94%
98%
94%
91%
n/a
N/A
90%
91%
91%
90%
80%
0
N/A
0
0
60%
2
85%
73%
91%
90%
0
0
0
0
0
0
0
0
0
0
100%
100%
100%
5
1
1
0
0
% End date
included
0
100%
100%
100%
93%
100%
% shifts 'at risk
staffing'
92%
0
13
% shifts
'minimum
staffing'
CTCC / CCU**
CTW *
6A *
5D*
Theatres**
100%
98%
100%
100%
100%
100%
4 & 20
% shifts 'agreed
staffing'
100%
100%
100%
91%
81%
83%
1
SIRIs Not Incl
Pressure Ulcers
Cardiology *
5
Single Sex
Breaches
96%
4
Compliance with
Nutritional
Assessments
100%
4
Pressure Ulcers
Grade 2/3/4 / Skin
Integrity
92%
4&9
Compliance with
Track and Trigger /
EWS
Antimicrobial
4
Medication errors
causing harm
8
Falls causing harm
8
% Correct
presciption
8
National Cleaning
Overall Score
CAS **
8
ANTT Injectables
Directorate
Medicine
Ward
Surg &
Vasc
PP
Cardiac, Vascular
and Thoracic (3)
Division
CQC Outcomes
C, V & T Quality Scorecard Board
Hand Hygiene
March Data
0
0
27%
68%
5%
0
0
32%
68%
0%
0
0
0
0
0
1
0
0
0
2
57%
95%
16%
77%
43%
5%
62%
23%
0%
0%
22%
0%
Track & Trigger; non- compliance is due to staff not documenting actions they have taken. Sister has reiterated at staff meeting & via communication book the importance of
documentation. Weekly audits initiated along with teaching. Medical staff are being reminded daily to change parameters as appropriate.
Pressure ulcers: All pressures ulcers reported are grade 2. All patients were assessed and nursed on pressure relieving mattresses.
Cardiology: In both cases nursing staff had taken the appropriate steps by ensuring patients were on pressure relieving mattresses, regular position changes occurred. The Tissue
Viability link nurse is producing a teaching for staff on pressure sore prevention and management.
CTCCU : - 4 patients sustained grade two pressure area damage to buttocks/sacral area, All of the patients were very high risk and long term, including being treated with
vasoconstricting drugs. Turning charts have been implemented. 1 patient sustained grade two pressure damage to nose and lip from nasogastric and ET tube. Patient was high
risk, invasive equipment gently moved once nursing team aware of skin injury. Ulcer continues to heal.
6A: All preventative pressure relieving measures were in place and ulcer has now healed.
CTW: 1 patient had pressure ulcer on neck on transfer from CTCCU, resulting from ECG leads being placed behind the neck whilst in bed. Staff are reminded to ensure the position
of leads are checked regularly. Ulcer is healing.
SIRI's; 3 orange graded incidents occurred; i) Patient suffered a PEA cardiac arrest during transfer from the operating table to bed. The surgical team were not present at the time
of the arrest. ii) Patient on CTCCU deteriorated at night and the Consultants on call were busy operating in theatre . iii) During an elective CABG a plastic shod was lost measuring
approximately 1cm. The consultant surgeon was aware at time, searched inside the chest and then proceeded with closure.
Staffing; This has been managed by staff being moved across division to mitigate risk and ensure patient safety.
Key
Poor
V. High Risk
**
>95
90-95
<90
Green
Fair
Good
High Risk
Significant Risk
*
>92
>85
87-92
80-85
<87
<80
Amber
Red
New Structure Metrics V 2
Final November 2011 SY
National Cleaning Specification (%)
Antimicrobial Prescribing
80% or more
70 - 79%
69% and below
96%
92%
0
0
93%
50%
50%
0
0
0
63%
0
0
100%
0%
0%
95%
92%
0
0
90%
73%
73%
0
0
84%
0
57%
0
0
100%
0%
0%
Childrens Ambulatory Care
95%
98%
100%
100%
0
0
0
0
88%
96%
0
0
0
0
N/A
100%
0
0
na
96%
0
0
0
0
99%
98%
1%
2%
0%
0%
88%
95%
0
0
92%
100%
100%
0
0
100%
0
80%
0
0
50%
50%
0%
96%
100%
0
0
92%
N/A
N/A
0
0
100%
0
80%
0
0
80%
20%
0%
100%
100%
0
0
88%
100%
100%
0
0
80%
0
85%
0
0
96%
4%
0%
0%
HGH Childrens W *
Bel / Dray *
Kamrans **
Melanies *
NNU**
SCBU**
PHDU**
PICU**
Catheter on
going care
Toms *
Robins *
Ward
Catheter
Insertion
% shifts 'at risk
staffing'
13
% shifts 'minimum
staffing'
4 & 20
% shifts 'agreed
staffing'
1
SIRIs Not Incl
Pressure Ulcers
5
Single Sex
Breaches
4
Compliance with
Nutritional
Assessments
4
Pressure Ulcers
Grade 2/3/4 / Skin
Integrity
4&9
Total No of
medication errors
that did harm
Antimicrobial
4
Total No of
Accidents that did
harm
8
% End date
included
8
% Correct
prescription
8
National Cleaning
Overall Score
8
C-Diff post 72 hrs
8
Saving Lives Catheter
Care
MRSA / MSSA
post 48 hrs
8
ANTT Injectables
8
Hand Hygiene
Directorate
Paediatrics
Paediatric
Critical Care
Children's
Division
CQC Outcomes
C & W Quality Scorecard Board
Compliance with
Track and Trigger /
EWS
March Data
100%
100%
0
0
96%
100%
100%
0
0
N/A
0
na
0
98%
2%
92%
100%
0
0
96%
100%
100%
0
0
N/A
0
na
0
100%
0%
0%
96%
95%
98%
96%
0
0
0
0
95%
92%
100%
100%
100%
100%
0
0
0
0
100%
100%
0
0
na
na
0
0
70%
80%
30%
20%
0%
0%
90-95
87-92
80-85
<90
<87
<80
Anti microbial - A re-audit was undertaken on Toms Ward and showed improvement
Nutritional scores - The Matron is embedding the compliance with STRONG assessment tool
Staffing - Staffing has been maintained by use of temporary staff, the movement of staff and through the management of available beds
Key
Poor
Fair
Good
New Structure Metrics V.2SY Final November 2011
National Cleaning Specification (%)
V. High Risk
**
>95
High Risk
*
>92
Significant Risk
>85
Green
Amber
Red
Antimicrobial Prescribing
80% or more
70 - 79%
69% and below
EMTA Quality Scorecard Board
75%
100%
75%
80%
100%
100%
98%
100%
100%
Closed
0%
0%
100%
98%
98%
100%
100%
100%
100%
100%
100%
0%
91%
85%
93%
92,5%
93%
93%
90%
89%
92%
87%
90%
93%
94%
91%
91%
87%
89%
N/A
NA
92%
NA
NA
NA
NA
NA
89%
0%
0%
0%
93%
71%
100%
85%
93%
93%
91%
73%
100%
100%
closed
♠
♠
90%
100%
100%
93%
100%
92%
100%
100%
79%
71%
100%
100%
100%
100%
100%
100%
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100%
100%
100%
100%
90%
90%
95%
98%
100%
0
0
0
0
0
1
0
0
1
closed
96%
100%
95%
100%
100%
100%
100%
0
1
0
1
0
0
0
0
0
0
0
0
0
0
0
5
1
85%
100%
85%
100%
85%
86%
100%
100%
100%
100%
100%
90%
97%
100%
0
1
0
0
0
0
0
0
0
na
0
0
0
0
0
0
0
0
0
0
13
4 & 20
SIRIs Not
Incl Pressure
Ulcers
4
Compliance
with
Nutritional
Assessments
Episodes of
Single Sex
Breaches
4
Hospital acquired
Pressure Ulcers
Grade 2/3/4
Falls that
caused harm
%
Correct
prescripti
on
% End
date
included
0%
4&9
Total No of
medication
errors that did
harm
Compliance
with Track
and Trigger /
EWS
Antimicrobial
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
% shifts 'at
risk staffing'
94%
100%
100%
100%
100%
100%
98%
95%
100%
50%
100%
100%
100%
78%
N/A
100%
N/A
8
% shifts
'minimum
staffing'
100%
95%
100%
100%
92%
92%
92%
100%
100%
8
% shifts
'agreed
staffing'
JR ED **
JR EAU *
HGH ED **
HGH EAU *
7A *
7B *
7C *
7D *
7F*
5C
5A *
PAU *
Oak *
Laburnam *
Juniper *
Level 4 *
ASU *
John Warin **
Geoffrey Harris *
Treatment Centre
Dermatology
Immunology
OCDEM Endocrine
OCDEM Diabetes
Sleep Physiology
GUM
Genetics
8
National
Cleaning
Overall Score
Ward
8
Hand Hygiene
Directorate
Emergency Medicine
Ambulatory, Chest, ID
Emergency Medicine, Therapies & Ambulatory (7)
Division
CQC Outcomes
ANTT
Injectables
March Data
74%
19%
97%
78%
41%
57%
39%
70%
61%
0%
12%
37%
94%
79%
72%
38%
62%
75%
15%
26%
65%
3%
22%
47%
21%
40%
19%
31%
0%
44%
48%
6%
21%
23%
62%
24%
17%
80%
0%
16%
0%
0%
11%
21%
21%
11%
8%
0%
45%
15%
0%
0%
0%
0%
14%
8%
5%
Pressure Ulcers
Geratology - One grade 3 pressure ulcer developed whilst on ward, patient was admitted with several existing pressure ulcers and was at very high risk. Preventative actions were put in place. Issue around clear documentation and photography being addressed and .
Improvement programme in place. 7A - A patient was admitted to the ward with various pressure ulcers, SPS/PCM/Photography/Care plans in place. Incident forms completed. 7B - Two patients admitted with category2 and 3 pressure sore. 1 Cat. 2 pressure sore
developed on ward despite turning charts and pressure relieving mattress mainly due to pt's compromised medical condition and continence issues. No further deterioration since developing and photograph taken. Incident forms completed and all pressure sores
photographed. Turning charts and appropriate pressure care mattresses and cushions in situ. 7C - Patient admitted with pressure sore to 7C from home. PSPS/PCM/Photography/Care plans in place. Incident form completed. 7D - 2 Grade 3 pressure sores - both patients
admitted with these to the unit. PSPS/PCM/Photography/Care plans in place. Incident forms completed. 7F - Grade 3 pressure sore when admitted to ward. Incident form completed, photographs taken, care plans in place, repose boots obtained, appropriate
pressure relief mattress insitu. HGH (EAU) - All grade 3-4 on admission not hospital acquired. Repose mattresses utilised and incident data recorded . JR (EAU)patient admitted with pressure ulcers and not acquired on EAU.
Cleaning Scores
Stroke Unit (5B) - Low cleaning score, action has been taken and there has been an overall improvement in the nursing cleaning score. Further measures were taken to address an issue around descaling sinks ,taps and clutter behind nurses station. 7C- Cleaning score 90%
overall , Carillion = 88%. Repeat cleaning audit undertaken by matron and infection control. Jobs list created and issues resolved. 2nd "red audit in 2 months but relate to different Carillion staff member. Close monitoring of current cleaner. JWW -Low cleaning scores.
Recommended that G4S supervisors attend JWW on a daily basis to monitor cleaning. Also suggested that regular cleaners are allocated for a 4 week period to see if continuity helps to improve the cleaning scores. JR (EAU) low cleaning score, to be managed by increased
focus by Sister on quality improvement. JR (ED) score below required standard, new daily cleaning audit staff introduced, however impact of low staffing on scores evident.
Staffing
7C- Vacancy and increased use of agency. Vacancy concerns raised - matron to consider returning permanent staff to 7C from escalation area. JR (EAU) - severe staffing issues due to increased vacancy rate and long term sickness, being managed by a change of role by the
Sister to concentrate on recruitment and retention. JR (ED) - severe staffing issues due to a combination of maternity leave and long term sickness. High focus on recruitment, strict management of roster and staffing levels to maintain core safety, dedicated HR support
requested at directorate level. Two of the JR matrons have offices physically based in the ward environment, thus providing easily accessible nursing leadership. Matrons also visit their clinical units at least daily.
C-Diff
7C - The patient was Post 72 hours c.diff and had type 6/7 stools per day for 5 days. A specimen was sent and staff followed appropriate precautions.
Single Sex Breaches
Single sex breach occurred to ensure appropriate management of care, measures were taken to ensure privacy and dignity were maintained.
Key
Poor
Fair
Good
New Structure Metrics V.2Final November 2011 SY
V. High Risk
High Risk
Significant Risk
National Cleaning Specification (%)
**
>95
*
>92
>85
90-95
87-92
80-85
<90
<87
<80
Green
Amber
Red
Antimicrobial Prescribing
80% or more
70 - 79%
69% and below
Single Sex
Breaches
0
0
0
0
0
0%
n/a
n/a
n/a
na
0
0
0
0
0
100%
na
na
na
na
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
na
na
na
na
na
na
na
na
0
0
0
0
0
0
0
0
% shifts 'at risk
staffing'
NA
*
NA
NA
NA
*
0
0
0
0
0
0
0
0
0
0
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
0
0
0
0
0
94%
95%
90%
93%
97%
99%
93%
93%
6%
5%
10%
7%
3%
1%
7%
7%
0%
0%
0%
0%
0%
0%
0%
0%
0
0
Hand Hygiene - The Matron will be working in Theatres (23 April 2012) to review hand hygiene and other practices,including WHO safety checklist. Individuals
identified as failing to comply with HH will be challenged by the Matron and identified to the Clinical Lead for action.
Track & Trigger - this is completed bi-monthly - Matron will do a spot audit
Staffing - Safe staffing levels were maintained through the use of staff working excess hours and the use of temporary staff.
Nutritional Assessments - The internal inspection undertaken by the Division showed that were relevant these were all completed
Key
Poor
Fair
Good
New Structure Metrics V.2
Final November 2011 SY
V. High Risk
High Risk
Significant Risk
National Cleaning Specification (%)
**
>95
*
>92
>85
90-95
87-92
80-85
<90
<87
<80
Green
Amber
Red
13
% shifts 'minimum
staffing'
92%
n/a
93%
95%
NA
*
NA
NA
NA
*
4 & 20
% shifts 'agreed
staffing'
0%
1
SIRIs Not Incl
Pressure Ulcers
79%
96%
88%
5
Compliance with
Nutritional
Assessments
Delivery Suite / Obs
100%
Spires Midwifery Led
Level 5
41%
Level 6
100%
Level 7
Maternity Assessment Unit
HGH Delivery Suite
HGH Post Natal Ward
100%
4
Pressure Ulcers
Grade 2/3/4 / Skin
Integrity
92%
90%
4
Compliance with
Track and Trigger
/ EWS
100%
100%
66%
4&9
Total No of
medication errors
that did harm
JR Gynae*
HGH Gynae*
Gynae Scrub
Gynae A & R
Maternity Theatres
4
Total No of Falls
That did harm
National Cleaning
Overall Score
Antimicrobial
% End date
included
8
% Correct
prescription
8
ANTT
Injectables
Directorate
8
Gynae
Ward
8
Maternity
Gynae and Maternity
Division
CQC Outcomes
Gynae and Maternity Quality Scorecard Board
Hand Hygiene
March Data
Antimicrobial Prescribing
80% or more
70 - 79%
69% and below
4&9
4
4
5
1
4 & 20
Pressure Ulcers
Grade 2/3/4/ Skin
Integrity
Compliance with
Nutritional
Assessments
Single Sex
Breaches
SIRIs Not Incl
Pressure Ulcers
Hand Hygiene
Combined
Antimicrobial
4
13
100%
100%
0
0
100%
0
95%
0
0
91%
9%
0%
89%
100%
100%
0
0
90%
0
85%
0
0
42%
38%
10%
Neurosciences OPD
100%
0
100%
0%
0%
2A *
95%
100%
89%
100%
70%
0
0
100%
4
100%
8
0
67%
24%
9%
100%
85%
100%
100%
0
0
100%
3
98%
0
0
50%
29%
21%
0%
% shifts 'at risk
staffing'
100%
% shifts
'minimum
staffing'
90%
90%
% shifts 'agreed
staffing'
95%
87%
% End date
included
NICU **
Ward
% Correct
prescription
Compliance with
Track and Trigger /
EWS
8
Total No of
medication errors
that did harm
8
National Cleaning
Overall Score
8
ANTT Injectables
8
Neurosciences IP *
Directorate
Neuro
Trauma
Specialist Surgery
Neuro, Trauma, Specialist
Surgery (3)
Division
CQC Outcomes
Total No of Falls
that did harm
NTSS Quality Scorecard Board
March Data
3A *
95%
Trauma OPD
95%
F Ward *
100%
85%
86%
100%
100%
0
0
98%
1
76%
0
0
73%
26%
1%
SSIP *
80%
100%
91%
100%
861%
0
0
100%
0
82%
0
0
88%
11%
1%
N/A
not done
0
Lichfield *
100%
90%
0
66%
34%
0%
SSOPD
100%
88%
0
50%
50%
0%
OPD Eye
OMFS OPD
96%
90%
93%
NOT AUDITED
0
0
32%
45%
23%
Pressure Ulcers - Ward 2A - Pressure Ulcer Cat 3 - patient admitted from home with long standing pressure ulcer history. Category 2 pressure ulcer unavoidable as all actions
taken. One category 2 developed as a result of foot drop splint despite being in place for a short time. One category 2 ulcer discovered on admission from another ward as part of
assessment. Ward 3A - one category 3 admitted with ulcer from home and two category 2 ulcers unavoidable as all required actions and risk assessments undertaken. F wardcategory 2 ulcer picked up on admission from home.
Nutritional assessments on F ward 76%. The Sister has spoken with staff and audits are now being undertaken twice monthly , together with monitoring and assessment of
compliance. The Sister will report results to Matron with a target to achieve improvement within one month. Nutritional Assessments SSIP and Neurosciences Ward both amber.
Audits to be completed at least twice a month until compliance achieved. The target is to achieve improvement within one month.
Single Sex breaches - The breach on 2A was unavoidable due to trust capacity overnight and maintaining the privacy and dignity of current inpatients. The breaches were
resolved the following morning.
At risk staffing - this was due to short notice sickness and not able to fill with bank or agency. Safety maintained in all areas
Cleaning audits - The Divisional Nurse has met with infection control to discuss and the Matrons are undertaking re-audits. Following a request, infection control staff
accompany other staff who undertake audit to ensure that audits are undertaken consistently.
Key
Poor
Fair
Good
Metrics V.2
Final SYNov 11
V. High Risk
High Risk
Significant Risk
National Cleaning Specification (%)
**
>95
*
>92
>85
90-95
87-92
80-85
<90
<87
<80
Green
Amber
Red
Antimicrobial Prescribing
80% or more
70 - 79%
69% and below
S & O Quality Scorecard Board
90%
94%
98%
90%
70%
80%
95%
100%
60%
100%
70%
70%
85%
93%
0
0
0
0
0
0
0
0
0
0
n/a
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
45%
74%
5%
64%
58%
58%
53%
92%
75%
98%
81%
46%
53%
33%
42%
23%
92%
16%
16%
13%
25%
8%
24%
1%
14%
40%
38%
54%
13%
3%
3%
20%
26%
29%
22%
0%
1%
1%
5%
14%
9%
13%
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
76%
100%
96%
70%
70%
87%
0%
0%
22%
0%
4%
30%
30%
13%
0%
0%
2%
0%
0%
0%
0%
0%
0%
0%
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100%
67%
0%
18%
0%
15%
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
100%
97%
NA
100%
100%
100%
100%
100%
80%
100%
90%
8000%
50%
90%
0
100%
97%
0
0
1
0
0
0
0
0
93%
0%
93%
0%
95%
97%
0
0
0
0
0
0
Antimicrobial
% Correct % End date
prescription included
100%
94%
100%
100%
50%
54%
100%
93%
100%
90%
NA
90%
89%
100%
100%
94%
100%
100%
50%
54%
80%
80%
100%
90%
NA
90%
89%
80%
0
0
0
0
0
0
0
0
0
0
0
0
Track and Trigger -Transplant ward - compliance 50% - This is a ward with step down High dependency beds and has medical staff available throughout the day. The
importance of documenting the actions and responses taken has been addressed by the matron with the ward staff. Action: Track and Trigger documentation compliance
will be audited weekly by the ward sister and any failures to comply will be escalated to the attention of the matron.
Nutritional Assessments - Poor documentation results for some wards. Ward dieticians will work with ward nursing teams to ensure that a nutritional assessment is
undertaken on admission for all patients. Action: Nutritional assessments will be audited weekly by ward sisters as part of an assurance programme.
ANTT- Results continue to improve across the division due to a focus on re-training and posters in all clinical areas have heightened awareness.
At risk staffing - this is due to vacancies and difficulties experienced filling with NHSP staff. Staff are moved to ward with highest acuity need and low staffing levels to
maintain clinical safety and this often compromises optimal staffing levels on provider ward.
Cleaning audits - The Matrons have met with infection control to discuss issues raised and Matrons and ward sisters are now always present at time of audits. Results are
fedback in real time to ward staff who can correct identified deficiencies and contact the helpdesk to record requests.
Key
Poor
Fair
Good
New Structure Metrics V.1Final August 2011 SY
V. High Risk
High Risk
Significant Risk
National Cleaning Specification (%)
**
>95
*
>92
>85
13
% shifts 'at risk
staffing'
4 & 20
% shifts
'minimum
staffing'
100%
0%
100%
0%
89%
100%
1
% shifts
'agreed
staffing'
80%
0%
100%
0%
100%
100%
5
SIRIs Not Incl
Pressure Ulcers
Oncology Treatment
Brody Centre HGH
Triage
Research
JR Endoscopy **
HGH Endoscopy **
4
Single Sex
Breaches
100%
95%
96%
100%
100%
73%
92%
90%
0%
Stoke Mandeville *
Milton Keynes *
Swindon *
Wycombe *
Th Churchill **
Th TDA / DCU *
97%
75%
98%
100%
100%
100%
88%
95%
4
Pressure Ulcers
Grade 2/3/4/
Skin Integrity
Oxford Man Unit*
4&9
Compliance with
Track and
Trigger / EWS
94%
91%
92%
91%
92%
92%
88%
na
92%
93%
0%
88%
96%
87%
4
Total No of
medication
errors that did
harm
National
Cleaning Overall
Score
96%
100%
100%
92%
93%
95%
100%
94%
95%
100%
95%
95%
89%
100%
8
Total No of Falls
that did harm
ANTT
Injectables
In Patient Wards
8
90%
100%
95%
100%
93%
100%
100%
95%
90%
91%
100%
96%
90%
80%
Oxford Tarver Dialysis*
Clinical Areas
8
Oncology Ward **
Haematology **
Sobell *
SEU D & Triage*
SEU E
SEU F *
5F *
HGH E Ward *
UGI *
Colorectal *
Jane Ashley *
Urology *
Transplant **
Renal Ward **
Ward
Surgery & Oncology (6)
8
Hand Hygiene
Division
CQC Outcomes
Compliance with
Nutritional
Assessments
March Data
90-95
87-92
80-85
<90
<87
<80
Green
Amber
Red
Antimicrobial Prescribing
80% or more
70 - 79%
69% and below
4 & 20
Pressure Ulcers
Grade 2/ 3/4 / Skin
Integrity
Compliance with
Nutritional
Assessments
13
% shifts 'at risk
staffing'
1
% shifts 'minimum
staffing'
5
% shifts 'agreed
staffing'
4
SIRIs Not Incl
Pressure Ulcers
4
Single Sex
Breaches
4&9
Total No of
medication errors
that did harm
Antimicrobial
4
Total No of Falls
that did harm
8
National Cleaning
Overall Score
8
ANTT
Injectables
8
Hand Hygiene
8
AICU **
81%
100%
93%
0%
0%
0
0
3
12
1
100%
0%
0%
CICU **
94%
100%
96%
100%
100%
0
0
0
0
0
100%
0%
0%
HGH CICU **
84%
100%
94%
92%
100%
0
0
0
7
0
100%
0%
0%
HGH DCU *
50%
93%
0
0
0
0
0
100%
0%
0%
Th West Wing **
80%
89%
87%
0
0
0
0
0
100%
0%
0%
Th JR **
60%
35%
82%
0
1
0
0
0
100%
0%
0%
Th HGH **
90%
100%
88%
0
0
0
0
0
100%
0%
0%
Directorate
Anaes / CC / Th
Critical Care,
Theatres,
Diagnostics &
Pharmacy (6)
Division
CQC Outcomes
Compliance with
Track and Trigger /
EWS
CCTDP Quality Scorecard Board
March Data
Ward
% Correct % End date
prescription
included
Cleaning Audit - The cleaning scores remain reduced at JR theatres. The Matron has now identified a team of Sisters responsible for making sure all
action points from the cleaning audits are undertaken. The night staff have now also been given a clear timetable identifying what cleaning needs to
take place overnight whilst there is reduced theatre activity .
ANTT - The new system of ANTT training was introduced during March 2012 and the results are showing an improvement.
Pressure Ulcers- There have been two orange incidents relating to pressure ulcers in CICU and CCU. On investigation both the pressure sores
originated from the referring hospitals.
There is one SIRI red regarding a patient that acquired a grade 3 Pressure Ulcer whilst being cared for on AICU. A full investigation is taking place and a
full report will be presented to the May 2012 Clinical Governance Committee.
Key
Poor
Fair
Good
New Structure Metrics V.2Final November 2011 SY
V. High Risk
High Risk
Significant Risk
National Cleaning Specification (%)
**
>95
*
>92
>85
90-95
87-92
80-85
<90
<87
<80
Green
Amber
Red
Antimicrobial Prescribing
80% or more
70 - 79%
69% and below
New Structure Metrics V.2Final November 2011 SY