THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
Board Paper - Cover Sheet
Date: 24th
February
2016
Lead Director
Report Title: Clinical Assurance
Toolkit (CAT)
Agenda Item A5(iv)
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(iv)
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 score, continues to be above 96% in
January, following a number of months between 94% and 95%. Clinical
staff will be consulted during February on question changes, which will take
effect from April.

Each month an aspect of CAT is analysed in more detail. This month the
focus is on the Nursing assessment documentation, at a Trust level.
Scores for these questions are high overall, which demonstrates that the
documentation is completed appropriately and risk assessments are carried
out.

An overview of the areas with red scores for two months that have been
escalated to Matrons. These were 4 areas in January, demonstrating an
improvement on previous months (6 in December). Cleanliness checks
were not red in any areas for the two months ending January, which reflects
high standards from the Matron peer review checks.

Details on the progress in the Acknowledging Continuous Excellence (ACE)
Awards. Four applications for an ACE Award are currently in progress.
RECOMMENDATION
To (i) note the content of this report (ii) comment accordingly.
Mrs Helen Lamont
Nursing & Patient Services Director
Mrs Elizabeth Harris
Deputy Director of Nursing & Patient Services (RVI)
8th February 2016
THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST
CLINICAL ASSURANCE TOOLKIT (CAT)
1.
INTRODUCTION
This is the third monthly report since the updating of questions in the October 2015
CAT survey.
2.
CAT REPORT SUMMARY
2.1
Scores & Trends
The table below demonstrates the trends within CAT over a period of six months.
Scores by Directorate can be found in Appendix 1. Staff Knowledge scores
continue to be ‘red’ at Trust level, due to a combination of issues, which have been
previously explained to Board, although gradual and continued progress is noted.
The scores from Environmental Cleanliness continue to demonstrate high
standards across the Trust. Staff value the importance of high environmental
standards and are proud of these. The CQC Inspectors commented upon the
‘spotlessly clean’ hospitals following their visit in January.
2.2
Nursing Assessment Documentation
This month, the focus and analysis in this section is on Nursing assessment
documentation. Many of the questions on CAT in this section relate to the risk
assessments undertaken for patients on admission to the Trust. The purpose of
having these questions in CAT is to ensure that these preventative risk
assessments have taken place at the appropriate time.
Overall, 362 patients had their risk assessment documentation reviewed as part of
CAT in January. Of these, 100% had a complete skin or wound assessment, 99%
had a falls risk assessment, 95% had a nutrition assessment, 100% had a moving
and handling assessment, 98% had a depression screening, and 100% had an
infection prevention and control assessment. These results are in line with
previous months, although the checks for moving and handling, depression
screening and IPC assessments were only introduced to the CAT in October 2015.
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In addition to the above checks, the recording of pain scores and documentation of
patient property are undertaken in Emergency Department RVI and Emergency
Admissions Suite Freeman. Of the eight patients checked for pain scores, seven
had a pain score recorded and six out of seven had property checks completed.
In Radiology Departments, equipment is checked before clinics every morning.
These checks had been documented in 100% of departments in January. Checks
on the identity of the patient and the need for the procedure being undertaken are
also important – these checks mitigate the risk that patients may be unnecessarily
exposed to radiation if they are misidentified. Of the 33 patients reviewed in
January, 100% had undergone an identity check before their procedure and 100%
had been checked to ensure that the procedure was required.
January’s results relating to Nursing assessment documentation are consistent
with previous months and demonstrate high levels of compliance with
documentation. As eRecord develops to include such assessment documentation,
the CAT scores will retrieve information from eRecord about compliance. This will
save Sisters/Charge Nurses some time but will also ensure that all patients are
audited, rather than a sample of five per area.
Next month the focus will be on NEWS documentation.
2.3
Escalation of ‘Red’ Areas
Any area that receives a red score (less than 91%) for the whole of the CAT over
two consecutive months will appear on the escalation report. There were four
areas with an overall red score for two consecutive months in January, compared
with 6 in December. This reduction is promising, although it is worth nothing that
any changes made to CAT questions from April are likely to have an impact on the
number of areas receiving a red score, as we have seen in previous question
changes. CAT users will be consulted in February to mitigate the chances of red
scores resulting from a lack of understanding or clarity about the questions.
Only one of those with two months of red scores in January appeared on the
escalation report in December, which demonstrates improvements in the other
areas which had previously been red. Ward 1A RVI appeared on this month’s and
last month’s report. An additional Senior Nurse has been moved to the Ward and
all staff are aware of the issues and working hard to address.
The same process for two months of consecutive red scores applies to the
Matrons’ cleanliness checks. There were no areas with an overall red score for
two consecutive months in January. This was a peer review month for the Matron
checks.
2.4
ACE Awards
The Acknowledging Continuous Excellence (ACE) awards continue to be high
priority, and the Corporate Patient Services, and the Patient Experience Teams,
are working together to develop the application process further and continue to
highlight the fantastic work that underpins this process. Any clinical area which
maintains high CAT scores for four out of six months is eligible to apply. Almost all
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areas completing CAT are eligible to apply for their Environmental Cleanliness
ACE award due to the high standard across the Trust.
There are four applications for awards pending and discussions are ongoing with
two other Directorates to determine the eligibility of their Wards and encourage
applications.
3.
CAT USER GROUP
The first meeting of the CAT User Group will take place in February. This group
was established to encourage engagement from clinical staff, following an
extensive piece of research work to assess the extent of inconsistent practices
among those collecting data for CAT. New guidance and training has been
developed and put in place but this group will help to ensure that discussions are
ongoing about how Sisters/Charges Nurses and other Clinical Leaders can get the
most out of the CAT process.
Meetings will be quarterly and will give staff a chance to have their say about the
future development of CAT, as well as sharing best practice (for example, about
the correct way to select samples of patients in order to answer the questions in
the tool each month). The number of red scores tends to increase after each sixmonthly change in the questions, but having a high level of input from those who
use the tool will ensure that scores are a true reflection of compliance, rather than
a lack of clarity about what is being asked.
4.
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.
Monitoring Nursing assessment documentation is one way of mitigating risk by
ensuring that preventative measures are taken, whether this is identifying patients
at risk of falling or ensuring that the correct patient has arrived for a Radiology
procedure.
The Board has previously been made aware of the escalation process which
highlights issues within clinical areas. No major issues or risks were identified
from the red scores.
5.
SUMMARY
The CAT continues to be viewed as a positive assurance method. Continued
involvement from clinical staff in the development of the CAT ensures that the tool
provides relevant assurance across a range of clinical settings. The focus of this
month’s paper demonstrated the importance of Nursing assessment
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documentation, ensuring that everything possible can be done to keep our patients
safe.
6.
RECOMMENDATION
To note the contents of this report and comment accordingly.
7.
KEY
Main CAT Measures
Less than 91%
Between 91% and 97.9%
98% or more
Mrs Helen Lamont
Nursing & Patient Services Director
Mrs Elizabeth Harris
Deputy Director of Nursing & Patient Services (RVI)
8th February 2016
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