inexcusable.” Within healthcare there
are times when staff and the Trust’s clinical services
make mistakes and do not provide optimal care for
patients. Key to understanding how these incidents
can be prevented in the future is having robust
investigation processes and making changes, which
can prevent recurrence of the same/ similar incidents
happening again. This quality priority has been
identified as it underpins the Trust’s patient safety
improvement programme.
How progress to achieve this priority
will be measured
In order to take this priority forward, the Trust will:
●● Undertake an external review of Serious
untoward incident (SUI) process and implement
the subsequent recommendations;
●● Put in place intelligent monitoring of incidents,
complaints and claims in place with aggregate
analysis and ability to identify recurrent themes;
●● Develop a lessons learned framework within
the Trust, which outlines how we learn as an
organization;
●● Develop a communications plan in relation to
learning lessons and patient safety;
●● Undertake a safety culture assessment using
recognised tool with improvement plans in place
linked to Organisational Development plans
Measurement. For year one of this priority for quality
improvement will be ensuring that the governance
systems and processes are in place and a baseline
assessment of recurring themes and culture is
undertaken.
How progress to achieve the priority
will be monitored
A quarterly update, tracking progress against this
priority, will be given to the Trust’s Quality and
Performance Committee, via receipt of the Trust’s
newly developed Quality Report. An update will be
given to the Trust’s Safety Board, reporting to the
Trust Programmes Board.
2. Priority for Quality Improvement
Improve the safety and clinical effectiveness
of patient care via the Mortality Review
Programme, with an aim of undertaking
independent auditing of deaths within the
Trust, to look at preventability and promote
learning and improved practice.
Rationale for selection for this priority
Whilst there are robust processes in place for
mortality review within the Trust, with every death
being validated and Mortality and Morbidity (M&M)
governance meetings in place to discuss mortality
reviews, the Trust has decided to further develop this
by creating a multi-disciplinary independent review
team. This will ensure a significant sample of deaths
are audited to assess preventability, using an evidence
based tool, and learning is communicated back to
the relevant practitioners and across the Trust.
How progress to achieve this priority
will be measured
A process will be implemented whereby a multidisciplinary team, using Hogan’s preventability
index, will independently audit a significant sample
of deaths. Feedback will be given to individual
practitioners and learning, where appropriate, will be
cascaded across the Trust via Mortality and Morbidity
meetings. Any specialties/clinicians being flagged as
PAGE 39
being an outlier on mortality indices will have deep
delves to look at mortality and preventability.
How progress to achieve the priority
will be monitored
Progress on mortality indices is monitored at Trust
Board meetings on a monthly basis via receipt of the
Trust’s Integrated Performance Report. In addition, a
review of the Mortality Review Process and learning
will be received at Trust Mortality and Morbidity
meetings and Trust Safety Committee.
3. Priority for Quality Improvement
Ensure the Trust meets the requirements in
relation to delivering the seven day working
clinical standards. The requirement is that
Acute Trusts must be working towards five
standards for 2015/16, working towards
all the standards for 2016/17 and be fully
compliant by 2017/18.
Rationale for selection for this priority
NHS England has set out a plan to drive seven
day services across the NHS over the next three
years. This will start with urgent care services
and supporting diagnostics. The national work
undertaken points to significant variation in
outcomes for patients admitted to hospitals at
the weekend across the NHS in England. This is a
problem affecting most healthcare systems around
the world.
This variation in patient outcomes is reflected in
mortality rates, patient experience feedback, the
length of hospital stays and hospital readmission
rates. For example, according to an analysis of
over 14 million hospital admissions in 2009/10,
the increased risk of mortality at the weekend at
hospitals across the country could be as high as 11%
on a Saturday and 16% on a Sunday. Causes include:
variable staffing levels in hospitals at the weekend;
fewer decisions makers of consultant level and
experience; a lack of consistent support services such
as diagnostics and a lack of community and primary
care services that could prevent some unnecessary
admissions and support timely discharge.
The requirement is that Acute Trusts must be working
towards five standards for 2015/16, working towards
all the standards for 2016/17 and be fully compliant
by 2017/18. The standards set out as follows:
Standard 1:
Patients, and where appropriate families and carers,
must be actively involved in shared decision making
and supported by clear information from health
and social care professionals to make fully informed
choices about investigations, treatment and on-going
care that reflect what is important to them. This
should happen consistently, seven days a week.
Standard 2:
All emergency admissions must be seen and have a
thorough clinical assessment by a suitable consultant
as soon as possible but at the latest within 14 hours
of arrival at hospital.
Standard 3:
All emergency inpatients must be assessed for
complex or on-going needs within 14 hours by a
multi-professional team, overseen by a competent
decision-maker, unless deemed unnecessary by the
responsible consultant. An integrated management
plan with estimated discharge date and physiological
and functional criteria for discharge must be in place
along with completed medicines reconciliation within
24 hours.
Standard 4:
Handovers must be led by a competent senior
decision maker and take place at a designated time
and place, with multi-professional participation
from the relevant in-coming and out-going shifts.
Handover processes, including communication and
documentation, must be reflected in hospital policy
and standardised across seven days of the week.
Standard 5:
Hospital inpatients must have scheduled sevenday access to diagnostic services such as x-ray,
ultrasound, computerised tomography (CT), magnetic
resonance imaging (MRI), echocardiography,
endoscopy, bronchoscopy and pathology. Consultantdirected diagnostic tests and completed reporting
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QUALITY ACCOUNTS REPORT 2014-15
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●● Within one hour for critical patients
steps in the patient’s care pathway, as determined by
the daily consultant-led review, can be taken.
●● Within 12 hours for urgent patients
Standard 10:
●● Within 24 hours for non-urgent patients
All those involved in the delivery of acute care must
participate in the review of patient outcomes to
drive care quality improvement. The duties, working
hours and supervision of trainees in all healthcare
professions must be consistent with the delivery of
high-quality, safe patient care, seven days a week.
will be available seven days a week:
Standard 6:
Hospital inpatients must have timely 24 hour
access, seven days a week, to consultant-directed
interventions that meet the relevant specialty
guidelines, either on-site or through formally agreed
networked arrangements with clear protocols, such
as:
●● Critical care
●● Interventional radiology
●● Interventional endoscopy
●● Emergency general surgery
Standard 7:
Where a mental health need is identified following
an acute admission the patient must be assessed by
psychiatric liaison within the appropriate timescales
24 hours a day, seven days a week:
●● Within one hour for emergency care needs
●● Within 14 hours for urgent care needs
Standard 8:
All patients on the AMU, SAU, ICU and other high
dependency areas must be seen and reviewed by a
consultant twice daily, including all acutely ill patients
directly transferred, or others who deteriorate. To
maximise continuity of care, consultants should be
working multiple day blocks. Once transferred from
the acute area of the hospital to a general ward
patients should be reviewed during a consultantdelivered ward round at least once every 24 hours,
seven days a week, unless it has been determined
that this would not affect the patient’s care pathway.
Standard 9:
Support services, both in the hospital and in primary,
community and mental health settings must be
available seven days a week to ensure that the next
How progress to achieve this priority
will be measured
Measurement will be via compliance and assurance
received on implementation of the standards. Key
Performance Indicators will be set out to ensure that
we can measure success.
How progress to achieve the priority
will be monitored
A quarterly update, tracking progress against this
priority, will be given to the Trust’s Quality and
Performance Committee, via receipt of the Trust’s
newly developed Quality Report, and also an update
will be given to commissioners via the North East
Quality Leads’ meeting.
2.13.3 Patient Experience
Priorities for 2015/16
1. Priority for Quality Improvement
Improve the safety and experience and quality
of care on wards via development of a Ward
Accreditation Scheme
Rationale for selection for this priority
The aim of a Ward Accreditation process is to
improve patient experience, patient safety and
provide a level of assurance about the quality of care
and standards on our hospital wards.
Our Ward Accreditation Scheme will involve
observing normal activities, checking standards,
PAGE 41
asking patients about their experience and talking
to staff working on the ward, in order to ensure a
thorough assessment can be made. Wards will then
be accredited as being:
●● ‘Gold’ - achieving the highest standards, with
evidence in the data and evidence of leadership
excellence;
●● ‘Silver’ - achieving the minimum standards, or
above, and actively improving with evidence of
impact in data;
●● ‘Bronze’ - achieving minimum standards and
undertaking active improvement work. If a ward
falls below the minimum standards they will not
be awarded accreditation status.
How progress to achieve this priority
will be measured
The agreed performance indicator for the Trust is to
have piloted the Ward Accreditation Scheme by the
end of June 2015, and rolled out across all wards by
the end of March 2016.
How progress to achieve the priority
will be monitored
A quarterly update will be given to the Trust’s Quality
and Performance Committee tracking progress
and shared learning from the Ward Accreditation
Scheme. For those wards that fail to meet minimum
standards and do not achieve a minimum of a
‘Bronze’ standard, an action plan will be developed
with the Ward Manager in conjunction with the
relevant Divisional Director of Nursing and monitored
by the Divisional Medical Director and the Divisional
Director of Operations, reporting into the Trust’s
Quality and Performance Committee, a subcommittee of the Trust’s Board of Directors.
2. Priority for Quality Improvement
Improve the patient experience by utilising
patient feedback methods across the hospital
and community services, to ensure care and
service changes support the needs of patients
and carers
Rationale for selection for this priority
Understanding the experience of patients and their
relatives and loved ones is fundamental to identifying
areas for improvement, and highlighting good
practice, which can be shared across other clinical
areas. Listening to patients and people who use/ visit
our services provides personal, accurate and timely
feedback on the quality and effectiveness of the care
that we provide.
Encouraging the development of a culture that
continuously views care through the eyes of a
patient:
●● helps to inform key decision making forums, to
ensure focus is maintained on improving services
for patients;
●● helps facilitate better health outcomes for
patients;
●● improves patient satisfaction; and
●● helps the Trust to understand the impact of
service change. How progress to achieve this priority
will be measured There are a number of patient-experience metrics
that have been agreed by the Board of Directors;
these are as follows:
●● to be within the top 20% of acute hospital Trusts
for the Net Promoter Score of the Friends and
Family Test (FFT);
●● development of a learning newsletter for
colleagues based on the feedback from patients;
and
●● reduce the percentage of complainants who are
dissatisfied with our response.
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QUALITY ACCOUNTS REPORT 2014-15
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How progress to achieve the priority
will be monitored How progress to achieve this priority
will be measured Monitoring of this priority will be included within the
Trust’s quarterly Quality Report, which is reported to
the Trust’s Quality and Performance Committee. There are six key objectives for the Dementia Strategy
within the Trust. These are:
3. Priority for Quality Improvement
Development of the Trust’s Dementia Strategy
with the aim of improving the experience of
patients with dementia in hospital
Rationale for selection for this priority We will continue with our focus on driving forward
the implementation of the National Dementia
Strategy - Living Well with Dementia (2009).
Development of our Trust’s Dementia Strategy will
set the framework for achieving the objectives
around service developments, pathway development
and environmental improvements with the purpose
of the Trust becoming a truly dementia-friendly
organisation. ●● inclusion and empowerment of people with
suspected or known dementia and involvement
of their carers/ advocates in their care;
●● becoming a dementia-friendly organisation;
●● developing a highly-skilled dementia-aware
workforce;
●● to champion improvements in dementia care at
all levels of the organisation;
●● work in collaboration with partner organisations;
and ●● actively participate in research and audit to
maintain and improve standards.
There will
be a strategic action plan to take forward the
Dementia Strategy within the Trust.
How progress to achieve the priority
will be monitored
Our Dementia Operational Group will monitor
progress with the Dementia Strategy, reporting into
the Trust’s Patient Experience Sub Committee.
PAGE 43
2.14 Review of Quality Performance Priorities
2014/15
Last year we set the following six key priority areas for quality improvement for 2014/15.
Building on the key priorities for improvement set out in last year’s Quality Accounts Report, the following
section includes a report on the progress and improvement we have made.
Quality Priority
Objective
Outcome
Achieved?
Hospital Mortality
Continue to effectively
manage hospital mortality
with a specific focus on
weekend mortality
The Trust’s hospital
mortality is within
expected range and our
HSMR is good compared
to peers.
Significant work has been
undertaken over the year
with a key focus being
on clinical leadership.
Progress continues on the
various actions set out
for The Royal Oldham
Hospital.
The Trust is working with
GP partners to improve
patient pathways.
Hospital Readmissions Build on the work
commenced during 201314 to ensure the outputs
are embedded to support
an ongoing reduction in
readmissions
The Trust is working
in collaboration with
its commissioners in
admission avoidance and
specifically looking at the
reasons for readmissions to
inform improvements. The
Trust will target specific
pathways as part of
CQUIN plans.
There has been no real
improvement during the
year. An audit is planned
as a basis for improvement
work.
Nutrition
Improve compliance with
the Malnutrition Universal
Screening Tool (MUST) and
ensure individualised care
plans are put in place and
implemented for patients
who are nutritionally
compromised.
Metrics established
and implemented
across the medical
and surgical wards.
Training programme also
established to support
compliance.
Improvement seen in
compliance. Initial baseline
of nutrition compliance for
nursing metrics was 76%
July 14, this increased in
March 15 to 90%.
Discharge criteria
Work with partner
agencies to ensure patients
are discharged in an
appropriate and timely
manner in line with the
Trust’s discharge policy
Local monitoring systems
established to improve the
flow of patients through
and out of hospital.
Remains a priority area for
improvement.
Collaborative working
with health and social care
partners improved.
This remains to be an area
for improvement.
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QUALITY ACCOUNTS REPORT 2014-15
PART 2
Quality Priority
Objective
Outcome
Achieved?
Referral to Treatment
(RTT)
Work with administration
teams to achieve
awareness and
understanding on the
impact of RTT standards
in clinical management
plans and on the patient
experience
Elective access division
has led on development
and delivery of training
programme to improve
engagement and
understanding of RTT. All
specialties were trained
including clinical admin
(secretaries) and health
records staff. Validation
process has been reviewed
and a more robust process
ensures that clinical
management plans are in
place.
Achieved significant
improvement and training
continues as a rolling
programme.
Cancer Pathways
Work with Clinical
Commissioning Groups
(CCGs) and tertiary Trusts
to agree amendments to
clinical pathways in order
to help improve efficiency,
safety and quality of service
for all cancer pathways
Recommendations of
review accepted by
Manchester Cancer
Board; Tumour Pathways
Boards now reviewing
recommendations and
working through how to
implement.
There were five cancer
pathways reviewed across
greater Manchester
including head & neck,
colorectal, lung, upper
gastro-intestinal and
urology (prostate).
The section below details the six mandated quality indicators that NHS acute provider Trusts were required to
report on in last year’s Quality Account and reports on our progress and performance against each indicator.
2.15 Performance during 2014/15
2.15.1 Hospital Mortality
Our hospital mortality is closely monitored and
discussed every month as part of our Medical
Director’s patient safety report which is presented at
our public Trust Board meetings. These reports are
publicly available on our website. Our mortality data
is also reported annually in our Quality Accounts and
Annual Reports.
We predominantly treat and care for patients from
communities that generally have health inequalities
and long-standing chronic health problems such
chest, heart and lung disease. There are differences
in the way mortality is calculated and variances in
primary diagnosis and appropriate coding. Adjusted
mortality enables the Trust to focus on key indicators,
improve performance and patient care, with other
nationally recognised benchmarking tools such as Dr
Foster Intelligence’s Hospital Standardised Mortality
Ratio (HSMR) and the Summary Hospital Level
Mortality Indicator (SHMI).
HSMR
Hospital Standardised Mortality Ratio (HSMR) is an
indicator of healthcare quality. This is a complex area
but helps compare a Trust’s actual number of patient
deaths to its expected or predicted number of patient
deaths. HSMR is a statistical number that enables the
PAGE 45
comparison of mortality rates between hospitals. This
prediction takes account of factors such as the age
and sex of patients, their primary clinical diagnosis
and complicating factors, and their length of stay
in hospital. Standardisation of mortality rates allows
comparison between different hospitals, serving
different communities.
HSMR is based on the likelihood of a patient dying
of the condition with which they were admitted
to hospital (i.e. the patient’s recorded primary
diagnosis). This means this methodology relies on
accurate diagnosis and record-keeping by doctors,
and appropriate data coding on patient records.
If a Trust has an HSMR of 100, this means that the
number of patients who died is exactly as would be
expected. Values above 100 suggest a higher than
expected mortality and those below as within an
acceptable range. HSMR is an important indicator
that acts as a “warning sign” or kind of “smoke
alarm” to highlight where attention should be
focussed to look at possible problems or where
patient care can be improved.
Our latest published year to date figures for HSMR
for the period from April 2014 to December 2014 is
83.05.
SHMI
The ‘Summary Hospital-level Mortality Indicator
(SHMI)’ looks at factors such as the patient’s age,
method of admission and underlying medical
conditions. The SHMI is a ratio of the observed
deaths over a period of time divided by the expected
Time Period
Pennine
Acute
National
Baseline
Jul13 - Jun14
1.052
Apr13 - Mar14
1.036
number given the characteristics of patients treated
by that Trust.
The data used to calculate the SHMI includes all
deaths in hospital, plus those deaths occurring
within 30 days after discharge from hospital. Worth
noting is that “after discharge” is a random moment
in time and responsibility for deaths that occur
between discharge and 30 days later are harder to
determine. The SHMI only attributes a death to the
hospital which last treated the patient prior to death.
It also does not adjust for palliative (end of life)
care because of the unreliability of coding. So some
hospitals may appear to have a worse SHMI than
they should because no allowance has been made
for patients admitted for care in the last days of life.
The data made available to the Trust by the Health
and Social Care Information Centre (HSCIC) with
regard to:
a) the value and banding of the summary hospitallevel mortality indicator (“SHMI”) for the Trust for
the reporting period is shown in the table at the
bottom of the page.
The Pennine Acute Hospitals NHS Trust Score is ‘as
expected’.
A ‘higher than expected’ SHMI should not
immediately be interpreted as indicating good or
bad performance and instead should be viewed as
a ‘smoke alarm’ which requires further investigation
by the Trust. The SHMI requires careful interpretation
and should be used in conjunction with other
indicators and information from other sources (e.g.
Higher than expected
Lower than expected
1.00
1.198 - Medway NHS
Foundation Trust
0.732 - Imperial College
Healthcare NHS Trust
1.00
1.197 - Blackpool Teaching
0.747 - Imperial College
Hospitals NHS Foundation Trust Healthcare NHS Trust
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QUALITY ACCOUNTS REPORT 2014-15
PART 2
patient feedback, staff surveys and other similar
material) that together form a holistic view of Trust
outcomes.
The SHMI can be used by hospital Trusts to
compare their mortality outcomes to the national
baseline. Regulators (for example, the Care Quality
Commission) and commissioning organisations
can also use the SHMI to investigate outcomes for
Trusts. However, it should not be used to directly
compare mortality outcomes between Trusts and it is
inappropriate to rank Trusts according to their SHMI.
a) the % of patient deaths with palliative care coded at either diagnosis or specialty level for the Trust for the
reporting period.
Time Period
Pennine
Acute
National
Average
Jul13 - Jun14
23.9
Apr13 - Mar14
23.6
Higher than expected
Lower than expected
24.6
49.00 - Salford Royal NHS
Foundation Trust
7.4 - University Hospital
of South Manchester NHS
Foundation Trust
23.6
48.50 - Salford Royal NHS
Foundation Trust
6.4 - Taunton and Somerset
NHS Foundation Trust
The palliative care indicator is a contextual indicator.
Data to produce the SHMI for the whole year 2014/15 is not available nationally until October 2015. The data is
refreshed on a 12-month rolling basis every quarter and the latest data available has been included in this report.
2.15.2 Hospital
Readmissions within 28
days of discharge
Emergency readmission indicators provide
information to help the NHS monitor success in
avoiding (or reducing to a minimum) readmission
of patients following discharge from hospital. Not
all emergency readmissions are likely to be part of
the originally planned treatment and some may be
potentially avoidable. Time Period
October 2013 to
September 2014 - All
October 2013 to
September 2014 0-14 years
October 2013 to
September 2014 15+ years
Pennine
Acute
All Acute
Peers
9.10%
7.86%
11.24%
8.74%
The data made available to the Trust by Dr Foster
with regard to the % of patients aged 0 to 14 and
15 or over, readmitted to a hospital which forms part
of the Trust within 28 days of being discharged from
a hospital which forms part of the Trust during the
reporting period. A lower percentage is better.
Dr Foster will publish the next set of data again in
Sept 2015. The data is six months in arrears as it is
compared to others in our peer group.
Higher than expected
East and North
Hertfordshire NHS Trust
10.02%
Lower than expected
University College London
Hospitals NHS Foundation
Trust 5.11%
8.43%
Hinchingbrooke Health
Care NHS Trust 14.36%
The Princess Alexandra
Hospital NHS Trust 4.14%
7.68%
East and North
Hertfordshire NHS Trust
9.82%
University College London
Hospitals NHS Foundation
Trust 5.00%
PAGE 47
Dr Foster 28 day Readmission Data
Readmissions
Admissions
Readmission Rate
October 2013 to September 2014
18232
200519
9.09%
October 2012 to September 2013
17915
203064
8.82%
Revised Paediatric Pathways
surgery and varicose vein procedures.
There is a need for the local NHS to work together to
improve the management of urgent care demand to
meet the needs of the local population and address
key health issues. During 2014/15 NHS Bury CCG in
partnership with The Pennine Acute Hospitals NHS
Trust and other partners including our other North
East Sector CCGs and Pennine Care NHS Foundation
Trust have been developing a number of initiatives to
reduce non-elective admissions.
PROMs are short, self-completed questionnaires
given to patients which measure the patient’s health
status or health-related quality of life at a single
point in time. The first questionnaire is given at the
time of pre-operative assessment or on the day of
admission to hospital. A second questionnaire is
sent out six months from date of surgery for hip
or knee replacements. For varicose vein and groin
hernia procedures the questionnaire is sent out three
months following surgery. In December 2014 in light of this, new robust
paediatric pathways to manage conditions that
can often lead to unnecessary A&E attendances
have been developed. Local GPs and colleagues in
community healthcare services have since been asked
to follow new patient pathways for a number of
conditions affecting children and young people with
conditions such as wheeze/asthma, dehydration/
gastroenteritis, and bronchiolitis. To support these
new pathways, the Bury Community Nursing Team
(CCNT) have been open 12 hours a day, seven days a
week and can respond to requests within two hours
when clinically required. A robust monitoring system
has been put in place to monitor patient throughput
for these conditions.
2.15.3 Patient Reported
Outcome Measures
(PROMs) NHS Trusts are required to report on patient-reported
outcome measures (PROMs). The information is
collected on NHS patients undergoing elective
(planned) hip or knee replacements, groin hernia
Data for 2014/15 is incomplete as a follow up
questionnaire is not sent out until three months post
operatively for groin hernia and varicose veins and
six months post operatively following hip and knee
replacement surgery. A patient who underwent their
surgery in March 2015 would not potentially be sent
a follow up questionnaire until October 2015.
PROMs provide us with the means of gaining an
insight into the way patients perceive their health
and the impact treatments or adjustments to lifestyle
have on their quality of life.
The data from the pre-operative questionnaire to the
post-operative questionnaire links to a specific set of
questions that nationally recognise the following:
EQ-5D Health Status – includes living arrangements,
mobility, able to self care, daily activities and mental
status.
EQ-VAS – this is a visual analogue scale that asks
the patient on the day they are completing the
questionnaire to assess their own state of health
ranging from 0 (worse imaginable health state) up to
100 (best possible imaginable health state).
PAGE 48
QUALITY ACCOUNTS REPORT 2014-15
PART 2
Adjusted average health gain on the EQ-5DTM Index by procedure
Adjusted average health gain
The Oxford Hip and Knee
Replacement and the Aberdeen
Varicose Vein scores are also
used as an additional measure
of assessing health and overall
outcomes of surgery.
Provisional Key Results
From 1st April 2013 to 31st March
2014, Pennine Acute had 1,990
eligible hospital episodes and
980 pre-operative questionnaires
were completed – a participation
rate of 49.2% compared to
77.3% nationally. A total of
73% of completed pre-operative
questionnaires have been linked to
eligible hospital procedures.
Of the post-operative
questionnaires completed, a total
of 969 (98.9%) have been sent
out on behalf of Pennine Acute
compared to 89.8% nationally.
Of the 969 post-operative
questionnaires sent out, 581 have
been returned - a response rate
of 60.0% compared to 67.8%
nationally.
Exclusion criteria at the
present time
At the present time if no blue box
appears in any of the following
tables this signifies that the
Trust has received less than 30
responses.
Hip and knee revision surgery is not
a common procedure within the
Trust and therefore the number of
responses is reflected in the charts
right. In addition fewer patients
are referred for varicose vein
Adjusted average health gain (England)
Groin hernia (98)
Hip - primary (134)
Table
1
Hip - revision (13)
Adjusted average health gain on the EQ-5D Index by procedure
Knee - primary (182)
Adjusted
Adjusted average health gain (England)
(10) average health gain
Knee - revision
Varicose
(21)(98)
Groinvein
hernia
-0.1
0.0
0.1
0.2
0.3
0.4
0.5
0.6
Hip - primary (134)
Average adjusted health gain: EQ-5D IndexTM
Hip - revision (13)
Knee
- primary (182)
TM
revision (10)
• Knee
The -adjusted
average health gain on the EQ-5D Index for groin hernia respondents
following
their operation in 2013/14 was 0.1 (0.085 in England) compared to 0.086
Varicose vein (21)
(0.085 in England) in 2012/13.
• The adjusted average
on the EQ-5D
Index
hip replacement
(primary)
-0.1 health
0.0 gain0.1
0.2
0.3 for0.4
0.5
0.6
respondents following their operation in 2013/14 was 0.46 (0.44
in England)
Average adjusted health gain: EQ-5D IndexTM
compared to 0.42 (0.44 in England) in 2012/13. • The adjusted average health gain on the EQ-5D Index for knee replacement
(primary) respondents following their operation in 2013/14 was 0.34 (0.32 in England)
areaverage
comparable
to gain
the 2012/13
results.Index
•these
Theresults
adjusted
health
on the EQ-5D
for groin hernia respondents
Table
2 following their operation in 2013/14 was 0.1 (0.085 in England) compared to 0.086
(0.085 in England) in 2012/13.
• The adjusted average health gain on the EQ-5D Index for hip replacement (primary)
health gain
on the EQ-VAS
by (0.44
procedure
respondentsAdjusted
followingaverage
their operation
in 2013/14
was 0.46
in England)
compared to 0.42 (0.44 in England) in 2012/13. Adjusted
average
health
gain
Adjusted
average
health
gain
(England)
• The adjusted average health gain on the EQ-5D Index for knee replacement
(primary)
respondents following their operation in 2013/14 was 0.34 (0.32 in England)
Groin
hernia (100)
these results are comparable to the 2012/13 results. Hip - primary (122)
Hip - revision (11)
Adjusted average health gain on the EQ-VAS by procedure
Knee - primary (160)
• The adjusted average health gain on the EQ-VAS for hip replacement (primary)
Adjusted
average health gain Adjusted average health gain (England)
Kneerespondents
- revision (9) following their operation in 2013/14 was 11.8 (11.5 in England).
Compared t 10.58 (11.63 in England) in 2012/13.
Groin hernia
(100)
vein (18)
•Varicose
The adjusted
average health gain on the EQ-VAS for knee replacement (primary)
respondents
following-5.0
their operation
in 2013/14
was 4.8 (5.7
in England).
Hip - primary (122)
-10.0
0.0
5.0
10.0
15.0
20.0
Compared to 4.54 (5.19 in England) in 2012/13.
Average adjusted health gain: EQ-VAS
Hip
revision
(11)
Knee - primary (160)
The graph below compares pre and post operative patient responses relating to
condition-specific
questions
demonstrating the improvements felt.
Knee - revision
(9)
• The adjusted average health gain on the EQ-VAS for groin hernia respondents
Table following
3 Varicosetheir
in 2013/14 was -0.1 (-1 in England). Compared to -1.40
veinoperation
(18)
(0.99 in England) in 2012/13.
-10.0 average
-5.0 health0.0
5.0 Oxford10.0
15.0
20.0
Adjusted
gain on the
Hip Score
/ Oxford Knee Score
by procedure
Average
adjusted health gain: EQ-VAS
53 Adjusted average health gain Adjusted average health gain (England)
Oxford Hip Score
• Hip
The
adjusted
average health gain on the EQ-VAS for groin hernia respondents
- primary
(141)
following their operation in 2013/14 was -0.1 (-1 in England). Compared to -1.40
Hip
- revision
(14) in 2012/13.
(0.99
in England)
Oxford Knee Score
53 Knee - primary (190)
Knee - revision (11)
0.0
5.0
10.0
15.0
20.0
25.0
Average adjusted health gain: Oxford Hip Score / Oxford Knee Score
•
•
The adjusted average health gain on the Oxford Score for hip replacement (primary)
respondents following their operation in 2013/14 was 22.1 (21.3 in England).
Compared to 20.1 (21.3 in England) in 2012/13.
The adjusted average health gain on the Oxford Score for knee replacement
(primary) respondents following their operation in 2013/14 was 17.1 (16.2 in
England). Compared to 16.3 (15.9 in England) in 2012/13.
The Pennine Acute Hospitals NHS Trust considers that this data is as described for the
following reasons:
•
•
•
Fewer patients are completing the questionnaires due to the high volume of other
surveys and questionnaire.
Health gains have been achieved.
Patients completing the questionnaires have a better understanding of PROMs.
The Pennine Acute Hospitals NHS Trust has taken the following actions to improve this
PAGE 49
surgery and this is demonstrated in the following
charts.
Table 1 compares pre and post-operative ‘EQ-5D
Index score’ (a combination of the five key criteria
concerning patients’ self-reported general health).
The results demonstrate an increase in patient
general health during this time period.
●● The adjusted average health gain on the EQ-5D
Index for groin hernia respondents following
their operation in 2013/14 was 0.1 (0.085 in
England) compared to 0.086 (0.085 in England)
in 2012/13.
●● The adjusted average health gain on the EQ-5D
Index for hip replacement (primary) respondents
following their operation in 2013/14 was 0.46
(0.44 in England) compared to 0.42 (0.44 in
England) in 2012/13.
●● The adjusted average health gain on the EQ-5D
Index for knee replacement (primary) respondents
following their operation in 2013/14 was 0.34
(0.32 in England), these results are comparable to
the 2012/13 results.
●● The adjusted average health gain on the EQVAS for groin hernia respondents following their
operation in 2013/14 was -0.1 (-1 in England).
Compared to -1.40 (0.99 in England) in 2012/13.
●● The adjusted average health gain on the EQVAS for hip replacement (primary) respondents
following their operation in 2013/14 was 11.8
(11.5 in England). Compared to 10.58 (11.63 in
England) in 2012/13.
●● The adjusted average health gain on the EQVAS for knee replacement (primary) respondents
following their operation in 2013/14 was 4.8 (5.7
in England). Compared to 4.54 (5.19 in England)
in 2012/13.
Table 3 compares pre and post operative patient
responses relating to condition-specific questions
demonstrating the improvements felt.
●● The adjusted average health gain on the Oxford
Score for hip replacement (primary) respondents
following their operation in 2013/14 was 22.1
(21.3 in England). Compared to 20.1 (21.3 in
England) in 2012/13.
●● The adjusted average health gain on the Oxford
Score for knee replacement (primary) respondents
following their operation in 2013/14 was 17.1
(16.2 in England). Compared to 16.3 (15.9 in
England) in 2012/13.
The Pennine Acute Hospitals NHS Trust considers that
this data is as described for the following reasons:
●● Fewer patients are completing the questionnaires
due to the high volume of other surveys and
questionnaires.
●● Health gains have been achieved.
●● Patients completing the questionnaires have a
better understanding of PROMs.
The Pennine Acute Hospitals NHS Trust has taken
the following actions to improve this percentage
and so the quality of its services, by undertaking
a review of how it recruits patients in the preoperative phase. The outcome of the review includes
recommendations for the Trust to:
●● Ensure all patients are requested to complete the
pre-operative questionnaire.
●● Continue to provide feedback on the outcome
data and benchmark health gains against Trusts
in the North West and national results.
●● Update the posters within the Pre-operative
Assessment Areas
●● Continue discussions with patients which includes
expected outcome of surgery.
The Trust is working to implement the
recommendations and anticipates that there will
be demonstrable improvement in reporting by the
HSCIC during 2015/16.
PAGE 50
QUALITY ACCOUNTS REPORT 2014-15
PART 2
2.15.4 Patient Safety Incident Reporting
NHS Trusts are required to submit the details of
incidents that involve patients to the National
Reporting and Learning Service (NRLS) on a regular
basis. The NRLS thereafter provides comparative
feedback to Trusts on a bi annual basis and in
arrears of six months. Trusts are able to utilise this
information to identify and tackle areas of low
reporting, as high reporting Trusts are considered to
have a stronger safety culture.
Patient safety incidents per 100 admissions
The information in the table below has been
extracted from the NRLS system and sets out the
Trust’s performance for the reporting periods April
2013 to September 2013 and October 2013 to
March 2014. The incidents were reported to NRLS
by the end of November 2014 and the data was
released April 2015. The table also compares the
Trust’s performance against a cluster of 38 similar
sized acute Trusts.
From Oct 13 to March 14
From Apr 14 to Sept 14
National average number
4,377
4,137
National average value
7.25
7.25
Minimum number for peers
787
201
Minimum value for peers
1.72
1.2
Maximum number for peers
8,015
12,020
Maximum value for peers
12.5
12.5
Pennine Acute number
6,430
7,095
Pennine Acute value
6.19
6.3
From Oct 13 to March 14
From Apr 14 to Sept 14
Patient safety incidents resulting in severe
harm
National average number
20
15
National average value
0.4
0.4
0
0
Minimum value for peers
0.0
0.0
Minimum number for peers
Maximum number for peers
102
74
Maximum value for peers
2.6
1.0
Pennine Acute number
12
19
Pennine Acute value
0.2
0.3
From Oct 13 to March 14
From Apr 14 to Sept 14
6
5
0.1
0.1
Patient safety incidents resulting in death
National average number
National average value
Minimum number for peers
0
0
Minimum value for peers
0.0
0.0
Maximum number for peers
14
27
Maximum value for peers
0.3
0.5
Pennine Acute number
10
18
Pennine Acute value
0.2
0.3
PAGE 51
Compared with its peers, the Trust’s general rate of
reporting and rate of reporting incidents to the NRLS
which have resulted in severe harm is low.
The Pennine Acute Hospitals NHS Trust considers that
this data is as described because a review of Patient
Safety Incidents (PSI) was conducted following
which the incidents were correctly categorised and
submitted to the NRLS.
The Trust has taken the following actions to improve
the quality of its services by conducting an external
Serious Untoward Incident (SUI) review. There
has also been a new appointment to the Head of
Patient Safety role whose responsibility it will be
to ensure a stronger safety culture through the
incident management system. The Trust has a Safety
Programme which specifically covers SUIs and the
harms that result from them.
Serious Untoward Incidents
Since 1 April 2014, the Trust has reported 103
serious incidents compared to 45 during 2013/14.
The main reasons for this is the increased focus and
encouragement of staff to report patient safety
incidents e.g. pressure ulcers. In addition, an internal
incident review highlighted that compared to other
similar Trusts, the Trust was a low reporter and
therefore the criteria for reporting serious incidents
has been more stringently applied.
During 2014 the Trust Chief Executive commissioned
an external review of the Trust’s Serious Incident
(SI) processes and policy by HASCAS (Health &
Social Care Advisory Service) in order to assess the
effectiveness of these as part of revised governance
arrangements across the Trust. Following the
review, which concluded in April 2015, the Trust is
now implementing a number of key changes and
improvements to its SI processes and policy and is
aligning these to the new National SI Framework.
Alongside the launch of the Incident Reporting Policy,
the Trust will be implementing ‘Speak Out Safely’
encouraging staff to raise concerns, report incidents
and near misses. This is to continue to improve the
Trust’s safety culture.
External Maternity Review
The Trust delivers 10,000 babies each year at its
purpose-built maternity units at North Manchester
General Hospital and The Royal Oldham Hospital,
including our specialist Level 2 (high dependency
special care baby unit) and Level 3 (neonatal intensive
care unit).
Shortly after the appointment of the Trust’s
new Chief Executive in April 2014, in order to
strengthen the Trust’s serious incident policy and
processes a system was introduced whereby all SUIs
(serious untoward incidents) were notified to the
executives within 24 hours and discussed at the
Senior Management Team (SMT) on a weekly basis.
This ensured the Trust could take any immediate
corrective action required and reduce risk. This
process highlighted several incidents within maternity
services.
In addition to the Trust’s own internal reviews and
to ensure no stone was left unturned, in late 2014
the Trust rightly and responsibly commissioned
an external independent expert review of a small
number of maternity service incidents dating back
to January 2012. These comprised cases involving
the sad and tragic death of six new born babies and
three maternal deaths. The terms of reference for the
review were agreed by the Trust Board.
In summary, the findings of the external review were:
●● The three maternal deaths did not appear to be
the result of deficiencies in care.
●● The Care Quality Commission’s (CQC) latest
analysis shows the Trust is not an outlier for
perinatal mortality rates. Data shows that
perinatal mortality rates at the Trust are similar
to expected. There are clearly areas of good
practice which are appropriately noted and
acknowledged and which should be widely
shared.
PAGE 52
QUALITY ACCOUNTS REPORT 2014-15
PART 2
●● The population of women cared for at Pennine
Acute Trust is diverse and challenging and includes
a significant number of high risk and vulnerable
women.
As part of the Trust’s communication and engagement
strategy for the maternity review, regular updates
have been provided by the Director of Governance to
the CQC.
The Trust has engaged with the families directly
affected in the maternal review as well as families
involved in serious incidents since July 2014. The
Trust has also worked closely to engage with internal
managers and staff in Maternity & Obstetrics, and
Trust wide staff. External health and regulatory
partners including CCGs, TDA, CQC and NHS
England sub-regions are regularly briefed along with
GP practices, clinical networks, coroners, local MPs,
local authorities, community partners and the public,
patients and media where appropriate.
As a result of this review, the Trust has developed
an improvement plan for our maternity services to
progress the learning from the investigations and the
external review. Any immediate improvements in care
required were implemented. The Trust is working with
our local NHS Commissioners (CCGs) and regulators
to support delivery of the plan. The implementation
of the improvement plan is being overseen across the
Trust by our Chief Nurse and Acting Medical Director.
Individual actions are being put in place by a whole
team of doctors, midwifery staff and the divisional
management. The improvement plan is available on
our website.
2.15.5 Venous
Thromboembolism (VTE)
Thrombosis is the term used to describe a blood clot
forming inside a blood vessel. The most common form
of thrombosis is a deep vein thrombosis (DVT) which
occurs in the leg. If the clot breaks off and travels to
the lungs it is known as a pulmonary embolism and
can be life threatening. It is thought that many cases
of blood clots developed in hospital are potentially
preventable, through risk assessment and prophylaxis
(actions undertaken to reduce the risk e.g. the use of
injections to thin the blood and support stockings).
Goal: 95% VTE risk assessments to be undertaken
within 24hrs admission to hospital
By when: April 2014
Actual Outcome: TARGET ACHIEVED -greater than
95% of VTE risk assessments undertaken
VTE Assessments - April 2014 to March 2015 where patient aged 18+
April to December 2014
Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
Total
Assessments 164,544
13,282 13,626 13,993 14,813 13,284 13,980 14,281 13,277 13,483 13,586 12,804 14,135 164,544
Admissions
170,962
13,865 14,204 14,622 15,343 13,791 14,438 14,847 13,854 13,995 14,068 13,314 14,621 170,962
% Assessed
96.25%
95.80% 95.93% 95.70% 96.55% 96.32% 96.83% 96.19% 95.84% 96.34% 96.57% 96.17% 96.68% 96.25%
Percentage of admitted patients risk-assessed for VTE - 2014/15
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
England
96.2%
96.1%
96.2%
96.4%
96.0%
96.2%
96.2%
96.0%
95.7%
96.0%
96.0%
Not
Published
Pennine Acute Hospitals NHS
Trust
95.8%
95.9%
95.7%
96.5%
96.3%
96.8%
96.2%
95.8%
96.3%
96.6%
96.2%
96.7%
Highest
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Lowest
85.7%
87.6%
83.7%
88.4%
82.8%
86.7%
88.9%
74.9%
74.0%
74.1%
Not
75.0% Published
Figures sourced from NHS England
PAGE 53
We have made the following improvements:
●● VTE policies have been updated to ensure
evidence based patient care that’s in line with
national quality standards
●● Data scrutinised by external auditors who have
confirmed the robustness of the process for data
validation
●● Investigation tools have been developed and
regularly used to review the harm caused,
putting actions into place to address and learn
from and omissions in care
●● Increased reporting in VTE via the Trust’s incident
reporting system
●● VTE E- learning programme (1737 members of
staff to date have undertaken VTE training 73%).
Further improvement plans for 2015/2016 include:
●● Implementing electronic case notes, including
an electronic version of the VTE risk assessment,
which will improve patient safety, provide robust
real time data that is easily accessible for audit
●● Continue to learn from all VTE incidents and
putting actions into place to address and learn
from when things go wrong
●● To work in collaboration with our community
partners with regards to developing best care
both in and out of hospital.
2.15.6 Healthcare
Acquired Infections
Infection prevention and control remains a high
priority for the Trust. We strongly believe that
protecting our patients and our staff against
healthcare acquired infections is the responsibility
of all our staff. This is supported by continued
scrutiny and improvement in our use of antibiotics,
sustaining high standards of cleanliness in our wards
and patient areas and an excellent annual training
programme for all our medical and nursing staff
including hand hygiene and asepsis protocols.
Our efforts to reduce the number of patients with
Healthcare Acquired Infections (HAIs), such as MRSA
(Methicillin Resistant Staphylococcus Aureus) and
Clostridium Difficile (C. Difficile), across our hospitals
and community services continue to be a top quality
improvement priority. Both Clostridium Difficile and
MRSA bacteraemia have been a national priority
for many years with every hospital acquired case
reported to the Health Protection Agency (HPA) as
part of a national surveillance programme.
Our healthcare acquired infection performance,
including reported cases of MRSA and C.Difficile,
are reported to our Trust Board of Directors and the
data is publically available on our website and also
reported back to our staff.
MRSA
In 2014/15 the national target for all acute hospitals
was zero MRSA Bacteraemias. We reported five cases.
We continue work to prevent bacteraemia (blood
stream infections), including MRSA with an extensive
programme of screening and decolonisation which
we continue for the duration of a patient stay. In
addition, we ensure high standards for infection
prevention and control practices including hand
hygiene and aseptic procedures.
An investigation is undertaken for each MRSA
involving the clinical and nursing team and
actions from lessons learnt are implemented with
personalised training and policy review. This includes
information sharing across all our hospital sites in
the form of ‘Patient Care Alerts’ where the actions
from the investigations are communicated at nursing
handover for each shift for a week. A key message
from the Patient Care Alert focussed on ensuring
screening for MRSA including any existing wounds
or lesions was carried out at the time of admission.
This has been regularly reviewed with a consistent
improvement in compliance observed.
Clostridium Difficile
Our national objective was fewer than 62 cases of
Clostridium difficile. We reported 72. We have seen a
substantial reduction and our antibiotic stewardship
is of a high standard and improvements in our
antibiotic guidelines are designed to minimise the risk
of Clostridium difficile.
PAGE 54
QUALITY ACCOUNTS REPORT 2014-15
PART 2
The Trust’s rate (per 100,000 bed days) cases of Clostridium difficile for April 2014 – March 2015 has been
reported as 16.4.
Rate (per 100,000 bed days) cases of Clostridium difficile
April 2013 – March 2014
Rate per 100,000
bed days
National average value
14.7
Minimum value for peers
0.0
Maximum value for peers
37.1
Pennine Acute Hospitals NHS Trust
12.5
Rate (per 100,000 bed days) cases of Clostridium difficile
April 2012 – March 2013
Rate per 100,000
bed days
National average value
17.3
Minimum value for peers
0.0
Maximum value for peers
30.8
Pennine Acute Hospitals NHS Trust
19.6
All hospital attributed cases of Clostridium difficile
receive a detailed root cause analysis in collaboration
with clinical, microbiology and pharmacy teams.
From the investigations, lessons learnt are
incorporated into actions and policy review.
What we will do in 2015/15
We aim to reduce Clostridium difficile infection to
an absolute minimum and we have a highly-active
Clostridium difficile programme and this is backed
up by a comprehensive action plan. Standards of
cleanliness in our wards have been a focus during
2014/15, including a deep clean where cases of
Clostridium difficile have been reported, which
includes the use of specialist decontamination
equipment such as hydrogen peroxide vapour. We
have enhanced our infection prevention and control
practices to support the rapid isolation of patients
with symptoms of diarrhoea with the launch of our
“Don’t wait, Isolate” campaign.
We will continue our focus on good practice to
reduce healthcare acquired infections, working with
staff to:
The national benchmark for all acute hospitals for
Clostridium difficile infections is reported as the rate
per 100,000 bed days and this remains comparable
to other hospitals of similar size across England.
The Pennine Acute Hospitals NHS Trust intends to
take the following actions to improve this rate per
100,000 bed days for Clostridium difficile and so the
quality of its service by:
●● Continue to improve infection prevention
clinical practices with a new ‘Don’t wait, Isolate’
campaign for patients with symptoms of
diarrhoea. This will focus on supporting the rapid
implementation of infection prevention practices,
including isolation for patients with diarrhoea.
●● Sustain and continually improve antibiotic
prescribing to enhance and support the national
“Start Smart, then Focus” antibiotic stewardship
programme.
●● Promote high standards in hand hygiene and
asepsis protocol through audit and education
programmes
●● Maintain the excellent standards of hospital
cleanliness, together with enhanced deep
cleaning and specialist decontamination of ward
environments.
PAGE 55
Ebola preparedness
In August 2014 the Trust initiated actions in response
to the emerging Ebola crisis in West Africa and the
international relief programme which followed. In
collaboration with the Emergency Planning team, the
Infection Prevention team and our regional specialist
Infectious Diseases unit based at North Manchester
General Hospital instigated an Ebola preparedness
programme.
This programme has been recognised both locally
and regionally as an example of good practice
and has been shared with other Trusts and local
authorities.
The Emergency Departments have received specially
designed action cards to support Ebola identification
and patient management and a similar action card
is in place for on call managers. The appropriate
Personal Protective Equipment (PPE) has been
sourced for all relevant departments together with
training and practice sessions for staff to be fully
confident in putting on and removing the PPE.
The Infectious Diseases Unit has been recognized
as the Greater Manchester referral centre for all
suspected Ebola cases and to support this,
regular live exercises have been simulated
within the department and the Trust
continues to liaise with external
agencies including Public Health
England to support the Greater
Manchester Ebola strategy.
2.15.7 NHS Staff Friends and Family Test
Research has shown a relationship between staff
engagement and individual and organisational
outcome measures, such as staff absenteeism and
turnover, patient satisfaction and mortality; and
safety measures, including infection rates. The more
engaged staff members are, the better the outcomes
for patients and the organisation generally.
In April 2014, NHS England introduced the new
Staff Friends and Family Test (FFT) in all NHS Trusts
providing acute, community, ambulance and mental
health services in England. The aim is for staff to
be given the opportunity to feedback their views
on their organisation at least once per year. This is
in addition to the annual NHS Staff Survey which
also looks at staff engagement and staff satisfaction
working in the NHS. It is hoped that Staff FFT will
help to promote a large scale cultural shift in the
NHS, where staff have opportunity and confidence
to speak up, and where the views of staff are
Staff FFT Question
increasingly heard and are
acted upon to improve
things for staff and
patients.
The new Staff FFT is a
feedback tool for staff,
predominantly for local
improvement work. It consists of
two questions (with options to give
free text feedback for each) through
which NHS Trusts can take a temperature
check of how staff are feeling. It is a quicker
feedback mechanism than the existing NHS annual
staff survey, and at its best will enable staff to voice
their concerns and for organisations to respond.
Since April 2014, every three months using the
support of the Picker Institute we have sent the Staff
FFT to hundreds of our staff for their feedback. The
table below shows the Trust’s score.
Q1
Q2
Q3*
Q4
How likely are you to recommend <this organisation> to
friends and family if they needed care or treatment?
67%
66%
54%
71%
How likely are you to recommend <this organisation> to
friends and family as a place to work?”
58%
58%
48%
59%
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QUALITY ACCOUNTS REPORT 2014-15
PART 2
The Pennine Acute Hospitals NHS Trust considers
that this data is as described as there are nationally
regulated assurance processes in place to ensure the
accuracy and validity of the data.
The Trust intends to take the following actions to
improve this percentage, and so the quality of its
services, by undertaking crowd sourcing surveys
to gain a better understanding of the issues and
concerns that staff have and therefore enable the
better targeting of appropriate action.
2.15.8 NHS Staff Survey
Results 2014
National staff survey results and the
actions planned in response to it
●● The Trust is beginning a journey to better engage
with its workforce and improve staff morale and
staff satisfaction. We intend to use the current
‘Pride in Pennine’ challenge - with its focus on
health, well-being and engagement - as the
launchpad for our action to address the issues
raised.
●● The Workforce and Leadership Programme Board
will report to the Trust Board on the key themes
coming out of the ‘Pride in Pennine’ challenge
and the subsequent action plan developed to
improve our performance, following the May
away day event.
●● Whilst our overall staff engagement score has yet
again improved on a marginal basis from 3.58 to
3.61 our results are significantly below average in
comparison with other NHS organisations.
●● The key themes were Healthy, Happy and Here.
Our workforce is fundamental to the delivery of high
quality care and this year’s results have shown some
progress in improving scores. However, in overall terms
they are well below where the Trust needs to be.
The results of the national staff attitude survey
2014 show that whilst the Trust has made some
progress, there is still a challenge to be climbed to
get to where we want to be. It is a proven fact that a
well-motivated and engaged workforce delivers high
quality care (Borrill & West 2001). This challenge is
acknowledged by the Trust Board of Directors and
this work will feature as a major part of the agenda
for the Workforce and Leadership Programme Board
going forward.
This year the annual staff survey was distributed to
all Trust staff in September 2014. A ‘mixed mode’
method of delivery was used which involved both
electronic and paper versions of the survey. The
return rate was 32.5% which was disappointing but
does reflect national reductions in return rates across
the NHS. This is thought to be due to the additional
Staff Friends and Family Test (FFT) surveys that have
been distributed this year. Although small in terms
of percentage, the results do represent the views of
over 2,700 staff across the Trust. In 2013, 505 staff
responded from the 850 sample giving a response
rate of 60%.
National England averages for quarter four:
●● Percent of staff recommending as a place to work
- 61.7%
●● Percent of staff that recommend as a place to
receive treatment - 77.2%
The results have been analysed by the Picker Institute
and then shared at a local level. In all, of the 29 key
findings, the Trust achieved significant improvement
in three areas:
●● KF16. Percentage of staff experiencing physical
violence from patients, relatives or the public in
last 12 months
●● KF18. Percentage of staff experiencing
harassment, bullying or abuse from patients,
relatives or the public in last 12 months
PAGE 57
●● KF17. Percentage of staff experiencing physical
violence from staff in last 12 months.
The Trust has seen a significant deterioration in one:
●● KF5. Percentage of staff working extra hours
Comparisons within the survey are also made against
other Trusts. The Trust has achieved significantly
better scores than other Trusts in the following five
areas:
●● KF16. Percentage of staff experiencing physical
violence from patients, relatives or the public in
last 12 months
●● KF17. Percentage of staff experiencing physical
violence from staff in last 12 months
●● KF5. Percentage of staff working extra hours
●● KF26. Percentage of staff having equality and
diversity training in last 12 months
●● KF15. Percentage of staff agreeing that they
would feel secure raising concerns about unsafe
clinical practice.
The Trust has achieved significantly worse scores than
other Trusts in the following five areas:
●● KF9. Support from immediate managers
●● KF4. Effective team working
●● KF8. Percentage of staff having well-structured
appraisals in last 12 months
●● KF23. Staff job satisfaction
●● KF29. Percentage of staff agreeing that
feedback from patients/service users is used to
make informed decisions in their directorate/
department.
The survey analysis provides a wealth of data both at
a divisional and site level. This will be assessed within
the Workforce and Organisational Development
team to identify key areas of action to improve staff
experience and staff engagement, along with the
results of the quarterly staff FFT results. Additionally,
crowd sourcing and other staff engagement methods
will be used again this year to gain additional
feedback from staff in this area.
The engagement of staff will form a major part
of the agenda for the Workforce and Leadership
programme Board going forward which will include
the development of an action plan/improvement
plan.
Pride in Pennine Online Staff Workshop
In May 2014 thousands of our staff shared over
27,000 contributions to our first Pride in Pennine
online workshop which helped us develop our
new Trust Vision, Values and five year strategic
Transformation Plan. Through this unique online
conversation, our staff said that a key corporate
priority must be to “create an environment so staff
choose to work with us, staff sickness and absence is
reduced, and staff morale increased.”
In March 2015, the Trust Chief Executive launched
the first quarterly Chief Executive’s Challenge to
address key issues and challenges facing the Trust.
Using our web-based Pride in Pennine online
workshop, all staff across the organisation were
invited to have their say on how the Trust can
improve staff health and wellbeing and reduce staff
sickness and absence.
Our online workshop allowed all staff the
opportunity to join a Trust-wide conversation,
anonymously share their thoughts, ideas and
comments, and vote the best ideas to the top. Using
this process over a three month period will enable
the Trust to identify and prioritise the best solutions,
and then develop actions to improve staff satisfaction
at work.
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QUALITY ACCOUNTS REPORT 2014-15
PART 2
2.15.9 Friends & Family Test
Since April 2013, and in line with The Department
of Health guidance, the Trust has been gathering
patient feedback via the national Friends and Family
Test (FFT).
Patients are asked at point of discharge whether
they would recommend a friend or family member
to be treated at our Trust. FFT data is being collected
in Accident and Emergency departments, maternity
services, and inpatient areas. The survey results
help the Trust to identify both good and bad areas
of performance. Patient comments from the FFT
data are displayed in most areas and action plans
are developed in areas of poor performance. The
Trust’s Quality and Performance Committee monitor
divisional performance in relation to FFT results and
reports are presented and discussed at the Trust
public Board meetings.
All inpatient areas use postcards to collect the FFT
data and response rates for inpatients remain above
the national average. The use of ‘voting coins’
currently used in our A&Es will discontinue in April
2015 following Department of Health Guidance and
will be replaced by a text messaging or an interactive
voice messaging
service
(IVM).
Since November 2014 patient feedback data
through FFT has been electronically collected in
our Outpatient departments and Community
areas through a third party company using a
proof of concept. In February 2015 the business
case was agreed and procurement for a provider
has commenced. By April 2015, all of our A&E
Departments, Outpatient and Community patient
feedback will be via text messaging or IVM. The
information will be produced in a more sophisticated
report allowing the Trust to drill down to specific
areas of poor or good performance.
Since October 2014 the previous method of
calculating Trust FFT scores using the Net Promoter
score has been discontinued nationally. The score is
now calculated by the percentage of patients that
would recommend the Trust, opposed to those that
would not.
In January 2015 Inpatient scores were 96.11%
recommended against a national average of
94.67%, Accident and Emergency scored 88.43%
recommended against a national average of
86.19% and Maternity score at touch point 2 was
96.95% recommended against a national average
of 96.61%. The scores collected are published on
the NHS Choices website and individual ward and
department scores are displayed on the “ward at a
glance” boards.
The Trust considers that this data is as described for
the following reasons:
Response rates for inpatients have exceeded the
national average and the Trust is one of the
top performing Trusts of its size in relation to
response rates. Scores are generally over the
national average and due to the change to
a more sophisticated reporting method the
Trust should see further improvements over
the coming months.
PAGE 59
2.15.10 National Survey Programme – 2014 survey results
The national survey programme is used as a key to
measure patient experience and perceptions across
the NHS and this Trust.
We are continually striving to ensure that the quality
of care provided meets expectation and we respond
to the needs of service users, including the listening
to patients, the need for privacy, information and
involving patients in decisions about their care.
National Day Case Survey
The following results summarise the findings from the
second national survey for Day Case Surgery 2014 in
which 16 Trusts nationwide participated.
The data presented in this summary has been
benchmarked and linked to all participating Trusts.
Section heading
2013
2014
Before Hospital
6.0
5.1 ↓
Arrival to Hospital
5.1
6.4 ↑
Operations and Procedures
7.3
6.8 ↓
Ward and Recovery
9.0
9.1 ↑
Doctors
8.6
8.6 -
Nurses
8.6
8.6 -
Care and Treatment
6.4
6.4 -
Leaving Hospital
7.4
7.2 ↓
Overall Experience
9.3
8.8 ↓
2013
2014
Hospital appointment date not changed by hospital
7.5
8.1 ↑
Hospital room or ward very clean or clean
9.9
10 ↑
Courtesy of the nurses rated as very good to good
9.6
9.9 ↑
Did not have to wait a long time before having the operation or procedure?
6.5
6.2 ↓
Was not given an explanation if had to wait?
6.2
6.0 ↓
Risks and benefits of the operation/procedure explained?
7.7
7.3 ↓
Not enough opportunity given for family to talk to a doctor?
4.4
5.3 ↑
Did not feel fully involved in decisions about discharge from hospital?
2.9
3.3 ↑
Family or someone close was not given enough notice about discharge?
2.2
2.6 ↓
Full explanation of medication side effects given?
4.0
4.1 ↑
Full explanation of any danger signals to watch for?
3.9
4.4 ↑
Examples of other responses
National Survey Questions
The areas that the Divisions / Trust need to review centre around the prior to admission, providing information
prior to and following an operation / procedure and leaving hospital.
QUALITY ACCOUNTS REPORT 2014-15
PART 2
The Division have been sent the results and asked to complete an action plan for each unit / hospital site and
progress will be monitored via the Patient Experience, Equality & Diversity Committee.
National highest and lowest rates for patient FFT data
Code
Response
Rate
Name
RTG
Derby Hospitals NHS Foundation Trust
26.47%
R1H
Barts Health NHS Trust
28.06%
RTD
The Newcastle Upon Tyne Hospitals NHS Foundation Trust
41.32%
RW6
Pennine Acute Hospitals NHS Trust
48.89%
RTH
Oxford University Hospitals NHS Trust
23.62%
RM1
Norfolk and Norwich University Hospitals NHS Foundation Trust
29.82%
RTR
South Tees Hospitals NHS Foundation Trust
38.21%
RWA
Hull and East Yorkshire Hospitals NHS Trust
38.57%
RF4
Barking, Havering And Redbridge University Hospitals NHS Trust
54.26%
RTE
Gloucestershire Hospitals NHS Foundation Trust
31.32%
Total eligible within +/- 700 of PAHT
Response Rate
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
Gloucester Hospitals
NHS Foundation Trust
Barking, Havering and
Redbridge University
Hull and East Yorkshire
Hospitals NHS Trust
South Tees Hospitals
NHS Foundation Trust
Norfolk and Norwich
Hospitals NHS Trust
Oxford University Hospitals
NHS Trust
Pennine Acute Hospital
NHS Trust
The Newcastle Upon Tyne
Hospitals NHS Foundation Trust
Barts Health NHS Trust
0.00%
Derbyshire Hospitals NHS
Foundation Trust
PAGE 60
PAGE 61
National Accident & Emergency Survey – 2014 survey results
The fifth survey of A&E patients involved 142 acute
and specialist NHS Trusts with a major accident and
emergency department. A total of responses were
received from nearly 40,000 patients, which is a
response rate of 34% compared to a 29% response
rate for the Trust.
The data presented in this summary has been
benchmarked and linked to all participating Trusts.
Section heading
2009
2012
2014
Not asked
7.9
7.9 -
Waiting times
6.3
7.6 ↑
6.6 ↓
Doctors and nurses
8.1
8.2 ↑
8.1 ↓
Care and treatment
8.1
8.2 ↑
7.7 ↓
Tests (answered by those who had tests)
7.2
8.5 ↑
8.4 ↓
Hospital environment and facilities
8.2
8.1 ↓
7.9 ↓
Leaving A&E
5.5
5.8 ↑
5.9 ↑
Not asked
7.1
8.2 ↑
Arrival at A&E
Experience overall
Results of the 2014 accident and emergency department survey were published in December 2014.
Examples of other responses
National Survey Questions
2009
2012
2014
Were you given enough privacy when discussing your condition with the
receptionist?
6.8
6.6 ↓
7.2 ↑
How long did you wait before being examined by a doctor or nurse
6.3
6.3 -
7.0 ↑
-
7.8
7.4 ↓
Were you involved as much as you wanted to be in decisions about your
care and treatment?
7.7
7.9 ↑
7.8 ↓
Did a member of staff explain why you needed these test(s) in a way you
could understand?
-
8.7
8.3 ↓
In your opinion, how clean was the A&E Department?
7.8
8.6 ↑
8.5 ↓
Did a member of staff tell you about medication side effects to watch for
when you went home?
3.5
3.4 ↓
5.2 ↑
-
7.9
7.8 ↓
If your family or someone else close to you wanted to talk to a doctor,
did they have enough opportunity to do so?
Overall experience
Each Accident and Emergency Department has completed an action plan and implementation will be monitored
via the Patient Experience, Equality & Diversity Committee.
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QUALITY ACCOUNTS REPORT 2014-15
PART 2
2.15.11 National Inpatient Survey
The national inpatient survey is used as a key to
measure patient experience and perceptions across
the NHS and this Trust. We are continually striving
to ensure that the quality of care provided meets
expectation and we respond to the needs of service
users, including the listening to patients, the need
for privacy, information and involving patients in
decisions about their care.
The NHS Outcomes Framework includes the domain
of ensuring that patients have a positive experience
of care and that organisations are responsive to inpatient personal needs. The domain’s score is based
in the mean number of questions within the National
Inpatient Survey 2014.
The Trust received some very positive results from
the 2014 national inpatient survey and improved
its scores in 18 out of the 60 questions which are
benchmarked against all participating Trusts. The key
areas of improvement have been around care and
treatment, leaving hospital and overall experience.
The Trust will continue to work with the Divisions
to make improvements in the overall inpatient
experience.
2014
2013
Significantly BETTER
than average in 1 (2%)
question compared to
3 (5%) in 2013.
Significantly WORSE
than average in 4 (7%)
questions compared to
2 (3.3%) in 2013.
Section heading
2012
2013
2014
The emergency / A&E department, answered by emergency patients only
8.6
8.7 ↑
8.2 ↓
Waiting lists and planned admissions,
(answered by those referred to hospital)
9.0
8.9 ↓
8.6 ↓
Waiting to get to a bed on a ward
8.0
7.8 ↓
7.5 ↓
The hospital and ward
8.4
8.2 ↓
8.2 -
Doctors
8.4
8.3 ↓
8.3 -
Nurses
8.6
8.4 ↓
8.4 -
Care and treatment
7.7
7.8 ↑
7.6 ↓
Operations and procedures (answered by patients who had an operation
or procedure)
8.2
8.1 ↓
7.7 ↓
Leaving hospital
6.9
7.0 ↑
6.8 ↓
Overall views care and services
5.0
5.1 ↑
5.5 ↑
-
8.0
8.1 ↑
Overall experience
PAGE 63
The results of the 2014/15 inpatient survey were published in May 2015 and the Clinical Audit Department
has provided Divisional reports to support the development of action plans linked to other patient experience
outcomes.
Examples of other responses
National Survey Questions
2012
2013
2014
Not ever bothered by noise at night from hospital staff?
8.3
8.0
8.0
Did not feel threatened during stay in hospital by other patients and visitors
9.9
9.6
9.8
In your opinion, how clean was the hospital room or ward that you were in?
9.0
9.0
9.0
Did you get enough help from staff to eat your meals?
7.9
7.3
7.7
When you had important questions to ask a nurse, did you get answers that
you could understand?
8.4
8.2
8.2
Were you involved as much as you wanted to be in decisions about your
care and treatment?
7.0
7.2
7.2
The areas that the Trust need to review centre
around the patient’s point of entry into hospital
and providing information prior to and following an
operation or procedure.
National Survey Questions
Were you involved as much
as you wanted to be in
decisions about your care?
Did you find someone in the
hospital to talk about your
worries and fears?
Were you given enough
privacy when discussing your
condition and treatment?
Did a member of hospital
staff tell you about
medication side effects to
watch for when you went
home?
Did hospital staff tell you
who to contact if you
were worried about your
treatment or condition when
you went home?
Overall Score
Trust
7.3
5.9
8.4
4.6
7.2
6.7
2012/13
National
Lowest – 6.3
Highest – 8.7
Lowest – 4.2
Highest – 7.8
Lowest – 7.8
Highest – 9.3
Lowest – 3.4
Highest – 7.5
Lowest – 6.6
Highest – 9.5
The Trust is currently participating in the following
national surveys:
●● National Neonatal Survey - Bliss
●● National Children and Young Person Cancer
Survey
●● National Children’s Survey (NATCS)
●● National Maternity Survey
Trust
7.2
5.9
8.9
4.8
7.3
6.8
2013/14
National
Lowest – 5.9
Highest – 8.6
Lowest – 3.9
Highest – 8.1
Lowest – 7.6
Highest – 9.2
Lowest – 3.6
Highest – 7.4
Lowest – 6.2
Highest – 9.7
Trust
7.2
5.5
8.3
4.3
7.0
6.5
2014/14
National
Lowest – 6.1
Highest – 9.2
Lowest – 4.3
Highest – 8.2
Lowest – 7.5
Highest – 9.4
Lowest – 3.7
Highest – 7.6
Lowest – 6.4
Highest – 9.7
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QUALITY ACCOUNTS REPORT 2014-15
PART 3
The survey data has been published nationally and
is currently being shared and considered with staff
across the Trust. Action plans are in development
with the Divisions and will start to be implemented in
July 2015, focusing on the lowest scoring questions
and areas where improvements were not achieved.
Progress on action plans are monitored by the
Trust’s Patient Experience and Equality and Diversity
Committee quarterly and reports to the Clinical
Governance and Quality Committee.
The key areas which the Trust has identified for
improvement over the coming 12 months are as
follows:
●● Information given to patients in A/E
●● Information given to patients on the wards
●● Involvement in the discharge process
●● Information given to patients prior to their
operation / procedure
●● Information given to patients after their operation
●● Involve patients more in decisions about their care
and treatment
●● Reducing Noise at Night
●● Quality of Food
●● The development of a Communication Folder
2.15.12 4 hour Emergency
Access Standard
Emergency and urgent care services are available
to people who need emergency medical advice,
diagnosis and treatment quickly and unexpectedly.
We work hard to ensure our patients are seen
as quickly as possible across our three Accident
& Emergency departments at North Manchester
General Hospital, Fairfield General Hospital and The
Royal Oldham Hospital, as well as our Urgent Care
Centre (UCC) at Rochdale Infirmary.
The Department of Health’s national 4-hour
Emergency Care Access Standard requires at least
95% of patients to be seen, treated, admitted,
transferred or discharged within four hours of
attendance at an A&E department, urgent care centre
or NHS walk-in centre.
We understand how important this standard is for
patients and their families. Patients deserve to be
seen as quickly as possible and this focus prevents
patients having to experience unnecessary delays
in A&E and also encourages our staff in wards and
other areas of the hospital to help inpatients recover,
receive rehabilitation and prevent unnecessary delays
in their discharge back home or in the community.
Despite our good A&E performance in the first two
quarters of 2014/15, the demand and pressure
on our services meant that as a Trust we did not
achieve the 95% 4 hour national standard for the
year. Our A&E Department at North Manchester
General Hospital did out-perform most other
A&E departments across Greater Manchester in
consistently meeting the national standard.
PAGE 65
The Trust’s monthly performance for each of our sites across all A&E quality indicators are publicly available on
our website under quality and performance at www.pat.nhs.uk. The table below shows performance for the
Trust by quarter and cumulative year to date up to the end of each quarter.
YTD
Q1
Q2
Q3
Q4
4 hour Trust Urgent Care
93.6
95.7
95.1
91.5
92.2
4 hour FGH Urgent Care
90.2
93.7
93.5
85.7
88
4 hour ROH Urgent Care
91.4
93.7
93.7
88.5
89.7
4 hour NMGH Urgent Care
95.2
97.2
95.2
94.3
94.3
4 hour RI Urgent Care
98.5
98.5
99.3
98
98.3
12 hour Trolley Waits
0
0
0
0
0
Demand on services
A&E departments across the country continue to be
extremely busy every day treating and dealing with
all kinds of patients. In 2014/15, the Trust saw over a
third of a million patients in our A&Es and UCC.
During the last year, A&E departments nationally
faced unpresented demand and pressures on
services and staff. This was particularly the case
during the winter where we saw extremely high
numbers of acutely ill patients presenting at our
A&E departments, many of whom were elderly and
required hospital admission and needed medical care
and treatment.
We also experienced an increased demand within
Paediatrics (this includes children’s A&E and our
children’s inpatient wards), particularly at The Royal
Oldham Hospital and North Manchester General
Hospital of 20%. A number of measures were put in
place to ensure that there were sufficient numbers
of paediatric nurses available to look after the sick
children being admitted to our hospitals and safely.
During the Christmas period our doctors were
publicly encouraging local residents to ‘stock up their
medicine cabinet’ and think carefully before going to
A&E, so that our staff could concentrate on treating
the seriously injured, critically ill and those in need of
emergency care. The plea came as the Trust recorded
the most number of patient attendances in one day
across its urgent care services on 15th December
2015 – a total of 1,093 patients. On average our
staff were seeing 80 more patients per day than
the same time the previous year in the run up to
Christmas.
In efforts to alleviate the pressures on our A&Es and
to ensure we could continue to provide safe patient
care, we opened extra hospital bed capacity, both
internal to the Trust and externally. Many of our
medical and nursing staff worked flexibly across our
clinical areas and sites to cope with the demand. Our
staff worked incredibly hard in our A&E departments,
medical assessment units and radiology departments
to ensure our patients are seen and treated as quickly
as possible but importantly to provide high quality of
care.
Despite these pressures and the importance of the
national 4 hour standard, we will not compromise
on patient safety, our high standards of care or
compassion.
Expansion of our A&Es
In May 2012, the Trust announced a huge multimillion pound capital investment programme
to expand and improve facilities at both A&E
departments at Fairfield General Hospital and at The
Royal Oldham Hospital. The expansion building work
at both A&E facilities completed in 2014/15 and
will now support and accommodate the increased
QUALITY ACCOUNTS REPORT 2014-15
PART 2
number of acutely ill patients
now being seen at our busy
A&E departments. More details
are set out in section 3.3.1 on
p83.
2.15.13 Referral To
Treatment (RTT) – 18
weeks
National and local NHS standards require patients
to be admitted for surgery or scheduled (elective)
services within 18 weeks of referral by their GP. This
standard is known as 18 weeks Referral To Treatment
(RTT). Like many other NHS Trusts across Greater
Manchester and across the country, we have been
getting through a past backlog of patients waiting
for an operation. In 2011/12 this backlog was about
1000 patients. This was, in part, due to emergency
demands on the Trust caused by the winter flu
outbreak and the adverse weather conditions in
December 2010 and January 2011. During the year
we have been working incredibly hard to reduce our
backlog. Our Trust has recently been working with
the Trust Development Authority (TDA) to reduce
the number of patients waiting over 18 weeks for
treatment. The TDA praised our teams for achieving
a “substantial reduction” to our over 18 week
backlog during February and March ensuring the
delivery of this important standard and recognizing
all that has been done to date against what has been
a challenging ask. Our work has made a significant
difference and positive impact to patients and their
experience.
The challenge facing us, like most other hospitals,
in particular is the large numbers of orthopaedic
patients requiring surgery. Our surgeons, theatre
staff and managers have been reviewing our patient
pathways for those needing an operation to ensure
they are efficient and effective. We have continued
to review the productivity of our theatres, ensure
they are running at full capacity and that the first
operation each morning starts promptly.
In early 2015, our Trauma and Orthopaedic
directorate recruited and appointed seven newly
qualified consultants. All of these new surgeons
now work across a range of sub specialities and the
majority have undertaken part of the training within
the Trust.
We continued to achieve the three RTT targets during
the tough winter period as a result of work to reduce
the waiting list backlogs prior to the winter period.
We have never had a breach of the 52 week target.
Admitted Backlog
900
800
700
600
500
400
300
200
100
0
Tolerance
Actual
29-Mar-15
01-Mar-15
01-Feb-15
04-Jan-15
07-Dec-14
09-Nov-14
12-Oct-14
14-Sep-14
17-Aug-14
20-Jul-14
22-Jun-14
25-May-14
27-Apr-14
Trajectory
30-Mar-14
PAGE 66
Non-Admitted Backlog
1600
1400
1200
1000
800
600
Tolerance
Admitted
AdmittedBacklog
Backlog
700
600
500
400
300
200
100
0
PAGE 67
Tolerance
Actual
Tolerance
Tolerance
Trajectory
Actual
Actual
Trajectory
Trajectory
29-Mar-15
27-Apr-14
30-Mar-14
30-Mar-14
25-May-14
27-Apr-14
27-Apr-14
22-Jun-14
25-May-14
25-May-14
22-Jun-14
20-Jul-14
22-Jun-14
20-Jul-14
17-Aug-14
20-Jul-14
17-Aug-14
14-Sep-14
17-Aug-14
14-Sep-14
14-Sep-14
12-Oct-14
12-Oct-14
12-Oct-14
09-Nov-14
09-Nov-14
09-Nov-14
07-Dec-14
07-Dec-14
07-Dec-14
04-Jan-15
04-Jan-15
04-Jan-15
01-Feb-15
01-Feb-15
01-Feb-15
01-Mar-15
01-Mar-15
01-Mar-15
29-Mar-15
29-Mar-15
30-Mar-14
900
900
800
800
700
700
600
600
500
500
400
400
300
300
200
200
100
100
0 0
Non-Admitted
Backlog
Non-Admitted
Non-AdmittedBacklog
Backlog
1600
1600
1400
1400
1200
1200
1000
1000
800
800
600
600
400
400
200
200
0 0
95%
29-Mar-15
30-Mar-14
30-Mar-14
25-May-14
27-Apr-14
27-Apr-14
22-Jun-14
25-May-14
25-May-14
22-Jun-14
20-Jul-14
22-Jun-14
20-Jul-14
17-Aug-14
20-Jul-14
17-Aug-14
14-Sep-14
17-Aug-14
14-Sep-14
14-Sep-14
12-Oct-14
12-Oct-14
12-Oct-14
09-Nov-14
09-Nov-14
09-Nov-14
07-Dec-14
07-Dec-14
07-Dec-14
04-Jan-15
04-Jan-15
04-Jan-15
01-Feb-15
01-Feb-15
01-Feb-15
01-Mar-15
01-Mar-15
01-Mar-15
29-Mar-15
29-Mar-15
100%
100%
100%
100%
95%
95%
95%
95%
90%
90%
90%
90%
100%
85%
85%
95%
85%
85%
80%
80%
80%
80%
90%
75%
75%
Apr-13
Apr-13
Jun-13
Jun-13
Aug-13
Aug-13
Oct-13
Oct-13
Dec-13
Dec-13
Feb-14
Feb-14
Apr-14
Apr-14
Jun-14
Jun-14
Aug-14
Aug-14
Oct-14
Oct-14
Dec-14
Dec-14
Feb-15
Feb-15
80%
Admitted
Actual
Admitted
Actual
85%
80%
Admitted
Target
Admitted
Target
Non-Admitted
Actual
Non-Admitted
Actual
Non-Admitted
Target
Non-Admitted
Target
Actual
Admitted
Target
TheAdmitted
Trust provides
cancer services
for all of
the main
cancer tumour groups. This includes palliative care
services. Each tumour group has an established
multidisciplinary team (MDT), comprising doctors,
specialist nurses and other health professionals from
different health disciplines.
Getting cancer diagnosed as early as possible and
starting treatment quickly are key to improving
survival for many cancers. Meeting national targets
introduced to ensure timely diagnosis and treatment
for patients with cancer is a priority for the Trust.
Feb-15
Dec-14
Oct-14
Aug-14
Jun-14
Apr-14
Feb-14
Dec-13
Oct-13
Aug-13
Jun-13
2.15.14 Cancer standards
Apr-13
Feb-15
Dec-14
Oct-14
Aug-14
Jun-14
Apr-14
Feb-14
Dec-13
Oct-13
Aug-13
Jun-13
75%
Apr-13
75%
90%
75%
75%
85%
Trajectory
Apr-13
Apr-13
Jun-13
Jun-13
Aug-13
Aug-13
Oct-13
Oct-13
Dec-13
Dec-13
Feb-14
Feb-14
Apr-14
Apr-14
Jun-14
Jun-14
Aug-14
Aug-14
Oct-14
Oct-14
Dec-14
Dec-14
Feb-15
Feb-15
100%
Tolerance
Tolerance
Tolerance
Actual
Actual
Trajectory
Trajectory
Actual
27-Apr-14
30-Mar-14
1600
1400
1200
1000
800
600
400
200
0
The Trust achieved all of the national cancer targets
for the year. The increasing levels of activity and
Non-Admitted Actual
Non-Admitted Target
complexity of presenting patients with cancer
continues to present a challenge to the Trust.
Staff are working hard to ensure that breaches are
avoided. The Trust did achieve the standard that
relates to onward referral to tertiary centres within
42 days ensuring that the tertiary centre was able to
assess and treat patients within the 62 day target.
The Breast symptomatic two week wait standard was
narrowly missed in Q1 because of increases in urgent
breast symptomatic referrals. Action was taken to
increase capacity in order to meet the increased levels
PAGE 68
QUALITY ACCOUNTS REPORT 2014-15
PART 2
The most recent national data shows that referrals
requiring a two week response time across all urgent
pathways have increased by 19% year on year
compared to a national increase of 12% for the same
case mix of patients. The Trust has worked closely
with commissioners to ensure that the increased
demand is reflected in 15-16 activity targets, and to
share information about future cancer awareness
programmes.
of demand. This target was subsequently achieved
for the remainder of the year. There continues to be
a steady increase in the numbers of patients referred
urgently by their GP with suspected breast cancer.
The Trust now provides a one-stop service on this
pathway which avoids patients having to come back
to the hospital a number of times, lengthening the
time it takes to complete their pathway and reducing
the anxiety caused by a prolonged wait.
QUARTERLY (national % target)
Q1
201415
Q2
201415
Q3
201415
Q4
201415
YTD
14-15
Cancer Two Week Wait
TWW (93%)
Rate
95.2%
95.1%
95.2%
95.7%
95.3%
Breast Symptom Two Week Wait
TWW_BREAST
(93%)
Rate
89.3%
93.0%
94.6%
98.2%
93.8%
31 Day First Treatment
31DAY (96%)
Rate
99.8%
99.8%
99.8%
100.0%
99.8%
31 Day Subsequent Treatment Drug
31DAY (98%)
Rate
100.0%
100.0%
100.0%
100.0%
100.0%
31 Day Subsequent Treatment Surgery
31DAY (94%)
Rate
100.0%
100.0%
100.0%
100.0%
100.0%
62 Day Cancer GP Referral
Standard
62DAY (85%)
Rate
85.8%
85.2%
85.9%
85.3%
85.6%
62 Day Screening Referral Standard
62DAY_SCREEN
(90%)
Rate
97.4%
100.0%
91.9%
84.2%
94.3%
62 Day Consultant Upgrade
Standard
62DAY_UPGRADE
(85%)
Rate
88.1%
89.3%
87.2%
89.2%
88.4%
62 Day Cancer GP Referral Local
Standard
62DAY
(85%)
Rate
81.7%
78.9%
79.1%
79.0%
79.6%
PAGE 69
PAGE 70
QUALITY ACCOUNTS REPORT 2014-15
PART 3
Part 3
3.1 Keeping you safe
3.1.1 Sign up to Safety –
Listen, Learn, Act
●● Achieve quality care related to CQUINs and Harm
Free Care such as eliminating avoidable falls and
avoidable pressure ulcers;
In December 2014, as a Trust we signed up to and
engaged with the three year national Sign up to
Safety Campaign and declared the below pledges in
support of NHS England’s patient safety improvement
quest to reduce avoidable harm by 50% in three
years.
●● Improving care around the management of
diabetes and the deteriorating patient as part of
the Trust’s Safety programme;
Sign up to Safety aims to deliver harm free care for
every patient, every time, everywhere. It champions
openness and honesty and supports everyone to
improve the safety of patients.
Our pledges were composed using the work we had
already started in relation to the Safety Programme
Board, awareness of our performance against
qualitative and safety indictors, and, importantly,
feedback received from our staff and patients. We
have focused on areas where we know we can make
improvements and have included areas of change
where work may have already begun. Our Trust
pledges that have been launched are available on our
website.
Our Pledges:
Put safety first
●● Deliver the aspirations contained within the Trust’s
Vision, Values and Corporate Priorities 2014-2015;
●● Embed a Safety Programme which is supported
by a project manager as part of the Trust’s
transformation agenda;
●● Reduce Sepsis related mortality as part of the
Safety Programme;
●● Continually improve Hospital Standardised
Mortality Ratios (HSMR) and Summary Hospitallevel Mortality Indicators (SHMI) by working
collaboratively both within the Trust and with
partners.
Continually learn
●● Continue to roll out the Friends and Family Test
and deliver improvements based on patient
feedback;
●● Continue with the ‘You said we did’ initiative
ensuring it is widely publicised;
●● Embed fundamental care nursing metrics across
all wards to ensure real time measurement of the
quality care we provide;
●● Further develop the ‘ward at a glance’ boards so
that patients, carers and staff are informed about
patient safety information and staffing levels;
●● Act on an independent review of our serious
incident process and fully implement the
recommendations.
Honesty
●● Publish our patient safety data in an open and
transparent way by utilizing newly developed
patient dashboards;
PAGE 71
●● Continue to participate in the Transparency
programme ensuring staffing levels are published
each month through NHS Choices;
●● To fully take on board views of patients and
family members when investigating incidents
ensuring final root cause analysis reports and
answer any concerns;
●● Embed the Duty of Candour responsibility
throughout the Trust so that when things go
wrong patients, carers and families are informed.
Collaborate
●● Lead a mortality reduction partnership across
North East Sector of Manchester as a local
Commissioning for Quality and Innovation
(CQUIN) 2014/15;
●● Participate in a national safety collaboration
and those run locally by The Advancing Quality
Alliance (AQuA);
●● Work with commissioners and primary care in
the effective management of those incidents and
safety themes identified across boundaries.
Support
●● Continue to deliver our Quality Improvement
Methodology Programme in collaboration with
AQUA;
●● Embed and deliver our ‘3 Steps to Excellence’
Nursing and Midwifery Strategy;
●● Re-energize our ‘Lessons Learned’ initiative
utilizing best practice from within the NHS and
beyond;
●● Offer teams of staff bespoke root-cause analysis
(RCA) training ensuring staff are
empowered and skilled to undertake
investigations.
Further work is being undertaken to develop a
focused action plan to take forward all of these
pledges over the next three years and to ensure that
this is integrated within the Trust’s Quality and Safety
strategies.
3.1.2 Safe Staffing
Guidance issued by NHS England and the Care
Quality Commission (CQC) last year states that every
hospital ward must now publicly display details of
planned and actual staffing levels, which forms part
of the government’s response to the Francis Report.
Trusts have also pledged to submit monthly staffing
reports to board meetings and these reports are
made available to the public online.
Over the past year we have worked hard to ensure
that there are robust systems and processes in place
to ensure that there is sufficient staffing capacity and
capability to provide high quality care to patients on
all wards and departments 24 hours a day, seven
days a week. We are committed to ensuring that
as a minimum, “one registered nurse cares for a
maximum of eight patients.” We regularly review our
staffing levels to ensure we get staffing right for the
patients we care for and look after on our wards.
Following a number of staffing reviews and
successful bids for monies all areas that were
understaffed have now received funding to recruit
additional nurses to ensure safe staffing. In the
meantime until recruitment to these posts occur use
of agency and bank staffing continues.
QUALITY ACCOUNTS REPORT 2014-15
PART 3
Pennine Acute Hospitals NHS Trust. This information
details the ‘Planned’ versus ‘Actual’ staffing levels
(Registered and Non-Registered) for each shift on
that day.
In 2013/14 the Trust invested in additional registered
nurses on all of our in-patient medicine and surgery
wards allowing the Senior Ward Sister/Charge
Nurse to adopt a supervisory role. Staffing levels are
electronically recorded on a shift by shift basis by the
ward teams; this information is then reviewed by the
divisional and corporate nursing management.
Average fill rate would not demonstrate safe staffing
as it wouldn’t account for peaks and troughs and/or
link to acuity and so this is not included in this report.
We believe that it’s important to provide assurance
and be open with our patients and service users that
we take safer staffing seriously.
The Trust is planning to undertake an overseas
nurse recruitment campaign across Spain, Portugal
and the Philippines starting in June 2015 where we
are expecting to recruit 100 high calibre nurses to
strengthen our nursing workforce. In parallel, we
are continuing to undertake our campaign in the UK
which includes A&E recruitment days, twice yearly
newly qualified nursing events, an open advert for
band 5 nurses and we are also looking to recruit
40 Health Care Support Workers for Maternity &
Midwifery. We have a generic recruitment email
address for Nursing & Midwifery, alongside other
promotional activities due to take place throughout
this coming year.
On a monthly basis the Chief Nurse updates the Trust
Board on our nurse staffing levels. These reports are
also published on our Trust website, together with
staffing levels by shift and actual versus planned
hours of care on each ward for the month in
question.
As a Trust we embrace this open and honest
approach and our aim is to be transparent around
ward staffing levels and we prominently display ward
staffing levels at the entrance to every ward at The
911 776 932 796 936 801 949 813 957 822 950 817
FTE
Mar-15
Headcount
FTE
Feb-15
Headcount
FTE
Jan-15
Headcount
FTE
Dec-14
Headcount
Nov-14
FTE
Oct-14
Headcount
Jul-14
FTE
Headcount
FTE
Headcount
Headcount
Sep-14
FTE
FTE
Aug-14
Headcount
Headcount
Jun-14
FTE
FTE
352 B - Integrated &
Community Services
May-14
Headcount
Division
Apr-14
FTE
Nursing Staff in post by division month by month for Apr 2014 – Mar 2015
Headcount
PAGE 72
352 C - Medicine
2183 1931 2193 1942 2191 1942 2185 1939 2192 1946 2195 1947 1729 1546 1715 1534 1703 1527 1710 1532 1703 1522 1684 1506
352 D - Surgery
1480 1346 1492 1357 1488 1354 1490 1357 1485 1354 1492 1361 1498 1369 1488 1361 1478 1355 1463 1341 1464 1343 1469 1348
352 E - Women &
Children
1104 943 1098 938 1102 941 1099 937 1090 928 1086 924 1093 931 1096 934 1091 929 1085 925 1089 928 1076 915
352 F - Diagnostics &
1959 1736 1960 1735 1967 1742 1958 1733 1968 1742 1969 1745 1579 1423 1595 1438 1595 1437 1603 1443 1597 1438 1595 1436
Clinical Support
352 G - Facilities
910 807 910 806 911 807 909 806 903 802 828 735 830 736 833 739 834 741 835 742 853 759 851 757
352 J - Elective
Access
720 582 719 581 713 577 700 570 684 556 679 551 676 551 677 553 663 546 658 543 656 541 649 536
352 K - Corporate
Services Other
649 583 649 585 642 581 647 586 645 584 711 643 706 639 709 641 719 650 719 651 724 657 718 651
TRUST TOTAL
9005 7928 9021 7944 9014 7943 8988 7928 8967 7910 8960 7906 9022 7970 9045 7995 9019 7986 9022 7990 9043 8009 8992 7966
Lead Employer PAHT
Based
217 211 215 209 212 207 212 207 229 222 226 219 217 211 221 214 224 217 221 214 216 210 217 211
GP Trainees
61
Last Updated
01.05.14
58
60
58
09.06.14
60
58
02.07.14
60
58
04.08.14
65
62
04.09.14
64
61
02.10.14
64
61
06.11.14
63
60
08.12.14
63
60
16.01.15
63
60
02.02.15
63
61
05.03.15
65
62
01.04.15
PAGE 73
3.1.3 Safeguarding Adults
and Children
single allegation about an event that happened 50
years ago at Birch Hill Hospital in Rochdale has been
conducted.
Our Safeguarding Team provides specialist advice,
support, supervision and training to staff on all
matters relating to the protection of adults and
children at risk. The team develop and update policy,
practice guidelines and procedures and ensure that
the Trust’s obligations under legislation and national
and local standards are met.
The investigation was overseen by The NHS Savile
Legacy Unit. The Trust worked very closely with
the patient concerned and fully supported them
throughout our investigation. We followed a robust
and thorough process aimed at protecting the
interest of the former patient. Our investigation
involved scrutinising available historical records and
took into account the testimonies from a number of
witnesses including former NHS staff at Birch Hill.
The Trust is represented on all of the Local
Safeguarding Children’s Boards and Safeguarding
Adults’ Boards within its footprint and are actively
engaged in Serious Case Review (SCR) and Domestic
Homicide Review activity.
Staff safeguarding training remains mandatory
for all staff. Last year 94% of our staff completed
Safeguarding Children and Safeguarding Adult
training at level two. Monitoring of information
sharing/safeguarding referrals to other disciplines and
agencies shows a year on year increase providing an
indication of the level of awareness and knowledge
among staff.
The Trust has signed up to the national Child
Protection Information Sharing system sponsored
by NHS England and has planned to ‘go live’ in the
Spring. This system will connect local authorities’
child protection social care IT systems with those
used by staff in NHS unscheduled care settings. This
will highlight to staff in unscheduled care settings
when a child is subject to a child protection plan or
care for by the Local Authority.
The Trust have recruited an additional member to
the Safeguarding Team. The Named Midwife for
Safeguarding is a full time position due to commence
in March 2015.
Jimmy Savile Investigation
Following information passed to the Trust by the NHS
Savile Legacy Unit in July 2014, a full and thorough
investigation into the circumstances surrounding a
The Trust investigation has shown that there is no
evidence that Jimmy Savile had any association with
Birch Hill Hospital or that he had any role within
the organisation. There is no evidence that Jimmy
Savile was at any time accorded special access or
other privileges to Birch Hill Hospital, or that he
was allowed any kind of unsupervised access to
the site or indeed any hospital premises now run
by this Trust. The report, which was published on
26th February 2015, has been shared with Greater
Manchester Police and the Chair of Rochdale
Safeguarding Children’s Board. The full report is
publicly available on our Trust website at www.pat.
nhs.uk/jimmy-savile
The safety and welfare of our patients, visitors and
staff is at the forefront of everything we do and is a
key priority. Every possible safeguard has been put
in place to maximise the protection of our patients.
As part of our investigative process to this allegation,
we have since thoroughly reviewed and refined our
policies including those relating to sanctioned visits
by high profile celebrities, representatives of local or
national external bodies, and VIPs.
National Research
Original research led by the University of Birmingham
in collaboration with the Trust has been published.
The reference is: White S, Wastell D, Smith S, Hall C,
Whitaker E, Debelle G, Mannion R, Waring J (2015).
PAGE 74
QUALITY ACCOUNTS REPORT 2014-15
PART 3
Improving practice in safeguarding at the interface
between hospital services and children’s social care:
a mixed-methods case study Health Services and
Delivery Research Volume: 3 Issue: 4.
following the pilot scheme at FGH initially, has
demonstrated that if our staff utilise the service by
asking opportunistic questions, then the interventions
provided by VS can lead to life changing outcomes.
Quality Assurance Framework for
patients with Learning Disabilities
Child Sexual
Exploitation
(CSE)
Following the completion of the ‘change and
improvement’ plans for patients with learning
disabilities last year, the Trust Learning Disability
Steering Group have produced a Care Pathway for
People with Learning Disabilities - Patient Journey
Good Practice Guidance. The aim for 2015/16 is
to assess the impact of the guidance in terms of
outcomes for patients with learning disabilities
and ensure that reasonable adjustments are made
wherever necessary.
Domestic Abuse joint initiative with
Victim Support (VS)
Analysis of the scheme so far has revealed very
positive outcomes.
●● From November 2013 to the end of September
2014, the number of referrals to VS from
all of the participating Trusts across Greater
Manchester was 239. Almost 50% came from
our Trust;
●● 40% of referrals were from Black and Minority
Ethnic (BME) communities;
●● 48% of the cases there were children involved/
present in the household and in 43% of these,
children’s services were already involved;
●● 35% of referrals met MARAC thresholds;
●● Of the people referred, police had been involved
167 times, the victim had attended A&E 153
times and attended their GPs 213 times in the
previous 12 months;
●● 75% of the clients reported multiple abuse at the
point of referral which was reduced to 29% at
the point of leaving the VS service.
Overall the impact of the scheme as expected
In October 2014,
a new report was
published into how
different countries
tackle child abuse,
in particular sexual
exploitation, and how
the UK can benefit
from this learning.
“Professor Rowland has
taken the opportunity
to use his wealth of
clinical experience and
research to further explore
ways we as healthcare
professionals and multiagencies, including those in
emergency medicine, can
improve the protection and
safeguarding of vulnerable
children. We would like
to congratulate Professor
Rowland on this report and
hope that it creates wider
debate and work across
health and social care at all
levels.”
‘Living on a railway
line. Turning the tide
of child abuse and
exploitation in the
UK and overseas:
international lessons
and evidence-based
recommendations’
Dr Gillian Fairfield,
is a report published
Chief Executive
by Professor Andrew
Rowland, the Trust’s
consultant in paediatric emergency medicine, in
association with The Winston Churchill Memorial
Trust and University of Salford. There are 10 key
recommendations for the UK together with 25
associated and enabling recommendations and
seven international recommendations. All of the
recommendations are designed to build strong and
healthy communities with children at their hearts.
Professor Rowland gathered evidence from the USA,
Singapore, Malaysia and Cambodia. He investigated
the impact of mandatory reporting of child abuse,
the work of children’s advocacy centres and learned
about strategies used to identify children at risk of
child sexual exploitation and trafficking. He uses his
PAGE 75
international experiences to make recommendations
for the UK and the international community.
The work contains over 300 scientific and other
references.
The launch coincided with the 25th anniversary of
the signing of the UN Convention on the Rights of
the Child. According to Professor Rowland’s report, a
quarter of a century later there are still laws, policies
and procedures in the UK and internationally which
fall way short of properly protecting children.
3.1.4 Patient Health
Records
We cannot deliver high quality care without our
patient health records being available and up to
date for our doctors and nursing staff when they are
required for clinical care and treatment.
During 2014/15 our Health Records Service worked
hard to achieve 99.86% of patient records being
made available for clinical care across the Trust. We
have continued to make improvements in processes
to reduce delays in moving case notes between our
hospital sites, improve communications flows, and
improve the tracking of case notes to continue to
improve the availability of patient records.
Patient Records Evolve
Over the past year the Trust has been preparing
to roll-out a new Trust-wide multi-million pound
electronic document record management system
(EDRMS) that will improve services for patients. The
new system, called “Evolve”, is a major change for
the Trust and will revolutionise and improve the
way thousands of our patient records are stored,
managed and viewed by doctors, nurses, health
professionals, ward clerks and medical secretaries. The Trust secured £4.2m of funding from NHS
England last year to implement the new Evolve
system in partnership with an external digital
technology supplier, Kainos. The scanning of our
existing paper records and
turning them into a digital
image that will be accessible
to our clinicians at any
time from any of our Trust
hospital sites will improve
patient care, reduce waiting
times and help the efficiency
of our services.
“Evolve is an important
development that will
revolutionise the way in
which we access patient
records. Having case notes
available electronically
across the organisation
when and where they
are needed will make
decision making and
treatment planning faster
and ultimately improve the
quality of care we provide
for our patients. Our clinical
and non-clinical staff will
have immediate and timely
access to patient records
electronically at the touch
of a button.”
This move to scanned
records has significant
clinical benefits in enabling
timely care and will improve
both patient safety and
experience. Once records
are scanned they will be
available 24 hours a day
electronically at exactly the
time and point they are
required. This removes the
Dr Anton Sinniah, Acting
need to locate paper records
Medical Director
and physically move them
around and between our
hospital sites to where they are required.
This will improve the patient
experience by reducing the
amount of appointments
and operations that
have to be cancelled
or rearranged
when health
records are not
available.
The availability
of case notes
electronically
will support
our clinicians
in providing
care in
locations
other than our
PAGE 76
QUALITY ACCOUNTS REPORT 2014-15
PART 3
main hospital sites particularly our
services that are provided out in the
community, including health centres,
primary care centres, patient’s homes
and schools. Access to the scanned
health records is fully secured based on
specific user roles and also our wider hospital
IT security arrangements.
Four clinical specialties within the Trust have been
piloting the Evolve system as ‘early adopters’ as the
organisation moves towards paper-light working. The
first specialty to have scanned notes was in Urology
which went live in February 2015. This will be
followed by paediatrics, stroke and diabetes. All four
specialties will have case notes on Evolve by the end
of April 2015, with other specialties following over
the course of 2015.
We have increased the workforce we have in Health
Records to ensure we can locate, prepare and send
our records for scanning and to ensure we continue
to provide paper health records for clinical care as we
go through the transition to scanned records.
“By changing work
behaviours and processes,
the project has had a
major impact on improving
patient care and safety,
and linking discharge
medications to Healthviews
has significantly increased
the quality and timeliness of
discharge summaries.”
Dr Georges Ng Man Kwong,
consultant chest physician and
3.1.5
Electronic
prescribing
Over the past year over
100 of our hospital wards
have installed the latest
technology to help clinical
and nursing staff with
electronic prescribing of
medicines.
Medchart is the Trust’s
electronic prescribing and
medicine administrative
system (ePMA) which uses software to improve
the management, legibility and safety of medicines
recorded within the Trust. The Pennine Acute Trust
clinical director
was the first Trust in the UK to go live on Medchart
last year. As part of the roll out of the new system,
over 5,000 staff have been trained on the system
with over 1,000 beds all live.
Previously drug prescriptions would be handwritten
which could mean that some were difficult to read
or could be lost, whereas doctors now use the new
system to prescribe drugs to patients and manage
discharge prescriptions. Nurses use the system to
record the administration of drugs to patients and
the system helps them to plan and organise their
drug rounds with legible prescription information,
which replaces the handwritten kardexes which were
kept at the end of the patients’ beds. This is seen as
a very important milestone on the electronic patient
record (EPR) programme which has totally removed
the main paper drug chart on all adult medical and
surgical wards, critical care and theatres across the
Trust.
3.1.6 Infection Control &
Prevention
The prevention and control of infection is a top
priority for The Pennine Acute Hospitals NHS Trust.
Our efforts to reduce the number of patients with
Healthcare Acquired Infections (HAIs), such as MRSA
(Methicillin Resistant Staphylococcus Aureus) and
Clostridium Difficile (CDT), across our hospitals
continues to be of vital importance in the way we
work.
All NHS organisations must ensure that they have
PAGE 77
effective systems in place to control healthcare
associated infection. We continue to reduce HAIs
by improving our use of antibiotics and by creating
an environment and culture whereby our staff
understand the importance of ensuring wards and
patient waiting areas are clean, and that we all
practice good infection control and hygiene when
caring for our patients.
As part of our staff mandatory job-related training,
all of our staff, both clinical and non-clinical, must
complete hand washing training every year and are
encouraged to be vigilant and report cleanliness
issues. We routinely ask patients and visitors to
use the hand gel provided before coming onto
and leaving our wards, outpatient clinics and other
clinical areas. All relevant elective (planned surgery)
and emergency patients are screened for MRSA,
MMSA (Meticillin Sensitive Staphylococcus Aureus)
bacteraemia and Ecoli Bacteraemia as required by the
Department of Health.
Ebola preparedness
In August 2014, the Trust initiated actions in
response to the emerging Ebola crisis in West Africa
and the international relief programme which
followed.
In collaboration with our Trust emergency planning
team, our infection prevention team and our regional
specialist Infectious Diseases unit based at North
Manchester General Hospital (NMGH) instigated an
Ebola preparedness programme. This programme
has been recognised both locally and regionally as an
example of good practice and has been shared with
other Trusts and local authorities.
Since August, the Trust has been monitoring the
Ebola situation and the Trust’s response plans
through fortnightly meetings with our specialist ID
consultants and infection prevention team. Our Ebola
group is chaired by our Director of Facilities and
Emergency Planning lead.
Our three Accident & Emergency Departments and
Urgent Care Centre have received specially designed
action cards to support Ebola identification and
patient management and a similar action card is in
place for on call managers. The appropriate Personal
Protective Equipment (PPE) has been sourced for all
relevant departments together with training and
practice sessions for staff to be fully confident in
putting on and removing the PPE.
Ebola is spread among people through close and
direct physical contact with infected body fluids (such
as blood, diarrhoea or vomit). People with Ebola can
only spread the virus to others once they have the
symptoms. Our specialist Infectious Diseases Unit at
NMGH has been designated as the primary referral
and receiving centre for all patients with suspected
Ebola in Greater Manchester. To support this, we
have invested in personal protective equipment (PPE)
and have held regular live simulation exercises within
the unit. We have robust and well tested systems
and procedures in place to deal safely with suspected
Ebola cases to protect our staff and the public from
infection.
Ebola is hard to catch. Despite the overall risk to the
general UK population continuing to be very low, we
continue to liaise with external agencies including
Public Health England (PHE) and NHS England to
support the Greater Manchester Ebola preparedness
plan.
Suspected Ebola case
In January 2015, a patient with
history of travel to West
Africa returning to the
UK with symptoms
of the Ebola virus
was brought by
ambulance and
was cared
for at our
specialist
clinical
infectious
diseases unit
at NMGH.
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QUALITY ACCOUNTS REPORT 2014-15
PART 3
The patient underwent a number of tests and, as a
precaution, one of which was for Ebola. The patient
was cared for on the unit in isolation, away from
other patients by our specialist ID doctors and nurses.
All measures were put in place to protect the patient,
our staff and other patients and visitors. The case
generated local and national media interest. The
results from the blood tests showed the patient did
not have Ebola.
In the same week it emerged that the condition
of 39-year-old Scottish nurse Pauline Cafferkey
had improved and no longer critical after receiving
treatment in London’s Royal Free Hospital. Cafferkey
tested positive for Ebola in December after returning
from Sierra Leone where she had been treating
victims. She has since made a full recovery. 3.2 Listening & Responding to you
3.2.1 Handover of Care
Communication (discharge
summaries)
The Trust has a contractual key performance
indicator (KPI) to send patient discharge summaries
to patient’s GPs within 24 hours of discharge.
Over the past 18 months the implementation of our
electronic prescribing/medicine administration system
(ePMA) and an eDischarge solution have improved
the quality of information our local GPs receive. By
undertaking revised processes over the past year, we
have improved the timeliness so that we are almost
meeting our agreed target of 95% sent within 24
hours of discharge.
Whilst the new processes and systems are still
embedding we have already seen excellent results.
At the end of March 2015, we met the Trust’s
contractual KPI compliance target for sending out
95% of handover of care communications (discharge
summaries) to our GPs within 24 hours. This is a
fantastic achievement and the result of the hard
work and dedication of all our junior doctors, project
and IT implementation staff.
Staff engagement has been very positive and our
continued improvement has been largely due to
the commitment and dedication of our clinicians
to provide good quality discharge summaries in a
timely manner to GPs for the continued care of their
patients.
In February 2015 the HealthViews discharge
summary was renamed “Handover of Care
Communication”, following agreement by the
Trust’s newly formed Clinical Communications Group
comprising a number of our senior consultants and
local GPs from primary care.
Historically the creation of discharge summaries has
been considered to be an administrative task, when
it should be seen as promoting continuity of care and
providing a safe handover to Primary Care Services
and local GPs.
This change is a significant move forward in joined
up working between the Trust and our local GPs
and colleagues in primary care. Handover of Care
Communication recognises the important role
this patient care record and discharge summary
information has in promoting continuity of care and
providing a safe handover of care from secondary
care to primary care services.
The Handover of Care Communication is now
live on over 90 wards, including our medical and
surgical wards, critical care, paediatrics and maternity
services. Following this change, an increasing number
of our wards are meeting the 95% and above
compliance target in the creation of the Handover of
Care Communication which are sent to primary care
regarding the patient.
PAGE 79
3.2.2 Patient
Communication
It is recognised within the Trust that open and honest
communication with patients and the population we
serve is vital in order to provide the highest quality
care. This is reflected in our Trust Values of being
quality-driven, responsible and compassionate.
The Trust is constantly seeking feedback on patient
care and patient experience and this is captured in a
number of different ways including:
●● Friends and Family Test
●● Inpatient Monthly Surveys
●● National Surveys
●● Patient/User groups
●● Complaints / Patient Advisory Liaison Service
(PALS)
●● NHS Choices
Patient Experience, Equality and
Diversity Committee
The Trust has formed a new revised “Patient
Experience, Equality and Diversity Committee” which
is chaired by the Chief Nurse. This will be comprised
of members of the public, senior Trust staff, members
of the CCG and Community Forum Healthwatch.
The approach of the Committee is based on the
following principles:
●● We will reflect the Trust’s in all that we
undertake;
●● We will work in partnership with patients and
service users so they can contribute to the
planning, monitoring and evaluation of our
services;
●● We will identify the needs, and recognise the
rights, of those who use our service and to
address them appropriately.
The Board of Directors receives regular reports on
patient experience and feedback from the surveys
that take place. They take an active role in striving
to deliver high quality patient experience in all areas
within the Trust.
Friends and Family Test (FFT)
There is a national requirement for the Friends and
Family Test (FFT). Implementation of FFT has taken
place in wards (inpatients), Accident and Emergency
departments and Maternity services throughout the
Trust. The response rates have been consistently
over 40%, above the national average over the past
12 months. Comments and scores received for each
area are displayed in most clinical areas for the public
The aims of this Committee are outlined as
“To ensure that statutory obligations relating to the involvement of
patients and the public are met, whilst ensuring that services are
developed and delivered based upon patient experiences”
AND
“To be responsible for promoting, encouraging and, ultimately,
delivering greater equality and diversity for the benefit of the Trust
patients and staff and to be the main vehicle for driving change
through the organisation”
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QUALITY ACCOUNTS REPORT 2014-15
PART 3
to view. Staff value patient feedback and use the
information in order to improve patient experience.
Work is currently ongoing to collect FFT data in
Outpatients, Day Services, Community and Dental
Services by April 2015 in line with guidance from
NHS England.
Special Needs and Disability
Effective communication is key to building
any human relationship, whether in a social or
professional context. One of the main aims of the
Trust is to ensure that all our services are equitable
and fair in terms of its accessibility. The Trust ensures
increased access to its services, and to promote social
inclusion, changing the way interpreting services are
used can improve patient care.
The Trust has collaborated with Oldham Learning
Disability Partnership Board and community leads for
learning disability and has been involved in events
with the Manchester Learning Disability Partnership
and local services. The Trust is also represented at
the Manchester Learning Disability Health Forum.
These interactions afforded the Trust an opportunity
to review current practice, discuss issues and gain
insight into needs which have been used to develop
and enhance the Trust action plan which is in place
to support patients with learning disability.
Following the formation of the Pennine Learning
Disability Partnership (PLDP), the Trust has
implemented strategies to ensure that improved
services are provided for patients with a learning
disability. The PLDP consists of staff from the acute
Trust, the Clinical Commissioning Groups (CCGs),
community learning disability teams and carers.
This ensures that opinions of service users influence
service developments within Pennine Acute.
Using feedback from service users, we have piloted a
pager system which allows patients freedom to move
around the hospital and be paged when required for
their appointment or procedure. In particular, this
helps patients with sensory difficulties, parents or
carers of people with learning disabilities and those
with language limitations. A successful pilot has now
seen the Trust exploring how it can be used in other
waiting areas and clinics.
Patient Information Review Group
(PIRG)
Our PIRG reads and comments on all aspects of
patient communications that are distributed by the
Trust. The group has staff members and patients and
carers, including a reader group that is accessed by
post and email communications.
Standard letters have been reviewed with the
development of a Trust Patient Appointment Letters’
Workgroup, which included various community
group representatives such as the Blind Society. The
patients’ forum was also involved advising on issues.
The Trust is also conducting an access audit across all
sites; this is being undertaken by representatives from
local community groups and third sector organisation
focussing in particular on disability access to and
around the Trust’s sites.
3.2.3 Patient Leaflets and
Public Information
In 2014, the Trust conducted an engagement
exercise with patients, staff and the third sector to
discuss whether patients felt they could readily access
information regarding the Trust, the services provided
and any further information to ensure that patients
are as informed as possible about their visit to any of
our hospitals.
The overwhelming response was that patient and
public information wasn’t easily accessible via the
Trust’s website and that letters were confusing and
convoluted.
The Patient Letters’ Review Group comprised
of relevant internal leads for each work stream
alongside patient representatives in order to provide
the team with speciality knowledge to develop
appropriate patient information. We also had
PAGE 81
representation from the Joint Health Overview and
Scrutiny Committee.
Two specific focus areas were identified. Firstly to
review, amend and simplify all Trust letters regarding
patient appointment notifications. The aim was
to identify all the variations of letters sent out to
patients across all departments, and for the Patient
Letters’ Review Group to make decisions on the
most appropriate and effective way of providing
information to ensure patients are prepared for their
appointments at the Trust. Secondly to establish a
Patient Information Webpage – that would enable
easy access for patients to obtain information and
also ensure all patient leaflets are available on the
webpage and by request via the post.
Whilst investigating the most appropriate way to
review and simplify all Trust letters, the Patient
Letters’ Review Group identified a need to reduce
the variation of the patient appointment notifications
and a need to ensure they are user friendly and easily
accessible by all patient groups. This required the
team to ensure the letters only contain information
that is required in simple, non-ambiguous plain
English, with no acronyms or confusing or conflicting
information.
All [patient] End User Letters for outpatient
appointments were reviewed and standardised
templates created to incorporate all appointment
letters generated by the Trust. There has been a
significant reduction of the number of templates
from 1400 to 20 generic templates alongside the
additional speciality letters. Reviewing the letters
identified the need to review all patient information
as many documents were out of date with some no
longer being in use.
The Patient Letters’ Review Group agreed that it
would be vital as part of this work to establish
a Patient Information Webpage which we could
signpost to in our letters. It was agreed that the
webpage would hold all the leaflets and patient
information for services across the Trust and provide
easy access for patients to obtain any relevant
information they may require. The webpage is also
an appropriate way of ensuring all information is up
to date and accurate, in a standardised Trust format,
making it user friendly for patients.
The patient webpage went live in April 2014 and
provides patients with much of the information they
will need before they visit, whether it is to plan their
journey or to prepare for their appointment. It also
holds a range of patient information leaflets that
provide advice on medical conditions, procedures and
treatments that patients and family members may
find helpful. Patients will also find useful information
such as car parking and visiting times on the menu
on the left hand side of this page. 3.2.4 Patient-Led
Assessments of the Care
Environment (PLACE) 2014
March 2014 saw the second year of the newly
established Patient-Led Assessment of the Care
Environment (PLACE) inspections. All assessments
were undertaken across our hospital sites using the
criteria issued by NHS England.
A total of 99 staff and 110 patient assessors
participated in our assessments Trust-wide and they
were accompanied by eight external validators from
neighbouring Trusts. All patient assessors reported
that they found the experience to be of value.
The assessments covered the following:
●● Cleanliness of all items commonly found in
healthcare premises;
●● The condition, appearance and maintenance of
all the premises and equipment;
●● All aspects of privacy, dignity and wellbeing,
including infrastructural/organisational aspects
such as provision of outdoor/recreation areas,
changing and waiting facilities, access to TV and
radios etc;
QUALITY ACCOUNTS REPORT 2014-15
PAGE 82
PART 3
“Overall the Trust has
excelled and produced
scores better than the
national average for food
and drink and cleanliness.
All of the patient assessors
were very complimentary
of the Trust and said they
had learnt a great deal by
taking part in the PLACE
inspections. They said they
were very proud of our
newly refurbished wards
and departments on all our
sites.”
3.2.5 New partial
appointment booking
system
●● Appropriate facilities for
single sex use and ensuring
patients are appropriately
dressed to protect their
dignity;
Following feedback from patients, our booking and
scheduling teams at the Trust have introduced a new
partial appointment booking system to reduce the
amount of outpatient clinics being cancelled or rebooked at our hospitals.
●● Dementia friendly
environment, including
floors, decor and signage;
●● An overview of food and
hydration.
The results for the Trust in
2014 compared to 2013 are
detailed in the table at the
bottom of the page.
Overall the 2014 results
show that the Trust has
Pam Miller, Deputy
improved its cleanliness and
Director of Facilities
condition, appearance and
maintenance as part of the
national PLACE assessment criteria.
There was a slight drop in the score for food and
hydration and privacy, dignity and wellbeing;
however the criteria of these aspects had changed
from the previous year. The Trust mainly scored above
the national average and recommendations received
from patient assessors have been taken into account
to improve the patient experience.
This new booking method, which was brought
in across a number of outpatient clinics in early
2015, will not affect the booking of new referral
appointments, but will place patients who need
follow-up bookings on a waiting list. These patients
will then have to ring the hospital to book their
follow-up appointments six weeks before they
are due to attend any clinic. The aim is to improve
patient choice and reduce waiting times for
outpatient appointments.
Patients now needing a follow-up clinic appointment
for specialities including cardiology, paediatrics,
diabetes, urology, endocrine services and
ophthalmology at Rochdale Infirmary and Fairfield,
will be able to book directly into a clinic slot via
the clinic receptionist. If a patient does not need
an appointment within six weeks they will instead
receive a letter through the post inviting them to call
Cleanliness 2014
Food &
Hydration 2014
Privacy, Dignity &
Wellbeing 2014
Condition,
Appearance &
Maintenance 2014
National Average
97.25%
88.79%
87.73%
91.97%
Pennine Acute Score
97.47%
88.85%
83.93%
91.17%
Fairfield
95.53%
89.80%
81.09%
87.23%
Manchester
96.67%
88.11%
82.39%
91.54%
Oldham
98.76%
88.88%
86.12%
92.75%
Rochdale
98.10%
89.07%
82.44%
89.36%
Henesy House
100%
96.81%
94.74%
84.85%
Floyd Unit
100%
90.41%
89.74%
89.06%
PAGE 83
the hospital booking and scheduling department
to arrange a date and time that is convenient for
the patient and the hospital. This will reduce the
chance that the appointment could be cancelled or
even forgotten by the patient. Every year thousands
of appointments are wasted when patients fail to
attend. Not only do missed appointments delay a
patient’s treatment and increase waiting times for
other patients, we also estimate this costs the Trust
over £1m every year.
We are now in the process of implementing this
booking system to another 16 specialties across the
Trust.
3.2.6 Advice, Liaison and
Complaints
The NHS Complaints system is a powerful and useful
mechanism for improving the quality of care and the
patient experience, both for individual complainants
and for the wider NHS, thus creating a culture of
learning from mistakes and putting things right.
Complaints about the NHS are a valuable way of
identifying issues in the service where change is
needed. Acknowledging these issues and taking
steps to rectify any problems identified is vital to
create an open and honest NHS. Complaints are
welcomed with a positive attitude by the Trust Board
and are valued as feedback on service performance
in the search for improvement.
Since 1 April 2014, all responses to complaints have
been reviewed and signed by the Chief Executive. Prior to the review by the Chief Executive all
responses are subject to a rigorous assurance process
that includes the following:
●● Confirmation of clinical input, view and opinion
●● Confirmation of Divisional Director review and
authorisation for the complaint response to be
submitted.
●● Review of response by the Head of Complaints
●● Review of the response by the Director of Clinical
Governance.
This process was introduced in order to further
improve clinical ownership of complaints, enhance
the lessons learned process and to provide further
confirmation that a comprehensive, sensitive and
clinically correct response was provided. A full review of the complaints process, has been
completed. This was based on the recently released
Parliamentary Health Service Ombudsman’s, userled vision for raising complaints and concerns that
will form the basis for future CQC inspections. The
proposed enhancements to local resolution and
the proposals to further streamline the complaints
process will aim to further improve the quality and
management of complaints, at the same time as
improving the timeliness of response. Currently 15%
of complaints are responded to within 25 working
days, however to improve the complaints handling
performance additional resources will be made
available to the complaints department to aid the
process, such as an increase in Patient Advice and
Liaison Service (PALS) resource.
Whilst the introduction of the enhanced resolution
process will aid improvements, it will also ensure
that all parties involved in the complaint handling
process, further embrace the notion of ‘putting
patients at the heart of the investigation’ and re-instil
the belief that every complaint offers the opportunity
to re-examine practice and improve future patient
experience, outcomes and achieve an outcome that
favours both complainant and staff alike.
During 2014/15, 756 formal complaints were
received by the Trust. The main themes in 14/15
were Failure to diagnose condition, Standard of
nursing care and inappropriate discharge. The Trust is
targeted to acknowledge 90% of complaints within
three working days and respond to the complaint
within 25 working days. Financial year to date, the
complaints departments has acknowledged 92%
within this timeframe. PAGE 84
QUALITY ACCOUNTS REPORT 2014-15
PART 3
In 2013/14 the Trust reported a satisfaction rate of
84% with complaint responses. This has increased to
95% in 2014/15.
3.2.7 Hospital Car Parking
Our Trust has the responsibility for managing 4,797
parking spaces across our four hospital sites. The
costs of providing these spaces, as with most NHS
Trusts in England, mean we have to charge for
hospital parking. We try to keep those charges
reasonable and similar to other parking charges in
our local area.
In August 2014 the Department for Health issued
guidelines for hospital parking. The Trust meets
all but one of these guidelines and is looking to
see where further improvements can be made,
particularly in the case of patient and visitor
experience and parking concessions. With regard to the only aspect which does
not currently meet the principles; the
consideration for introduction of
payment on exit for parking.
A new payment system
would currently
require substantial
investment and
changes to
our parking
management, but options are being considered for
introduction in the future.
We are currently constructing a new staff parking
area on Westwood Park at The Royal Oldham
Hospital, which will enable further changes to
parking at the hospital site when completed. During
the next 12 months we will review and develop the
specification for our future parking management,
which will further take in to account the parking
guidance published by the Department of Health.
3.2.8 Operation
Hospital Food
In 2014, our catering team at The Royal Oldham
Hospital took part in the BBC series “Operation
Hospital Food” where celebrity TV chef James Martin
worked with our chefs and patients to see how he
could help us to improve the meal services on our
children’s wards.
With his help, new nutritious but appetising
children’s menus were designed and a new dining
room was created. Following his visit our dining
tables were laid with colourful crockery and cutlery
to encourage children to eat together away from
their beds and to encourage social interaction which
provides a degree of ‘normality’ at an otherwise
stressful time.
The revised menu that the team and James worked
on incorporated foods like homemade soup, pizza,
chicken nuggets and fish fingers as well as simple
sauce recipes which can be served with pasta, jacket
potatoes, salad, or a mixture. The aim of the project
was to give the children meals that they enjoy and
will eat. The whole project improved communication
between our nurses, dietitians and catering team; it
motivated the chefs and provided the patients on the
paediatric wards with dishes that they enjoy.
During his time at Oldham, James inspired two
of our hospital chefs to enter the National Salon
Culinaire Competition in London. Both were awarded
PAGE 85
a bronze medal after competing in the live cookery
competition. The catering team was also named
Catering Team of the Year in the Hospital Caterers’
Association National Conference Awards for their
work in Operation Hospital Food and for their
continued involvement in national Nutrition and
Hydration Week.
3.2.9 #Hello my
name is………
During 2014/15, we signed up to the inspiring “Hello
My Name Is…” campaign which aims to encourage
NHS staff and healthcare professionals to introduce
themselves by their first name to patients.
More than 100 NHS organisations have now signed
up to the social media campaign started by a
terminally ill consultant, Dr Kate Granger in Leeds.
The doctor who initially informed her that her cancer
had spread did not introduce himself to her and
did not look her in the eye. Kate felt dismayed and
frustrated by staff who failed to tell her their names
when caring for her.
As well as the 400,000 doctors, nurses, therapists,
porters and receptionists who have signed up,
the Prime Minister and Health Secretary are also
supporting the campaign. Her campaign reminds
all staff to go back to basics, build trust and make a
vital human connection with patients by – at the very
least – giving their names. Our campaign is being
rolled out and embedded across the Trust as part of
our own Trust values which is about our staff being
quality-driven, responsible and compassionate.
3.3 Improving Our Services/Your Care
3.3.1 Improvements
in A&E
Oldham A&E
The A&E department at The Royal Oldham Hospital
currently sees an average of 250 patients per day;
approximately 91,000 patients a year. Of these,
around 80 children aged under 16 are seen every
day.
Our £4.4m capital investment to expand and improve
the emergency department facilities at Oldham
completed in summer 2014. The department has
benefited from the development of separate,
dedicated A&E facilities for children and young
people. The new reception and waiting room for
paediatrics has a transport theme with a bus, traffic
lights and road markings, making a more welcoming
environment for patients and young children.
The building work has also seen the completion of a
new major treatment area with 11 cubicles, and two
treatment rooms and the refurbishment of the eightbedded A&E ward. A ‘state of the art’ resuscitation
area has also been opened, providing seven bays,
including a separate room for children. An additional
x-ray room has also been built and a new corridor
formed to provide improved links to the x-ray
department and the main hospital building.
In March 2015, children’s charity MedEquip4Kids
celebrated the completion of over a year of
fundraising for the new children’s A&E. The charity
has kindly provided medical equipment, seating,
toys and distraction items to make sure that the
new facility is fully kitted out and child-friendly.
MedEquip4Kids has raised over £25,000 to kit out
the new unit, thanks to fantastic support from the
medical and nursing team at the hospital and from
the wider community of Oldham.
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QUALITY ACCOUNTS REPORT 2014-15
PART 3
Bury A&E
North Manchester A&E
Construction work to expand and improve facilities
at our A&E department at Fairfield General Hospital
completed in autumn 2014. The A&E department
was originally designed to accommodate 45,000
patients. Over the last few years, the department has
treated over 65,000 patients per year. Completion
of the £2.25m expansion means the hospital has
benefited from two extensions to the existing
A&E department. One of the extended areas now
provides dedicated, state of the art A&E facilities
for children and young people and the other
allows staff to separate minor and major cases. The
department consists of 11 new ‘major incident’
treatment bays with updated bed head services and
improved lighting, together with additional essential
clinical storage and utility rooms. The improved
physical layout and expansion of clinical treatment
areas will allow the A&E department to streamline
patients more effectively and reduce waiting times
by separating patients with minor injuries from those
who are critically ill.
In February 2015, the Trust partnered with
LloydsPharmacy to trial an innovative new pharmacyled clinic at our busy A&E department at North
Manchester General Hospital.
Rochdale UCC
In August 2014, Rochdale Infirmary opened its
purpose designed sensory/distraction cubicles for
children and patients attending the Urgent Care
Centre (UCC). The room was the brain-child of
Sister Jackie Gunn who is a nurse practitioner in
the UCC and a trained paediatric nurse. The new
room is used to treat all children and some adults
who have learning disabilities. Over the winter the
room became so popular as a part of the treatment
plan of a child that a second one has been created.
The Urgent Care Centre is open 24/7, 365 days a
year and run by experienced nurse practitioners and
doctors. The unit opened in April 2011 and treats on
average 4,500 patients per month. Staff can treat
non life-threatening walk-in injuries and ailments
which don’t require an A&E department, but cannot
wait for a GP or on-call doctor’s appointment.
The LloydsPharmacy First Care Clinic pilot has been
developed to explore and understand how pharmacy
can support and be integrated within an emergency
department to form part of the solution to meet the
growing demand and pressures facing A&Es. This is
the first time LloydsPharmacy has partnered with a
hospital to develop its pioneering First Care Clinic in
an A&E department. The service provides patients
with free treatment by a clinically trained pharmacist
for minor injuries and common ailments such as
minor burns, scalds, neck sprains and earache. The
clinic aims to see patients within 30 minutes of arrival
and 15 minutes after triage.
Our A&E department at North Manchester sees over
100,000 patients each year. It is one of the best
performing A&E department in Greater Manchester
and one of the best in the country for the four hour
emergency access standard, due, in part, to the
Trust’s willingness to innovate with initiatives such
as the First Care Clinic pilot, which aims to further
improve waiting times in A&E and health outcomes
for patients.
PAGE 87
3.3.2 Dementia Care
One quarter of people accessing acute hospitals
are likely to have dementia and the number with
the condition is expected to double over the next
30 years. Dementia can be caused by a number of
illnesses. It results in progressive decline in multiple
areas of function, including memory function,
communication and the ability to carry out daily
activities. The two most common forms of dementia
are Alzheimer’s disease and vascular dementia.
Through our Dementia Strategy we are developing
ways to improve the hospital experience for dementia
patients and their carers. Early diagnosis of dementia
and interventions are key priorities for the Trust
as is improving the quality of care for people with
dementia in general wards.
We want to ensure our staff have the necessary skills
to offer the best quality of care by providing training
and through other actions including:
●● Increasing the numbers of patients who are
assessed for the possibility of dementia on
admission to hospital
●● Including dementia training in staff inductions
●● Staff annual training programmes to include
dementia training and enhanced dementia
training for a core group of clinicians so at least
one nurse per shift is available with this level of
knowledge
●● Having a clear treatment plan for those patients
assessed and identified as ‘at risk’
●● Raising the profile of the dementia care pathway
and the standard of care provision.
Over the past year we have developed a range
of training materials and courses for our staff, in
particular those who are responsible for patient care
and are based on wards and in clinical areas.
We are committed to listening to our patients, their
families and their carers. Working with and involving
carers and patients enables us to design better care
pathways. We continue to work closely with the
Alzheimer’s Society, local Healthwatch and voluntary
organisations, which will support us in this work.
3.3.3 Oasis Dementia
Medical Unit
Our new medical unit for patients with dementia
from the Rochdale borough was officially opened at
Rochdale Infirmary in April 2014.
Commissioned by NHS Heywood, Middleton and
Rochdale CCG, the Oasis Unit is a new five-bed
facility which allows the assessment and diagnosis
of patients with dementia and confusion arriving
with acute medical conditions, either through
the Infirmary’s Urgent Care Centre, the Clinical
Assessment Unit (CAU), or through direct GP referral.
Since the unit opened, hundreds of patients and
their loved ones have benefitted from a ‘dementia
friendly’ environment, enhanced nurse staffing
ratios, and the specialist input of registered mental
nurses. Daily medical input from doctors is provided
by the CAU medical staff and patients are able to
receive the same wide range of diagnostic
facilities available at the hospital.
The unit is believed to be the
first of its kind in a hospital
setting in England.
In addition to the
five beds, the unit
boasts its own
relaxing lounge
area, kitchen
and dining area
tailored for the
needs of patients
and their families
and carers.
A patient’s length
of stay is between
5-7 days depending
on their individual
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QUALITY ACCOUNTS REPORT 2014-15
PART 3
“Patients with dementia
are increasing in number
and newspaper headlines
suggest that their care has
not always been what it
should. I believe that the
Oasis Unit is the start of a
change in how we as the
NHS, working in partnership
with the community to
deliver care to this group; a
change we can build upon
in the future.”
needs, as opposed to the
48-hour length of stay and
discharge target for the
CAU. This ensures referral
and care pathways are
designed to meet the needs
of each individual patient,
providing a better quality of
continuing care. The visiting
hours for relatives and
carers are also longer.
The service is provided by
a multi-disciplinary team
of doctors, nurses and
healthcare professionals
Dr Shona McCallum,
from our Trust and Pennine
consultant and clinical lead at
Care NHS Foundation Trust.
Rochdale Infirmary
It also has a social worker
from Rochdale Council
Social Services based within the team.
The development has brought together a wide
range of agencies and professionals including input
from what are seen traditionally as non medical or
nursing teams, for example the catering department
researching the best crockery and cutlery to
encourage the patients to eat and developing the
dining room, and our estates team looking at best
practice and bringing it all together to
design a dementia friendly
environment.
3.3.4 New Hybrid Theatre
at Oldham
Our new special hybrid operating theatre has been
developed at The Royal Oldham Hospital. The new
build project, which completed at the end of March
2015, saw the conversion of the existing theatre
number three at the hospital following an investment
of £1.3m.
Known as the specialist vascular service theatre,
the hybrid operating room is a state-of-the-art
environment where high definition imaging and
surgical tools are
“This is a very exciting
available. The
surgical theatre is
development for the
equipped with an
Trust in terms of offering
advanced medical
a new high-tech theatre
imaging scanner
which combines a normal
which allows for
operating theatre with
advanced imaging
an ultra-high quality
to be available at all
fixed imaging suite. It
times during invasive
can function as either a
procedures on
conventional operating
patients undergoing
theatre, or as a state-ofendovascular
the-art imaging facility, and
operations. This will
crucially allows intra and
mean that patients
post-operative imaging
are able to have
any imaging and
and intervention on the
surgical procedures
operating table.”
simultaneously,
Mr Riza Ibrahim, consultant
rather than having
vascular surgeon
to go through two
different procedures
on separate occasions.
3.3.5 Physios Make Every
Contact Count
Our Trust Physiotherapy Department has embarked
on an initiative called ‘Make Every Contact Count’, to
engage in ‘healthy conversations’ with their patients
PAGE 89
“Physiotherapists are
exercise specialists and we
have a key role to play in
improving public health, in
particular around promoting
the benefits of exercise and
the importance of making
healthy lifestyle choices.
We work with our patients
on a daily basis to help
them make behavioural
changes in order to selfmanage their conditions
and gain better long-term
outcomes.”
regarding physical
activity levels. The
initiative has been
driven by a growing
demand for Allied
Health Professionals
(AHPs) to take a
proactive approach
to health prevention.
The recently
published NHS
Five Year Forward
View highlights
the importance of
this, due to such
factors as an aging
population and a
Deborah Bancroft, Advanced
rise in obesity levels,
Physiotherapy Practitioner
placing greater
strain on public
resources. It points out that in order for the NHS to
be sustainable, there needs to be a ‘radical upgrade
in prevention in public health’.
As part of the campaign, a number of our
physiotherapists at Fairfield General Hospital are
supporting a local Bury fitness campaign which
looks to encourage women to take part in physical
activity or sport. Over twenty of our female staff
across the hospital have signed up to the ‘I will if
you will’ campaign which is an initiative managed by
Bury Council and awarded £2.3m last year by Sport
England. It adopts a ‘behavioural change model’
to engage more women in the area to participate
in regular physical activity or sport. The project aims
to get 10,000 women and girls (over 14) engaged
in regular activity and asks women to sign up to do
30 minutes of exercise a week for 10 weeks. If the
project achieves its outcomes the model could be
rolled out to other UK towns.
3.3.6 Home Intravenous
(IV) Therapy Service
In early 2015, our home intravenous (IV) therapy
team was commissioned by North Manchester CCG
to provide community intravenous therapy for North
Manchester registered ambulatory care patients.
Our team now provides care and treatment in the
community for patients who require intravenous
therapy and do not need to be in hospital.
Intravenous therapy is the giving of medication, fluid
or nutrition directly into a vein through a small plastic
line. The line can remain in place for up to a year,
depending on the treatment required, and the type
of line being used. The treatment is administered
through the line by a specialist nurse in the
community either at a health centre or at home.
There are many benefits for both patient and
healthcare staff, most importantly it allows patient
care to be delivered in their own home. The home
intravenous therapy team at North Manchester
has been developed using national evidence which
illustrates the benefits of community led intravenous
therapy services, enables admission avoidance and
facilitates a patient’s early discharge from the acute
sector into the community.
3.3.7 New Doppler Scan
Service at Rochdale
In early 2015, we successfully introduced a new
Doppler scan service at Rochdale Infirmary for
patients with suspected Deep Vein Thrombosis (DVT).
The new scanner can be used to find out how fast
blood is flowing through a blood vessel and can help
our doctors identify if there is a block caused by a
possible blood clot.
The new service now means that patients with
symptoms of DVT presenting at our Clinical
Assessment Unit (CAU) and Urgent Care Centre at
the Infirmary can be usually booked in to be scanned
on the same day. The service will help reduce patient
waiting times, improve patient care and patient flow
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QUALITY ACCOUNTS REPORT 2014-15
PART 3
on the CAU, and avoid patients having to travel to
Fairfield General Hospital for a scan. It will also help
the Trust save money as there is less demand on our
pharmacy service at Rochdale as patients no longer
need to take home prophylactic treatment to use
while they wait for their scan appointment.
3.3.8 Learning
and Organisational
Development
During 2014/15 our Learning and Organisational
Development (L&OD) department work has focused
on supporting the Trust through implementation
of our workforce strategy. The department
recorded almost 100,000 episodes of learning and
development activities over the last 12 months and
over 33,000 staff attendances at learning activities.
Compliance with statutory and mandatory training
has also improved greatly over the same period.
We continue to offer our staff development
opportunities through a variety of approaches, from
one-on-one consultations, virtual e-learning, to faceface classes for departments, facilitation of learning
boards, and specialist library support. Our blended
approaches have helped to increase and maintain
compliance in the ten core mandatory training topics.
Over the last five years all areas have increased
compliance, with overall increases for each area.
The department’s prospectus continues to grow with
new award-winning simulation courses in clinical
skills; e.g. medicines management training helping to
support our staff deliver quality care to patients. Our
state-of-the-art Clinical Skills and Simulation Centre
at North Manchester General Hospital has gained
course, facilitator and centre accreditation with the
North West Simulation Education Network (HENW)
being the first centre in the region to complete this.
New e-learning provision includes ‘Tailor-Made
Training’ that enables staff to show their existing
knowledge is sufficient to maintain individual
compliance. Our library quality accreditation
framework remains at 98% putting us in third place
overall across the region.
Our Practice Education Facilitation (PEF) team also
achieved 96% (NW average 87%) and Silver level
compliance in their outcomes monitoring from
HENW this relates to the quality of the placement
provider for pre-registration learners.
Quality Improvement Methodologies
Programme (QuIMP)
Our L&OD department in conjunction with the
regional Advancing Quality Academy (AQuA) have
supported the development and roll out a Quality
Improvement Methodologies Programme (QuIMP).
All staff involved in the QuIMP programme undertake
a quality improvement project aligned to the Trust’s
corporate priorities and quality agenda. Participant’s
baseline skills assessments are measured before
and after the programme and demonstrate a
significant increased level of skill and application in
the workplace. The QuIMP programme is central to
supporting the Trust in its strategic goal of becoming
a high performing safe organisation consistently
delivering safe patient care, patient experience and
doing no harm.
The first group of staff to take part in the programme
were our nurse ward managers. Since then, the
programme has involved three cohort of staff
producing a fantastic array of projects that show real
impact and improvement in the quality of patient
care across the Trust. The aims of projects include the
following:
Streamlining the discharge process of patients from
ward T5 at ROH by March 2015;
●● 100% of HIV patients at NMGH to be assessed
holistically at their outpatients’ appointment
using the Wellness Thermometer assessment tool
by June 2015;
●● 100% of patients on ward D6 at NMGH to be
correctly risk assessed as per Trust requirements
PAGE 91
for nursing risk assessments by January 2015;
●● 100% of our patients’ plain musculoskeletal
images performed at Oldham will either
demonstrate collimation according to department
standards or have a reason for deviation
documented on the Computerised Radiology
System (CRIS) by December 2014;
●● To reduce the incidence of Delirium in Critical
Care at FGH by 75% by April 2015;
●● To implement the Gold standard framework
prognostic indicator tool within the active case
management patients assessment by 100% by
April 2015;
●● To provide continuity of dietetic care to all
adult patients requiring oral nutrition support
when they transfer between NMGH and North
Manchester community dietetic services by April
2015.
3.3.9 “3 Steps to
Excellence” in Nursing &
Midwifery
In September 2014, our 4,000 nurses and midwives
working across our hospitals and community services
made a commitment to provide the best possible
patient care following the launch of a new nursing
strategy called the ‘3 Steps to Excellence’.
The three year programme seeks to enable the
delivery of the very highest standards of nursing and
midwifery care. It comprises four key work streams:
professional image, standards of care, workforce
and patient experience. Each work stream states the
aims of the nurses and midwives to enable them to
deliver excellence. Our goal is that patients and their
families have the best possible care experience when
they use our services.
●● Standards of care – the care will be safe,
efficient and evidence based. Nursing staff will
deliver the kind of care that patients and their
families want to receive.
●● Patient experience –
patients and their
families will have
the best experience
possible when
receiving care, 24
hours a day, seven
days a week.
“Our goal is that patients
and their families have
the best possible care
experience when they use
our services. This is an
exciting time for nursing
and midwifery across the
Trust on our journey to
provide the best nursing
and midwifery care in the
NHS. I want this Trust to be
nationally recognised as the
leading Trust for nursing
and midwifery.”
●● Professional
image – nurses and
midwives are the
biggest workforce in
the Trust with direct
patient contact all
day, every day. It is
vital that they are
Mandie Sunderland, Former
smart, recognisable
Chief Nurse
for who they are and
portray empathy,
professionalism and integrity.
●● Workforce – staff will have the knowledge
and skills to do their jobs and the capability to
deliver the highest standards of care through
professional development and appraisal.
As part of this new strategy, the Trust has
implemented a new nursing metrics programme to
ensure that staff deliver high quality nursing care.
On a monthly basis nursing staff will now measure
standards of patient care to help ensure the very best
of care is being provided and to identify any issues
for improvement.
These care indicators cover those areas which are
deemed the highest concerns in terms of patient risk
and can be used to monitor and reassure the Trust
Board regarding nursing quality at ward level. These
include; patient observations, safeguarding, pain
management, falls and continence assessment, tissue
viability (pressure ulcers), nutritional assessment,
medication administration, infection prevention
and control, diabetes and checking nursing
documentation.
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QUALITY ACCOUNTS REPORT 2014-15
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3.4 Meeting Standards
3.4.1Nursing Care
Indicators
As part of our Quality Improvement Strategy we
introduced a set of nursing metrics across our
medical and surgical wards during 2014. The metrics
form part of our “3 Steps to Excellence Nursing &
Midwifery Programme”.
These indicators cover those areas which are deemed
the highest concerns in terms of patient risk and can
be used to monitor and reassure the Trust Board of
Directors regarding nursing quality at ward level:
●● Patient observations
●● Pain management
●● Falls assessment
●● Tissue Viability
●● Nutritional assessment
●● Continence Assessment
●● Medication administration
●● Infection Prevention and Control
●● Diabetes
●● Resuscitation Trolley
Metrics are captured electronically, enabling wards
to have access to real time data and compare results
across all wards by hospital site and by division.
Work is now underway to expand the number of
areas where metric audits are undertaken, to include
critical care and outpatient areas.
Central to our quality programme is our ongoing
work to reduce harm from pressure ulcers, falls,
VTE and catheter-related urinary infections which is
captured through the Safety Thermometer. The NHS
safety thermometer is a local improvement tool for
measuring, monitoring and analysing patient harms
and harm-free care. The safety thermometer provides
a quick and simple method for surveying patient
harms and analysing results so that you can measure
and monitor local improvement and harm-free care
over time. Using this measure our performance
shows that as an organisation we deliver over 94%
harm-free care.
To provide greater transparency across wards and
departments we have commenced work with
our information department to develop a nursing
dashboard. The nursing dashboard will provide
an electronic system that will be used to support
improvements within wards and departments by
ensuring the data we collect on patient care and
nursing metrics is immediately available.
We are also developing a ward assurance programme
to support even greater transparency. This will involve
measuring and assessing wards against agreed
standards, highlighting areas of excellent care and
areas for improvement. To support delivery of this
work we have established a Nursing and Midwifery
Performance committee. The inaugural meeting was
held in December 2014 and meetings will be held
quarterly to monitor standards of nursing care and
ensure delivery of action plans where required.
End of Life Care (EOLC)
There have been numerous developments designed
to improve the quality of End of Life Care provided
across the Trust during 2014/15. A significant
initiative has been the Trust’s sign up to a National
EoLC transformation programme, focused around
service improvements which better meet the needs
of people approaching the end of their life, while
making best use of the resources available.
The Transform Programme is based on five key
enablers of care. One of the enablers includes the
introduction of the five Key NHS principles of Care at
PAGE 93
the EoL which have been introduced in the form of
an individualised EoLC plan following the withdrawal
of the Liverpool Care Pathway (LCP).
This programme is currently being piloted across two
wards on each site of PAHT. Some of the benefits of
this to patients and carers are:
Other achievements have included:
●● The development of an Advance Care Plan
and patient leaflet to accompany this. This was
developed by a patient / carer user group;
●● The standardisation of bereavement packs
provided to carers / relatives of the deceased;
●● They receive optimum end of life care, before
death, at time of death and following death into
bereavement
●● The development of Trust EoLC standards which
are to be launched in May and was developed as
part of a Listening Into Action event;
●● They are given choices in regards to preferred
place of care and death, experience fewer crises
and unplanned events with a focus on their
needs and preferences through advance care
planning.
Policy and guideline development has included:
●● This is also having significant benefits for
the workforce and organisation as staff are
appropriately trained to deliver optimum end of
life care with better team co-ordination and cross
boundary care.
●● Care after Death, Guidelines for Care in the Last
Days of Adult Life, Time of Death and Following
Death;
●● Religious and faith requirements relevant to
hospital admissions: Guidance for Staff, Rapid
Transfer pathway for patients at the EOL.
3.5 Working with our partners
3.5.1 Integrated Health &
Social Care
As part of our strategic transformation map, in 2014
we created a new fifth division for community and
integrated services in response to the growing joint
working and service delivery we are developing with
our health and social care partners.
In addition to our hospital-based services, we
currently provide a wide range of community
and integrated services across the north part of
the city of Manchester. Such services include an
integrated health and social care crisis response
team, an integrated discharge team based at North
Manchester General Hospital, a multi-disciplinary
community and social care team, Active Case
Managers who provide a non-emergency service
which specialises in helping people with long term
conditions, and an Acute Respiratory Assessment
Service (ARAS) and COPD support team. Over the past year we have stepped up our work
with Manchester City Council and North Manchester
CCG in driving forward plans to radically transform
Manchester’s community care system and reform
health and social care services. This has involved
planning and developing new ways of working
and new models of community-based care to
support more people in their own homes and in
the community, keeping people out of hospital
and residential care, and to reduce admission and
readmission to hospital.
Living Longer Living Better (LLLB)
We are making integrated health and social care
services a core part of our business through the
Living Longer Living Better (LLB) programme
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QUALITY ACCOUNTS REPORT 2014-15
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for improving health outcomes for residents of
Manchester. The LLLB programme is being led jointly
by Manchester City Council, the Manchester CCGs
and NHS healthcare providers, including ourselves,
to radically transform Manchester’s community care
system and reform health and social care services by
2020, co-ordinating and delivering them in a way
that achieves better outcomes for people.
The main aim of LLLB is to develop new ways of
working and new models of community-based care
to support more people in their own homes and
in the community, keeping people out of hospital
and residential care, and to reduce admission and
readmission to hospital. By 2020, community services
will seek to achieve a 20% shift from hospital and
residential care.
Our Trust and the Local Authority are keen to develop
new integrated models for health and social care
and build on our success across North Manchester
so far. Our integrated services are already working
well; these include our integrated health and social
crisis response team, our integrated discharge team
based at North Manchester General Hospital, and our
multidisciplinary primary, community and social care
team. Examples of new integrated care under LLLB
will include opportunities to reconfigure intermediate
care and re-ablement services to support people
at home and configure teams of integrated health
and social care workers (from the NHS and local
authority) based within four neighbourhoods, or
“hubs”, each covering 40-50k people.
The LLLB proposals include full integration of adults’
social care services of Manchester City Council with
our community health services of the Trust. This
will begin later in 2015. It will see the merging of
management structures first, supported by a single
performance framework, shared goals, joint IM&T
systems and shared access to online records, clear
governance and clear accountability.
Home from Hospital Service
From 1st April 2014,
hundreds of elderly
Manchester residents
have benefited from
a new personalised
hospital discharge
support service for
patients who have
been discharged from
our wards at North
Manchester General
Hospital and need
to be taken back
home or to a nursing
care home in the
community.
“We are really excited by
this pilot; it’s a simple idea
that offers massive benefits
for older patients when
they are likely to be feeling
very vulnerable and afraid.
It also offers benefits to
hospital staff who can be
confident to discharge
patients home knowing
that Care and Repair
are there to support the
patient.”
Helen Speed, Programme
Director Urgent Care at North
The new service
Manchester CCG
builds on the highly
successful and well
established home from hospital service which offers
a telephone follow up service to all over 60s who
have visited A&E or been discharged after a stay in
hospital. The Home from Hospital service, which is
delivered at North Manchester General Hospital by
Manchester Care and Repair, ensures that vulnerable
or isolated patients aged over 60 are provided with
personalised discharge support which is tailored to
their needs.
The one year pilot project was commissioned by the
Trust in partnership with Manchester City Council
and North Manchester CCG. National and local
research has demonstrated that for many older
and vulnerable adults, the point of transition from
hospital back to their own home is an unsatisfactory
experience. Many patients who are over 60, may
feel socially isolated and lack the active support of
an extended family. Discharge is therefore often
accompanied by feelings of abandonment, isolation
and depression.
PAGE 95
Hospital discharge support services have
demonstrated that through a simple assessment tool,
barriers to health and independence can be identified
and emotional and practical support delivered, which
reduces risks and allows isolated individuals to reconnect with sources of local support.
Manchester Care and Repair is a local charity and
award winning home improvement agency which has
been supporting older and vulnerable Manchester
residents for over 20 years.
Intermediate Care at NMGH
Intermediate care is a rehabilitation approach to
prevent people going into hospital, and to facilitate
their return home from a hospital setting. In
November 2014, intermediate care was enhanced
for patients in the North Manchester area following
collaborative working between the Trust and our
local commissioner, North Manchester CCG.
The majority of patients in the North Manchester
area accessing intermediate care services are over
75 years of age and the enhanced service is aimed
at people who do not require, or no longer need
specialist acute hospital care and treatment, but
who need support within a community setting. Nine
newly developed and funded enhanced community
intermediate care beds were opened on ward J5 at
North Manchester General Hospital which offers
patients support in the transition period between
illness and recovery.
The additional temporary beds are part of a
business plan which will transform the way in
which intermediate care for patients is delivered
and will ultimately result in a new capital build for
intermediate care beds on the North Manchester
General Hospital site next year.
The nine beds take patients following hospital
discharge who are registered with a North
Manchester GP. Our intermediate care team will
screen all referrals and assessments. The beds will be
in addition to the 15 beds currently at Henesy House
which will stay in place until a new capital build
has been completed in 2016. Henesy House is a 15
bedded residential home in Collyhurst, Manchester.
We provide all services to support patients in
the ward including our occupational therapists,
physiotherapists and nurses, pharmacy, podiatry,
speech and language therapy.
Integrated Diabetes Service in Bury
In September 2014, our new integrated diabetes
service for people with diabetes across Bury and the
Rochdale borough went live.
The service has been jointly commissioned by
NHS Bury CCG and NHS Heywood, Middleton
and Rochdale CCG and is jointly provided by our
staff and staff from Pennine Care NHS Foundation
Trust. The new service has brought community and
hospital-based diabetes staff together to form a
single integrated service called the Bury and HMR
diabetes service.
Depending on the needs of patients and the
complexity of their condition, patients could be cared
for by the service directly, or by their GP or practice
nurse. Only people needing the most complex and
specialist services will now receive their care at
Fairfield General Hospital or Rochdale Infirmary.
The service also delivers nationally accredited training
and education for both service users and healthcare
professionals to support effective management of
their condition and reduce the risks of complications
developing. Benefits for patients include a better
experience overall, better quality and improved
coordination of care, reduced risk of hospital
admission, care closer to home for many people, and
faster access to specialist care.
Greater Manchester Devolution
In February 2015, we welcomed the ground-breaking
plans around the future development and provision
of health and social care across Greater Manchester,
announced by the Government.
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QUALITY ACCOUNTS REPORT 2014-15
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“This is a significant and
exciting step towards
greater integration of
health and social care
across Greater Manchester
which we as a Trust and as
a large NHS care provider
fully support. It is a genuine
opportunity for the NHS
across the region and
local authorities to further
bring services together
to enhance and improve
the health and outcomes
for the people of Greater
Manchester. We believe
the health and social care
system must join and work
together and build on the
work and progress we
have made over the last
few years by integrating
services.”
Dr Gillian Fairfield,
The signed Memorandum
of Understanding between
Greater Manchester and
NHS England confirms a
commitment to devolve
from Government and
bring together the cityregion’s £6bn health
and social care budget.
The deal involves a joint
agreement between NHS
England, the 12 NHS
Clinical Commissioning
Groups (CCGs) and 10
local authorities for a
framework for health and
social care and plans for
joint decision-making on
integrated care to support
physical, mental and social
wellbeing.
specialist multidisciplinary team are now better
able to make expert judgements about appropriate
treatments and have access to the highest standard
of facilities.
3.5.2
HepatoBiliary
Service (HPB)
3.5.3 Surgical Vitro-Retinal
(VR) Service
Chief Executive
Following the Greater
Manchester Cancer
Summit in 2012, it was agreed by commissioners
that the HepatoBiliary Service (HPB) surgical service
for Greater Manchester and Cheshire patients
should be established on a single acute hospital site
and developed in a way that is fully compliant with
national Improving Outcomes Guidance (IOG) for
cancer services.
The HPB service moved to the Manchester Royal
Infirmary site in October 2014, creating a single
specialist site. The rationale for the service transfer
was that clinical quality and patient outcomes,
particularly for cancer patients, would be improved
through the centralisation and concentration of
expertise and facilities on one hospital site. One
A number of our staff have joined with Central
Manchester Trust (CMFT) staff to make up the new
specialist merged service. Revised clinical guidelines,
operational policies and clinical and diagnostics
pathways have been created as part of the new
service.
The treatment of liver, pancreatic and bile duct
cancer will now only be undertaken at CMFT.
Pennine Acute Trust will continue to provide
operative and endoscopic treatment of gallstone
disease as well as some palliative procedures in
advanced cancer, such as endoscopic stenting.
We will also continue to be represented on the
Manchester Cancer HPB Pathway Board and have
an influence on how the HPB service develops, to
improve outcomes for all patients with HPB cancer.
From 1st January 2015, we have worked jointly
with Central Manchester University Hospitals NHS
Foundation Trust (CMFT) to continue to provide a
surgical vitro-retinal (VR) service for our patients.
New arrangements were agreed between the two
acute Trusts and put in place following the main
consultant who specialised in our vitro-retinal
surgery left the Trust in 2014. The Trust was not
able to provide the service within our specialist
ophthalmology team as there were no other
consultants trained in this specific surgical procedure.
Discussions took place with Central Manchester
who were keen to continue to deliver the VR service
for the Pennine population locally. Mr Assad Jalil,
consultant ophthalmologist from CMFT, is now
providing two theatre sessions and a Friday morning
outpatient clinic within our Eye Unit at Rochdale
Infirmary.
PAGE 97
3.5.4 Healthier Together
(Greater Manchester)
The Healthier Together public consultation (which
ran between July–October 2014) set out proposals
to improve quality standards across hospitals
and to improve the health of people through the
reconfiguration of primary and secondary care
services across Greater Manchester.
A number of our senior clinical staff have been
working with and advising the Healthier Together
team in drawing up models of care across a range of
hospital and community based services.
Our response to the consultation was formally
published on 30th September 2014. This is available
on our website. The final hospital configuration
models, adopting a single service model across a
number of specialties currently operated by the Trust,
offer the opportunity to raise standards of care,
reduce variation and duplication, maximise workforce
availability and skills, whilst making the best use of
challenged financial resources across the NHS.
Our Trust is unique in Greater Manchester in
operating a single service across our four hospital
sites with a population in excess of 820,000 people;
no other Trust or configuration of Trusts has achieved
this in the Greater Manchester conurbation. The
development of our single service has taken much
hard work and effort on the part of a wide range of
clinicians and staff, and it is an achievement of which
we are very proud. Specific achievements of our
single service include: Creation of a joined up model
of single service hospital provision through two
“hot” emergency sites supported by an emergency
medical and elective surgery centre at Fairfield
General Hospital and the integrated care hub and
specialist day surgery centre at Rochdale Infirmary.
We believe that we already operate a successful
single service across our four-hospital-site footprint.
This single service is based on a robust governance
and operational model under the leadership of
one Trust Board. We believe that this service can
flex successfully to accommodate the changes
proposed for our hospitals in the Healthier Together
consultation.
Whilst the new models have not yet been fully
completed, additional opportunities are being made
for Trusts to shape the options going forward.
The final outcome of the Healthier Together plans
is unlikely to be published until June 2015 at the
earliest. The governance arrangements relating to
the Healthier Together Programme Board have been
further revised. The Trust will be ensuring it is well
represented by senior managers and senior clinicians
in all meetings. Irrespective of the final outcome and
timing of Healthier Together, this Trust will need to
continue its clinical transformation work to ensure
we can deliver a clinically and financially
stable organisation across our
services.
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3.6 Investing in our staff
3.6.1 Clinical service
redesign at NMGH A&E
Our Emergency Department at North Manchester
General Hospital (NMGH) has successfully delivered
a clinical service redesign programme which
has resulted in improvements in patient care,
performance and cost efficiency.
During 2014/15 we have created and brought in
an innovative workforce plan and new medical
staffing model forming two hybrid medical teams.
The senior team is made up of equal numbers of
traditional A&E consultants and specialty GPs. The
new medical workforce model can be applied in
any emergency service in the UK. The middle grade
team has established a hybrid team of advanced
nurse practitioners and ‘middle grade’ doctors. The
models are now almost fully established allowing the
A&E department to deliver excellent care providing
significant cost savings over the old model by
reduced spend on agency staffing. This workforce
model has enabled the A&E to meet its national four
hour emergency access standard
every quarter since
November 2013 –
becoming one of
only two A&E
departments in Greater Manchester to meet the four
hour standard consistently.
Partnering with key partner health and social care
organisations, our staff at NMGH has built mutually
beneficial relationships which enhance patient care
and professional development while also delivering
better cost efficiencies. The most important
neighbouring organisations are our General Practices
and the department recently entered into an exciting
and ground-breaking joint venture with five local
General Practices to provide a Vertically Integrated
Urgent Care Service (‘VICS’).
Speciality GPs
The A&E department has successfully attracted and
recruited four full-time ‘Specialty GPs’ to the VICS.
Each specialty GP works four days per week in the
department and also provide on call cover for the
A&E on a 1:8 basis supported by an A&E consultant
on call with them. This innovative new model of
integrating local GPs to work as part of the A&E
department at NMGH has recently generated interest
and support from The Royal College of Emergency
Medicine and attracted extensive national media
coverage.
Paediatric Public Health Research
The department has used a variety of ways to
attract and recruit new consultants to the hospital
including a video on YouTube and via social media. In
August 2014, we appointed a new consultant post
in paediatric public health, enabling some ground
breaking research at the interface of paediatric
primary care and secondary care.
New management approach
A new hospital operational management team
has been created comprising two clinical directors,
PAGE 99
two directorate managers and one divisional nurse
manager. The team meets daily to manage patient
flow and discuss any major operational issues that
may affect patient care, clinical effectiveness and
patient experience. The team has a relentless focus
on reducing ‘length of stay’ and has delivered a
sustained improvement over the last three years.
3.6.2 Divisional
Operational Management
Triumvirate
In 2014/15, the Trust introduced a new triumvirate
operational management and governance leadership
model for our five divisions (Medicine, Surgery,
Women & Children’s, Integrated & Community
Services, Diagnostics & Clinical Support Services).
This means that each clinical division is now
managed and led by a Divisional Medical Director,
Divisional Nursing Director and Divisional Director
(management). This arrangement greatly increases
the level of senior clinical input and shared decision
making to the operational running of the Trusts
services.
A number of key appointments to the Trust’s
management team during the year have also
been established to enhance our governance
arrangements and promote patient safety and
improve patient care across our services. These posts
include a new Chief Nurse, a new Deputy Chief
Nurse, a new Director of Clinical Governance, a new
Head of Partnerships, a new Director of Strategy and
Commercial Development, a new Head of Patient
Safety, and a new Head of Quality.
3.7 What others say about the Trust
3.7.1 North East Sector
NHS Commissioner
Response
Thank you for asking us to comment on your
draft Quality Account for 2014/15. We were
pleased to read the detailed Quality Account which
demonstrated the Trust’s on-going commitment and
dedication to improving quality across the Trust.
NHS Bury Clinical Commissioning Group (CCG),
along with our neighbouring commissioning
colleagues in Heywood, Middleton and Rochdale
CCG, Oldham CCG and North Manchester CCG
have continued to work collaboratively on a wide
range of quality surveillance and improvement
work streams throughout the year through formal
performance and quality meetings, through visits
to the Trust for walk rounds and visits to specific
clinical areas. During 2015/16 the Commissioners
will be working with the Trust on other improvement
programmes, particularly the maternity action plan,
the new national serious incident management
framework and the infection control framework. The
Trust has been accommodating to us at all times and
demonstrates proactive inclusion of Commissioners
in all aspects of their quality strategy.
The Commissioner walk around visits has provided
an excellent opportunity to talk to the front line staff
at the Trust. We were impressed by the standards
of care delivered in A&E on all the sites during the
extremely busy period at the end of December
and January. Whilst performance figures dipped
there was evidence that the staff have done all
that they could do to meet the patients’ needs and
remained motivated to deliver the highest standards
of care. The Quality Premium for 2015/16 includes
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QUALITY ACCOUNTS REPORT 2014-15
PART 3
improvements in data collection and coding in
a range of areas including A&E and we hope to
support the Trust in meeting the Quality Premium
objectives.
The Quality Account for 2015/16 accurately includes
both national and local priorities that have been
discussed with Commissioners, and is reflective of
the priorities that each CCG has identified for their
local population. The CCGs are not responsible for
verifying data contained within the Quality Account;
that is not part of these contractual or performance
monitoring processes.
The Trust has made a great effort in engaging
with staff through a variety of events, including
Listening into Action and the nursing conference.
We would like to see more staff recommending the
Trust as a place to work in 2015/16, but do feel the
Trust has made good plans to continue their staff
support, training and engagement programmes.
Additionally the Trust needs to celebrate its successes
and promote the excellent work that is happening;
the extensive audits and CQUIN programme
demonstrates the commitment to improving quality
by doctors and other front line staff.
Safe and timely discharges are a priority for the
Trust and for Commissioners and we would like
to see a continuation in improving processes in
which a patient’s discharge is well planned and
communicated with the patient and family, and that
the receiving organisation, e.g. Nursing Home or GP
is informed in a timely and accurate way. Discharge
summary improvements remain a priority for CCGs
to ensure the continuity of care for our local people.
The Trust has engaged with the Commissioners
to improve discharge pathways for patients, for
example in elderly care and dietetics and have been
working closely with community providers to seek
solutions to challenges.
The Trust continues to be one of the leading Trusts
in Greater Manchester in the Friends and Family
Test response rates, demonstrating an effective
programme for collecting patients and carers
feedback. The inpatient scores are consistently
good across the Trust, and any outlying scores are
investigated. Complaints handling has changed
during the year which has created a delay in the
response time to complaints, however the numbers
of come backs have dropped and we are assured that
the quality of the complaint handling has improved.
We welcome the Trust’s action plan to improve the
process so that patient complaints are handled more
quickly.
The Trust has responded to national reports
regarding nursing care quality failings, e.g. The
Francis Inquiry, through its comprehensive quality
improvement programme. We welcome the
initiatives which include focusing on the six ‘C’s
(Compassion, Courage, Commitment, Competency,
Care and Communication) and the introduction
of Supernumerary Ward Managers to ensure that
nursing care is delivered safely and with care and
compassion. We have seen across the organisation
the introduction of the nursing metrics which helps
the Trust to assess a range of quality indicators and
be responsive to changing situations on the wards.
The Trust’s achievement in reducing mortality rates
is to be commended and we support the Trust in
making this a continuing priority for 2015/16, noting
an ambitious target of 80 for the Standardised
Mortality Ratio (HSMR). The Trust has worked hard
to improve the safety of patients in their care by
many initiatives including a whole system change
to reporting of incidents and sharing lessons learnt
across the organisation through a new framework
which produces ‘Lessons Learned Bulletins’ and
‘Patient Care Alerts’ and actively shares this
information with their staff. The Trust acknowledges
that their incident reporting system requires
strengthening as there are inconsistencies across the
organisation and a back log of completed root cause
analysis. However the Senior Management Team
PAGE 101
has prioritised this work stream and has started to
make progress. The Commissioners are engaged and
supportive in moving this programme forward.
●● Active Case Managers: this service provides
a non-emergency service which specialises in
helping people with long term conditions
Commissioners acknowledge the dedication and care
provided by the staff at the Trust to local people and
feels confident that the Trust has identified the right
quality improvement priority areas to focus on in the
coming year. We support the quality improvements
achieved and look forward to working with The
Pennine Acute Hospitals NHS Trust to further develop
high quality services for our populations in 2015/16.
●● Partnership working around the hospital at
home service: this is a new personalised hospital
discharge support service for patients who
have been discharged from wards at North
Manchester General Hospital and need to be
taken back home or to a nursing care home in
the community.
Catherine Jackson, Executive Nurse NHS Bury CCG
on behalf of:
●● ● NHS Bury CCG
●● ● NHS HMR CCG
●● ● NHS Oldham CCG
●● ● NHS North Manchester CCG
North Manchester Clinical
Commissioning Group (CCG) Response
North Manchester Clinical Commissioning Group has
a separate contract with The Pennine Acute Hospitals
NHS Trust for the provision of community services.
North Manchester Clinical Commissioning Group
welcomes the opportunity to comment on the Trust’s
Quality Account Report for 2014/15 in respect of
community services.
The Quality Account evidences improvements
made in community services during 2014/15.
North Manchester CCG would like to commend
the engagement of the Trust with the CCG and
Manchester City Council in driving forward plans to
support more people in their own homes and in the
community and keeping people out of hospital.
We would like to highlight the following areas of
good practice and innovation:
●● Integrated health and social care crisis response
team: this team intervenes rapidly to prevent
admission to hospital, ensuring appropriate
clinical care, in the right place at the right time.
The CCG commends the engagement and
enthusiasm of the Trust in engaging with Health
and Social Care Commissioners and the voluntary
sector in driving forward plans to radically transform
Manchester’s community care system and reform
health and social care services.
Martin Whiting
Chief Clinical Officer, North Manchester Clinical
Commissioning Group
3.7.2 Joint Health
Overview and Scrutiny
Committee (JHOSC)
The JHSOC will not be submitting a commentary in
respect of the Quality Account.
3.7.3 Local Healthwatch
organisations
The Trust offered the opportunity for local
Healthwatch groups to provide comment on the Trust
draft Quality Account, however they have written to
us to say they are unable to do so this year.
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QUALITY ACCOUNTS REPORT 2014-15
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3.8 Statement of Director’s responsibilities in
respect of the Quality Account
The Directors are required under the Health Act
2009, National Health Service (Quality Accounts)
Regulations 2010 and National Health Service
(Quality Account) Amendment Regulation 2011 to
prepare Quality Accounts for each financial year. The
Department of Health has issued guidance on the
form and content of annual Quality Accounts (which
incorporate the above legal requirements).
In preparing the Quality Account, directors are
required to take steps to satisfy themselves that:
●● the Quality Accounts presents a balanced picture
of the Trust’s performance over the period
covered;
●● the performance information reported in the
Quality Account is reliable and accurate;
●● there are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Account,
and these controls are subject to review to
confirm that they are working effectively in
practice;
●● the data underpinning the measures of
performance reported in the Quality Account is
robust and reliable, conforms to specified data
quality standards and prescribed definitions, is
subject to appropriate scrutiny and review; and
●● the Quality Account has been prepared in
accordance with Department of Health guidance.
The Directors confirm to the best of their knowledge
and belief they have complied with the above
requirements in preparing the Quality Account.
By order of the Board
Chairman
28 May 2015
Chief Executive
28 May 2015
PAGE 103
3.9 Independent auditors’ limited assurance
report to the Directors of PAHT on the
Quality Account
We are required to perform an independent
assurance engagement in respect of The Pennine
Acute Hospitals NHS Trust’s Quality Account for the
year ended 31 March 2015 (“the Quality Account”)
and certain performance indicators contained therein
as part of our work. NHS trusts are required by
section 8 of the Health Act 2009 to publish a Quality
Account which must include prescribed information
set out in The National Health Service (Quality
Account) Regulations 2010, the National Health
Service (Quality Account) Amendment Regulations
2011 and the National Health Service (Quality
Account) Amendment Regulations 2012 (“the
Regulations”).
In preparing the Quality Account, the Directors are
required to take steps to satisfy themselves that:
Scope and subject matter
The indicators for the year ended 31 March 2015
subject to limited assurance consist of the following
indicators:
●● the data underpinning the measures of
performance reported in the Quality Account is
robust and reliable, conforms to specified data
quality standards and prescribed definitions, and
is subject to appropriate scrutiny and review; and
●● Percentage of patients risk-assessed for venous
thromboembolism (VTE); and
●● the Quality Account has been prepared in
accordance with Department of Health guidance.
●● Rate of clostridium difficile infections.
The Directors are required to confirm compliance
with these requirements in a statement of directors’
responsibilities within the Quality Account.
We refer to these two indicators collectively as “the
indicators”.
Respective responsibilities
of the Directors and the
auditor
The Directors are required under the Health Act 2009
to prepare a Quality Account for each financial year.
The Department of Health has issued guidance on
the form and content of annual Quality Accounts
(which incorporates the legal requirements in the
Health Act 2009 and the Regulations).
●● the Quality Account presents a balanced picture
of the trust’s performance over the period
covered;
●● the performance information reported in the
Quality Account is reliable and accurate;
●● there are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Account,
and these controls are subject to review to
confirm that they are working effectively in
practice;
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 Account is not prepared in all material
respects in line with the criteria set out in the
Regulations;
●● the Quality Account is not consistent in all
material respects with the sources specified in the
NHS Quality Accounts Auditor Guidance 2014-15
(“the Guidance”); and
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QUALITY ACCOUNTS REPORT 2014-15
PART 3
●● the indicators in the Quality Account identified
as having been the subject of limited assurance
in the Quality Account are not reasonably stated
in all material respects in accordance with the
Regulations and the six dimensions of data
quality set out in the Guidance.
We read the Quality Account and conclude whether
it is consistent with the requirements of the
Regulations and to consider the implications for our
report if we become aware of any material omissions.
We read the other information contained in the
Quality Account and consider whether it is materially
inconsistent with:
●● Board minutes for the period April 2014 to March
2015;
●● papers relating to quality reported to the Board
over the period April 2014 to March 2015;
●● feedback from the Commissioners dated May
2015;
●● the Trust’s complaints report published under
regulation 18 of the Local Authority, Social
Services and NHS Complaints (England)
Regulations 2009, dated June 2015
●● the 2014 national patient survey dated May
2015;
●● the 2014 national staff survey dated December
2014;
●● the Head of Internal Audit’s annual opinion over
the trust’s control environment dated April 2015;
●● the annual governance statement dated 4 June
2015; and
●● the Care Quality Commission’s Hospital Intelligent
Monitoring Report dated May 2015.
We consider the implications for our report if we
become aware of any apparent misstatements or
material inconsistencies with these documents
(collectively the “documents”). Our responsibilities
do not extend to any other information.
This report, including the conclusion, is made solely
to the Board of Directors of The Pennine Acute
Hospitals NHS Trust.
We permit the disclosure of this report to enable
the Board of Directors to demonstrate that they
have discharged their governance responsibilities
by commissioning an independent assurance report
in connection with the indicators. To the fullest
extent permissible by law, we do not accept or
assume responsibility to anyone other than the
Board of Directors as a body and The Pennine Acute
Hospitals NHS Trust for our work or this report save
where terms are expressly agreed and with our prior
consent in writing.
Assurance work performed
We conducted this limited assurance engagement
under the terms of the Guidance. Our limited
assurance procedures included:
●● evaluating the design and implementation of the
key processes and controls for managing and
reporting the indicators;
●● making enquiries of management;
●● 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 of the Quality Account to
the requirements of the Regulations; and
●● reading the documents.
A limited assurance engagement is narrower in
scope than a reasonable assurance engagement.
The nature, timing and extent of procedures for
gathering sufficient appropriate evidence are
deliberately limited relative to a reasonable assurance
engagement.
PAGE 105
Limitations
Conclusion
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.
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 absence of a significant body of established
practice on which to draw allows for the selection
of different but acceptable measurement
techniques which can result in materially different
measurements and can impact comparability. The
precision of different measurement techniques may
also vary. Furthermore, the nature and methods
used to determine such information, as well as the
measurement criteria and the precision thereof, may
change over time. It is important to read the Quality
Account in the context of the criteria set out in the
Regulations.
The nature, form and content required of Quality
Accounts are determined by the Department of
Health. This may result in the omission of information
relevant to other users, for example for the
purpose of comparing the results of different NHS
organisations.
In addition, the scope of our assurance work has not
included governance over quality or non-mandated
indicators which have been determined locally by The
Pennine Acute Hospitals NHS Trust.
the Quality Account is not prepared in all material
respects in line with the criteria set out in the
Regulations;
the Quality Account is not consistent in all material
respects with the sources specified in the Guidance;
and
the indicators in the Quality Account subject to
limited assurance have not been reasonably stated
in all material respects in accordance with the
Regulations and the six dimensions of data quality set
out in the Guidance.
KPMG LLP
1 St. Peter’s Square
Manchester
M2 3AE
30 June 2015
Trust Headquarters
North Manchester
General Hospital
Delaunays Road
Crumpsall
M8 5RB
Tel: 0161 624 0420
@PennineAcuteNHS
https://www.youtube.com/user/
PennineAcuteNHSTrust
http://www.pat.nhs.uk