Quality - NHS Choices Home Page · NCH&Creceives 16,500 referralsfromGPsand ... Total 280 313 380 432 429 391 427 485 457 499 566 535 5194. ... andChildHealth 2010/11whichtheacutetrustscollect

Looking after you locally

QualityAccount2011/12

2 Norfolk Community Health and Care NHS Trust

We have

3,000members of dedicated

NHS staff acrossthe county

We havearound

300patient bedsin Norfolk

More than

3,000patients per yearare admitted toour community

hospitals

Our SchoolNurses hold

1,300face-to-faceappointmentswith childreneach year

NCH&C receives

16,500referrals from GPs and

other healthcareprofessionalsevery month

We deliverhealth services

to over

400schools and

colleges

We delivermore than

70different servicesin and around

Norfolk

Our CommunityNursing teamshave around

108,000face-to-face contacts

with patientsevery month

OurHealth Visitorssee more than

1,000new familiesevery month

The content of this Quality Account has beenendorsed by the Trust Board and has taken intoaccount feedback from our lead commissioners,and our local population via the representativeorganisations, LINks and the Health Overview andScrutiny Committee. We trust that you will find ourQuality Account informative and helpful in reviewingour progress against our key priorities for theforthcoming year.

Contents

Quality Account Norfolk Community Health and Care NHS Trust 3

Part 11.1 Statement on quality 4

1.2 Our vision for the future 6

Part 22.1 Priorities for quality improvement

(2012/2013) 7

2.1.1 Annual priorities and Quality Goals 7for 2012/2013

2.1.2 Patient experience in 2012/13 8

2.1.3 Commissioning for Quality, Innovation,Productivity, Prevention (QIPP) 9

2.1.4 Our staff - workforce planningand development 11

2.1.5 Performance monitoring for 2012/13 12

2.2 Statements of assurance from the Board 14

2.2.1 Review of services 14

2.2.2 Participation in clinical audits 15

2.2.3 Participation in clinical research 18

2.2.4 Goals agreed with commissioners 19

2.2.5 Statement from theCare Quality Commission 19

2.2.6 Data quality 21

2.2.7 Information GovernanceToolkit attainment levels 23

2.2.8 Clinical coding error rate 23

Part 33.1 Review of quality performance

in 2011/12 24

3.1.1 Overview 24

3.1.2 Summary of positive achievementsin the last year 24

3.1.3 Staff achievements 25

3.1.4 Commissioning for Quality and Innovation 27

3.1.5 Performance highlights 28

3.1.6 Clinical quality and Quality Goals 31

3.1.7 Patient experience 37

3.1.8 Learning from incidents and complaints 44

3.1.9 Safeguarding adults and children 49

3.1.10 Effectiveness of care 51

3.2 Explanation of who has beeninvolved and engaged with 56

3.2.1 Third Party Statements 56

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4 Quality Account Norfolk Community Health and Care NHS Trust

1.1 Statement on quality

Welcome to Norfolk Community Health & CareNHS Trust’s (NCH&C) Quality Account for 2011/12.

We hope that you enjoy reading about our activitiesand achievements over the previous year and that yougain some valuable insight into our plans and prioritiesfor the next year.

NCH&C is an independent health and care organisationwhich is part of the National Health Service (NHS),employs NHS staff and provides NHS health and careto local people.

We serve a population of around 870,000 people inand around Norfolk, making us one of the largestproviders of NHS community health and care servicesin the country. Our aim is to constantly improve ourpatients’ lives by providing you with the best care,close to where you live.

We currently employ over 2,300 whole time equivalentsubstantive members of staff. 80% of these areclinicians; healthcare professionals such as doctors,dentists, nurses, health visitors and physiotherapists. Theremainder are the people who help to keep our servicesrunning, or who support our patients and clients duringtheir stay with us or in planning their appointments.

Specialised care for allOur specialist teams all across Norfolk providepersonalised health and care services for everyone,from babies to the elderly.

Our health visitors provide services covering pregnancyand the first 5 years of life, while children are cared forin schools by our school nurses. We help to keep peoplehealthy with our Smokefree Norfolk service, and workwith patients to regain their independence and qualityof life after a brain injury, stroke or fall. We also provideend-of-life care services within people’s homes orspecialist inpatient units, to allow people to pass awaycomfortably and with dignity.

We care for the most disadvantaged and vulnerable inour communities who can find it very difficult ordaunting to access the right healthcare, for example sexworkers and homeless people, and we support peopleof all ages with Learning Disabilities, empowering themto live healthy and independent lives.

Range of servicesThe trust delivers a diverse range of 34 clinical servicesthat are organised into 3 main business units; children’sservices, specialist services and a locality unit(comprising north, south, west and central localities)through which the bulk of NCH&C’s services areprovided. This new structure is a result of areorganisation that took place in January 2012 toensure that our services operate from the same area asthe new GP Clinical Commissioning Group boundariesacross Norfolk to better serve the population.

Frail Older PeopleMany of the Trust’s targets for 2011/12 were specificallyaimed at the care of patients within this group andincluded clinical improvements in patient safety in anumber of areas. These include; catheter acquiredurinary tract infections, reduction of avoidable pressureulcers, end of life care, personal health planning,nutritional care, and admissions avoidance for patientsover 65 years old on a case manager/communitymatrons case load.

Telehealth and telecare are active components ofmanaging case load numbers and helping the elderlywith long term conditions manage their health. In2011/12 a significant programme of work has beendelivered in the community specifically around the useof telehealth home pods by community teams andcurrently 170 telehealth units are deployed withNCH&C patients. This technology has been wellreceived by patients and many of our clinicians,ensuring patients can be supported at home inmanaging their long term condition. The Trust has

Part 1 1.1 Statement on quality 5

worked collaboratively with the Norfolk and NorwichUniversity Hospital Foundation Trust to deliver thisprogramme. We recognise that there is still more workto do to improve our IT communication systems tosupport the practical application of telehealth care. Wewill continue to engage clinicians in the developmentand implementation of telehealth care to ensure thatthe benefits of this new technology bring to patientsare fully realised. During 2012/13 we will continue tobuild on existing achievements and learning from ourexperiences in 2011/12.

Telecare is also integral to the falls and dementiapathways. NCH&C has recently recruited four ‘FallsChampions’ to support the work of preventing injuriousfalls. They have received training for Telecare fromNorfolk County Council and are also receiving dementiaawareness training from Norfolk and Suffolk NHSFoundation Trust. In turn, the champions are in theprocess of delivering training to the communityintegrated teams to widen awareness of dementia careand falls prevention across the Trust.

Dementia careAs part of a Norfolk-wide initiative NCH&C approacheda wide range of key stakeholders and partners over thepast year to help inform the design of the first stage ofan integrated community dementia pathway acrossNorfolk. Partners in this process have includedcommissioners, social services, Norfolk and Suffolk NHSFoundation Trust, 3rd sector (Age UK, Alzheimer’sSociety), Healthwatch and acute provider organisations.

The fundamental aim of this pathway design has beento deliver against the Department of Health’s nineoutcomes for dementia which captured what peoplewith dementia say about their expectations of healthand social care systems.

The integrated community dementia pathway steeringgroup have designed a pathway which following asuccessful pilot, is now being implemented across all thelocalities within Norfolk. Critical to this success has beenthe joint care approach between both NCH&C integratedcommunity teams and community mental health teams.This ensures that the patient and carer have anappropriate Care Co-ordinator or Case Manager.

To ensure that the increase in prevalence of dementia isrecognised and that patients are treated with respectand dignity by skilled staff, NCH&C is in the process ofimplementing an extensive training programme. TheTrust is also a partner of a Health Innovation andEducation Cluster (HIEC) with private and public sectorpartners whose focus is dementia. Our palliative careco-ordinators have trained over 500 staff on dementiaand end of life care whilst working in partnership withAge UK and the Alzheimer’s Society. This work has beenshared at national end of life conferences.

Admission avoidanceNCH&C plays a significant role in the local healtheconomy. Our Trust has helped local people to avoidover 1,000 acute hospital admissions in less than fivemonths for those patients over 65 years old who are ona Case Manager’s or Community Matron’s caseload.This equates to one avoided emergency admission perGP practice, per week.

Our Trust will continue to offer excellent service topeople right across Norfolk, but we will also enablemore people from outside of Norfolk to benefit fromour expert community health and care. We will workto bring expertise and good ideas from across the UKto Norfolk, allowing our patients to benefitfrom best practice from across the NHS.


1.2 Our vision for the future

More and more people in Norfolk and surroundingareas are living with long term conditions, such as

diabetes and heart disease. Our population of frail andelderly people is also growing. As the population ages,and more people are affected by illnesses caused bylifestyle choices, such as smoking, the types of servicesneeded by our community is changing.

We will aim to develop new services, often inpartnership with others, to meet these changing needs,from tackling childhood obesity to improving care forolder people with dementia.

We want to help keep our patients well – providing careas early as possible, to help them avoid having to stay inan acute hospital, or supporting them to return homeas quickly and safely as possible after a hospital stay.

As a provider of community based health and care, wecan act as the ‘glue’ between different services providedby the NHS, social care and others, so our patients canbenefit from joined up care.

This Quality Account has been developed in conjunctionwith our annual planning processes which has producedthe Annual Plan for 2012/13 and is part of the Trust’sAnnual Report.

The content of this Quality Account has been endorsedby the Trust Board and has taken into accountfeedback, where provided from our lead commissioners,our local population via Norfolk LINks and NorfolkCounty Council’s Health Overview and ScrutinyCommittee. I hope you will find our Quality Accountinformative and helpful in reviewing our progressagainst our key priorities for the forthcoming year.

The information supporting the content of this QualityAccount is, to my knowledge, accurate andpublished by the Board on 27th June 2012.

Michael ScottChief Executive

The Trust was a successful pilot of Integrated CareOrganisations (ICOs) with GPs and social care and we willcontinue to build on this foundation and increase its scale.

The Trust’s vision will also be delivered through theachievement of a number of corporate objectives andits commercial strategy.

The Trust’s longer term corporate objectives are:

• Improving quality for patients and the publicand offering the best patient experience in theEast of England

• Transforming services – being the commissioners’first choice provider and being the positive alternativeto acute hospital care

• Building the organisation – The Trust wants to bethe first choice employer for staff and be a clinicallyled, high performing organisation

• Building sustainability – to deliver a long termfinancial model that demonstrates value for money,delivers innovative services and meets therequirements of the Trust’s regulators

• Building reputation – to be the first choice forpatients, Clinical Commissioning Groups and play aleading role within the local health economy

2.1.1 Annual prioritiesand Quality Goalsfor 2012/13

The Trust Board identified seven priorities for2012/13 that bring together our strategies and servicedevelopments which go towards achieving the Trust’sobjectives. These annual priorities are;

1. To improve the quality of the Trust’s services for patients

2. To deliver excellent services and delight our customers

3. To truly inspire our staff

4. To embed the locality based service model

5. To achieve the Trust’s Financial Targets

6. To grow the Trust’s services and focus on theright services

7. To achieve Foundation Trust status

Each of these priorities is supported by a number ofobjectives and more detailed milestones. Both thepriorities and milestones were developed after involvingclinicians and managers outside of the Board.

2.1 Priorities for qualityimprovement (2012/13)

Part 2 2.1 Priorities for quality improvement (2012/13) 72.1.1 Annual priorities and Quality Goals for 2012/13

The Trust’s vision is to “Look after you locally”. We will improvethe quality of people’s lives, in their homes and community,

through providing the best in ‘joined up’ care. The starting pointfor the Trust is the patient which means that quality is at the heartof everything NCH&C does. Our vision is supported by the waythe Trust structures its services and wherever possible, ourservices are delivered in an integrated way with social care.

The Quality Goals for NCH&Cfor 2012/13The Trust is utilising the Safety Thermometer, a nationaldata collection programme to measure four potential‘harms’; venous thromboembolism (VTE), pressure ulcers,catheter acquired infections and falls. The first submissionwas made in March 2012. The data gives a snapshot intime and cannot show trends at this stage, but it isrecognised that its value will increase in future and theTrust will participate in the programme fully this year.

The Quality Goals for 2012/13 are:

1. Implement safety thermometer targets in fourkey areas:

• Achieve 95% Venous Thrombo-embolismassessments for inpatients by December 2012

• 50% reduction in Catheter acquired urinary tractinfections by December 2012

• Reduction in the levels of injurious falls in ourinpatient units to four per 1,000 OBDs

• Eradication of avoidable pressure ulcers (as below)

2. Deliver zero avoidable Pressure Ulcer target byDecember 2012 (Grades 2–4)

3. Improve patient satisfaction to 70% very satisfiedand no area < 50%

4. Implement the net promoter score system and meettarget set for inpatients

5. To achieve ‘you’re welcome’ accreditation in schoolnursing service

6. To achieve UNICEF ‘baby friendly’ accreditation atlevel 2

2.1.2 Patient experiencein 2012/13

Our vision for Patient Experience and Involvement isthat NCH&C is a patient focused organisation activelyseeking the views of our patients and carers andengaging them in shaping and developing our serviceswhilst consistently providing high level, quality care. Wewant our patients to have the very best experience ofcommunity services in the East of England.

We genuinely want to work with our patients and localcommunity so that together we make a difference tothe experiences of our current and future patients anddesign and provide our services around their needs.

In 2012/13 the Trust aims to build on an excellent yearof patient experience in 2011/12 (see section 3.1.7) byimplementing the following projects:

• Demonstrate improvements in patient experienceusing the “Net Promoter Score”

• Review results from the Community Services Surveyand implement actions as required

• Continue to embed patient stories within NCH&Censuring the methodology is utilised where there is atargeted need for in depth information, deliver moretraining and consider involving Healthwatch membersas interviewers alongside NCH&C staff

• Work in partnership with services to support locallymanaged surveys and other methodologies forcapturing patient/carer experiences

• Work in partnership with NCH&C members andexternal voluntary organisations ensuring effectivepatient engagement/involvement

• Work in partnership with NCH&C Learning Educationand Development Team ensuring staff have the coreskills, beliefs and values necessary for a good patientor carer experience

• Work with Kings College, London to participate in aresearch project to seek views of parents into thehealth visiting service


Advocacy - Net PromoterNCH&C has made good progress in the use of the netpromoter methodology in 2011/12 and will continueto develop this tool as a key indicator of patientsatisfaction and service quality. This is a standardisedapproach with a single metric to obtain real-timemonitoring of patient experience. The ‘net promoter’score captures perceptions of the local populationabout the health care they have received. The score isthe difference between the proportion of peoplesurveyed who said they would recommend the localservice and the proportion who said they would not.

Net promoter methodology remains in its infancy withinthe Trust and it will be further developed within thenext year. All NCH&C inpatient units will participate inthe survey from April 2012 to March 2013. A minimumof 10% of the weekly footfall of patients will be askedthe question on the day of discharge or up to 48 hourspost discharge. They will also have the opportunity toleave any comments. A baseline net promoter scorewill be established during month 1 and a 10 pointimprovement score agreed over the next year. Alongsidethis survey, a methodology will be developed for usewithin community based services and implemented laterin the year.

2.1.3 Commissioningfor Quality andInnovation (CQuIN)Scheme for 2012/13

The CQuIN scheme requires Primary Care Trusts (PCTs)to commission for quality and innovation throughdiscussing, agreeing and monitoring quality indicatorswith providers. A CQUIN scheme is the locally agreedpackage of quality improvement goals and indicators,which in total, if achieved, enables the provider to earnits full CQUIN payment.

A CQUIN scheme should address the three domains ofquality: safety, effectiveness and patient experience; andreflect innovation. Indicators should be realistic so that aprovider is able to have a reasonable expectation thatthey can achieve the requirements. Achieving theindicator set will enable providers to receive a qualitybased payment. The monies to meet the cost of thispayment will come from incentivising a proportion ofannual uplift of contract values of 2.5% for 2012/13divided into three elements;

• 0.5% for four national indicators

• 1.0% for locally agreed indicators

• 1.0% for a system wide indicator based on reducingemergency admissions into the acute hospitals

These indicators will be set within the contract as partof the established quality schedule and monitored bythe PCT through clinical review.

Part 2 2.1 Priorities for quality improvement (2012/13) 92.1.3 Commissioning for Quality and Innovation Scheme for 2012/13

NCH&C and NHS Norfolk & Waveney have agreed a setof quality measures to be assessed as part of the CQUINinitiative which focus on the following areas for 2012/13:


Goal Description of Goal Quality Indicator NameNo Domains National/Local/System-wide

1 To reduce avoidable death, disability and chronic Safety VTE risk assessmentill health from Venous-thromboembolism (VTE) and prophylaxis

National

2 To improve responsiveness to personal needs of Patient VOICES surveypatients/carers experience Local

3 Improve collection of data in relation to pressure ulcers, Safety NHS Safety Thermometerfalls, urinary tract infection in those with a catheter, VTE National

4 Development of the Care pathway for patients risk Patient safety Dementia Pathwayassessed as having dementia by the acute providers Effectiveness Nationalin collaboration with other providers Experience

5 Patient satisfaction: “How likely is it that you would Patient Net promoterrecommend this service to friends and family? experience National

6 Partnership Working Safety Assurance processSystem wide

7 Provision of a dedicated community nurse for each Patient Dedicated community nurseGP practice to support admission avoidance experience for GP practices

Effectiveness Local

8 Pharmaceutical care plans for “at risk” patients Safety Medicines ManagementLocal

9 End of Life care - For NCH&C care home facilitators to roll Patient End of Life careout training for ACP/Preferred place of care (PPoc) and experience Localensure that PPoC is utilised where clinically appropriate.20 Care homes will be targeted and supported.

10 Improve the care of paediatric patients in the Patient Paediatric carecommunity through the introduction of an experience LocalIntravenous therapy (IV) service Effectiveness

11 Achieve improved outcomes for patients of the Effectiveness Community nursing andcommunity nursing and therapy service in 5 key areas therapy outcome indicators

Local

12 Avoid acute hospital admissions through effective case Effectiveness Case Management of highmanagement of those at greater risk of admission risk patients

Local

2.1.4 Our staff - workforceplanning anddevelopment

The NCH&C Trust Board has approved a WorkforceStrategy that provides a long term strategic frameworkunder which exists a number of more detailed workforceplans and strategies such as Organisational Development,Talent and Leadership and Health and Wellbeing. TheWorkforce Strategy contributes to our overall strategyand is integrated with other supporting strategies suchas our Clinical Strategy, Estates Strategy and InformationManagement and Technology (IM&T) strategy.

The Workforce Strategy is to ensure that we have aworkforce that is affordable, the right shape and hasthe capacity and capability to deliver excellent healthcare for the people we serve. It outlines the range ofinterventions that will provide the workforce with theskills, knowledge and development to sustain theorganisation, ensure they are committed and alignedto our strategic objectives and enable them to havefulfilling careers.

Staff engagement is at the centre of achievingour aspiration to deliver high quality patient care.Our response to the staff survey results is to prioritisestaff engagement.

The workforce strategy contains a number ofstrategic objectives:

Develop clinically led workforce planning

The Trust aims to establish clinically led workforceplanning with full integration between corporateand operational services. Recently more integratedworkforce planning has taken place for example withproject teams set up to support tenders. This modelwas particularly successful in our winning Sure Start bid.We will encourage and build on this model in all ourworkforce planning activities.

Provide quality education and developmentopportunities for all our staff

The strategy describes how the Trust will provide highquality education, training and development for theworkforce, ensuring that skills are developed to supportthe provision of high quality, patient focused care. TheTrust’s approach to training includes a focus on care,compassion and personalised care and technical skillsas well as leadership and management.

To truly inspire our staff

The Trust’s Organisational Development (OD) Strategywill ensure the processes, structures, systems andculture necessary to achieve our vision is achieved.Central to this strategy is staff engagement.

The Trust has well developed and shared organisationalvalues including a supporting behaviour framework.

Promote staff health and well being

The Trust’s Health and Well Being Strategy supports theWorkforce Strategy and acknowledges that the work,health and well being of our employees are interlinked.

The Trust will ensure that managers have the key skills,knowledge and ability to support employees at work, tomanage absence and also work with staff to ensureissues which may impact negatively on staff health areidentified and minimised.

Part 2 2.1 Priorities for quality improvement (2012/13) 112.1.4 Our staff - workforce planning and development

2.1.5 Performancemonitoring for 2012/13

NCH&C will be ensuring that our reporting systems willreport at locality level and align with our ClinicalCommissioning Groups (CCGs).

Where possible, and where common data is available,we will be looking to benchmark against othercommunity trusts.

The functionality of the Trust’s ICARUS reporting systemwill continue to be developed during 2012/13.Incorporating data from other departments, such asHuman Resources and from other systems (such asDATIX) will be actively explored to enhance the scopeof reporting performance information.

2.1.5.1 Planned changes toperformance reporting for2012/13 Quality Accounts

The National Quality Board has recently considered howto foster readers’ understanding of comparativeperformance whilst maintaining local ownership. Theyhave subsequently recommended the introduction ofmandatory reporting against a small set of qualityindicators for inclusion in Quality Accounts that aredue to be published in June 2013. The intention isthat trusts will be required to report:

• Their performance against these indicators

• The national average

• A supporting commentary, which may explainvariation from the national average and any stepstaken or planned to improve quality

Reporting against the indicators is not mandatoryfor 2011/12, however, NCH&C have reviewed theindicators and have provided a summary against thosethat are relevant to our organisation and for which wehave current data under ‘Domain 5: Treating and caringfor people in a safe environment and protecting themfrom avoidable harm’.

Percentage of admitted patients risk-assessmentfor Venous Thromboembolism (VTE)

As shown below, as at March 2012 the Trust hasachieved 90.4% against the national target of 90% VTEassessments. For 2012/13 the target will be 95% byDecember 2012. The Trust’s aim is to maintain itsexcellent performance and ensure that any underperformance is escalated quickly and effectively to theTrust’s Medical Director. The increase to 95% will besupported by location specific plans led by the ModernMatron in charge of the inpatient units.

Percentage of VTE assessments completedon admission to NCH&C inpatient units

Local standard in month: 90%

Actual: 83.6% total year to date

90.4% March 2012

Local performance: Achieving


50%

60%

80%

100%

Actual cumulative

Feb-1

2

Jan-1

2

Dec-1

1

Nov-11

Oct-1

1

Sep-1

1

Aug-11

Jul-1

1

Jun-1

1

May

-11

Apr-11

70%

90%

Service spec trajectory

55%

75%

95%

65%

85%

Mar

-12

Part 2 2.1 Priorities for quality improvement (2012/13) 132.1.5 Performance monitoring

Rate of patient safety incidents and percentageresulting in severe harm or death

Reduction in harm incidents

The table below shows incident data collected via DATIX-web from April 2011 to March 2012 and a reduction inthe number of severe harm incidents is noted.

These figures demonstrate that only 2.14% of incidentsover the period April 2011 to March 2012 resulted insevere harm or unexpected death.

The National Patient Safety Agency (NPSA) report from1 April to 30 September 2011 states that NCH&C’sreporting rate = 102.3 incidents reported per 1,000 beddays (compared with other community trusts) places theorganisation in the highest 25% of reporters comparedwith 19 primary care organisations with inpatientprovision in the East of England.

The NPSA states: “Organisations that report moreincidents usually have a better and more effective safetyculture. You can’t learn and improve if you don’t knowwhat the problems are.”

Month April May June July Aug Sept Oct Nov Dec Jan Feb Mar Total

No Harm 157 147 191 208 184 181 180 200 193 208 264 215 2328

Low 97 125 150 183 193 171 204 236 231 248 254 282 2374

Moderate 21 35 32 38 35 27 32 37 27 34 40 33 381

Severe 4 6 7 10 14 10 11 10 5 8 4 5 94

Unexpected 1 0 0 3 3 2 0 2 1 1 4 0 17death

Total 280 313 380 432 429 391 427 485 457 499 566 535 5194


2.2.1 Review of servicesDuring the period April 2011 to March 2012 NorfolkCommunity Health & Care NHS Trust (NCH&C) providedand/or sub-contracted 34 NHS services.

NCH&C has reviewed all the data available to them onthe quality of the care in 34 of these NHS services.

The income generated by the NHS services reviewed in2011/12 represents 97% per cent of the total incomegenerated from the provision of NHS services byNCH&C for 2011/12.

All services are subject to monthly risk assessmentthrough the use of an Early Warning Trigger Tool(EWTT). The Trust has introduced it to act as an earlywarning system to flag up potential quality and patientsafety issues before they occur. Implementation of thetool should reduce the number of Serious IncidentsRequiring Investigation (SIRIs), reduce the risk of anunfavourable CQC report and prevent services goinginto crisis.

The original tool was produced by the National PatientSafety Agency (NPSA) in response to the quality of careat Mid Staffordshire NHS Foundation Trust and has beenadapted locally to better reflect community services.Patient views and experience are integral to the tooland is reflected in the use of patient surveys and thelevel of complaints received.

Since September 2011 staff across community teamsand the inpatient units assess their areas against achecklist with weighted scores, which resulted in anoverall RAG-rated score and an indication of whataction is required:

Green rating (score of 10 or less)No action required, re-assess area next month

Amber rating (a score between 11 and 15)Undertake full risk assessment and agree action plan for‘red’ items within one month. Add to local risk register

Red rating (a score of 16 or more)Inform line manager immediately and undertake full riskassessment within one week. Produce an action planfor red items within one week

The data from the tool is reviewed monthly in order toidentify services with potential issues, as well asidentifying key themes common to a number of teamsor departments. Key risks are escalated to the Trust’sManagement Team and Executive Directors. (see section3.1.8 for more details)

The Trust Board also receives a monthly IntegratedPerformance Report, which focuses on a number ofdomains including patient safety, quality and risk. Thedata is presented in a dashboard format, using Red-Amber-Green (RAG) ratings to highlight any areas ofadverse performance supported by a narrativeexplaining the reason for the variance, and actionsbeing taken to mitigate future risks impacting onperformance. The Board also receives a Quality and Riskreport which provides more operational detail on thoseareas reported in the IPR. This report is also presented tothe Quality and Risk Assurance Committee, andincludes the following areas;

• Serious Incidents requiring investigation (SIRIs)

• Medication Incidents

• Falls

• Pressure Ulcers

• Infection rates

• Complaints and compliments

2.2 Statements of assurancefrom the Board

Part 2 2.2 Statements of assurance from the Board 152.2.1 Review of services2.2.2 Participation in clinical audits

2.2.2 Participation inclinical audits

During April 2011 – March 2012, 6 national clinical auditsand 1 confidential enquiry covered NHS services thatNCH&C provides.

During that period NCH&C participated in 33.3%of national clinical audits and 0% of nationalconfidential enquiries of the national clinical auditsand national confidential enquiries which it waseligible to participate in.

The national clinical audits and national confidentialenquiries that NCH&C was eligible to participate induring April 2011 – March 2012 are as follows:

Name of National Audit Lead organisation Participation from NCH&C?

Epilepsy12 Royal College of Paediatrics Yesand Child Health

National Diabetes Audit NHS Information Centre Yes

Heart Failure Audit National Institute for clinical No – there was no applicable dataoutcome research (NICOR) available within collection period

Sentinal Stroke Audit Royal College of Physicians No – there was no applicable dataavailable within collection period(Led by the Norfolk & Norwich Hospital)

Continence Care Audit Royal College of Physicians No – there was no applicable dataavailable within collection period

Stroke improvement national audit Royal College of Physicians No – there was no applicable dataavailable within collection period

Name of National Confidential Enquiry Applicable to NCH&C? Participation from NCH&C?

National Confidential Enquiry into Yes No - there was no applicable dataPatient Outcome and Death (NCEPOD) available within the collection period.


The national clinical audits and national confidentialenquiries that NCH&C participated in, and for whichdata collection was completed during April 2011 –March 2012, are listed below alongside the numberof cases submitted to each audit or enquiry as apercentage of the number of registered cases requiredby the terms of that audit or enquiry.

The report of two clinical audits – Epilepsy12, and theNational Diabetes Audit were reviewed by the providerin April 2011 – March 2012 and NCH&C intends totake the following actions to improve the quality ofhealthcare provided:

Description of actions:

• Epilepsy12 – training for all consultant paediatricianswho work across the pathway covered by NCH&C,the Norfolk and Norwich University Hospitals NHSFoundation Trust, and the Queen Elizabeth HospitalKing’s Lynn NHS Foundation Trust

• National Diabetes Audit – The 2010/11 Auditis currently in progress. The NDA report will bepublished in June 2012 (the NHS Information Centrefor Health and Social Care)

Name Lead organisation Number of cases submitted or percentage ofnumbers of registered cases required

Epilepsy12 Royal College of Paediatrics This is a retrospective audit reviewing data fromand Child Health 2010/11 which the acute trusts collect

National Diabetes Audit NHS Information Centre Unable to quantify as data collected and casessubmitted by GP practices across Norfolk

Part 2 2.2 Statements of assurance from the Board 172.2.2 Participation in clinical audits

Local clinical auditsThe reports of 32 local clinical audits were reviewed bythe provider during the period from April 2011 toMarch 2012 and NCH&C intends to take the followingactions to improve the quality of healthcare provided:

Description of a selection of actions:

• Reducing harm from omitted or delayed deliveryof medicines in hospital – has achieved thefollowing results:

• Reduced the number of patients experiencing anomitted or delayed dose (from 65% to 48%)

• Reduced the average number of omitted or delayeddoses occurring (from 4.34 doses/patient to 2.06doses/patient)

• Reduced the potential harm caused by omissionsor delays in the administration of medicines(from an average risk score of 5.75 to 3.06)

• Improved practices around the administrationof medicines

• Increased awareness amongst staff about this issueand the need for accurate and complete records ofmedicines administration.

• Essence of Care – Dignity and Respect, localconsent form devised and implemented

• Paracentesis (procedure to drain fluid from theabdomen), Guidelines updated to include that it isappropriate to consider draining to dryness in patientswith peripheral oedema

• Pressure Ulcer (annual, mandatory), a standardisedprocess implemented to ensure a patient has aWaterlow assessment completed within 6 hoursof admission and baseline risk assessments of theMUST nutrition tool are completed, continence andmobility/moving and handling assessments are alsocompleted for all patients

• Safeguarding Supervisor’s (Children’s Services),the safeguarding team to arrange a workshop ongroup supervision and group dynamics

• Vestibular baseline audit, following initial gapanalysis findings, to re-audit and develop a businesscase to present to our commissioners to expedite thediagnosis and management of ‘dizzy’ patient’s withinNCH&C care

• Falls assessment audit, an audit was carried out inNovember 2011 to determine the number of patientswho had a Falls Assessment within 48 hours ofadmission to our inpatient units. The results from thisaudit demonstrate that we achieved 92%, a 11%improvement on our quarter two audit results

• Hand hygiene audits, the Infection Control Teamconduct monthly ‘hand hygiene’ audits at localitiesand in 2011/12 results across the trust provided ahigh level of assurance of 99% compliance acrossthe organisation


2.2.3 Participation inclinical research

The number of patients receiving NHS services providedor sub-contracted by NCH&C in 2011/12 that wererecruited during that period to participate in researchapproved by a research ethics committee was 690.

This is an increase of 42% compared with 2010/11period and shows evidence of NCH&C’s expandingresearch portfolio.

Participation in clinical research demonstrates NCH&C’scommitment to improving the quality of care we offerand to making our contribution to wider healthimprovement. Our clinical staff stay abreast of the latestpossible treatment possibilities and active participationin research leads to successful patient outcomes.

NCH&C were involved in conducting 49 researchstudies during 2011/12 showing a moderate (5%)increase compared with the 2010/11 reporting period.However 65% of studies were national portfolio,compared with 35% in the previous year. 18 of thesestudies were new projects which were given permissionto start in 2011/12. Median approval time was 36 dayswhich is an improvement on last year’s median approvaltime of 47 days.

During 2011/12 five of our clinical teams have beensupported in their clinical research activity by theComprehensive Local Research Network (CLRN) fundedResearch Site Initiative Scheme, which aims to developresearch activity within community care teams andenable teams to host national portfolio research studiesto recruit to time and target. All but one of the fiveteams has been successful in hosting at least onenational portfolio study in 2011/12. It is anticipated thatteams will build on this success during 2012/13, and thatthe outcomes of these studies will, in the future, help toinform innovations in the delivery of high-quality care toimprove the health and well-being of our patients.

There were 29 clinical staff participating in research (asparticipants) approved by a research ethics committeeat NCH&C during 2011/12. This represents an increaseof 62% on last year’s figures.

Stroke Research StudiesOver the 2011/12 period NCH&C conducted sevenclinical research studies within the area of stroke(care/rehabilitation). Over the same period, mortalityamenable to mortality rate from causes preventablein stroke rehabilitation changed from the previous yearby 2.5%. The improvement in patient health outcomesin the area of stroke rehabilitation at NCH&Cdemonstrates that a commitment to clinical researchcan lead to better treatments for patients.

Research bursariesResearch bursaries are awarded to enable staff todevelop their research ideas with academic partnersinto fully funded research proposals Two of last year’s(2010/11) research bursaries awarded to staff atNCH&C have resulted in full applications for fundingto the National Institute for Health Research (NIHR)Research for Patient Benefit Scheme in 2011/12 inthe area of Person Centered Care for dementia, andcomplicated grief for people with learning difficulties;the outcome for both is awaited. Two further researchbursaries have been awarded in 2011/12.

For the 2011/12 period NCH&C has not recordedany publications that have arisen as a result of ourinvolvement in NIHR research. We plan to collect suchinformation during 2012/13 and will be able to reporton this activity in next year’s Quality Account.

Part 2 2.2 Statements of assurance from the Board 192.2.3 Participation in clinical research2.2.4 Goals agreed with commissioners2.2.5 Statement from Care Quality Commission (CQC)

2.2.4 Goals agreed withcommissioners

Use of the Commissioning for Quality and Innovation(CQuIN) payment framework

A proportion of NCH&C’s income during April 2011to March 2012 was conditional on achieving qualityimprovement and innovation goals agreed betweenNCH&C and any person or body they entered intoa contract, agreement or arrangement with for theprovision of NHS services, through the CQuINpayment framework.

Further details of the agreed goals for April 2011 toMarch 2012 are set out in Part 3 of the Quality Accountand for the period April 2012 to March 2013 can befound in Part 2.1

2.2.5 Statement fromthe Care QualityCommission

NCH&C is required to register with the Care QualityCommission (CQC) and its current registration statusis ‘registered without restrictive conditions’.

From April 2011 to October 2011 NCH&C had thefollowing conditions on its registration:

April 2011 – Registration with the CQC was confirmed,we were however registered with the followingconditions:

a. The Registered provider must not carry on theregulated activity “Treatment of Disease Disorder orInjury” in the Local Discharge Unit at HMP Norwich,Knox Road, Norwich, Norfolk, NR1 4LU.

This condition was in place following a visit the CQCundertook at HMP Norwich when authorising anotherprovider’s registration. They found that the DischargeUnit did not comply with the regulations because itdid not protect people’s right to privacy, dignity, choiceand confidentiality.

b. The Registered Provider must ensure that theregulated activity of “Accommodation for peoplewho require nursing or personal care” is managedby an individual who is registered as a manager inrespect of the activities at or from all Locations.

This condition was imposed as the CQC confirmed thatthis regulated activity must be managed by a ‘registeredmanager’ as the service is seen to have a social careaspect. There were three Locations affected by thiscondition, (Mill Close an adult respite unit, Little Acornsand Squirrels both children’s respite units).


And has taken the following actions:

Condition a) To ensure privacy and dignity ismaintained at all times, NCH&C ensured that the roomis only utilised by one clinician at any time. Two bencheshave been installed in the recess outside theadjudication room providing a waiting area a fewmetres away from the consultation room. It will not bepossible for any waiting prisoners to overhear anyconsultations. Privacy screens have also been allocatedto the room to protect peoples privacy and dignity. Bymaking the above changes we now protect people'srights to privacy, dignity, choice and confidentiality

3rd June 2011 – NCH&C had confirmation from theCare Quality Commission through issue of a Notice ofDecision that the condition applied to our registration,restricting it from providing “Treatment of DiseaseDisorder or Injury” from the treatment room in the LocalDischarge Unit at HMP Norwich, has now been lifted.

Condition b) Registered Managers at each of our [3]respite units were appropriately registered with theCQC and the condition regarding these respite unitswas removed in September 2011

23rd November 2011 – our most recent and up-to-date Certificate of Registration was issued withoutrestrictive conditions

The Care Quality Commission has not takenenforcement action against NCH&C during the periodApril 2011 to March 2012.

NCH&C has participated in special reviews orinvestigations by the Care Quality Commission relating tothe following areas during April 2011 and March 2012:

Three inspections were made within our JointCommunity Learning Disability Teams (which areregistered through Norfolk County Council) and onewithin our Learning Disability Adult Respite Unit duringthe period April 2011 to March 2012. The results are asfollows:

• Western Joint Community Learning Disability Team wasmeeting all the essential standards of quality and safety

• City Joint Community Learning Disability Team wasmeeting all the essential standards of quality and safety

• North Joint Community Learning Disability Team wasmeeting all the essential standards of quality andsafety but to maintain this it was suggested that wemade improvements to ensure we have local systemsin place to monitor the quality of the service

• Mill Close Adult Respite Unit was found to bemeeting the essential standards of quality and safetyas listed below:

• Outcome 1: People should be treated withDignity and Respect

• Outcome 4: People should receive safe,appropriate care

• Outcome 7: People should be protected from abuse

• Outcome 16: The service should have qualitychecking systems in place

NCH&C intends to take the following action to addressthe conclusions or requirements reported by the CQC:

• Develop a local feedback questionnaire which will besent to users of the service with a pre-paid envelope.

NCH&C has made the following progress by 31st March2012 in taking such action:

• A local feedback questionnaire has been developedwhich will be sent to users of the service with a pre-paidenvelope. In addition there is established NorfolkCounty Council feedback systems in place, wherebyclients and carers can comment on care /servicesreceived. Both Norfolk County Council and NCH&C alsohave compliments and complaints pathways in place

Part 2 2.2 Statements of assurance from the Board 212.2.6 Data quality

2.2.6 Data qualityGood quality information underpins the effectivedelivery of patient care and is essential if improvementsin quality of care are to be made. Improving dataquality, which includes the quality of ethnicity andother equality data, should improve patient care andimprove value for money.

NCH&C will be taking the following actions to improvedata quality:

A number of data quality reports have been designed tomonitor a range of key performance indicators on amonthly basis, and the Secondary Uses Service (SUS)dashboards are reviewed regularly in relation to nationalkey indicators. A selection of these indicators are alsoreported to monthly performance meetings whereoperational services are held to account for the qualityof data held on SystmOne and the PatientAdministration System (PAS). These reports are held ona networked drive to ensure they are accessible to keystaff involved in the monitoring and reporting ofperformance and activity data.

The Trust has a Data Quality Strategy which will becritical to a number of the Trust’s priorities andobjectives, including improving the quality of patientcare, compliance with the Information GovernanceToolkit version 9 and the need to introduce and monitorthe Community Information Data Set (CIDS). Thisstrategy is underpinned by a Data Quality Policy. Thepurpose of this policy is to ensure the highest standardsof data quality throughout NCH&C are achieved. Thispolicy is for all staff collecting and using data and theymust adhere to the local and national standards as laidout in this policy.


The Trust has established a Data Quality Forum (DFQ)chaired by the Assistant Director for Performance.The purpose of this forum is:

• To assist NCH&C to work to a common set ofprinciples over data quality issues

• To share experience, ideas and examples of goodpractice in business units and corporate functions intaking forward the data quality agenda

• To assist NCH&C in the delivery of the data qualityagenda in support of key national initiatives, eg,Transforming Community Services Quality Indicators,patient safety, QIPP, and the NHS Outcomes Framework

• To action collectively-agreed data quality initiatives

• To assist business units and corporate functions inraising the profile of data quality at a local level andmaking the linkages with the wider agenda outlinedin above

• To provide a forum for co-ordination of user issues,support arrangements and developments for DataQuality reporting

• To review where available, local and nationalbenchmarking resources to identify any issues of dataquality and consider the necessary actions required

• To review the Data Quality Dashboard against localbenchmarks and targets as defined in the Data QualityImprovement Plan, and to monitor trends over time inorder to assess progress in improving data quality

• The role and function of the DQF has been recentlyreviewed to ensure it meets the Trust’s strategic andpolicy objectives in relation to data quality

• External validation of our information systems hasbeen undertaken during 2011/12 by our internalauditors and action plans have been developed tofurther improve these systems

NHS Number and General MedicalPractice Code ValidityNCH&C submitted records during 2011/12 to the SUSfor inclusion in the Hospital Episode Statistics which areincluded in the latest published data under organisationcode RY3.

The percentage of records in the published data which:

• included the patient’s valid NHS number was:

• 100% for admitted patient care

• 100% for out patient care

• included the patient’s valid General Medical Practicecode was:

• 100% for admitted patient care

• 100% for out patient care

Part 2 2.2 Statements of assurance from the Board 232.2.7 Information Governance Toolkit attainment levels2.2.8 Clinical coding error rate

2.2.7 InformationGovernance Toolkitattainment levels

NCH&C Information Governance Assessment Reportoverall score for 2011/12 was 66% thereby achievingcompliance at Level 2 and was graded by NHSConnecting for Health as follows:

* 66% is the target score for achieving level 2 as set byNHS Connecting for Health and represents a % of allrequirements met which are individually weighted

The Information Governance toolkit is available on theConnecting for Health website:www.igt.connectingforhealth.nhs.uk

The Information Quality and Records Managementattainment levels assessed within the InformationGovernance Toolkit provide an overall measure of thequality of data systems, standards and processes withinan organisation.

2.2.8 Clinical codingerror rate

NCH&C was not subject to the Payment by Results(PbR) clinical coding audit during 2011/12 by theAudit Commission.

Assessment Level 2 Exempt Total requests Overall score Grade

Version 9 (2011-12) 40 1 41 66%* Satisfactory


3.1.1 OverviewThe Trust has had a challenging year on a number offronts that are described in detail below. An externalreview was published into a service previously run bythe Trust that offered a number of criticisms and whichhas significantly shaped the efforts of the Trust duringthe year. Nevertheless, the year has also seen significantachievements such as high patient satisfaction, asignificant tender win and the introduction of new rolesto support admissions avoidance to an acute hospital.

3.1.2 Summary of positiveachievements in thelast year

The Trust is proud of its many achievements in the lastyear. Building on its values of pioneering, personalisedcare delivered closer to people’s homes, the Trust hasdelivered exciting and challenging projects andcelebrated growth in nationally recognised services.

The Trust was proud to be designated as an EarlyImplementer Site for the national health visitingprogramme. This designation recognised the highquality of our services and the Trust’s ability to innovatewithin the field of service redesign.

In 2011/12 the Trust continued to deliver significantcapital development projects in partnership withcommissioners and local communities. New buildingprojects were commenced and/or completed at bothNorth Walsham and Aylsham that will bring a newrange of services closer to these communities.

Continuing the theme of innovation, one of the Trust’sschool nurses received an award for innovation fromAnglia Ruskin University for his invention that isdesigned to help children taking their medication forasthma. The Trust’s Falls Service also received a runnerup commendation from the East of England as part oftheir Celebrating Success Awards.

The Trust was awarded a contract worth in excess of£21m for the delivery of 31 Sure Start Children’sCentres that were tendered by Norfolk County Council.This award built on the Ofsted rated ‘outstanding’delivery of the Trust’s current 3 centres.

3.1 Review of quality performancein 2011/12

Part 3 3.1 Review of quality performance in 2011/12 253.1.1 Overview3.1.2 Summary of positive achievements in the last year3.1.3 Staff achievements

3.1.3 Staff achievementsLiving our values awards spanned a range of roleswithin NCH&C from consultants, community nurses,technical instructors and occupational therapists toeducation facilitators. The award categories arereflective of our Trust’s four values:

1. Home and Community – Someone who regularlydemonstrates that they exist to improve the lives ofour patients, whenever and wherever neededWinner – Community Integrated Team,North Walsham

2. Pioneering – Someone who looks for innovative andmore efficient ways of delivering care to our patientsWinners – Palliative Care Coordinators

3. Personalised care – They strive to understand eachindividual patient’s total needs and join up theirhealth and care requirementsWinner – Occupational Therapist, City 4 Team

4. Enabling our people – This colleague is anincredible motivator or encourages others tobe the best they canWinner – Education Facilitator (Palliative Care)Colman Hospital

I would like to offer my congratulations to eachof the winners, as well as the nominees. They

truly embody our Trust’s values and I would like tocongratulate them on receiving this recognition...I have been deeply impressed by the many examplesof colleagues striving to deliver the best possiblecare and to further improve services for our patients.These dedicated staff are trueambassadors of NCH&C…”

Michael Scott, Chief Executive

Finalist at national awardsA community nurse and care manager was namedas a finalist in the national General Practice Awards,‘Nurse of the Year’ category. Based at Sapphire House,Norwich, Tracey Blazey was one of just over 200nominations in this category put forward by colleagues.Tracey, who has 30 years’ NHS experience wasnominated for the consistently high-quality of careshe provides to adults who have learning disabilities.

Queen’s Nurse honourA Specialist Neurology Nurse was awarded the title of‘Queen’s Nurse’ in recognition of her commitment todelivering further improved community-based care.Katrine ‘Trine’ Kiertzner, who has 25 years’ nursingexperience, received the title from community nurses’charity the Queen’s Nursing Institute. The title aims tounite nurses who have promoted high standards of careand encourages them to champion new ways ofdelivering innovative practices.


Improving teenagers’ mental healthSchool Nurse, Bernadette Osterberg, is rolling out a trialproject to provide innovative care for high schoolstudents who have a history of self-harm, substanceabuse and risk-taking behaviours. Bernadette aims toimprove their mental wellbeing by facilitating joinedup care, working with partners such as Child andAdolescent Mental Health Services (CAMHS) and theMancroft Advice Project (MAP) to enable young peopleto get access to counsellors, youth workers, and advisers.

Family praises ‘absolutely fantastic’Community MatronA Community Matron has been hailed as ‘an amazingambassador of the NHS and mankind’ by the family of aformer patient. Fiona Baldwin received the praise aftercaring for the patient at their home for over a year. In aletter, the family said “Fiona showed such competence,care and support to the whole family… and despitemum’s poor health, she would perk up at just the soundof Fiona’s voice... As a person I think she is a trulywonderful lady… and my family extend our warmestthanks to her.”

Certificates of recognitionEach month we celebrate the commitment of our staffto the continued delivery of excellent care and support.Staff receive a Certificate of Recognition at theManagement Forum and are named in the staffnewsletter, ‘The Exchange’.

Compliments and ‘Thank you’s’to our staffBelow are selections of the hundreds of complimentsour staff receive over the course of a year:

Beech Ward, NCHMany small acts of kindness noticed.All added to the tranquil, positiveatmosphere of the ward...

Pulmonary Rehab Service, Kelling HospitalI can bend to put my socks on whichI couldn’t before. A very good team,which I hope will continue tohelp a lot more old codgers...

Cranmer House, FakenhamMy husband was very lucky to have landedwithin your ‘embrace’. You runa superb ship. Congratulations...

Alder Ward, NCHDads last days were made so muchbetter than they could have been...

Staff at the Mulberry Unit, NCHYou are all earth angels...

Community Nursing and Therapy team, NCHYou all smile which means a lot tous old ‘uns’ Patient aged 92 ½...

District NursingThank you so much for your support inmaking Dad’s last days easier for himto bear, at home, with loved ones…

Foxley Ward, Dereham HospitalThanks for all the staff for all their help andfriendship for my speedy recovery.I have enjoyed my time with you…

Speech and Language Therapy TeamThe support I received was excellent andmy speech has improved greatly. I stillhave difficulties recalling words, butI continue to use the helpfulstrategies that you taught me...

Part 3 3.1 Review of quality performance in 2011/12 273.1.4 Commissioning for Quality and Innovation (CQUIN)

3.1.4 Commissioningfor Quality andInnovation (CQUIN)

NCH&C has made excellent progress against its CQUINScheme by quarter in 2011/12 bringing our total CQUINearnings for the last financial year to circa £1.25m.

CQUINs are contractual commitments which encourageprogress to be made within key areas of local services.

As a reward for meeting these commitments our Trustwill now receive significant investment from ourcommissioners which is funding that can be used tomake further improvements in the future.

Indicator Achievement/OutcomeQuarter 1 Quarter 2 Quarter 3 Quarter 4

Increase number of patients provided 85% 100% 100% TBCwith telehealth in the community andaudit the outcomes

Use of the End of Life, 100% 66% No payment due 100%Gold standard framework

Use of the End of Life, 100% 100% 100% TBCLiverpool Care pathway

Medicines management 100% 100% 100% 100%

Patient satisfaction - Adults 100% 100% No payment due 100%

Patient satisfaction – Children’s services 100% 100% No payment due 75%

Reduction in injurious falls No payment due No payment due No payment due 100%

Improve carer experience - Adults 100% 100% 100% 100%

Improve carer experience – Children’s 100% 100% 100% 100%

Achieve UNICEF accreditation stage 1 No payment due No payment due 100% 100%

TOTAL 96% 98% 100% TBC


3.1.5 Performancehighlights

Areas of achievementDuring 2011/12 the Trust had a number of importanttargets to achieve or maintain. One of the keyperformance targets to be achieved was the 18 weekwait Referral to Treatment (RTT) target, where 100%of admitted and non-admitted patients had to receivea definitive treatment or intervention within 18 weeksof referral.

Throughout the year, NCH&C made significantimprovement with most services either achieving thetarget on a consistent basis, or being close to 100%.The one service that did not meet this until the end ofMarch 2012, was podiatric surgery.

Throughout the year, and in line with the previous year,NCH&C maintained low levels of delayed transfers ofcare. On average, patients whose discharge wasdelayed for non-medical reasons occupied only 4.1% ofbeds, compared to 4.4% the previous year. There areno contractual targets in place for this measure. Thisimprovement in the discharge process is as a result ofthe implementation of the ‘Productive Ward’ acrossNCH&C’s community hospitals. Analysis of the datafrom Norfolk and Norwich University Hospitals NHSFoundation Trust (NNUH) suggests there may becircumstances that cause regular and significant peaksin demand for community beds. If the peak in demandis unavoidable, the commissioner will need to decidewhether to increase capacity or accept delays will occur.

In 2010/11 the Trust experienced nine cases of C.diff.For 2011/12, NCH&C had a ceiling of no more thannine cases for C.diff and one for MRSA bacteraemias.By the end of March 2012, there were eight reportedcases of C.diff and no MRSA bacteraemias. All reportedcases have been subject to Root Cause Analysis (RCA)to review lessons learned.

As part of the Provider Management Regime (PMR)with NHS Midlands and East, NCH&C is required toreport the number of items delivered to patients fromits Central Equipment Store. Throughout the year, theTrust delivered in excess of 23,600 items of which morethan 99.3% were delivered within seven days of receiptof a referral. The SHA target is 100% of items deliveredwithin seven days.

From April 2011, the NHS East of England (priorto the clustering of strategic health authorities),requested that the Trust commence reporting ofVenous Thromboembolism (VTE) assessments forpatients admitted to its community hospitals.The Trust established a locally agreed trajectory,against which it would be monitored, and to thenachieve the national target of 90% compliance byFebruary 2012. By January 2012 the 90% targetwas achieved.

Part 3 3.1 Review of quality performance in 2011/12 293.1.5 Performance highlights

Indicator Target or upper ceiling 2011/12 Trendperformance

MRSA bacteraemia No more than one case during 2011/12 0 cases Stable

MRSA screening 100% of patients having planned 100% Stable- elective patients surgery screened for MRSA

Clostridium difficile No more than nine cases during 2011/12 8 cases Stable

Delayed transfers of care No more than 6% of beds occupied by patients 4.1% Stablewhose discharge is delayed for non-medical reasons

Venous Thromboembolism Percentage of admissions who had a VTE 90.4% Increasing(VTE) assessments assessment undertaken

Community equipment >99% of items delivered within seven days of receipt 99.4% Stablestore (CES) response within seven days of a referral

Health visiting 95% or more of mothers receiving a New Birth Visit 97.1% Stablewithin 28 days of birth

Injurious falls Achieve a reduction in the number of falls resulting 4.03 Decliningin harm per 1,000 Occupied Bed Days

Meeting targets 2011/12


Areas of non-deliveryThere was one consistent variant to 18 weekperformance. This was within the Podiatric SurgeryService. During the year a number of operationalactions were introduced and underpinned bycomprehensive analysis and modelling of demand,capacity, backlog and activity. This enabled the serviceto work towards full compliance with the 18 weekwait target. A performance notice and exceptionnotice were issued (without incurred financial penalty)which remains in place at the time of writing.

This service has been 18 week compliant sinceApril 2012.

The Smoking Cessation service agreed an annual targetfor 2011/12 with NHS Norfolk of 2,700 quits. Despite acomprehensive restructure of the service to deliver thequit target, achieving the necessary level of referralssupported by a strong conversion rate provedchallenging. It became apparent during the year thatthe Trust was starting to deviate from its trajectory anda number of actions were established to improvereferrals rates. However, the subsequent referralsgenerated were not sufficient to recover the level ofquits required, and as such the Trust failed this target.

For 2012/13, the Trust will work in partnership withNHS Norfolk and Waveney to understand thedemographic context of the targets and look at newways of working with partner organisations to improvequit rates and referrals. A target of 2000 quits has beenset for 2012/13 by the commissioners. The focus for theservice for the coming year will be to achieve its targetof 2000 quits including an impact on target groupssuch as routine manual workers and to demonstratehow it has supported the wider health system inachieving their overall target of 6000 (see section3.1.10 (d) research project).

The Trust was commissioned by NHS Norfolk andWaveney to provide a Continuing Health Careassessment service. Throughout the year, the Trust failedto achieve NHS Norfolk and Waveney’s target of 100%of assessments undertaken within 28 days of referral.Although this was in part, compounded by factorsrelated to external agencies, the management of theservice transferred to NHS Norfolk and Waveney inFebruary 2012 in order that they may take controlof a wider strategy around continuing care.

Indicator Target or upper ceiling 2011/12 Trendperformance

18 weeks Referral 100% of patients seen within 18 weeks of referral 98.7% Stableto Treatment

Smoking cessation To achieve 2,700 successful quits during 2011/12 2,051 Declining

Missing targets 2011/12

Part 3 3.1 Review of quality performance in 2011/12 313.1.6 Clinical quality and Quality Goals

3.1.6 Clinical quality andQuality Goals

This section outlines the Trust’s progress againstnational and regional quality improvement priorities aswell as the Trust’s own priorities and Quality Goals from2011/12 under the following headings;

• Patient safety – protecting people from harm

• Effectiveness of care – promoting a culture ofcontinuous improvement through audit and researchprojects and implementing NICE guidance

• Patient experience – listening to what our serviceusers think

Our Quality Goals for 2011/12 were developed throughthe annual planning process and reported in theforward-looking section of our Quality Accountfor 2010/11 and linked to the Trust’s QualityImprovement Strategy. They are listed as follows:

1. To reduce levels of pressure ulcers

2. To reduce levels of attributal clostridium difficile (C. Diff)

3. To reduce levels of MRSA bacteraemia

4. To reduce levels of falls resulting in serious harm

5. To reduce levels of medication errors

Under the Patient Experience heading we also set thefollowing goals (see section 3.1.7 for details):

1. Establishment of a patient experience tracker tool(CQuIN indicator 5)

2. Carer satisfaction surveys (CQuIN indicator 7)

3. Improvement of the Ipsos Mori areas that scored<50% (Communication, Environment, Informationand involvement)

Quality Goal 1 - To reduce levels ofpressure ulcersThe Trust is committed to achieving the aim ofeliminating all avoidable pressure ulcers by December2012 and this is our top clinical improvement priorityfor 2012/13.

To achieve this aim the Trust has set up a strategy groupwhich is chaired by our Chief Executive and has clinicaland corporate support on the steering group. Tosupport this activity, the following task and finishgroups have been formed:

• Clinical improvement and outcomes

• Partnership working and patient engagement

• Performance and improvement

• Education, clinical competencies and skills training

During 2011/12 NCH&Creported 111 serious incidentsrequiring investigation (SIRIs) of grade 3 and 4 pressureulcers. The Trust has sought to encourage a positivereporting culture and has held a number of learningevents to raise awareness of the positive effects ofreporting all incidents and Pressure Ulcers specifically.At the beginning of 2011, NCH&C agreed a variationon deadlines for pressure ulcer reporting with NHSNorfolk and Waveney (NHSN&W). It was agreed thatthe full root cause analysis 45 day report would not berequired but instead a more detailed seven day updatewould be submitted.

In order to closely monitor the ambition to eliminateGrade 2, 3 & 4 avoidable pressure ulcers, a change inSIRI reporting requirements to NHSN&W and theMidlands and East Strategic Health Authority has beenagreed as from May 2012.


Three workshops have been held across the county tolaunch the new Prevention and Management of PressureUlcer policy which were well attended by our clinicalstaff. Each of the three sessions included shared learning,e-learning, incident reporting, the use of pressure reliefequipment, Nutrition Malnutrition Universal ScreeningTool (MUST) tool and Waterlow scoring training. Animportant outcome of the workshop was to resourcethe clinical leaders to train their teams in the use of themanagement tools. This was achieved. This is beingfollowed up through the provision of a number of‘roadshows’ for all teams in 2012/13.

In the last year, the Trust set a target of 100% of olderpeople identified as at risk to be assessed within 48hours of admission using the MUST tool in line with thelocal QIPP target. Against this 48 hour assessment targetwhilst quarter 4 results were lower than quarter 3 wecan report an overall improvement for the year of 8%:

Qtr 1: 80.5% Qtr 2: 85.4%

Qtr 3: 90.3% Qtr 4: 87.6%

Outcomes from the recent organisation-wide pressureulcer audit will be used to inform the focus of theclinical improvement programme. The Trust has alsoengaged with the SHA Expert Pressure Ulcer Group andthe Tissue Viability Network Group, and is seeking toimplement a tissue viability team through additionalcommissioning income and via internal resources.

Going forward, the Trust will continue roll out ofthe Safety Thermometer for the four ‘harms’ whichincludes the recording of pressure ulcer data (see 2.1.1for more information).

Quality Goal 2 – Reduction inhealthcare acquired infections (HCAI)During 2011/12 the Infection Prevention and Control(IPC) team have worked closely with NHS Norfolk tofurther develop key information packs for MRSA andNorovirus which are in use within NCH&C and thecommunity generally. We have endeavoured to workclosely with all healthcare providers within Norfolk todevelop a joint response to Norovirus and the issues itcauses across the health economy. Following the ChiefNursing Officer’s letter of March 2011 and as discussedbelow we have developed a Clostridium Difficile (C.diff)scrutiny group which will allow us to more accuratelyreport our levels of C.diff.

In the future (2012/13) the Trust plans to work withNHS Norfolk to develop a business case for an IPCliaison nurse to develop IPAC within primary careensuring high risk patients are identified and treated forMRSA and closely monitor patients at risk of a relapseof C.diff. The IPC team also hope to further engagewith primary care in protecting patients from healthcareacquired infections across Norfolk.


a. Catheter Acquired Urinary Tract Infection (CAUTI)

The monitoring of catheter acquired infections is ofhigh importance to NCH&C. The Trust aims to reducecatheter acquired infections by 50% by December 2012in line with a local QIPP target. In working towards thistarget a clinical task force has achieved the followingoutputs in the last year:

• A working definition of CAUTI has been agreed withthe Consultant Microbiologist

• An Infection Control Nurse attends a pan Norfolkmeeting regularly to update on progress

• A Catheter Care Policy: Competencies and Guidelineshas been completed and is awaiting approval

• Regular training has been organised for staff via theTrust’s Training Department

• A pathway has been completed and approval isawaited for a ‘trial without catheters’ to be carriedout by the continence team

• Intermittent self catheterisation assessment andtraining is ongoing as per NICE guidelines

• A catheter care plan has been completed

• Appropriate measures and baselines have been putin place to inform work going forward. This wasrequired before a formal target could be put in place

b. To reduce levels of attributable Clostridiumdifficile (C.diff)

Following a period of four months with no C.diff casesoccurring, NCH&C has reported one new case forJanuary 2012. This brings our total for the year April2011 to March 2012 to eight cases against an annualceiling of nine. This compares to nine cases in 2010/11.

NCH&C has a robust procedure in place which dictatesthat all C.diff positive specimens are also tested forlactoferrin, in line with national guidance. A positivelactorferrin result indicates an inflammatory responsewithin the bowel, ie, a true infection rather thancolonization. This ensures only true cases of C.diffinfection are reported and not cases of colonization.

A scrutiny group is convened, for each case of C.diff,which discusses the findings of the root cause analysis.

C.diff cases against a monthly trajectory April 2011to March 2012

c. To reduce levels of MRSA bacteraemia

There were no cases of MRSA bacteraemia in 2011/12.This compares to one case in 2010/11.

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Quality Goal 3 – To reduce levelsof falls resulting in serious harmThe aim for 2011/12 was to improve outcomes forpatients in inpatient units through the reduction offalls to meet or be below 4.4 per 1000 Occupied BedDays (OBD).

The graph below shows the degree of harm of patientfalls from April 2011 to March 2012.

Inpatient falls reported by degree of harm

The graph below demonstrates the inpatient fallscompared to 1000 OBD for April 2011 to March 2012.March saw average Injurious Falls/OBD results againfall well below last year’s performance and significantlybelow the CQuIN target of 4.4. This has led to a finalyear average against the CQuIN marker of 4.0 InjuriousFalls/1000 OBD down from 5.2 last year. There remainssignificant variation month by month, and unit by unit,as even a small number of falls can raise this figurevery quickly.

This improvement has been a result of significant andongoing work around reducing falls across units to thepoint that further significant reductions are notexpected as current evidence-based interventions andimprovement techniques have now been put in place.The evidence seems to back this up suggesting therewas a step change earlier in the year at which point theaverage has stabilised rather than continuing toimprove. As such performance is expected to remain atthis level if techniques are continued and with no otherchanges arising (e.g. change in patient profile).

Falls/1000 OBD performance - inpatient units

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Patient safety

The low rate of falls within our inpatient unitsdemonstrates that patients are continuing to receive highquality and safe services from our Trust. Injurious fallspresent a significant risk to the health and independenceof patients as they can extend a patient’s length of stayor even result in an acute hospital admission.

Clinical Audit

An audit was carried in November 2011 to determine thenumber of patients who had a falls assessment within48 hours of admission to our inpatient units. The resultsfrom this audit demonstrate that we achieved 92%, an11% improvement on our quarter two audit results.

An action plan was produced in quarter one followingthe guidance from Patient Safety First. The action planhas been updated demonstrating the actions carriedout during quarter three, such as a programme oftraining, an environment review, an assistive technologypilot on one of the wards and the roll-out of the‘intentional rounding’ pilot.

Falls Service named ‘runner up’

NCH&C’s Falls Prevention Service was named as runnerup at the NHS East of England Strategic HealthAuthority’s ‘Celebrating our Success’ Awards last year.The service was shortlisted in the ‘Whole HealthEconomy Engagement’ category for its work to helppeople avoid a fall by providing proactive interventionsand support to at-risk patients. The team ensured over444 unnecessary hospital admissions due to falls wereavoided between April and June 2011. They developeda joined up approach alongside other NCH&C servicesand partners – such as GPs, Norfolk County Council,NHS Norfolk and care homes – to identify and providecare to patients at risk of suffering a fall. FallsChampions have also been introduced to delivertraining to other clinicians to help them to identifycauses of falls and consider effective interventions.

Quality Goal 4 – To reduce levels ofmedication incidentsThe corporate objective of fewer than 20 incidents ofmoderate harm or above has been achieved with 13occurring in the period April 2011 to March 2012.

The following graph shows the trend of severity sinceApril 2011, and indicates that moderate harm incidentsare stable at between 1 to 3 per month (mean = 1), lowharm incidents increasing very gradually, and no harmincidents increasing steadily, indicating the continuingdevelopment of a healthy reporting culture. This stillrepresents a very small proportion of the activity involvingmedicines within the Trust.

Breakdown of incidents by severity, with trends

The dip in no harm incidents reported in March needsfurther investigation. The number of incidents in theprison setting has reduced since a peak in November;30 incidents were reported in November, and only 13in March. This gradual reduction was off-set by anincrease in the in-patient units due to a focus onreporting all incidents of delayed or omitted doses,which related to ongoing audits as part of the CQUINscheme. However, in-patient units reported 41 no harmincidents in February, but only 16 in March. Thereduction in no harm incidents may also be related toother factors such as low staffing numbers or end ofyear tasks that have taken the focus off incidentreporting were there was no harm.

The split of medication incidents across the Trust is mostlyin proportion with previous months, with the majoritybeing reported in the prisons and inpatient units.

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Controlled Drugs Incidents

The incidents occurring involved a range of differentissues, including missed doses, syringe driver issues,wrong patient administration and management ofCD stocks. For quarter 4 (January 2012 – March 2012)there were no incidents resulting in moderate harm.

Controlled drug incidents by month and severity

Clinical Audit: Reducing harm from omitted ordelayed delivery of medicines in hospital:

In February 2010 the NPSA issued an alert warning ofthe risks of delaying or omitting the administration ofmedicines in inpatient units. To ensure that this alert wasembedded thoroughly into practice and there was ademonstrable improvement, it was decided that theinpatient units would be audited and a campaign run toraise staff awareness and implement the required actions.

The audit found that there is much good practiceoccurring and the vast majority of medicines wereadministered at the right time and recorded correctlyand appropriately.

This campaign has, over the course of the last12 months, demonstrably:

• Reduced the number of patients experiencinga omitted or delayed dose (from 65% to 48%)

• Reduced the average number of omitted or delayeddoses occurring (from 4.34 doses/patient to 2.06doses/patient)

• Reduced the potential harm caused by omissionsor delays in the administration of medicines(from an average risk score of 5.75 to 3.06)

• Improved practices around the administrationof medicines

• Increased awareness amongst staff about this issueand the need for accurate and complete records ofmedicines administration.

Percentage change in mean risk score

This graph shows that the mean risk score has reducedfrom an average of 5.75 in the baseline audit to 3.06 inthe quarter 4 audit. This is very close to the target of 3.The units that have not yet achieved the agreed targetsfor this audit will be asked to produce an action planto remedy their local issues. These units will then bere-audited within 3 months to check progress. All unitswill be re-audited annually to ensure that this issueremains high on the agenda.

There are still areas where the Trust can improve,such as reducing interruptions during medicine rounds,ensuring robust systems are in place for recordingadministration and reviewing prescription charts, andthese should continue to be monitored locally. Thereshould also be an annual audit of prescription chartswith the audit targets set in this campaign as thebaseline standard.

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Part 3 3.1 Review of quality performance in 2011/12 373.1.7 Patient experience

3.1.7 Patient experiencePatient experience is a main pillar of NCH&C’s strategyto keep the patient at the centre of all that we do. Thefollowing patient and carer experience survey work hastaken place as part of the delivery of NCH&C PatientExperience and Involvement Strategy April 2011 –March 2013. Work will continue into 2012/13 before arefreshed strategy based on findings from this periodwill be implemented. Early studies show some excellentresults for the Trust and are described below.

3.1.7.1 Patient and carer surveysPicker Inpatient Survey Results

NCH&C commissioned the Picker Institute Europe toconduct a survey among inpatients staying in the Trust’scommunity hospitals. Face-to-face interviews wereconducted in 13 community hospitals by professionalmarket research interviewers during February 2011.A total of 122 (48%) of patients from participatinghospitals took part in the survey which is an excellentresponse rate.

The overall ratings were as follows:

• 97% of respondents rated care as excellent, very goodor good (39% excellent, 45% very good, 13% good)

• 97% said they would recommend the hospital toothers (83% said definitely while 14% said probably)

• 90% of respondents felt they were always treatedwith respect and dignity by hospital staff

• Almost nine out of ten patients (86%) felt that the nursescaring for them were always responsive to their needs

• 89% felt they were involved in decisions about their careand treatment (67% definitely and 23% to some extent)

The Trust has taken a number of actions as a resultof recommendations:

• Healthy food options are always available andnutritional booklets are utilised with the patient tosupport them in selecting healthy food options and thecatering satisfaction survey has been updated to includea question about healthy food options being available.

• Provision of ward information on admission anda general patient information booklet has beendeveloped and agreed. Unit specific detailedinformation is currently being developed basedon an agreed template.


Local Patient Experience Surveys

Adult services

3551 local surveys were completed to gather feedbackand subsequently improve patient experience focusingattention on adult services at Norwich CommunityHospital and St James Clinic, King’s Lynn; OrthopaedicTriage, MSK Physiotherapy, Podiatry and Biomechanics.The methodology used to collect data was through thepatient experience software system Meridian whereinformation is collected in a variety of ways:

• electronically through email

• through a touch-screen kiosk

• through paper surveys

The reporting of all results was service specific. Therewere three key themes for the survey; information/involvement, environment and communication as wellas ‘general’ covering overall satisfaction and would yourecommend this service.

All surveys went live on 1 July 2011 and continued untilend February 2012. The key results are show below:

Survey Theme Overall satisfactionrating

General 96%

Information/Involvement 95%

Environment 100%

Communication 98%

The comments received resulted in a number of actions:

• Improved service specific information has beendeveloped including information on what to expect atfirst appointment. Patient Information leaflets havebeen produced for all four services and are sent withappointment letters

• Improved directions and parking information atNorwich Community Hospital is now issued; a newsite map has been produced giving clearer details onparking and directions to the site and once on site

• Improved signage at Norwich Community Hospitalhas been put up from the car park to main receptionfor clinics and clearer signage once inside the mainbuilding for clinic areas has been added

• Improved Biomechanics and Orthopaedic Triagewaiting areas at Norwich Community Hospitalthrough both areas being de-cluttered, clear noticesnow being displayed in Biomechanics welcomingpatients to the service and the reception staffedregularly, notice board displays have been updated inOrthopaedic Triage. This work is in progress currently

3551surveyscompleted

97.4%overall

satisfactionacross allsurveys


Children’s Services

A programme to gather and improve information tobe used to improve children and families experiencefocusing attention on clinics provided at Upton RoadChildren’s Centre, Norwich was delivered during 2011/12.

The methodology used to collect data was throughthe patient experience software system Meridian’where information is collected in a variety of ways;electronically through email, through a touch-screenkiosk or paper surveys with the reporting of all resultsservice specific. There were three key themes for thesurvey; information/involvement, environment andcommunication as well as ‘general’ covering overallsatisfaction and would you recommend this service.All surveys went live on 1 July 2011 and continueduntil end February 2012.

The results of this survey are shown below:

Survey Theme Overall satisfactionrating

General 92%

Information/Involvement 91%

Environment 99%

Communication 96%

The comments received resulted in a number of actions:

• Existing Patient Information leaflets have all beenupdated to include additional information requestedprior to first appointment

• Improved waiting area for children of all ages;additional toys acquired

• A more accessible version of the survey wasdeveloped via an easy-read format

Local Carer’s Experience Surveys

Within the Trust a holistic approach to care ischampioned and carer and family feedback is ofsignificant importance to us in measuring our overallperformance. Two surveys were delivered in 2011/12with this group specifically in mind.

A carer’s satisfaction survey was carried out focussingon interactions with Case Managers and in the Trust’sresidential short breaks service for children.

The methodology used in both surveys was a systemcalled ‘health feedback’ consisting of a very simple A5size survey card completed manually, online or via a freephone number. The surveys commenced in July 2011and ran to December 2011.

In addition to the survey questions respondents were alsoasked for their comments. The findings were as follows:

Adult services:

•100% felt they were always or usually treated withrespect by staff

• 99% of carers felt they were involved as they wantedto be

• 99% felt the information they were given had beenvery or fairly helpful

• 95% felt very satisfied with the overall experience,5% fairly satisfied

• 91% felt they were very satisfied with the way staffcommunicated with them

1015surveyscompleted

95.2%overall

satisfactionacross allsurveys


As a result of this survey, the following key actions havebeen taken:

• Improved information leaflets have been drafted andwill be personalised to each area

• Commitment has been taken to ensure a change ofCommunity Matron will be well communicated andexplained to carers

• A carers focus group took place in March2012 to discuss survey results, actions andfuture recommendations

Children’s services:

• 96% parents/carers felt very or fairly involved in theplanning of care for their child

• 65% said there had been no changes to theirbooking with 35% saying it had been changedonly once or twice

• 55% said they were very satisfied with the allocationchange, 25% fairly, 15% neither satisfied nor dissatisfied

• 74% felt their child had always been treated withrespect with 26% saying usually

• 52% felt very confident their child’s individual needshad been met, 43% fairly

• 70% said staff had been very helpful with 30%saying fairly helpful

• 70% were very satisfied with their overall experienceof the service and 30% were fairly satisfied

As a result of this survey, the following key actions havebeen taken:

• Improved involvement of parent/carers in the planningof care for the child; each child will have a full reviewof their short breaks care package six monthly

• Named member of staff responsible for organising thebooking with Parents/carers contacted by phone iftheir booking needs to be amended giving them asmuch notice as possible

• A privacy and dignity action plan is being written foreach unit. To maintain this during personal care“stop” and “go” signs have been placed on toilet andbathroom doors. Each child will also have a nameplate and a photograph on their room during eachstay to identify personal space

• Increased communication is aided through anewsletter which has been developed to improvecommunication between parents/carers and the units

• A re-survey took during March 2012 to determine ifactions put in place have improved satisfaction

Community Services Survey – February 2012

NCH&C took part in a community services survey,coordinated by Hounslow and Richmond CommunityHealthcare for all community trusts. Patient Perspectivehas been commissioned to conduct the survey andprovide analysis and reporting to each participatingtrust. The survey focused on Podiatric Surgery,Continence, Paediatric Speech and Language Therapy(SALT), Adult SALT and Wheelchair Services. The surveyclosed at the end of March 2012 and results showcomparative data for NCH&C with five othercommunity trusts. Scores for privacy, dignity and respectgave the highest scores for NCH&C, closely followed bythe quality of service received and inclusion indiscussions about care. Lower comparative scores wererecieved for patients being told how long the time ofwaiting for an appointment was likely to be, transportto and from hospital and the opening hours of services.


3.1.7.2 Patient StoriesA key objective within NCH&C Patient Experience &Involvement Strategy April 2011 to March 2013 is to“embed patient stories as an in-depth qualitativemethodology in NCH&C”. The Trust has made a numberof service improvements as a result of this work.

• SureStart Children’s Centre at Bowthorpe, WestEarlham and Costessey has increased communicationwithin GP surgeries, local libraries and schools aboutservices offered at the Centre. The content of a “Stayand Play” session had been altered to meet therequested needs of parents attending with theirchildren. The centre was assessed in 2011 as“outstanding” by Ofsted and commended on their useof parent stories, requesting more were conducted.

• Starfish West Learning Disability & Behaviour teamhave a new service leaflet designed for parents/carersand have improved the referral process fromPaediatricians into the service.

• Colman Centre for Specialist Rehabilitation Serviceshas involved patients more in the discharge planningprocess and has improved transition processes fromin-patients to outpatient services.

Advocacy – Net Promoter

NCH&C has made good progress in the use of the netpromoter methodology in 2011/12 and will continue todevelop this tool as a key indicator of patient satisfactionand service quality. The results from 2011/12 specificallyrelating to net promoter are as follows:

From the Picker Institute Survey 2011

97% said they would recommend the hospital to others(83% said definitely while 14% said probably). 3% saidthey would not.

From the Adult Services Survey 2011/12

94.5% said they would recommend the service to afriend or relative if they needed similar treatment, care oradvice (85.5% very likely while 9% said fairly likely). Justunder 1% were very or fairly unlikely to recommend.

From the Children’s Services Survey 2011/12

95% said they would recommend the service to a friendor relative if they needed similar treatment, care oradvice (79.5% very likely while 15.5% said fairly likely).3% were very or fairly unlikely to recommend.

Comparison to results in 2010

Survey results from 2011/12 show a significantimprovement compared to the results of the Ipsos MORIPatient Experience Survey in 2010 where 68% ofpatients were very likely to recommend and 58%of parent/guardians.


3.1.7.3 Six Lives Programme –improving access tohealthcare for peoplewith a learning disability

The Trust has embraced the challenge of implementingthe Six Lives programme with commitment. Severalprojects have been delivered to improve the quality ofcare given to patients with a learning disability and theirexperience of the Trust’s services.

A new protocol ‘Improving Access to Healthcare forPeople with a Learning Disability’ has been developed andthe ‘Information for Patients’ policy has been reviewedand reflects the requirement to provide accessibleinformation to all patients. Both documents have beenlaunched and are available on the Trust’s intranet.

A three-tiered approach to staff training hasbeen agreed:

1. Basic learning disability awareness – provided aspart of Trust induction and all existing staff havereceived a basic awareness information sheet

2. Learning disability awareness – two hour trainingsession available to all staff but as a minimum allTeam Leaders are required to attend and cascade totheir teams (over 300 staff have attended to date)

3. Learning Disability Champions – the developmentof a full day programme is underway

A process for flagging patients with a learning disabilityon electronic patient systems is available. Theseprocesses also prompt staff to document any reasonableadjustments that are made to meet individual needs.Work is underway to develop a system for those servicesnot currently using these electronic systems.

A programme of work for the next 12 months willembed into practice the policies and processes thathave been developed to support compliance against SixLives and ensure sustainability. This programme includesthe review of care planning documentation to facilitatethe recording of any reasonable adjustments that arebeing made within the in-patient units and training forteams using SystmOne so that the method adopted toflag patients and record any reasonable adjustments isclearly communicated.

The Patient Experience and Involvement Team will adopta range of approaches to ensure both patient and carersatisfaction and involvement in service development isembedded within processes. This has commenced withone focus group already being held and a programme ofactivity is planned during 2012 whereby representativeswill attend the existing Carer’s Forums across the countyto listen to views and action plan accordingly. Thepatient story methodology will also be used to captureexperiences of patients with learning disabilities andtheir carers which will provide depth to the datacaptured and further strengthen the evaluation process.

The Project Lead will continue with monthly steeringgroup meetings to ensure actions against the evaluationphase of this project are carried out and reported on asappropriate e.g. patient and carer experience surveys,Essence of Care audits. A programme of specific auditswill also be conducted, commencing in June 2012.

3.1.7.4 Single Sex AccommodationThe Trust continues to prioritise patient privacy anddignity. During 2011/12 there have been no breaches ofany milestones as set out in NCH&C’s Eliminating MixedSex Accommodation (EMSA) plan and therefore nofinancial penalties incurred.

Further, there were no reportable breaches of single sexaccommodation. The Trust expects this performance tocontinue into 2012/13.


3.1.7.5 Patient Environment ActionTeam (PEAT) Results for 2011

In April 2012, the National Patient Safety Agencyconfirmed NCH&C’s PEAT results 2011 for environment,food and privacy and dignity for each hospital withinour organisation as follows:

It should be noted that as from 10 May 2012St Michaels hospital closed and services weretransferred to the new build North Walsham Hospital.

Any required improvements to the buildings/environment will be conducted as part of the2012/13 capital and minor works plan.

The results of PEAT are published on the NHSInformation Centre website www.ic.nhs.uk and arealso available to the public on www.data.gov.uk

Site Name Environment Score Food Score Privacy andDignity Score

Colman Hospital Good Good Good

Norwich Community Hospital Good Good Good

Dereham Hospital Acceptable Excellent Good

North Walsham Hospital Acceptable Good Good

St Michaels Hospital Good Good Excellent

Kelling Hospital Acceptable Good Good

Swaffham Community Hospital Acceptable Excellent Good

Ogden Court, Wymondham Good Good Excellent

Cranmer House, Fakenham Good Excellent Excellent

Benjamin Court, Cromer Good Good Excellent


3.1.8 Learning fromincidents andcomplaints

Complaints and ComplimentsFrom April 2011 to March 2012 NCH&C received192 complaints, in comparison to 195 during the year2010/11. The Trust continues to use the number ofcomplaints as a clear indicator of patient satisfactionalongside our patient experience programme. Two mainthemes arising from analysis of complaints include thesingle point of referral, which is under review, andattitude of staff, which is also receiving attention fromour internal training team. New courses are underdevelopment focussing on customer care andprofessional behaviours.

Patient compliments are also measured and this yearthe Trust has received around 335 compliments. Thededication and commitment of our frontline staff is arecurring theme of the compliments received. (seesection 3.1.3 for a summary)

Learning from complaints is collated from theService Managers following an investigation andcommunicated across the organisation via the Quality& Risk monthly report (seen at Quality & Risk AssuranceCommittee and the Trust Board) which is published onthe Trust’s website and through the monthly staffnewsletter. Themes from complaints are taken to thesenior clinical management team (CMT) for discussionand forward planning.

Serious Incidents RequiringInvestigation (SIRIs) and Never EventsSerious Incidents are reported into a central team andinformation is collated via DATIX a web-based riskmanagement tool. The Executive team see every seriousincident and are able to ensure that corporate supportfor investigations is given to operational teams whererequired. Themes from serious incidents inform learningevents which are held quarterly and attended by seniorclinicians and management. The SIRI log and tracker arepresented at the Trust’s Clinical Management Teammonthly to share learning and information across allclinical teams.

From April 2011 to March 2012 NCH&C have reported136 SIRIs, these can be broken down as shown below.

From April 2011, NCH&C and NHS Norfolk made thedecision in line with national best practice to report allgrade 3 and 4 pressure ulcers as a SIRI. This led to anincrease in the numbers reported.

NCH&C reported two allegations of potential abuse.One is still under investigation and a member of staff hasbeen dismissed for allegedly abusing an adult patient.

NCH&C reported on a competency issue which involvedan agency nurse. The nurse is currently under an interimorder by the Nursing and Midwifery Council (NMC) andsuspended from practice.

There were six unexpected deaths in the inpatient unitsand all were investigated (four were referred to theCoroner) and none identified as attributable to the careor competence of the staff.

Part 3 3.1 Review of quality performance in 2011/12 453.1.8 Learning from incidents and complaints

Breakdown of SIRIs by type 2011/12

SIRI information TotalApr 2011 toMarch 2012

Pressure Ulcer Acquired undercare of NCH&C - Grade 3 75

Pressure Ulcer Acquired undercare of NCH&C - Grade 4 36

Pressure Ulcer Acquired outsidethe care of NCH&C

Abuse 2

Professional competence 1

Patient Accident 10

Unexpected Death 6

Medication 2

Information / Documentation 1

Child Protection 1

Infection control 1

IT 1

Expected Death

Self harming behaviour

Media interest (potential)

Other

Total 136

Never EventsThe Department of Health have produced an updatedlist of 25 “never events” for use in the NHS in 2012/13.These incidents are considered unacceptable andeminently preventable.

The Trust is pleased to report it has had no ‘neverevents’ during 2011/12.

National Patient Safety AgencyReport (NPSA)The National Patient Safety Agency have recentlypublished its latest Patient Safety Incident Report.The report demonstrates that NCH&C are amongst thehighest 25% of reporters within its cluster. The NPSAstates “That organisations that report more incidentsusually have a better and more effective safety culture.”

Incident reporting across NCH&C has steadily increasedsince the implementation of DATIX Web together withincreased training and awareness promoted throughoutthe organisation.

The number of incidents under the type“Implementation of care and ongoing monitoring /review” is significantly higher than other organisationswithin the cluster, this is largely due to the increase inpressure ulcer reporting.

The NPSA state “not all organisations apply the nationalcoding of harm in a consistent way, which can makecomparison of harm profiles of organisations difficult”.As part of the final approval process of incidents, theQuality & Risk team ensure that the national coding ofharm is used in a correct and consistent way beforesubmission of incidents to the NPSA. We are assured thatthe figures within the report accurately reflect the actualdegree of harm caused to patients as described by theNPSA requirements. The report indicates that we have ahigher than average rate of low harm incidents howeverwe have a lower level of moderate harm incidents.

We also have a higher level of severe harm incidents,this is mainly due to increased pressure ulcer reportingas all Grade 4 pressure ulcers should be graded assevere harm.


Learning from incidents

During 2011/12 the Quality & Risk team facilitated threelearning events for our clinical staff; the first wasregarding the prevention and management of pressureulcers, the second regarding insulin dependent patientsand patients requiring INR testing and managementand the third was aimed at ‘Enabling people to die incomfort and with dignity’. Attendees heard from expertspeakers about how partnership working can deliverthe best patients outcomes in end of life care. It wasalso an opportunity to discuss the new regional ‘Do NotAttempt Cardio-Pulmonary Resuscitation’ form andlaunch our Trust’s revised Resuscitation Policy.

The aim of these events is to share learning and goodpractice across the Trust with the ultimate aim ofimproving quality.

Four Learning Events are being arranged during 2012 tocelebrate ‘best practice’ and to give staff an opportunityto discuss how further improvements can be delivered.Each event will be themed around real-life incidents orissues which have been reported by our staff andpatients and will be a chance to share the subsequentlearning from these issues.

The topic for the next event, due to take place inMay 2012 will be regarding the principles of goodrecord keeping and data quality which will also discussthe results of the annual organisation-wide recordkeeping audit.

Learning from Downham Market Health Centre

Arguably the most significant quality related event forthe Trust during 2011/12 was the publication of theindependent report by Collingham HealthcareEducation Centre (CHEC) (a consultancy specialisingin reviews into GP practice), into the circumstancessurrounding the Downham Market Health Centre.This was a nurse led Primary Medical Service (PMS) GPpractice. There were four serious incidents requiringinvestigation (SIRIs) that occurred within the practice inMarch and July 2010 and January and February 2011.

The review concluded that the practice had fallen belowthe managerial radar of the Trust and therefore thestandards of care fell below the excellent services wewould aspire to and patients should expect. The reviewfound no direct evidence of patient harm as a result ofthe failings identified. The review concluded with anumber of recommendations for various organisations.The recommendation for NCH&C was that the Trustshould reflect as an organisation on the contents of thereview, acknowledge its responsibility, put in placerobust measures to translate the findings into itsorganisational culture and to ensure that failuresdescribed here can never be repeated.

The circumstances and criticisms rightly informed theorganisation. Athough the Trust no longer providesthese services the Trust Board and teams have reflectedextensively and continues to do so on the circumstancesand their wider implications.

The Trust had already begun to address the concernsidentified in the CHEC report and had developed anaction plan that was later adapted into a wider projectto embed quality systems across the organisation. Keyinterventions and improvements during the last yearinclude the introduction of monthly Business UnitPerformance Meetings. These triangulate in detailquality, financial and performance information forteams and services. A number of staff have moved onand the medical leadership of the Trust has beenstrengthened with the appointment of a substantiveexperienced Medical Director with increased hours aswell as an experienced associate Medical Director.

A closure report detailing all the learning points andactions taken was approved at the public Boardmeeting in April 2012 and can be found on ourwebsite: www.nchandc.co.uk

Part 3 3.1 Review of quality performance in 2011/12 473.1.8 Learning from incidents and complaints

Early Warning Trigger Tool

In September 2011, the Trust introduced an EarlyWarning Trigger Tool (EWTT) adapted from the NPSA’stool to be more relevant to a community setting, to actas an early warning system to flag up potential qualityand patient safety issues before they occur. Theindicators explicitly capture the circumstances ofDownham Market such as change in senior cliniciansand staffing. The tool is completed by all teams on amonthly basis. During the year the threshold forescalation has been lowered to ensure more services aresubject to increased scrutiny. Implementation of the toolshould reduce the number of Serious IncidentsRequiring Investigation (SIRIs), reduce the risk of anunfavourable CQC report and prevent services goinginto crisis.

Each month, staff across community teams and theinpatient units assess their areas against a checklist withweighted scores, which results in an overall RAG-ratedscore and an indication of what action is required:

• Score of 10 or less - Green ratingNo action required, re-assess area next month

• A score between 11 and 15 - Amber ratingUndertake full risk assessment and agree actionplan for red items within one month. Add to localrisk register

• A score of 16 or more - Red ratingInform line manager immediately and undertake fullrisk assessment within one week. Produce action planfor red items within one week

The Trust now has six months’ of assessments of theEWTT, and there are some clear recurring themes whichare common across many teams and units, and whichwill need to be addressed at a local level. These include:

• Staff not updating clinical records within 24 hours ofthe contact taking place

• No formal feedback obtained from patients during thelast 12 months (e.g. questionnaires or surveys)

• Vacancy rate higher than 3% (2 points) or 6% (3 points)

The chart on page 48 shows the frequency with whichthemes were occurring in March 2012.

The Trust also reviewed those services that had thepotential to share possible characteristics withDownham Market – such as small or geographicalisolated. The Board has also approved a BoardAssurance and Escalation framework to articulatethe process of how concerns and risks flow from thefrontline services to the Board. The Board also reviewedits board assurance framework which identifies thehigh level strategic risks which are linked to the Trust’sobectives In addition, an extensive programme ofservice visits has been completed by both Executiveand Non-Executive Directors and a programme for2012/13 is being developed.


Two or more formal complaints in a month

No evidence of resolution to recurring themes, eg, complaints,medication errors, falls (excluding pressure ulcers)

New Serious Incidents Requiring Investigation(SIRIs) reported in month

No evidence of effective multidisciplinary/multi-professionalteam working

Extreme demands on service exceeding capacity to deliver(eg, pandemic, norovirus, outbreak)

Unfilled shifts is higher than 6%

Cleanliness audits not performed

No monthly review of key quality indicators byBusiness Unit meetings

No involvement of Team Leader in Business Unitor Trust meetings

Hand hygiene audits not performed

Ongoing investigation or disciplinary investigation(including RCAs & infection control RCAs)

Department/office appears untidy

More than 5% of shifts covered by bank, excess hoursand agency

Annual appraisals completed within last 12 monthsbelow 88%

No evidence of adequate clinical supervision in place

Mandatory training compliance below 88%

Change or absence of a Lead Clinician(within last six months)

Overspent against budget

New or no line manager in post (within last six months)

Sickness and maternity absence rate higher than 4.5%

Vacancy rate higher than 3% (2 points) or 6% (3 points)

No formal feedback obtained from patients during the last12 months (eg, questionnaires or surveys)

Staff not updating clinical records within 24 hours

0 10 20 30 40 50 60

Frequency of theme occuring

Early Warning Trigger Tool Trust-wide frequency of themes (March 2012)

Part 3 3.1 Review of quality performance in 2011/12 493.1.9 Safeguarding Adults and Children

3.1.9 Safeguarding Adultsand Children

‘Together we are stronger’ making vulnerable peoplesafer was an event aimed at keeping children and adultsin Norfolk safer by more joined up working betweenour staff and others was held in October 2011. TheDepartment of Health Lead for Safeguarding Adults wasone of the keynote speakers at the event which aimedto help the NHS, Police and Council staff share theirexperiences on some of the complexities of dealing withsafeguarding issues and to find effective solutions.

Safeguarding Arrangementsin NCH&CNCH&C has established Executive and Non-ExecutiveLeads for both Safeguarding Adults and Childrenas follows:

• Director of Operations, Executive Lead forSafeguarding both Adults and Children

• Non-Executive Lead for Safeguarding Children

• Non-Executive Lead for Safeguarding Adults

NCH&C has well established, highly experiencedoperational Leads for safeguarding children whoprovide comprehensive training and supervision for staffand also provide expert interventions for reviews,reports and clinical input.

The post of Head of Adult Safeguarding and Transfer ofCare was recruited to in May 2011 and will facilitate theimplementation of the No Secrets guidance withinclinical practice, it will also provide assurance to theboard through evidence reporting and by supportingstaff in the management of Safeguarding issues,training and linking with external partner agencies.

Main Issues for Safeguarding AdultsSafeguarding Adults is an evolving area of practice;whilst the severe cases of physical abuse is clearlyrecognised by staff, areas such as neglect, poor careand patient experience are not easily seen as reportablesafeguarding concerns.

The key issues for Safeguarding Adults in the last yearhave been:

• Lack of recognition of abuse

• Not referring patients early enough to theMultiagency Safeguarding Team

• Lack of understanding on management ofabuse victims

• Poor understanding of the Mental Capacity Act,consent and Deprivation of Liberties


Main Issues for Safeguarding ChildrenThe current key issues for safeguarding children in thelast year:

• Nationally and locally there has been a rise in thenumber of looked-after children (LAC) and a rise inthe level of need across the tiers of intervention

• In line with changes to national guidance allsafeguarding children training has been reviewedand a new training strategy enacted

• There have been two multi-agency management reviews

• Multiagency Safeguarding children and LACarrangements in Norfolk have been inspected by theOffice for Standards in Education (OFSTED) and theCare Quality Commission (CQC) in June 2011

• The impact of reduction in support services offered byother agencies due to financial constraints

Organisational LearningOpportunitiesThere are many ways in which NCH&C intends to raiseawareness of important safeguarding issues including,formalising the organisational leadership and direction,disseminating policies and procedures and implementingtraining and supervision. NCH&C is committed to takingall opportunities to share learning from safeguardingactivities and serious cases and is holding a conferencefor NCH&C staff and our partners to raise awarenessand influence practice.

The conference entitled “Together we are stronger”took place on 5th October 2011 and 130 delegates,including staff from other organisations, heard howNHS, police, council, and voluntary sector staff canimplement even more effective support for vulnerableadults and children. Shared learning from the event isnow being taken forward by our Safeguarding Team,which will consider how we can further improve ourprocesses and staff training and work even more closelywith our partners.

NCH&C safeguarding teams have produced quarterlyreports for adults and children to the Trust Board thisyear. These reports have identified the main issues andNCH&C strategic approach to minimising the associatedrisks for the organisation. It highlights the significantprogress made in strengthening the leadership for bothadults and children and the progress made againstcompliance with national policy and guidelines. It alsodetails some of the priorities for the coming year.

Part 3 3.1 Review of quality performance in 2011/12 513.1.10 Effectiveness of care

3.1.10 Effectiveness of care

a. National Institute for Health andClinical Excellence (NICE)

NICE have devised a number of audit tools for newguidance which is being released, and this has beenpositively received by NCH&C clinicians as it providesthem with an ‘off the shelf’ resource for sharing newguidance with colleagues.

NICE have also produced an online ’pathway tool’which provides quick and easy access, topic by topic,to the range of guidance from NICE, including qualitystandards, technology appraisals, clinical and publichealth guidance and NICE implementation tools. Thesepathway tools are simple to navigate, and allow staff toexplore in increasing detail NICE recommendations andadvice, giving clinicians confidence that they are up todate with everything NICE have recommended.‘Hot topic’ pathways include; Diabetes, Dementia,Hypertension, Chronic Obstructive Pulmonary Disease.

Six audits based upon NICE guidance were put into thisyear’s clinical audit plan:

1. Transient Loss of Consciousness – CG109

2. Female continence (NCH&C audit proposal based onCG97 – Lower Urinary Tract Infections in Men

3. Depression – NICE Clinical Guideline 90

4. Hypertension – NICE Clinical Guildeline127

5. Osteoporosis (re-audit) – NICE TechnologyAppraisal161

6. Osteoarthritis – NICE Clinical Guideline 59

Two other pieces of NICE guidance were flagged asbeing relevant to NCH&C services, but did notnecessarily initiate a clinical audit to be undertaken;

1. PH32 Skin Cancer Prevention – prevention usingpublic information, sun protection, resources andchanges to the environment (January 2011), thisguidance was used to implement a plan of actionby Children’s Services

• Undertake a baseline audit to determine level ofactivity with regard to sun safety messages withinHealth Visiting and School of Nursing services

• Review activities for sun safety within short-breakservices, Sure Start Children’s Centres and Nurseries

• Develop plan for consistent delivery of seasonalsafety in the sun messages across all services

• Assess if there are any training needs to supportimplementation of the guidance

2. CG133 Self Harm – Longer Term Management(November 2011), this guidance was flagged asrelevant by prison healthcare services, and actionplanning will follow.


b. National Clinical auditsActive participation in National Clinical Audits meansthat we can review NCH&C’s performance againstsimilar community provider trusts, allowing us tobenchmark our performance as an organisation.Participation in National audits are also reported in ourannual Quality Account which is a public document.

Each year the majority of National Audits available onthe National Clinical Audit and Patient OutcomeProgramme (NCAPOP) are ‘acute trust’ focused, but alist of those which are applicable to us as a ‘provider’trust are circulated to clinicians at the end of each year,to establish interest and clinical commitment to conductthese audits within NCH&C. Due to the size and remitof these large national audits, data is collected over aperiod of months and then collated and analysed byeither a Royal College or a nominated charity beforerelease of the final report in quarter 2 or 3 of thefollowing year.

Within 2011/12 NCH&C participated in 3 NationalAudits, namely; National (Adult) Diabetes Audit,Epilepsy12 (this was year 3 of 3 of this children’sNational audit), and the Parkinson’s National Auditwhich was run by ‘Parkinson’s UK’. Reports from allthree of these national audits should be made availablein Q2/3 of 2012/13

Links with other organisations

These national audits follow individual patient pathwayswhich cross primary and secondary care. To follow is abrief description of how this worked for each of ournational audits:

Parkinson’s Audit – our Specialist Nurses provided‘community data’ which was used to track the progressof patients diagnosed with Parkinson’s Diseasefollowing discharge from the Norfolk and NorwichUniversity Hospital NHS Foundation Trust hospital.

National Epilepsy12 (Children’s) audit – NCH&Cworked with the Paediatric specialists in the Norfolk andNorwich University Hospital NHS Foundation Trusthospital in order to follow patient pathways andmeasure clinical care received in both the Acute andcommunity environment against best practice standardsproduced by the Royal College of Paediatrics and ChildHealth (RCPCH).

National Diabetes Audit (Adults) – our DiabetesSpecialist Nurse team in the west of the county workedclosely with GP consortia in order to record data againstadult Diabetic patients for the National Diabetes Audit(Adults), and for the purposes of this audit thisinformation was used to demonstrate the effectivenessof individual patient journeys through primary tocommunity care.


c. Local Clinical audit projectstatistics for 2011/12

The table below demonstrates the breakdown ofprojects registered by type between 1st April 2011and 31st March 2012.

2011/12 saw a number of ‘service evaluation’ styleaudits using ‘levels of assurance’ which are takenfrom the 2012 NCH&C clinical audit template. Theyrecognise ‘high’ as over 85% compliance, ‘moderate’ asbetween 60% - 84% compliance, and ‘low’ as below59% compliance against clinical audit standards.

Of the 67 proposed audits, 33 were completedduring 2011/12:

• 33% gave high assurance, including hand hygiene,essential steps and the community hospitalsantibiotics audit

• 53% provided moderate assurance and theseincluded: safeguarding children’s supervision andreducing harm from omitted and delayed medicines

• Those audits providing low assurance were generallydue to small or insufficient sample sizes being audited

Type of project Examples Number % of totalclinical audits

Priority 1 Internal ‘must do’ audits CQuIN audits, Schedule 16 (Commissioning 22 33%Audits), NICE Technology Appraisals (TAs).

Priority 2 ‘External ‘must do’ audits National Clinical Audits, National Service 8 12%Framework Audits

Priority 3 Operational business Service specific audits, baseline audits for 11 16%unit priority audits business case proposals etc

Priority 4 Clinical interest audits Clinical speciality led audits, 26 39%NICE (other than TAs)

Total 67 100%

14%

33%

53%

High

Moderate

Low


A summary of these are as follows:

• “Safeguarding Children – Supervisors Audit”,which provided moderate (73%) assurance, thatSafeguarding Supervisors working within Children’sServices were receiving adequate support and trainingin their professional roles (June 2011).

• “Reduction of Falls/preventing falls and reducing harmfrom falls”, which provided high (92%) assurance thatin-patient units within community hospitals werecompleting a falls assessment within 48 hours ofadmission, this service evaluation was a CQUIN target,and was achieved.

• “Reducing the harm from omitted and delayedmedicines in hospital. A re-audit of NCH&C inpatientunits, December 2011”, provided moderate assurancethat teams and individuals were adhering to NationalPatient Safety Agency (NPSA) guidance to reduceoccurrences of missed and delayed medicines given inour community in-patient sites.

• The Infection Control Team conduct monthly ‘handhygiene’ audits at localities and in 2011/12 resultsacross the trust provided high assurance (99%)

d. Research & DevelopmentNCH&C patients with venous leg ulcers take partin biggest ever leg ulcer study

Patients with venous leg ulcers under the care ofNCH&C’s community nursing teams in Norwich, LongStratton, Diss and Dereham have been involved in apiece of research that is looking at two differenttreatments used to treat this debilitating, long-termcondition. The study is the largest ever of its kind in theUK, involving more than 30 Trusts. It will provide thelatest evidence on which treatment is most effective,ie, has a faster healing time, by comparing four-layerbandaging with compression hosiery (stockings).

The results, (due out in autumn 2012) will enablecommunity nurses to offer the best treatments topatients, in line with this new evidence. As a result ofthis it is hoped that the length of time patients needto be treated for leg ulcers in the future will besignificantly reduced.


Norfolk Sure Start Centres involved in nationalprogramme of research

Several Sure Start Children’s Centres run by NCH&C areinvolved in a five-year national research programmewhich aims to improve understanding of children’saccidents and effect a change in behaviour with parentsand families around child safety. The project looks atthe following areas:

• house fires

• falls

• scalds

• poisoning

As part of the research, an injury prevention briefing(IPB) on specific aspects of injuries in the home to pre-school children is being developed that will be tested ina group of children’s centres, including Norwich. Thebriefing will be sent to centres in four study areas:Nottingham, Bristol, Newcastle and Norwich. Some willalso receive support from the project team to help themtake forward key messages in the IPB.

When the 12-month study has been completed thestudy team will roll-out a revised briefing outside thestudy areas. The research will show whether, as a resultof Centre staff using the briefing, there are changes insome families’ home safety behaviour, and ultimatelythis should result in a reduction in children’s injuries andhospital admissions.

Important research involving users of NCH&C’sStop Smoking service

A study looking at the effectiveness and cost-effectiveness of a set of eight booklets (called ForeverFree) designed for the prevention of smoking relapsein people who have stopped smoking for at least fourweeks was launched in July 2011 at NCH&C. This largestudy (it requires 1,400 people to take part) involvesStop Smoking Advisors who will recruit four-weekquitters over a period of 21 months, with telephonefollow-ups at three and 12 months post quit. Studyparticipants are randomly allocated to receiving eitherthe intervention, the self-help booklets, or to usualcare, the current NHS leaflet. To date, 388 peoplehave been recruited.

The study hopes to show that people receiving the newbooklets ‘stay quit’ for much longer than those who donot. The booklets may prove to be a useful tool advisorscan use to help people who suffer smoking relapsewithin six months of the end of NHS Stop Smokingtreatment to stay smoke-free.

Research study offers support for recovering strokepatients who have communication difficulties

A study examining the effectiveness of specialist skillsfor hospital staff in communicating with recoveringstroke patients with aphasia (a communication disorderwhich affects speaking and understanding), has beenrunning for just over a year at NCH&C’s stroke unit.

The first phase of the study has provided staff trainingin ‘supported communication’ techniques. The secondphase, beginning in late 2012, will involve patients inNorfolk with moderate to severe aphasia after a firststroke who will receive care from staff trained in‘supported communication’ and compare their healthoutcomes with a group of patients in Cambridge whowill receive normal care from their local strokerehabilitation therapy team.

The research findings will determine how effectivethis new technique has been from both the staff andpatient perspective. It is hoped that the research willlead to recommendations for a staff training protocolfor wider implementation across the NHS.


• LINk and Public Involvement at Trust Board meetingsand other committees, including Quality & RiskAssurance Committee, Patient Experience SteeringGroup and PEAT inspections

• Development of the Integrated Business Plan (IBP) byBoard members and clinical reference group

• Development of the Annual Plan by ExecutiveDirectors, Assistant Directors and clinicians

• Quality & Risk Assurance Committee providesassurance to the Board and has a LINk representativein attendance

• Third party commentary requested from Norfolk LINk,NCC Health Overview and Scrutiny Committee andNHS Norfolk & Waveney

Comments from Norfolk HealthOverview and Scrutiny CommitteeThe Norfolk Health Overview and Scrutiny Committeehas decided not to comment on any of the Norfolkprovider Trusts' Quality Accounts for 2011/12 andwould like to stress that this should in no way be takenas a negative comment. The Committee has taken theview that it is appropriate for Norfolk's LocalInvolvement Network to consider the Quality Accountsand comment accordingly.

Comments from Norfolk LINkNorfolk LINk welcomes the Community Health and CareTrust’s approach to improving services as set out in theQuality Account. We agree with the priorities identifiedfor 2012/13. We hope that staffing levels arecommensurate with the activity needed to achieve theQuality Goals.

The Trust has a very good approach to stakeholderinvolvement. This is based on our experience of beinginvolved in meetings where service issues are discussedin-depth; our ability to obtain information easily fromthe Trust; and our involvement in ‘Patient Stories’. Weknow that the Trust is also actively engaging with otherstakeholders such as Age UK Norfolk to gather theviews of patients from diverse backgrounds.

We are pleased that the Trust is looking towards in-depth surveys for qualitative information about thepatient experience. Although it was only in 2012 thatthe ‘Patient Stories’ initiative got off the ground, wecan confirm that this is now well-underway with LINkvolunteers being trained to record patient stories.

However Norfolk LINk is not convinced that “NetPromoter” is a suitably valid tool for accuratemeasurement of the patient experience whererespondent numbers are less than 60 per cent.

Regarding patient safety issues, the Trust is yet to acton two safety issues that we raised with the StrokeRehabilitation Unit after a visit in November 2011.These were around the absence of emergency/help pullcords inside toilets and showers; and clear access to thefire evacuation area.

We are pleased to see that the Account has severalexamples of the outstanding staff working within the Trustand can confirm that several initiatives are in progress, eg,improving care for older people with dementia.

3.2 Explanation of who has beeninvolved and engaged with

Part 3 3.2 Explanation of who has been involved and engaged with 57

Comments from NHS Norfolkand WaveneyStatement of Information Verification withinthe Quality Account submitted to NHS Norfolkby Norfolk Community Health & Care NHS TrustJune 2012

NHS Norfolk and Waveney as lead commissioners forNorfolk Community Health & Care NHS Trust arepleased to support the Trust in its publication of the2011/12 Quality Account.

We have reviewed the mandatory data elementsrequired within this account and can confirm that thoseincluded are consistent with that known to NHSN&W.

The report presents detailed and comprehensiveinformation relating to the quality and safety of caredelivered within the prioritised areas identified by theTrust. The Quality Goals for 2012/13 are relevant andare substantiated by involvement with the clinicalquality and patient safety agenda via theCommissioning for Quality & Innovation paymentframework (CQuIN) We commend staff for their workto improve outcomes within these areas and we lookforward to the inclusion of an update on achievementsin these areas in next year’s Quality Account.

NHSN&W have appreciated the continued support ofthe clinical quality review meetings which are vital inassuring the local population that services contractedfrom the Trust are safe and of good quality. They enablediscussions to take place concerning new initiatives andcurrent thinking and practice. They also facilitatechallenges regarding current performance.

With the elimination of avoidable Grade 2, 3 & 4pressure ulcers being an ambition for NHS Midlands andEast, it is clear that through the implementation of datacollection via the NHS Safety Thermometer and theTrust’s Pressure Ulcer Clinical Improvement Programmethat the Trust is supportive of this ambition.

The Trust acknowledges the learning that arose from theDownham Market Health Centre enquiry and thefindings of the independent report commissioned by theSHA. The Trust outlines where the learning has led tosignificant changes in organisational processes in orderto assure that the failures described will not be repeated.

This has been a year in which the Trust has demonstratedimprovements in many areas and we look forward toworking alongside them in supporting their qualityinitiatives in the coming year.

Andrew MorganChief Executive OfficerNHS Norfolk & Waveney

Head Office: Elliot House, 130 Ber Street, Norwich NR1 3FR

Online: www.norfolkcommunityhealthandcare.nhs.uk

Telephone: 01603 697300

Documents

Quality - NHS Choices Home Page · NCH&Creceives 16,500 referralsfromGPsand ... Total 280 313 380 432 429 391 427 485 457 499 566 535 5194. ... andChildHealth 2010/11whichtheacutetrustscollect