THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
Board Paper - Cover Sheet
Date
Lead Director
Report Title: Assurance Toolkit (CAT) Agenda Item A5(iii)
Nursing & Patient Services Director
Report Author Helen Lamont, Nursing and Patient Services Director
Elizabeth Harris, Head of Nursing RVI
Classification
NHS Unclassified / NHS Protect / NHS Confidential
Purpose (Tick
one only)
Approval
Links to
Strategic
Objectives

Links to CQC
Domains/
Fundamental
Standard(s)
Identified
Risk? (If yes,
risk reference)
Resource
Implications
Legal
implications
and equality
and diversity
assessment
Discussion
For Information

To put patients and carers at the centre of all we do and to provide
care of the highest standard in terms of both safety and quality
 To continue to be recognised as a first-class teaching hospital,
counted amongst the top 10 in the country, which promotes a
culture of excellence, in all that we do
Regulation 9, 11, 12, 13, 14, 15, 17, 18
None
No additional resource implications
Failure to assure high quality and safe care may lead to patient harm,
litigation against the Trust and loss of reputation.
There are no specific equality and diversity implications from this
paper.
Benefit to
patients and
the public
Assuring patient safety
Report History
This is a regular monthly update to the Board on the results from the
Clinical Assurance Toolkit (CAT) and to provide assurance of the
progress and priorities attaches to a range of patient safety and quality
issues.
To read, discuss and note this paper
Next steps
Agenda item A5(iii)
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
CLINICAL ASSURANCE TOOLKIT (CAT)
EXECUTIVE SUMMARY
This paper provides the regular monthly report to support Nursing and clinical
quality assurance
The Board is aware that the Clinical Assurance Toolkit (CAT) is a monthly 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.
This month’s report contains the following:

Trend information on the overall CAT scores, which have been consistently
between 94% and 95% in recent months. October’s overall CAT score was
95%, which means that scores have not been adversely affected by the sixmonthly question changes. Staff Knowledge is now at 89%, following
changes to the wording of some questions which reflect feedback from
clinical staff.

Each month an aspect of CAT is analysed in more detail. This month the
focus is on the Theatres questions at a Trust level. Scores for these
questions are high, which is demonstrates that appropriate pre-operative
checks have taken place and that appropriate post-operative action has
been taken for any infectious patients.

An overview of the areas with red scores for two months that have been
escalated to Matrons of 12 areas. Cleanliness checks were red in only one
area for the two months ending October.

Details on the progress in the Acknowledging Continual Excellence (ACE)
Awards, a number of Matrons have now begun the process of applying for
ACE Awards for their areas.
RECOMMENDATION
To (i) note the content of this report (ii) comment accordingly.
Mrs Helen Lamont
Nursing & Patient Services Director
17th November 2015
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
CLINICAL ASSURANCE TOOLKIT (CAT)
1.
INTRODUCTION
This is the first monthly report since the updating of questions in the October 2015
CAT survey.
2.
CAT REPORT SUMMARY
2.1
Scores & Trends
Following the question changes in October, scores have not fallen as we have
seen in previous question changes. Particular care was taken to work with clinical
staff and the specialists for each question group in order to ensure that questions
which previously generated low scores were clear and unambiguous. Scores by
Directorate can be found in Appendix 1.
The table below demonstrates the trends within CAT over a period of six months,
as presented every month to the Board. Staff Knowledge scores continue to be
‘red’ at Trust level, due to a combination of issues, which have been previously
explained to Board. Changes to Safeguarding and Medical Staff Knowledge
questions have resulted in an improvement of more than 2% between September
and October. The ‘amber’ scores for Assurance Measures relate mostly to
documentation questions, including patient risk assessments.
The scores from Environmental Cleanliness continue to demonstrate high
standards across the Trust. These are triangulated by annual audits by the Deputy
Directors of Nursing and Patient Service, and also Hotel Services checking
procedure - ‘Credits for Cleaning’.
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2.2
Focus on Theatres
This month, the focus and analysis in this section is on the questions which give
assurance in Theatres. The CAT questions ensure that the appropriate checks for
patients undergoing surgery have been carried out and, as with other CAT
questions, were developed by the clinical leaders to ensure they are both relevant
and comprehensive.
There were 60 patients reviewed as part of the Theatres CAT in October across
the Trust. The World Health Organisation (WHO) checklist is a crucial part of the
pre-operative checks, and this was found to have been documented and complete
in 97% of cases, this is good practice and the 3% non-compliance has been
followed up. The data also tell us that the Theatre Register was completed in
100% of cases, this is excellent practice. Prophylactic antibiotics are essential to
preventing infections during or after surgery and were given prior to incision in
100% of relevant cases in October.
Clinical alerts for patients include issues such as infection risks, which it is
important for the surgical team to know about in advance so that they can take
appropriate action. The CAT tool tests if this happens in practice, reassuringly,
clinical alerts were discussed in 100% of cases reviewed For infectious patients,
the Theatre must be ‘terminal cleaned’, which occurred in 100% of cases. Where
samples are taken, it is essential that the accompanying information is accurate for
that patient. The specimens check during October had the correct patient
information in 100% of cases.
During surgery, it is important that both the patient’s temperature and glucose
levels are maintained. Evidence that the temperature was maintained was
documented in 96% of cases and that glucose levels were maintained in 100% of
cases. October’s results relating to nutrition are consistent with previous months
(98% overall) and demonstrate that best practice is being followed by Theatre staff
across the Trust.
Overall, the analysis of the Theatre questions has revealed good assurance. Next
month the focus will be on Outpatient clinic waiting times.
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 12 areas
with an overall red score for two consecutive months in October, compared with 11
in September. It is worth nothing that 9 of the 12 areas with red scores had a
slightly improved score in the second month. Matrons have all been informed of
these scores so they can follow up with Sisters/Charge Nurses and other Clinical
Leaders.
Overall, Medical staff knowledge has improved by around 5% and Safeguarding
staff knowledge by around 11% between September and October, due to the
question changes. This highlights the importance of clinical staff engagement in
the development of CAT to ensure that the questions are right.
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The same process for two months of consecutive red scores applies to the
Matrons’ cleanliness checks. There was one area with an overall red score for two
consecutive months in October’s Matrons’ cleanliness checks, which was also a
peer review month.
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. Progress to date has been slow, despite the process for the
awards being known to all Matrons and Sisters/Charge Nurses; no further areas
have achieved an ACE Award since July. This is disappointing as there are many
areas who are eligible to apply.
Sisters/Charge Nurses have been sent an email with a report showing which areas
can apply for which part of the ACE Award. They have been encouraged to
discuss their application with their Matron as soon as possible. The newly
appointed Practice Development Senior Nurse in Patient Services is taking a lead
in promoting and encouraging this process.
3.
RISKS AND RISK MITIGATION
The key focus of CAT is to mitigate risks through the monitoring of a range of
patient safety issues. Ward Sisters/Charge Nurses and other Clinical Leaders are
encouraged to view their results alongside other assurance data, such as the
results of other audits and their Care Summary reports, in order to build a
complete picture of their area’s strengths and weaknesses.
The focus of this month’s paper demonstrated the importance of the checks
carried out in theatres, ensuring patient safety in the peri-operative environment.
The Board has 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.
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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
17th November 2015
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