Agenda item 7(iii)
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
COUNCIL OF GOVERNORS
CLINICAL ASSURANCE TOOLKIT (CAT)
EXECUTIVE SUMMARY
This paper provides the regular monthly report to support Nursing and clinical
quality assurance
Governors are aware that the Clinical Assurance Toolkit (CAT) is a selfassessment process undertaken by Sisters/Charge Nurses, regarding clinical
standards at Ward and Department level, as well as environmental cleanliness
checks by the Matrons (in the acute setting) which are peer reviewed quarterly.
Following the question changes in April, scores fell from an average of 97% in
March to an average of 93% in April, recovering slightly to 94% in May, and still
further to 95% in June. Both the decrease and recovery were expected given the
new areas of assurance being tested following April’s changes.
The specific focus of this paper varies each month as a particular aspect of
practice is reviewed. This month, the focus is on Infection Prevention & Control
(IPC) Practice questions.
The reporting of escalated ‘red scores’ to the Board occurs on the second
consecutive month reported to be red.
This paper also details progress in the Acknowledging Continual Excellence (ACE)
Awards.
RECOMMENDATION
To (i) note the content of this report (ii) comment accordingly.
Mrs Helen Lamont
Nursing & Patient Services Director
10th September 2015
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
COUNCIL OF GOVERNORS
CLINICAL ASSURANCE TOOLKIT (CAT)
1.
INTRODUCTION
This is the third monthly report since the updating of questions in the April 2015
CAT survey.
2.
CAT REPORT SUMMARY
2.1
Scores & Trends
Following the question changes in April, scores fell from an average of 97% in
February and March to an average of 93% in April, recovering slightly to 94% in
May, and still further to 95% in June, all of which was expected as it is a pattern
we have previously seen. Scores by Directorate can be found in Appendix 1.
2.2
Focus on IPC Practice
Each month, this section of the report takes a particular area of practice that is
audited via CAT, and analyses the data in more detail. This month, the focus is on
IPC Practice, which provides questions to ensure that potentially infectious
patients are isolated, and that appropriate care has been given.
In order to minimise the risk of spreading infection, it is essential that patients are
isolated if they are known or suspected to be infectious. Monitoring of isolation is
an important function within CAT. In June, 84 Wards reviewed their IPC Practice
in relation to isolation (including adults, paediatrics, critical care and maternity) and
93% of these areas were able to isolate all patients who required isolation.
It is not always possible to isolate patients due to the limited availability of cubicles
in some Wards, and the need to prioritise other patients. In all cases where there
is limited availability of cubicles, risk assessments are undertaken and patients are
barrier nursed in bays where isolation is not possible. The IPC Team and Estates
are working together on a long-term plan to ensure that Directorates are situated
in the best location according to the isolation needs of their patients.
For patients who have potentially infectious diarrhoea, it is important they are
isolated promptly. CAT questions, therefore, ask staff whether they have been
able to comply with the Trust standard to isolate patients after the first episode of
diarrhoea, and send a sample on the second episode of diarrhoea. The results tell
us that patients were isolated on the first episode of loose stool in 95% of Wards
during June, with a specimen sent to the lab on the second episode of loose stool
on 100% of Wards. Sending a specimen at this time is important in order to
identify the cause of the infection. Both of these results demonstrate good
practice.
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Diarrhoea care pathways are important for ensuring that patients are monitored
appropriately, with any changes in condition documented. CAT results
demonstrate 95% of Wards had appropriately completed care pathways for
diarrhoeal patients. Where staff feel a patient’s diarrhoea is non-infectious (for
example, if it is felt to be caused by medication), a review by medical staff must be
undertaken. This occurred in 95% of Wards in June.
Admission screening for MRSA is routinely undertaken for the majority of patients
who are admitted to the Trust. In June, 100% of Wards had screened all of their
MRSA positive patients on admission and care pathways were complete for all
patients on 100% of Wards. Again, this demonstrates excellent care and
compliance with policy.
June’s results relating to IPC Practice are consistent with previous months and
demonstrate that best practice is being followed by Ward staff. The appropriate
management of patients with known or potential infections is a high priority for
Ward staff.
Next month the focus will be on Invasive Devices.
2.3
Escalation of ‘Red’ Areas
Any area that achieves a red score (less than 91%) for the whole of the CAT over
two consecutive months will appear on the escalation report.
There were 19 areas with an overall red score for two consecutive months in June,
which is much higher than usual (as with last month), mostly due to question
changes for Smoking Cessation and Safeguarding staff knowledge. NEWS
documentation compliance has improved steadily since January and is now above
80% for the Trust but this continues to have an impact on scores for adult inpatient
Wards. However, question changes for NEWS have been agreed and will come
into force this month following discussions at the Deteriorating Patient Steering
Group. This involves the addition of a N/A answer option for all patients who do
not require piped oxygen. It is expected that the change will improve scores for
adult inpatient Wards.
The same process for two months of consecutive red scores applies to the
Matrons’ cleanliness checks.
There were three areas with an overall red score for two consecutive months in
the June’s Matrons’ cleanliness checks, which have been followed up with
Matrons. These areas are Ward 49 RVI, Ward 32/33 RVI and Prosthodontics
Dental Hospital. Ward 49 RVI has now decanted to the Freeman Hospital, to
allow the necessary refurbishment work to take place, which will resolve the
Estates issues which created the poor results. Ward 32/33 RVI had issues with
the documentation of cleanliness checks, which have been highlighted to staff by
Matron. Prosthodontics have reported their equipment to Estates for repair but
this has caused low scores.
Cleanliness checks are also peer-reviewed on a quarterly basis – the peer review
months are April, July, October and January. The next peer review cleanliness
check is due to take place in July.
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2.4
ACE Awards
The Trust now gives Acknowledging Continual Excellence (ACE) Awards to those
clinical areas where high CAT scores are maintained for four out of six months, in
order to encourage and reward Clinical Leaders. Awards are presented at Clinical
Leaders’ Forum, with Ward 37 ICCU Freeman receiving an award for cleanliness
and assurance in July, as well as Pre-assessment (Freeman and RVI) who were
awarded for assurance measures and clinical assurance.
3.
RISKS AND RISK MITIGATION
This report collates information related to providing clinical assurance, with the key
focus being risk mitigation through the monitoring of a range of patient safety and
patient experience issues.
Governors have previously been made aware of the escalation process which
highlights issues within clinical areas.
4.
SUMMARY
The CAT continues to be viewed as a positive assurance method. The ‘How we
are doing’ boards are the Trust’s method of communicating CAT scores, harm-free
care and infection control information to both members of staff on the wards and
the public and are visible at ward level. Development of a new format for the
information on the boards is underway, led by the Clinical Educators, to make
boards more accessible for patients and visitors.
5.
RECOMMENDATION
To note the contents of this report and comment accordingly.
6.
KEY
Main CAT Measures
Less than 91%
Between 91% and 97.9%
98% or more
Mrs Helen Lamont
Nursing & Patient Services Director
10th September 2015
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