Download Kettering General Hospital NHS Foundation Trust QUALITY

Affiliated Teaching Hospital
Kettering General Hospital NHS Foundation Trust
QUALITY ACCOUNT 2015 - 2016
QUALITY ACCOUNT 2015/16
Independent auditor’s report to the council of governors of Kettering
General Hospital NHS Foundation Trust on the Quality Account
INDEPENDENT AUDITOR’S REPORT TO THE COUNCIL OF GOVERNORS OF KETTERING
GENERAL HOSPITAL NHS FOUNDATION TRUST ON THE QUALITY REPORT
We have been engaged by the Council of Governors of Kettering General Hospital NHS Foundation
Trust to perform an independent assurance engagement in respect of Kettering General Hospital NHS
Foundation Trust’s Quality Report for the year ended 31 March 2016 (the ‘Quality Report’) and certain
performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2016 subject to limited assurance consist of the following
two national priority indicators (the indicators):
• A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge; and
• maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers.
Monitor intended that we should review the ‘percentage of incomplete pathways within 18 weeks for
patients on incomplete pathways at the end of the reporting period. However, the Trust has agreed with
Monitor that this indicator need not be presented in the Trust’s Quality Report. Monitor has advised that,
in this instance, the selection for assurance should be the cancer waits indicator.
Respective responsibilities of the directors and auditors
The directors are responsible for the content and the preparation of the Quality Report in accordance
with the criteria set out in the NHS Foundation Trust Annual Reporting Manual issued by Monitor.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything
has come to our attention that causes us to believe that:
•
the Quality Report is not prepared in all material respects in line with the criteria set out in the
NHS Foundation Trust Annual Reporting Manual and supporting guidance;
•
the Quality Report is not consistent in all material respects with the sources specified in the
Detailed Guidance for External Assurance on Quality Reports 2015/16 (‘the Guidance’); and
•
the indicator in the Quality Report identified as having been the subject of limited assurance in
the Quality Report are not reasonably stated in all material respects in accordance with the NHS
Foundation Trust Annual Reporting Manual and supporting guidance and the six dimensions of
data quality set out in the Guidance.
We read the Quality Report and consider whether it addresses the content requirements of the NHS
Foundation Trust Annual Reporting Manual and supporting guidance and consider the implications for
our report if we become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is materially
inconsistent with the FT ARM 2015/16 and other documents, listed below:
•
board minutes and papers for the period April 2015 to May 2016;
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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•
papers relating to quality reported to the board over the period April 2015 to May 2016;
•
feedback from commissioners May 2016;
•
feedback from governors May 2016;
•
feedback from local Healthwatch organisations April 2016;
•
feedback from Northamptonshire Council dated 18 May 2016;
•
the trust’s complaints report published under regulation 18 of the Local Authority Social Services
and NHS Complaints Regulations 2009;
•
the national staff survey published February 2016;
•
the 2015/16 Head of Internal Audit’s annual opinion over the trust’s control environment May
2016; and
•
the CQC Report September 2014.
We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with those documents (collectively, the ‘documents’). Our responsibilities do
not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the Institute
of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised
assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors of
Kettering General Hospital NHS Foundation Trust as a body, to assist the Council of Governors in
reporting the NHS Foundation Trust’s quality agenda, performance and activities. We permit the
disclosure of this report within the Annual Report for the year ended 31 March 2016, to enable the
Council of Governors to demonstrate they have discharged their governance responsibilities by
commissioning an independent assurance report in connection with the indicator. To the fullest extent
permitted by law, we do not accept or assume responsibility to anyone other than the Council of
Governors as a body and Kettering General Hospital NHS Foundation Trust for our work or this report,
except where terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on
Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of
Historical Financial Information’, issued by the International Auditing and Assurance Standards Board
(‘ISAE 3000’). Our limited assurance procedures included:
•
evaluating the design and implementation of the key processes and controls for managing and
reporting the indicator;
•
making enquiries of management;
•
testing key management controls;
•
limited testing, on a selective basis, of the data used to calculate the indicator back to
supporting documentation;
•
comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to
the categories reported in the Quality Report; and
•
eading the documents.
A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately
limited relative to a reasonable assurance engagement.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Non-financial performance information is subject to more inherent limitations than financial information,
given the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of
different, but acceptable measurement techniques which can result in materially different
measurements and can affect comparability. The precision of different measurement techniques may
also vary. Furthermore, the nature and methods used to determine such information, as well as the
measurement criteria and the precision of these criteria, may change over time. It is important to read
the quality report in the context of the criteria set out in the NHS Foundation Trust Annual Reporting
Manual.
The scope of our assurance work has not included governance over quality or the non-mandated
indicator, which was determined locally by Kettering General Hospital NHS Foundation Trust.
Basis for qualified conclusion
As set out in the Statement of Director’s Responsibility from the Chief Executive of the Foundation Trust
in the Appendix to the Trust’s Quality Report, the Trust currently has concerns with the accuracy of data
for the Percentage of patients with a total time in A&E of four hours or less from arrival to admission,
transfer or discharge (4 hours A&E) indicator.
The Trust has not reported data for the period ending 31 March 2016 for the 4 hours A&E indicator in
line with the national guidance. In addition, we found from our testing that supporting data did not
corroborate the “start or stop times” recorded by the Trust in a number of the cases tested. As a
consequence we are unable to conclude on the completeness, reliability, validity and accuracy of the 4
hours A&E indicator included in the published Quality Report. As a result of the issues described above
we are unable to conclude that nothing has come to our attention that causes us to believe that the 4
Hours A&E indicator for the year ended 31 March 2016 has been reasonably stated in all material
respects in accordance with the NHS Foundation Trust Annual Reporting Manual and supporting
guidance and the six dimensions of data quality set out in the Guidance.
Qualified conclusion
Based on the results of our procedures, except for the effects of the matters described in the ‘Basis for
qualified conclusion’ section above, nothing has come to our attention that causes us to believe that, for
the year ended 31 March 2016:
•
the Quality Report is not prepared in all material respects in line with the criteria set out in the
NHS Foundation Trust Annual Reporting Manual and supporting guidance;
•
the Quality Report is not consistent in all material respects with the sources specified in the
Guidance; and
•
the remaining indicator in the Quality Report subject to limited assurance (maximum waiting
time of 62 days from urgent GP referral to first treatment for all cancers) has not been
reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual
Reporting Manual and supporting guidance and the six dimensions of data quality set out in the
Guidance.
KPMG LLP
One Snowhill
Snowhill Queensway
Birmingham
B4 6GH
27 May 2016
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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INTRODUCTION
The purpose of this quality account is to detail
Part Three contains further information
for patients, their families and carers, staff,
providing a picture of some of the other
members of the local communities and local
initiatives that have been implemented at the
commissioners, the quality of services that the
Trust to improve quality. The latter sections
Trust provides.
outline some commentaries expressing the
views of some of the Trust’s key
The quality account is one aspect of the
stakeholders. We are pleased to report on
continued drive to improve the quality and
some of our external awards linked to quality
safety of the services we provide.
during 2015/16; maternity services received
the Unicef ‘Baby Friendly’ Accreditation, our
In Part One, there is a statement on quality
Cardiac Investigations Department received a
from the Chief Executive, David Sissling. An
Silver Award at the Heart Rhythm Congress
update is also provided on the priorities that
and an award from Allocate Software for our
were set by the trust for 2015/16 and details of use of the Health Assure electronic system
the priorities set for the coming year.
supporting our quality improvement work.
In Part Two, we have provided details of our
Throughout all parts of this quality account,
priorities for quality improvement that we
where information on performance in previous
intend to deliver in 2016/17 and details of how
years is available this has been included. The
we progressed in 2015/16.
most up to date national and local information
has also been included throughout.
There are also a number of Statements of
Assurance regarding specific aspects of
Thank you for taking the time to read our
service provision. The Trust is required to
quality account. If you would like to comment
provide these statements to meet
on any aspect of this document, we would
the requirements of the Department of Health
welcome your feedback.
and Monitor.
You can contact us at:
[email protected]
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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CONTENTS
Page No
Independent Auditor’s report
2
Introduction
5
Part 1:
Statement on quality from the Chief Executive
7
Part 2:
Our chosen priorities for 2016/17
8
Statements of assurance from the board of directors
13
Reporting against core indicators
30
Part 3:
Other information:
How we performed against the priorities set for 2015/16
44
Performance against 2015/16 key national priorities
54
Annexes:
55
Feedback from Nene and Corby Clinical Commissioning Groups
Feedback from the Healthwatch Northamptonshire
Feedback from Northamptonshire County Council
Feedback from Governors
Statement of directors’ responsibilities in respect of the quality account
EASY READ PRIORITIES
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Part One
Statement on quality from the Chief Executive
Welcome to our Quality Account for 2015/16.
It sets out the work we have carried out to
ensure care is delivered to appropriate
quality standards and identifies our priorities
for focused action in the future.
We are continually seeking to improve
quality and safety standards. We base our
action on relevant information, patient
experiences and the invaluable insights of
our staff. We assess risk; to anticipate and
address potential problems. And when
problems do regrettably occur, we take
measured action to prevent a recurrence.
Our focus is always on the patient and we
fully recognise the requirement to be open,
transparent and effective in our
communication.
Areas of current and future focus include
data quality. We have significant challenges
in relation to our RTT and to an extent, to our
emergency care data. We are taking action
to ensure necessary improvements take
place. We are also building on the success
of the ‘I Will’ safety campaign and have
introduced the ‘We Will Care Together’
programme. This will focus on staff
engagement and the opportunity to improve
quality of care in our urgent and planned
care activities.
Our current registration status with the CQC
is unconditional and the Commission has not
taken any enforcement actions against the
Trust during 2015/16. The CQC inspected
the Trust in September 2014. During
2015/16 we made significant progress in
completing the improvements recommended
by the Inspection Team.
Improving and acting on patient experience
has developed during the year, supported by
our new Patient Experience and Involvement
Strategy, produced and monitored by our
Patient Experience Steering Group. The
engagement and support from our lay
members, governors and Healthwatch
Northamptonshire has ensured that we are in
a stronger position to make the required
improvements.
We routinely take part in national clinical
audits as well as designing and undertaking
local ones. This process helps us identify
what works well in the delivery of clinical care,
what we need to change and whether we
have met the standards which were set for us
nationally. We use these findings to inform
quality improvements.
Financial challenges within the NHS sees us
working collaboratively with colleagues in
Commissioning Groups and other partners to
strive for quality while delivering the
efficiencies needed.
Our Priorities for 2016/17, established through
consultation will be:
Clinical Effectiveness
•
Acute Kidney Injury
•
Dementia Discharge Process
•
Implementation of John’s
Campaign – Dementia Care
Patient Safety
•
Reducing risks associated with
medication
•
Reducing the risk of falling in
hospital
•
Preventing avoidable deterioration
(sepsis management)
Patient Experience
•
End of life care
•
Discharge experience
•
Complaints management
I hope the following pages give you a sense
of our commitment to the quality of care we
provide, and that you will read with interest
our plans for the future.
Working together to deliver the improvements
our patients deserve is our priority.
David Sissling
Chief Executive
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
April 2016
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Part Two
Priorities for Improvement 2016/17
As part of the quality account process, the
Trust is required to set priorities for
improvement. These are issues considered
important to patients, local communities and
our stakeholders.
Governors have been involved in the
agreement of our priorities.
Progress made since the publication of the
2014/15 quality account is described in Part
Three.
Patient Safety Priorities 2016/17
To continue to reduce harm and avoidable
deaths, three key priority areas were
identified and selected through consultation
and approved by Trust Board:
"
"
Integration of the full National
Medication Safety Thermometer with
the NSIs, with nursing staff collecting
the data.
Longer term delivery of electronic
prescribing and medicines
administration
How will we measure our improvement
and what are our targets?
We will measure our targets through audits
as part of our participation in Safety
Thermometer Reporting and incident
reporting.
How will we report and monitor our
progress?
Medication
Why have we chosen this priority?
Prescribing or administering medicines to our
patients is our most common therapeutic
activity. We want to make sure that our
patients are cared for safely when medication
is required.
Omission of Critical Medications has been
selected by our Governors for audit by our
auditors, KPMG. This provides external
assurance on how we manage such
incidents.
How will we improve?
"
"
Learning from errors and near misses,
through thematic reviews and detailed
analysis of reported medication errors.
Mind the Gap campaign to reduce the
occurrence of omitted doses of
medications.
Our progress will be reported through:
" Quality Dashboard considered
monthly by our Integrated
Governance Committee.
"
Quarterly reports to our Patient
Safety Advisory Group and
Medicines Management Committee.
"
Monthly reporting to our Medication
Safety Committee.
"
Quarterly reporting through our Sign
up to Safety Patient Safety Reports
to Quality Governance Steering
Group and Patient Safety Advisory
Group.
Any issues of concern will be escalated to
the Trust Board via the Integrated
Governance Committee Chair’s report.
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Falls
Early Warning System - Sepsis
Why have we chosen this priority?
Reducing the number of falls is critical to
reducing harm to our patients. Incidents
where patients fall are reported at a higher
rate than other patient safety incident. We
want to be able to identify the risk of falling
and manage this effectively to improve the
safety of patients, without compromising their
freedom.
Why have we chosen this priority?
Early recognition and management of the
deteriorating patient is critical to be able to
intervene rapidly and effectively to avoid harm
to our patients.
How will we improve? ‘WE WILL’ :
" Review our falls policy to make our risk
assessment and care planning more
effective.
" Appoint a Practice Improvement
Facilitator Nurse to champion falls
prevention work.
" Review the work of our Falls
Prevention Steering Group for an
improved focus on prevention of falls.
" Review our equipment and its
effectiveness in reducing falls.
" Review how those at risk of falling are
cared for by our nursing staff.
" Enhance education on falls prevention.
How will we improve? ‘WE WILL’
" Launch an education programme on
early detection of and management of
sepsis;
" Implement and monitor the
effectiveness of learning from incidents;
" Introduce sepsis boxes to each ward
area to assist with prompt clinical
management.
" Implement the revised national sepsis
guidelines (March 2016) and pathway
and ensure our staff are aware of
these.
" Continue to audit the effectiveness of
our education programme on a
quarterly basis.
How will we measure our improvement and
what are our targets?
" Quarterly audit results will show our
How will we measure our improvement and
progress against the CQUIN standards
what are our targets?
of ‘Sepsis screening’ and ‘sepsis
We will continue to audit our performance and
administration’ which includes post
monitor falls, together with harm from falls
chemotherapy patients.
against targets for risk assessment,
Measurement of our previous CQUIN
documentation, management of risks and
indicators of:
number of falls.
" 2a (Sepsis screening) requires an
established local protocol that defines
How will we report and monitor our
which patients require sepsis screening
progress?
when presenting to emergency
departments.
" Monthly to the Falls Prevention Group
" 2b relies on administering intravenous
and onward to Patient Safety Advisory
antibiotics within 1 hour (best practice)
Group.
to all patients who present with severe
" Monthly to the Quality Governance
sepsis, red flag sepsis or septic shock
Steering Group.
to emergency departments.
How will we report and monitor our
" Monitored against targets within the
progress?
Quality Dashboard monthly to
The sepsis steering group will meet monthly to
Integrated Governance Committee.
review audit results and monitor progress.
Results will be escalated quarterly to the KGH
Any issues will be escalated to the Trust
Quality Governance Steering Group.
Board via the Chair of the Integrated
Governance Committee.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Patient Experience Priorities 2016/17
End of Life Care
Discharge Experience
Why we have chosen this priority?
This was a patient experience priority during
2015/16 and one we wish to continue to
develop and improve on during 2016/17. We
want to provide assurance that the actions
taken during 2015/16 are effectively fully
embedded in our practice.
Why have we chosen this priority?
We know that safe discharge with effective
communication is essential for patients
returning home or to a care setting in the
community. Feedback indicates to us that we
can improve this experience for our patients.
How will we improve? ‘ WE WILL’
"
"
"
"
Provide assurance that our end of life
care bundle, practice against standards
underpinned by our End of Life
Strategy is effective.
Provide evidence of compliance with
training and education and measure its
effectiveness.
Work collaboratively with the work
underway through Healthier
Northamptonshire to improve end of life
care.
Continue to build on our 2014 CQC
inspection rating of good for the
compassionate care we provide
through continued standard setting
and support to our clinicians by our End
of Life Lead.
How will we improve? ‘WE WILL’
"
"
"
"
"
Improve the quality and timeliness of
sending discharge letters to General
Practitioners.
Implement learning from our audit
undertaken in 2015/16 about delayed
discharges.
Work closely with other healthcare
providers so that timely discharge to
their services is improved.
Implement our Patient Experience and
Involvement Strategy
Continue to engage with Healthwatch
Northamptonshire.
How will we measure our improvement and
what are our targets?
We will measure improvements on
experiences reported through PALS,
complaints and other feedback mechanisms,
including Healthwatch Northamptonshire visits
How will we measure our improvement and .
Our target is to reduce negative experiences
what are our targets?
reported to us by 50%.
We will measure improvement against the
How will we report and monitor our
targets set within our End of Life Strategy
progress?
using audits and other patient experience
sources of information such as surveys,
" Quarterly patient experience reports
PALS, complaints, Chaplaincy and carers
and progress with our Patient
representatives.
Experience and Involvement Strategy
will be reported quarterly to our Patient
How will we report and monitor our
Experience Steering Group.
progress?
" Our Annual Complaints/Patient
Experience Report to Trust Board.
We will report to our Quality Governance
Steering Group.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Complaints Management
Clinical Effectiveness Priorities
2016/17
Why we have chosen this priority?
Acting on feedback is essential to improve the
quality of services provided. It is important to
give priority to investigations and respond to
people within agreed timescales. This is a
continued priority from 2015/16 because we
did not achieve all targets.
Our Clinical Effectiveness Priorities for
2016/17 are also amongst a number of agreed
CQUINs for the forthcoming year with our
commissioners.
How will we improve? ‘ WE WILL’
" Implement our Complaints
Management Recovery Plan to ensure
that we respond to complaints within
agreed timescales and give assurance
on learning from complaints.
" Improve accessibility for raising
concerns.
" Undertake thematic reviews of
identified themes in order to make
Trust-wide quality improvements.
" Improve compliance with our
performance targets in responding to
formal complaints.
" Improve how we engage with
complainants when complex
investigations may require more time.
Acute Kidney Injury
Why have we chosen this priority?
This was a 15/16 CQUIN (Commissioning for
Quality and Innovation via our commissioners)
which we wish to quality develop further
during 16/17. Acute kidney Injury (AKI)
remains a key national and international
priority with NHS England commencing a
national AKI Programme.
How will we improve? ‘WE WILL’
Ensure appropriate follow up to minimise short
and long term consequences and improve the
recovery of individuals with Acute Kidney
Injury.
How will we measure our improvement and
what are our targets?
How will we measure our improvement and
what are our targets?
We will measure our compliance with
response timescales on a monthly basis.
Our target is that 80% of all formal complaints
will be responded to within agreed timescales.
How will we report and monitor our
progress?
Our progress will be monitored through our
monthly Quality Dashboard to Integrated
Governance Committee and by quarterly
Patient Experience Reports to the Patient
Experience Steering Group and Quality
Governance Steering Group.
For patients with Acute Kidney Injury detected
through pathology laboratory information
management systems (LIMS) and who
progress to discharge, we will measure the
care provided via the discharge summaries of
those patients, together with the number of
discharge summaries.
How will we report and monitor our
progress?
Our progress will be monitored quarterly to
Quality Governance Steering Group and
through the Clinical Commissioning Group’s
Clinical Quality Review Meetings held
throughout the year.
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Implementation of John’s Campaign
Dementia Discharge Information
Why have we chosen this priority?
Why have we chosen this priority?
This priority is focussed on improving the
experience of those with dementia by
facilitating more flexible approaches to visiting
by carers. As a national CQUIN in 2015/16
this is an opportunity to build on the work
completed within that year and develop further
during 2016/17.
As a national CQUIN in 15/16, we wish to
develop quality further during 2016/17.
An early diagnosis of dementia is beneficial
because some causes of dementia are
treatable and fully or partially reversible.
Conditions such as some vitamin deficiencies,
side effects of medications and certain brain
tumours may fall into this category.
Hospital stays are particularly detrimental for
people with dementia who experience longer
stays and poorer outcomes than the general
population. People with dementia may not be
able to return home when the acute episode
of care is completed, due to further
disablement during the hospital stay, which is
devastating for them and their families and it
has significant cost consequences for the care
system.
How will we improve? ‘WE WILL’
Introduce ‘follow on recommendations’ as part
of discharge planning for patients with
dementia to improve the management of
dementia and delirium and to prompt
appropriate referral, follow up after discharge
and communication between acute,
community and primary care.
How will we measure our improvement and
How will we improve? ‘WE WILL’
what are our targets?
The discharge summary ‘follow on
recommendation’ will include information on:
" Recognise the value that
families/carers can provide on insight,
" Diagnosis of delirium where this was
facilitate communication (and informed
made and any new diagnosis of
consent).
dementia during the admission with
appropriate use of regional coding
" Ensure families/carers can make
guidance.
hospital visits without restriction on
relevant wards, supporting continuity of
" Details of any cognitive tests performed
care.
and substantial changes to needs.
" A plan to modify or stop any antiHow will we measure our improvement and
psychotics or sedative drugs (within 3
what are our targets?
weeks).
Through the development of a Trust wide
" Details of any referrals already made
policy, carers survey and further provision of
and any team already involved.
dementia training across the Trust.
" Recommendations for further
assessment or onward referral in line
How will we report and monitor our
with locally agreed care pathways.
progress?
" Recommendations for liaison and
Our progress will be monitored quarterly to the
communication if the usual place of
Quality Governance Steering Group and
residence is a care home or carers;
through the Clinical Commissioning Group’s
Clinical Quality Review Meeting throughout
How will we report and monitor our
the year.
progress?
Our progress will be monitored quarterly to
" Recommendations for patients with
Quality Governance Steering Group and
delirium in line with NICE Delirium
through the Clinical Commissioning Group’s
Quality Standards 4 and 5
Clinical Quality Review Meeting throughout
the year.
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PART TWO
Statements of assurance from the board of directors
These statements of assurance follow the
statutory requirements for the presentation of
quality accounts, as set out in the Department
of Health’s quality accounts regulations.
Implementing our Duty of Candour
When things go wrong, we place great
importance on Being Open with patients and
where appropriate, their carers/family or
nominated next of kin (known as the ‘relevant
person’).
We measure how we meet our Statutory Duty
to do this relating to those patient safety
incidents that result in moderate or greater
levels of harm.
We are open and transparent with the
‘relevant person’ when such incidents occur,
advising what the incident was and provide
them with the necessary support. This
includes an apology that the incident has
occurred, followed up in writing.
We monitor our compliance against this
statutory requirement and our own Duty of
Candour Policy and provide assurance of this
to our commissioners and in our investigation
reports shared with the ‘relevant person’, staff
and again with our commissioners.
We provide training to staff on Duty of
Candour as part of our management of
incidents and investigation training. Our
Quality Governance Team also support
clinical staff in engagement with the ‘relevant
person’, providing apologies and giving the
opportunity to add to our terms of reference
for any investigations.
Our target is 100% compliance.
Our Staff Survey Results
The NHS Staff Survey provides an opportunity
for the Trust to survey its staff in a consistent
and systematic way. The 2015 National NHS
Staff Survey was conducted between 25th
September and 27th November 2015.
All staff in our employment or under contract
in our Trust were requested to complete the
annual staff survey. The results are published
in February each year. 27% of our staff
completed the survey.
Two indicators have been selected by Monitor
for inclusion in this Quality Account in relation
to the Workforce Race and Equality Standard:
Staff experiencing harassment, bullying or
abuse from staff in the last 12 months
2% of those responding said that they had
experienced harassment, bullying or abuse
from staff in the last 12 months. This has
reduced from 3% in the previous year. 2%
aligns with the national average for acute
Trusts.
Percentage of staff believing that the Trust
provides equal opportunities for career
progression or promotion
88% of those responding said that the Trust
provides equal opportunities for career
progress or promotion. This represents an
increase from the previous year (86%). The
national average for acute Trusts is 87%.
The Trust Board considered the full results of
the staff survey in February 2016, noting that
an action plan in line with the Trust’s
Workforce Strategy will be developed. This
will aim to build upon actions from last year
and to address all areas of concern from the
2015 survey.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Our Patient Safety Improvement Plan as part of the
NHS Sign up to Safety Campaign
A national ‘Sign up to safety’ campaign was
launched in 2014 with the overall aim of
reducing avoidable harm in the NHS by 50%
and saving 6000 lives (nationally). The Trust
signed up to the Campaign in August 2014
and detailed what it intended to achieve
against the five sign up to safety pledges
which are:
Our Board of Directors participated in a Board
Development Programme with a focus on
patient safety. This involved engagement with
Advancing Quality Alliance (AQuA) - an NHS
health and care quality improvement
organisation.
How will we improve? ‘WE WILL’
" Launch the ‘We will care together’
•
Put safety first
initiative to advance staff engagement
•
Continually learn
in improvement.
•
Be honest and transparent
" Refresh the ‘I Will’ campaign for
•
Support collaborative learning
continued quality improvement and
•
Support staff when things go wrong
monitoring of our Quality and Safety
Strategy.
The Campaign requires Trusts to develop and
" Continue our programme of safety and
publish a Safety Improvement Plan detailing
quality visits to wards/areas.
the work they will undertake to reduce harm
" Continue with mock CQC inspections.
and support the campaign. The Trust has
" Robust quality governance reporting
already developed the ‘I will’ Patient Safety
from all our Clinical Business Units to
Campaign as part of the Quality and Safety
our Quality Governance Steering
Strategy and this work has formed the basis of
Group.
our KGH Safety Improvement Plan.
" Develop monthly Quality Review
Panels for wards/areas to give
We refreshed our patient safety target areas
assurance on safety actions being
during 2015/16 against which we will monitor
taken and monitoring of safety targets.
progress against targets for
" Continue to focus on the quality
reduction/elimination within our monthly
element of Monthly Clinical Business
Quality Dashboard and Patient Safety
Unit Performance Reviews
Improvement Plan.
" Implement thematic reviews and
assurance on learning against themes.
Our patient safety target areas
" Continue with collaborative working
with East Midlands Patient Safety
" Infection control covering C Diff, MRSA
Collaborative for local and national
and hand washing compliance
patient safety initiatives.
" Reducing falls
" Implement risk profiling of key metrics
" Reducing pressure tissue damage
to ensure targets are balanced against
" Reducing risks associated with surgery
our patient groups.
" Management of deterioration
" Implement our Patient Experience
" Medication management
Strategy.
" Stroke care
How will we report and monitor our
" Dementia care
progress?
" Mortality rates
We will report monthly to the Patient Safety
" Patient Experience
Advisory Group and quarterly to the Quality
Governance Steering Group with summary
reporting to the Integrated Governance
Committee.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- "%
Our Ratings from the Care Quality Commission (CQC)
Our CQC ratings grid is based on the inspection undertaken by the CQC in September 2014
for the areas shown below. Many of our required actions to make improvements are
completed, with the remainder progressing during this reporting period.
Our rating for our services:
Service
Safe
Urgent and
Emergency Services
Effective
Caring
Responsive
Well-led
Overall
Not rated
Medical Care
Surgery
Critical Care
Maternity
And Gynaecology
Services for Children
and Young People
End of Life Care
Outpatients and Diagnostic
Imaging
Not rated
Overall
Key
Not rated
The CQC did not assess this domain
Good
Requires Improvement
Inadequate
Areas for improvement and our actions
Urgent and Emergency Services
Safe
Installation of CCTV and swipe card access
Further development of the Trust-wide sepsis care bundle
Upgrade of our medicine storage cabinets
Audit and review of our medication safety work plan
Review of and additional staffing
Responsive
Alcohol Liaison Nurse and psychiatric services available to
support vulnerable adults
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
Completed =
or Completion
Date
2016/17
Continual cycle
+,.- "&
Areas for improvement and our actions
Medical Care
Safe
Additional staffing following benchmarking and review
Upgrade of medicine storage cabinets
Audit and review of our medication safety work plan
Further development of the Trust-wide sepsis care bundle
Monitoring of standard of care of deteriorating patients
Improvement of care planning
Effective
Dementia care pathway mapped to Northamptonshire
Healthcare NHS Foundation Trust services
Appointment of an Admiral Nurse for Dementia
Surgery
Safe
Additional medical staff recruited
Additional out of hours emergency surgical nurse practitioners
Monitoring of standard of care of deteriorating patients
Replacement and additional equipment in place
Audit and review of our medication safety work plan
Responsive
Dementia care pathway mapped to Northamptonshire
Healthcare NHS Foundation Trust services
Appointment of an Admiral Nurse for Dementia
Critical Care
Safe
Staffing levels reviewed and in line with national requirements
New system for allocation of patients in place
Well-led
Business development plans in place together with a peer
review and revision of business unit strategy
Maternity and Gynaecology
Effective
Recruitment of a patient safety lead and improved governance
engagement
Greater consultant involvement in policy and procedure reviews
Benchmarking in place with National Maternity Guidance
Well-led
Standards and behaviour team sessions in place
End of Life Care
Safe
Audit of ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ forms
Effective
Membership of Healthier Northamptonshire Steering Group
Survey monitoring for quality care of bereaved
Introduction of symptom control pathways
Introduction of nutrition and hydration care plans
Responsive
Pilot of and implementation of adult care bundles
Well-led
Medical lead appointed
Recruitment of a MacMillan Transformation Lead Nurse
End of Life Care Strategy in Plan with monitoring
Outpatients and Diagnostic Imaging
Safe
Audit and review of our medication safety work plan
Additional equipment in place
Risk summit and monitoring of compliance for availability of
medical records
Responsive
Outpatient productivity programme in place to review utilisation
Well-led
Lead Nurse appointed, with regular team meetings and huddles
and business development plan in place
Outpatient productivity programme
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
Continual cycle
2016/17
2016/17
2016/17
Continual cycle
2016/17
2016/17
+,.- "'
Information on the review of services
Services sub-contracted by the Trust
During 2015/16 Kettering General Hospital
NHS Foundation Trust provided and/or
subcontracted with 27 relevant health services
providers.
During 2015/2016 Kettering General Hospital
NHS Foundation Trust sub-contracted
services to 23 key organisations for relevant
health services.
Kettering General Hospital NHS Foundation
Trust has reviewed all the data available to
them on the quality of care in these relevant
health services.
These sub-contracted services are as follows:
Services for medical staffing with;
Northampton General Hospital NHS Trust,
Oxfordshire University Hospitals NHS Trust,
Heart of England NHS Foundation Trust,
University Hospitals Leicester NHS Trust and
United Lincolnshire Hospitals NHS Trust.
During 2015/16 Kettering General Hospital
NHS Foundation Trust held two key contracts
with NHS commissioners to provide services.
The Trust‘s primary contract is with: NHS
Corby Clinical Commissioning Group and
NHS Nene Clinical Commissioning Group, this
contract constitutes a range of acute hospital
services including elective, non-elective, day
case and outpatients.
In addition the Trust holds a contract with
NHS England for Prescribed services such as
the provision of a special baby care unit,
specialised cardiac interventions, neonatal
intensive care and other specialised services.
The Trust also provides a variety of services
to other NHS organisations, public sector
organisations and private sector companies.
Key contracts are held with:
" Northampton General Hospital NHS
Trust
" University Hospitals Leicester NHS
Trust
" Northamptonshire Healthcare NHS
Foundation Trust
" Ramsay Healthcare United Kingdom
" Lakeside Plus Limited
" Woodsend Medical Centre.
Northamptonshire Healthcare NHS
Foundation Trust for delivery of therapy
services including; Physiotherapy,
Occupational Therapy, Speech and Language
Therapy, Dietetics, Consultant Psychiatry,
Speech and Language Therapy, Podiatry,
Dietetics, Specialist Nursing (including
Paediatric Community Nursing, Diabetics
Specialist Nursing, Palliative Care Service),
Extended Scope Physiotherapy (EMG) and
Special Needs Dentistry.
In October of 2015, the Trust also entered a
contract, with Northamptonshire Healthcare
NHS Foundation Trust for the provision of
Primary Care Streaming services within
Accident and Emergency, there are aspects of
this services that they sub-contract to other
providers.
The Trust also commissions 4Ways
Healthcare Limited for the provision of
Radiology Reporting services, Inhealth
Limited with respect to mobile MRI services
and CDI Partners in Imaging for ultrasound
services.
Provision of services includes medical staffing
and support services, such as Pathology,
Radiology and Pharmacy.
Where services provided are from Trust
premises staff work to Trust policies and
processes.
The income generated by the relevant health
services reviewed in 2015/16 represents
90.1% of the total income generated from the
provision of relevant health services by
Kettering General Hospital NHS Foundation
Trust for 2015/16.
During 2015/16 the Trust entered a contract
with a number of providers for services
delivered not on Trust premises.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- "(
The Trust entered into a contract with Brighter
Kind Limited for the provision of short term
Nursing services at Claremont Parkway
Nursing Home, Kettering and Elm Bank
Nursing Home, Kettering. In addition the Trust
has entered contracts for services specifically
aimed at supporting the delivery of the 18
week referral to treatment target with Ramsay
Health Care UK Operations Limited T/A
Woodland Hospital, delivered from the
Woodland Hospital, Kettering site and also
separately with Spire Leicester Hospital
delivered at the Leicester site and
Hinchingbrooke Health Care NHS Trust,
delivered in Hinchingbrooke.
The Trust has a number of contracts with
Medicines Homecare providers which include:
Healthcare at Home, Bupa Healthcare, Alcura
Healthcare and Evolution Healthcare
Technology House.
The Trust has a contract with Stor-a-file
Limited for the provision of offsite medical
records storage and retrieval.
Contract/performance management
frameworks exist for the main contracts held
by the Trust and through these commissioner
and provider responsibilities are clearly stated
and monitored. All sub-contracts include
standard NHS terms and conditions and
performance requirements in terms of quality
and delivery. The Trust holds quarterly
contract meetings with sub-contractors to
monitor performance against the contract.
However concerns raised about the quality of
subcontractors can also be raised at any point
in the year and a formal contract meeting will
take place to discuss concerns and address
issues.
The Trust also undertakes unannounced visits
to relevant in-patient areas in order to check
the quality of service provision
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- ")
National Clinical Audit
Information on participation in clinical
audits and national confidential enquiries:
During 2015/16, 38 national clinical audits and
five national enquiries covered relevant health
services that Kettering General Hospital NHS
Foundation Trust provides.
During that period, Kettering General Hospital
NHS Foundation Trust participated in 84% of
national clinical audits and 100% of national
confidential enquiries of the national clinical
audits and national confidential enquiries
which it was eligible to participate in.
The national clinical audits and national
confidential enquiries that Kettering General
Hospital NHS Foundation Trust was eligible to
participate in during 2015/16 are as follows:
National Clinical Audit
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
Acute Coronary Syndrome or Acute
Myocardial Infarction (MINAP)
Adult Asthma
Adult Bronchiectasis Audit (BTS)
Bowel Cancer (NBOCAP)
Cardiac Rhythm Management (CRM)
Case Mix Programme (CMP)
Coronary Angioplasty/National Audit of
Percutaneous Coronary Interventions (PCI)
Diabetes (Paediatric) (NPDA)
Elective Surgery (National PROMs
Programme)
Emergency Use of Oxygen
Falls and Fragility Fractures Audit programme
(FFFAP)
Head and Neck Cancer Audit
Inflammatory Bowel Disease (IBD)
programme
Major Trauma Audit (TARN)
National Cardiac Arrest Audit (NCAA)
National Chronic Obstructive Pulmonary
Disease (COPD) Audit programme
National Comparative Audit of Blood
Transfusion programme
" National Complicated Diverticulitis Audit
(CAD)
" National Diabetes Audit – Adults
" National Emergency Laparotomy Audit
(NELA)
" National Heart Failure Audit
" National Joint Registry (NJR)
" National Lung Cancer Audit (NLCA)
" National Ophthalmology Audit
" National Prostate Cancer Audit
" Neonatal Intensive and Special Care
(NNAP)
" Non-Invasive Ventilation – Adults
" Oesophago-gastric Cancer (NAOGC)
" Paediatric Asthma
" Paediatric Bronchiectasis
" Procedural Sedation (College of
Emergency Medicine)
" Rheumatoid and Early Inflammatory
Arthritis
" Sentinel Stroke National Audit programme
(SSNAP)
" Vital Signs in Children (College of
Emergency Medicine)
" VTE in Patients with lower limb
immobilisation (College of Emergency
Medicine)
" UK Parkinson’s Audit
National Confidential Enquiries
"
"
"
"
"
"
NCEPOD
Mental Health
Acute Pancreatitis
Sepsis
Gastrointestinal Haemorrhage
Maternal, infant and newborn clinical
outcome review programme (MBRRACEUK)
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- "*
The national clinical audits and national
confidential enquiries that Kettering General
Hospital NHS Foundation Trust participated in
during 2015/16 are as follows:
National Clinical Audit
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
"
Acute Coronary Syndrome or Acute
Myocardial Infarction (MINAP)
Bowel Cancer (NBOCAP)
Cardiac Rhythm Management (CRM)
Case Mix Programme (CMP)
Coronary Angioplasty/National Audit of
Percutaneous Coronary Interventions
(PCI)
Diabetes (Paediatric) (NPDA)
Elective Surgery (National PROMs
Programme)
Emergency Use of Oxygen
Falls and Fragility Fractures Audit
programme (FFFAP)
Head and Neck Cancer Audit
Inflammatory Bowel Disease (IBD)
programme
Major Trauma Audit (TARN)
National Cardiac Arrest Audit (NCAA)
National Chronic Obstructive Pulmonary
Disease (COPD) Audit programme
National Comparative Audit of Blood
Transfusion programme
National Complicated Diverticulitis Audit
(CAD)
National Diabetes Audit – Adults
National Emergency Laparotomy Audit
(NELA)
National Heart Failure Audit
National Joint Registry (NJR)
National Lung Cancer Audit (NLCA)
"
"
"
"
"
"
"
"
"
"
National Prostate Cancer Audit
Neonatal Intensive and Special Care
(NNAP)
Oesophago-gastric Cancer (NAOGC)
Paediatric Asthma
Procedural Sedation (College of
Emergency Medicine)
Rheumatoid and Early Inflammatory
Arthritis
Sentinel Stroke National Audit programme
(SSNAP)
Vital Signs in Children (College of
Emergency Medicine)
VTE in Patients with lower limb
immobilisation (College of Emergency
Medicine)
UK Parkinson’s Audit
National Confidential Enquiries
"
"
"
"
"
"
NCEPOD
Mental Health
Acute Pancreatitis
Sepsis
Gastrointestinal Haemorrhage
Maternal, infant and newborn clinical
outcome review programme
(MBRRACE-UK)
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- #!
The national clinical audits and national enquiries that Kettering General Hospital NHS
Foundation Trust participated in, and for which data collection was completed during 2015/16,
are listed below alongside the number of cases submitted to each audit or enquiry as a
percentage of the number of registered cases required by the terms of that audit or enquiry.
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Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- #"
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Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- ##
The reports of 5 national clinical audits were
reviewed by the provider in 2015/16 and
Kettering General Hospital NHS Foundation
Trust intends to take the following actions to
improve the quality of healthcare provided.
National Audit - Initial Management of the
fitting child 2014/2015 (CEM)
Performance against Standard 1 at KGH was
below RCEM standard. This is an area for
improvement as it is felt that a hospital would
be on very difficult ground medico-legally if a
patient came to harm and it could not be
shown that a risk assessment had been
performed.
To improve the quality of health care,
The core aim of the audit was to identify
Kettering General Hospital NHS Foundation
current performance in EDs against best
Trust is undertaking a number of actions in
practice clinical standards and display the
response to the findings of the audit. These
results in order to facilitate quality
include the development of a proforma for
improvement.
mental health assessment to help clinical staff
structure and document their assessments;
The overall standards of clinical care appear
review the recommendations of the
to be generally high, with a couple of cautions: Psychiatric Liaison Accreditation Network
Nationally, only about one in 20 children was
regarding assessment room features and
still fitting on arrival at the Emergency
layout; and to review timeliness of service
Department; but it is still concerning that:
provided with the evidence from this audit.
a) blood sugar is not being routinely recorded
in fitting children.
b) once hypoglycaemia was recognised,
correct treatment is not being instituted and/or
being recorded as instituted.
To improve the quality of health care,
Kettering General Hospital NHS Foundation
Trust have adopted the recommended actions
from the National Report which are tracked
monthly via the monthly Clinical Business Unit
Governance Meeting.
National Audit - Mental Health in EDs
2014/2015
The core aim of the audit was to identify
current performance in EDs against best
practice clinical standards and display the
results in order to facilitate quality
improvement.
Two of the standards were Fundamental
(‘must achieve’) Standards:
Standard 1 - Patients who have self-harmed
should have a risk assessment in the ED
Standard 7 - An appropriate facility is
available for the assessment of mental health
patients in the ED.
National Audit - Assessing for Cognitive
Impairment in Older People 2014/2015
This audit aimed to identify current
performance in EDs against best practice
clinical standards, in order to facilitate quality
improvement. The audit focused on:
1. Assessment of cognitive impairment by ED
staff.
2. Communication of assessment findings with
relevant services, carers and GP.
3. Documentation of EWS.
Standard 6 is a fundamental Standard. Our
performance against Standard 6 was below
RCEM Standard.
To improve the quality of health care,
Kettering General Hospital NHS Foundation
Trust is undertaking a number of actions in
response to the findings of the audit. These
include a review of the Early Warning Score
position, screening for dementia / delirium in
over 75s in the ED and for ED leads to review
the articles cited (Schnitker et al, March 2015,
Academic Emergency Medicine) to consider
best practice interventions.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- #$
National Inpatient Falls
Local clinical audits
The aim was to see whether or not various
guidelines (primarily NICE) are being followed
on falls assessment and prevention.
The reports of 8 local clinical audits were
reviewed by the provider in 2015/16 and
Kettering General Hospital NHS Foundation
Trust intends to take the following actions to
improve the quality of healthcare provided.
The audit looked at the care provided to a
sample of up to 30 patients (15 consecutively
admitted patients over 2 days) aged over 65,
who were in hospital for over 48 hours, after
being admitted for a non-elective reason.
To improve the quality of health care,
Kettering General Hospital NHS Foundation
Trust is undertaking a number of actions in
response to the findings of the audit and as
part of our wider review of inpatient falls work.
These include improving the initial
assessment, to check postural BP where
appropriate, to provide written information to
the patients as well as to family, a clear falls
care plan and to improve reach to the mobility
aid i.e. stick, frame etc.
National Bowel Cancer Audit
The audit aims to improve the quality of care
and survival of patients with bowel cancer,
and meets the requirements as set out in the
NHS cancer plan, NICE guidelines and the
report of the Bristol Royal Infirmary inquiry.
On reviewing the report, Kettering General
Hospital NHS Foundation Trust found that
there were some discrepancies between the
data and the cases undertaken. In order to
improve the quality of health care, a greater
involvement with the audit is required from the
Trust’s Clinical Audit Team. In addition, future
audits now have a locally developed data
collection form. This will enable the data to be
verified prior to uploading and that all the
boxes have been completed.
Trust wide Documentation Audit
"
"
"
To look into the possibility of how the
audit would be carried out more
frequently. This will be done quarterly
from April 2016.
Lead Nurses will, via their Matrons,
ensure that there is a process for a
continuously accessible supply of
addressograph stickers.
A signature list to be used for every
nursing patient record.
Use of Antibiotics in early neonatal sepsis
- Are we following NICE Guidelines?
No action required as audit met expected
levels.
Audit of management of children with fever
in under 5 years
No action required as audit met expected
levels.
Audit admission related to Diabetes 20142015
No action required as audit met expected
levels.
Audit of compliance to the "Guidelines for
the management of pregnant and postnatal
women who present for care outside the
maternity unit"
" A new pro forma has been suggested
to avoid the Obstetric & Gynaecology
team not being informed of admissions.
Audit of the Management of Glandular
Neoplasia at KGH
No action required as audit met expected
levels.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- #%
Caesarean Section Audit
No action required as audit met expected
levels.
Audit to demonstrate compliance against
UKNSC standards of offer and consent of
antenatal and new born screening
programmes
"
"
The Trust should continue with plans to
introduce the order comms IT package
to pathology.
The recording of results for Sickle Cell
and Thalassaemia, Infectious Diseases
in Pregnancy and Downs Syndrome
Screening was disappointingly low
since implementation of Medway
compared to previous audit. Therefore
all areas to be contacted and reminded
of mandatory compliance to standards
of record keeping and Trust guidance.
Audit of SSKIN bundle documentation
"
"
"
A PIF (practice improvement facilitator)
to be in place in the ED
A local action plan be formulated to
address areas that require
improvement and assessment of
pressure relieving equipment that may
be needed in the ED
A comparison audit of compliance with
trust guidelines of other areas or wards
using the SSKIN 2 bundle. To compare
adherence to specified time frames on
admission to ascertain any differences
in performance
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- #&
Information on use of the CQUIN Framework
As the Trust selected the default tariff option
within in 2015/16 no proportion of Kettering
General Hospital NHS Foundation Trust income
was conditional on achieving quality
improvement and innovation goals through the
Commissioning for Quality and Innovation
payment framework.
In 2013/14 the Trust has achieved 84% of all
CQUIN indicators, which will attract an
associated payment of £3.6 million (based on
2.5% of the total actual outturn of all acute
contracted activity).
CQUINs can be separated into two
categories those indicators which are
national and therefore broadly mandated for
all Acute Trusts, and local CQUINs which
are those agreed between Trusts and their
local Commissioners
There were four national CQUIN themes for
2015-16. These were:
Acute kidney injury, sepsis screening and
antibiotic administration, improving dementia
care, including sustained improvement in
finding people with dementia, assessing and
In 2014/15 the Trust achieved 85% of all CQUIN investigating their symptoms and referring
indicators, which attracted an associated
for support (FAIR) and reducing the
payment of £3.5 million (based on 2.5% of the
proportion of avoidable emergency
total actual outturn of all acute contracted
admissions to hospital.
activity). The Trust was paid for CQUINs based
on expected delivery against actual
performance within 2014/15.
The Trust‘s performance against the local
In 2015/16 the Trust completed the selfassessment for all CQUIN indicators, but as the
Trust selected the default tariff option within in
2015/16, no proportion of Kettering General
Hospital NHS Foundation Trust income was
conditional on achieving quality improvement
and innovation goals through the
Commissioning for Quality and Innovation
payment framework.
CQUINs agreed with our commissioners is
shown on the following page. At the time of
writing the Quality Account the final position
for Q4 has not been validated and will
require final sign off from commissioners.
Further details of the agreed goals for 2015/16
(based on self-assessment are shown on the
next page).
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- #'
Theme
CQUIN Goal
AKI
Improvement goal
Sepsis
Sepsis screening
Sepsis
Sepsis antibiotic admin
Dementia
FAIRI
Dementia
Staff training
Dementia
Supporting Carers
UEC
Reducing the proportion of avoidable emergency
admissions to hospital
Cancer
Chemotherapy Services: Telephone follow ups for
Chemotherapy patients 7 days post day 1 treatments
Cancer
Chemotherapy services: Inpatient pre chemotherapy
assessment in emergency admissions for chemotherapy
End of Life
Implementation of the End of Life Care Strategy – End of
Life Care Bundle
End of Life
Implementation of the End of Life Care Strategy – End of
Life Care Training and Education Strategy
Cardiology
Heart Failure – single point of access
Stroke
Improved Speech & Language Therapy Service for
stroke patients
Stroke
Improved Psychology Support for stroke patients
Neonates
2 year outcomes for infants < 30 weeks gestation and
neonatal critical care
Qtr
1
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
Qtr
2
Qtr
3
Qtr
4
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Information relating to registration with the Care Quality Commission and
periodic/special reviews:
Kettering General Hospital NHS Foundation Trust is required to register with the Care Quality
Commission and its current registration status is unconditional.
The Care Quality Commission has not taken enforcement action against Kettering General
Hospital NHS Foundation Trust during 2015/16.
Kettering General Hospital NHS Foundation Trust has not been subject to any special reviews
or investigations by the CQC during the reporting period.
In March 2015 the Trust, as part of the review of services provided across Northamptonshire
for Looked after Children, received a visit from the CQC. Measurement of these services is
different to others inspected by the CQC and is intended to provide a critical review rather than
an overall rating. A number of recommendations were made to all agencies, Kettering General
Hospital NHS Foundation Trust, Northampton General Hospital NHS Trust and
Northamptonshire Healthcare NHS Foundation Trust. As a consequence, representatives from
each have worked in partnership to implement change. This culminated in a summit as a subgroup of the Strategic Health Safeguarding Forum to challenge actions and evidence across
the parties.
Formal report(s) are awaited from the CQC’s visits on 2nd and 10th February 2016. The visits
focused on management of capacity and accident and emergency.
Information on participation in clinical research
The number of patients receiving relevant health services provided or sub-contracted by
Kettering General Hospital NHS Foundation Trust in 2015/16 that were recruited during that
period to participate in research approved by a research ethics committee was 4,291 patients.
This consisted of 384 patients recruited into National Institute of Health Research (NIHR)
portfolio studies and 3,907 into non-portfolio studies.
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Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
*()-').
+,.- #)
Information on the quality of data:
Quality of data
Kettering General Hospital NHS Foundation
Trust submitted records during 2015/16 to the
Secondary Uses service for inclusion in the
Hospital Episode Statistics which are included
in the latest published data. The percentage
of records in the published data:
Kettering General Hospital NHS Foundation
Trust will be taking the following actions to
improve data quality:
Which included the patient’s valid NHS
Number was:
"
"
"
99.4% (March 2016) for admitted
patient care
99.7% (March 2016) for outpatient care
95.9% (March 2016) for accident and
emergency care
The Trust was pleased to receive a National
Award for the way it uses modern technology
to improve the working lives of staff. The trust
won first place in the Allocate Award 2015 in
the ‘Improving Working Lives through
Technology’ category. The National event
noted that the Trust’s Nurse Sensitive
Indicator System saves about 288
administration hours each month that can
instead be used for patient care by ward staff.
Information Governance
Kettering General Hospital NHS Foundation
Trust’s Information Governance Assessment
Report overall score for 2015/16 as measured
by the Information Governance Toolkit.
Although the Trust declared 70% and
achieved level 2 in most areas with 5 areas
declared at level 3, IG13-5-5 Audit was
declared at level 1 - unsatisfactory (red)
grading.
The Trust has an action plan in place to
ensure the score for 2016/17 is satisfactory
(green).
Payment by results
Kettering General Hospital NHS Foundation
Trust was not subject to the Payments by
Results clinical coding audit during 2015/16.
"
"
"
"
Continue provision of training to staff
on data quality and verification checks.
Sustained data verification work
between clinical coding staff and
healthcare professionals.
Increasing the establishment of the
Data Quality Team.
Review of standards of reporting from
Datix (patient safety incidents)
In terms of Referral to Treatment data, the
Trust has identified significant issues with the
quality of the data used to track, record and
monitor patients awaiting planned treatment.
These issues are partly historic and originally
stem from the initial transfer of pathways and
patients to the PAS system (patient
information system), and current data
collection and recording of pathways by staff.
After some changes implemented in August
2015 it became apparent over the following
months that the issues with the data were far
greater than originally thought. Despite many
changes to the reporting mechanism to
establish the true size of the waiting list, there
still remains significant concerns that the scale
of the waiting list is not truly understood.
The Trust is currently undertaking a significant
review of its data and validation of patient
records to ensure that it can accurately report
RTT performance going forward, however at
this time the Trust is not able to report relating
to RTT performance, with the Trust
suspending reporting due to; Insufficient
confidence in the underlying data being
reported, any information provided would be
inaccurate, un-validated and misleading.
An internal audit report was commissioned in
January 2016 around A&E transit time
reporting. As a result of this, the Trust is
taking action to improve the quality and
accuracy of data including regular review of
case notes and changes to operational
processes.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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PART TWO:
Reporting against core indicators
All Trusts are now required to report against a
core set of indicators using a standardised
statement set out in the NHS (quality
accounts) Amendment Regulations 2012.
Some of the indicators are not relevant to this
trust, for instance, ambulance response times
which are relevant to ambulance trusts only.
Since 2012/13 NHS Foundation Trusts have
been required to report performance against a
core set of indicators using data made
available to the trust by the Health and Social
Care Information Centre (HSCIC). Where
available from the HSCIC we have show a
comparison of numbers, percentages, values,
scores or for each of the indicators that are
applicable to this trust, with regard to:
"
The national average for the same; and
Those NHS Trusts and the NHS
Foundation Trusts with the highest and
lowest of the same.
We are required to report against core
indicators that include mortality ratios.
What is the Hospital Standardised Mortality
Ratio?
The Hospital Standardised Mortality Ratio
(HSMR) is an indicator of healthcare quality
that measures whether the mortality rate at a
hospital is higher or lower than you would
expect. Like all statistical indicators, HSMR is
not perfect. If a hospital has a high HSMR, it
cannot be said for certain that this reflects
failings in the care provided by the hospital.
However, it can be a warning sign that things
are going wrong.
What is the Summary Hospital-level Mortality
Indicator?
The Summary Hospital-level Mortality
Indicator (SHMI) is a high level hospital
mortality indicator that is published by the
Department of Health on a quarterly basis.
The SHMI follows a similar principle to the
general standardised mortality ratio; a
measure based upon a nationally expected
value. SHMI can be used as a potential
smoke alarm for potential deviations away
from regular practice.
Our HSMR and SHMI information available for
the reporting period is detailed in the following
pages.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- $!
Measurement of SHMI
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HSMR
91.43
88.87
SHMR
100.92
100.98
HMSR – National average: 100
SHMI – our rates reflect the national average
We extract our mortality data from Dr Foster. The Trust’s HSMR for the most recent 12 month
period (Dec 2014 to November 2015) is 89.94 which is statistically significantly lower than
expected considering our case mix of patients and the national picture. Previous year’s data is
shown above.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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HMSR mortality rates for emergency admissions weekday and weekend are within or beneath
the statistical confidence limits (National comparison shown by graph below)
"
"
Weekday HSMR (emergency admissions) = 89.64 statistically ‘lower than expected’
Weekend HSMR (emergency admissions) = 89.93 statistically ‘within expected’
Mortality SHMI
The latest (Oct 14 to Sep 15) Summary Hospital Level Mortality Indicator (SHMI) is currently
102.1 ‘as expected’ (band 2). Comparative: for Oct 13 to Sep 14 the SHMI was 98.09. The
Trust position compared with the national position is shown below:
KGH SHMI = 102.1
Prescribed Information
(a) The value and banding of the summary
hospital level mortality indicator
(“SHMI”) for the trust for the reporting
period; and (b) the percentage of
patient deaths with palliative care
coded at either diagnosis or specialty
level for the trust for the reporting
period. Kettering General Hospital
NHS Foundation Trust considers that
this data is as described for the
following reasons:
"
"
"
Regular reporting is in place
considered by the Patient Safety
Advisory Group, Quality Governance
Steering group and Clinical Business
Unit Mortality Groups.
There are Trust-wide presentations in
place and alerts are discussed at the
Patient Safety Advisory Group.
Mortality is on the Trust Quality
Dashboard and discussed at Integrated
Governance Committee monthly and at
each Trust Board.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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We review and monitor morbidity and mortality as part of our governance patient safety
processes and below is a summary of this work:
"
"
"
"
"
"
"
Retrospective case record review (RCRR) using nationally validated PRISM forms and
independent reviewers were done looking at 100case notes. Following national
definitions, we had 2% cases which were deemed slight evidence of avoidability. This is
well under the nationally quoted figure of 4-5%. In the same review, problems in
healthcare were identified and lessons shared in Trust –wide Lessons learnt forums and
Patient Safety Newsletter.
Dr. Foster’s data is reviewed every month at Patient Safety Advisory Group (PSAG),
and alerts are then reviewed by a Clinician, looking at Root causes and learning is
shared.
Standardised Morbidity and Mortality (M&M) Meetings- Every Clinical Business Units
has standardised M&M meetings using Royal College of Anaesthesia guidelines.
Lessons learnt are shared within teams and also trust-wide.
Trust- wide and County wide M&M meetings have proved an important focus point for
improvement of quality of M&M meetings, sharing lessons and platform for open and
transparent discussions.
Patient Safety Lessons Learnt Forum (PS LLF) chaired by Medical Director (every 8
weeks) is trust-wide multi-disciplinary forum, including Non-executive Directors. PS LLF
provides a platform for sharing lessons learnt from never events, serious incidents, and
M&M meetings
SI (Serious Incidents) meetings (weekly) review all unexpected mortality and investigate
using Trust guidelines.
Recently published Mortality Guidance tool from NHS England has been looked at and
we are in the process of completing a gap analysis in the next 2 months.
The flowchart below illustrates the Governance structure for Review of Mortality from Ward
to Board.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Reporting of Patient Reported Outcome Measures (PROMS):
Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS
patients from the patient perspective. Currently covering four clinical procedures, PROMs
calculate the health gains after surgical treatment using pre- and post-operative surveys.
The procedures are:
•
•
•
•
hip replacements
knee replacements
groin hernia
varicose veins*
*Kettering General Hospital NHS Foundation Trust does not conduct varicose vein procedures.
PROMs have been collected by all providers of NHS-funded care since April 2009.
PROMs measure a patient’s health status or health-related quality of life at a single point in
time, and are collected through short, self-completed questionnaires. This health status
information is collected before and after a procedure and provides an indication of the
outcomes or quality of care delivered to NHS patients.
PROMS are collated quarterly, and due to information captured, the surveys run 2 quarters
behind. Therefore, the data included is for the last full year (2014/15). The data for 2015-16 is
currently only provisional.
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Comparative data against previous years is shown on the next page.
PROMS are collated quarterly, and due to information captured, the surveys run 2 quarters
behind. Therefore, the data included is for the last full year (2014/15). The data for 2015-16 is
currently only provisional.
The Trust’s ranking has been calculated against national data via the Health and Social Care
Information Centre (HSCIC).
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Groin Hernia
From
01.04.2014
01.04.2013
**
To
31.03.2015
31.03.2014
Value
**
**
Nat Avg
63.8%
65.7%
Rank
**
**
For Groin Hernia data, the value has not been reported on at a national level as less than 30
complete records were used. This means that there would be a chance of affecting patient
confidentiality if the results were published.
Hip Replacement
From
To
01.04.2014
31.03.2015
01.04.2013
31.03.2014
Value
67.3%
77.4%
Nat Avg
75.1%
78.5%
Rank
96
217
Knee Replacement
From
To
01.04.2014
31.03.2015
Value
67.8%
Nat Avg
70.1%
Rank
40
01.04.2013
69.7%
76.7%
206
31.03.2014
Prescribed Information
Groin hernia surgery, varicose vein surgery, hip replacement surgery and knee replacement
surgery during 2015/16.
Kettering General Hospital NHS Foundation Trust considers that this data is as
described for the following reasons:
PROMS are collated quarterly and due to the information captured, the surveys run two
quarters behind. Therefore the data included is for the last full year (2014/15) and part year of
2015/16. It should be noted that a higher figure for national average indicates a better
performance.
The Trust intends to take the following actions to improve these outcomes scores, and
the quality of its services by:
"
"
"
Liaising with surgeons from the Trauma and orthopaedic department to ascertain why
there is a difference in results for Hips and Knees.
The Clinical Audit Department will work with surgeons around Hernia operations to
ascertain why patients are reporting their conditions are worsening post-op.
The Clinical Audit Department will continue to work with the Pre-assessment team to
ensure that the participation rate remains as high as possible, matching the pre-op
questionnaire response with the operation date. This will increase the chances of the
post-operation questionnaire to be returned and the Trust target of 70% participation
rate to be met.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Reporting of Re-admissions:
Quality of care together with safe and appropriate discharge is essential. Monitoring the rate of
re-admissions to our hospital for those discharged within 28 days enables us to assess and
investigate where necessary, reasons for re-admissions.
Data for the reporting period 2015/16 is unavailable at the date of this Quality Account.
The Health and Social Care Information Centre (HSCIC) has not published national
readmission rates by year since 2013. And as a result we are unable to benchmark our
performance nationally, this national data is due to be updated in August 2016.
0-15 Years
From
01.04.2014
01.04.2013
To
31.03.2015
31.03.2014
Value
9.0%
8.6%
16+
From
01.04.2014
01.04.2013
To
31.03.2015
31.03.2014
Value
8%
6.5%
Prescribed information
Percentage of patients (i) 0 – 15 and (ii) 16 or
over, readmitted to a hospital which forms part
of the Trust within 28 days of being
discharged from a hospital which forms part of
the Trust during the reporting period.
Kettering General Hospital NHS Foundation
Trust has taken the following actions to
improve these percentages, and the quality of
its services by:
"
Kettering General Hospital NHS Foundation
Trust considers that this data is as described
for the following reasons:
Improving care pathways, use of
ambulatory care and improvements to
our discharge processes.
The information is provided to the Hospital
Episode Statistics and is published. We have
analysed this information from Dr Foster, a
national system available to all Trusts.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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The Trust’s responsiveness to the personal needs of its patients
We want to ensure our patients, their families and carers receive the best experience possible.
We welcome all feedback; compliments, suggestions, concerns and complaints and use them
as a source of information for learning and improvement. The Patient Experience and
Involvement Strategy 2015-2018 will support improvements in listening and acting on patient
experiences.
We measure our improvement through various feedback methods such as the Friends and
Family Test, NHS Choices, patient stories, local surveys, safety and quality walkabouts and
Healthwatch Northamptonshire’s 15 steps challenge in clinical areas and other visits.
Examples of feedback from NHS Choices during 2015/16:
Rating
Excerpts from NHS Choices Website 2015/16
Urgent Care and Cardiology
Paediatric Ward
“……Without exception, the care and support I was given throughout
the six hours I remained in your hospital was exemplary; the treatment I
received was first class and I would rate the experience as professional
health care at its best. This applies to both your A&E and Cardiology
teams…….”
Anon, Visited in February 2016. Posted on 03 March 2016
“……..the staff nurses, HCAs, play team, consultant, anaesthetist and
doctors were brilliant with him, very friendly and always made him feel
reassured. The staff also made parents feel at ease and reassured…..”
Kelly, Visited in January 2016. Posted on 19 January 2016
Friends and Family Indicator (National Net Promoter Score):
Period
Score
National Average
2013/14
63.5
National average not available
2014/15
68.1
2015/16
72.2
Kettering General Hospital NHS
Prescribed Information
Foundation Trust has taken the following
actions to improve this percentage, and
The data made available and covering
the quality of its services, by:
services for inpatients and patients discharged
(Gateway reference 00931).
" In order to increase response rates we
will continue to promote the Friends
Kettering General Hospital NHS
and Family Test throughout the
Foundation Trust considers this data is as
organisation. Currently data is
described for the following reasons:
collected through a paper based
system. We will explore the use of
" We actively survey patients following
web-based and/or text messaging.
their discharge in relation to the
This has proved a successful method
national Friends and Family Test. All
for increasing response rates in similar
comments received via the Friends and
organisations.
Family surveys are shared with the
" Improvements in the response rate to
relevant teams.
the Friends and Family test means we
will have a better understanding of
what our patients think of our services,
enabling us to work towards continuous
quality improvement.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Measurement of staff who would recommend the Trust as a provider of care to their
family and friends
Period
2015 Survey
2014 Survey
Value who recommend
3.54
3.42
National Average
3.76
3.67
Prescribed Information
The percentage of staff employed by, or under
contract to, the Trust during the reporting
period who would recommend the Trust as a
provider of care to their family or friends.
Kettering General Hospital NHS
Foundation Trust has taken the following
actions to improve this percentage, and
the quality of its services by:
Kettering General Hospital NHS
Foundation Trust considers that this data
is as described for the following reasons:
Following the 2015 staff survey results the
Trust will produce an action plan to address
the key findings of the survey.
The results of the 2015 NHS staff survey were
reported to the Trust Board on 26th February
2016.
In addition the Trust will be undertaking
specific work with regards to engagement in
line with the Trust objectives and operational
plan. This work will be via the We Will CARE
Together programme. This programme will
emphasise the inherent link between staff and
patient experience, reviewing the Trusts
CARE values, ensuring they are embedded in
practice.
During the reporting year, hundreds of Trust individuals and teams were nominated for Smile
Awards as part of the Trust’s Listening into Action engagement programme.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- $)
Measurement of VTE
Venous Thromboembolism, or VTE as it is known, is a collective term for deep vein thrombosis
(DVT) and pulmonary embolism. VTE is a significant cause of mortality, long-term disability
and chronic ill-health problems, many of which are avoidable and its prevention has been
recognised as a clinical priority for the NHS. Measuring our compliance with risk assessing
patients for VTE is therefore important to maintain patient safety.
Period
From
To
Admissions
VTE
Value
Assessed
01.04.2015
31.03.2016 57021
56627
99.31%
01.04.2014
31.03.2015 70596
69870
98.97%
01.04.2013
31.03.2014 67576
65369
96.7%
VTE Return – Data Submissions
Number of
Number of
Month
Risk
Admissions
Assessments
Apr 15
Mar 15
Jun 15
Jul 15
Aug 15
Sep 15
Oct 15
Nov 15
Dec 15
Jan 16
Feb 16
Mar 16
5841
6024
6313
6662
5495
6463
6632
6691
6506
6390
6389
6455
5882
6074
6341
6701
5549
6487
6670
6737
6580
6434
6428
6508
Kettering General Hospital NHS
Foundation Trust considers that this data
is as described for the following reasons:
The Trust’s VTE risk assessment compliance
is monitored by an established audit process.
Data has been taken from the EasyNote
discharge summary review which includes all
patients admitted to the Trust.
Data is reported each month to the VTE
steering group. There is attendance from the
Surgical and Obstetric directorates but
currently no Medical representation. This data
is then reported to the CBUs for discussion at
Governance meetings and is also discussed
at the Patient Safety Advisory Group.
%
Compliance
Target
99.3%
95%
99.2%
95%
99.6%
95%
99.4%
95%
99.0%
95%
99.6%
95%
99.4%
95%
99.3%
95%
98.9%
95%
99.3%
95%
99.4%
95%
99.2%
95%
The Trust has taken the following actions
to improve this percentage, and the quality
of its services, by:
" Focussing on communication with
patients with the provision of verbal and
written information both at admission
and discharge.
" Meeting with all junior doctors at Trust
induction to provide VTE teaching,
together with additional teaching
sessions.
" Working with workforce planning for
VTE prevention training to be included
in mandatory training matrix for staff.
" VTE awareness campaign for National
Thrombosis Week during 2016/17.
" Root Cause Analysis of all VTE
incidents with reporting into the VTE
Steering Group
" Further audits.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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From the quarterly information available from HSCIC, the Trust has calculated the Trust’s VTE
risk assessment performance against the national average score.
2013/14
2014/15
2015/16
Admissions
15901
17593
18297
VTE Assessed
15355
17318
18178
Q1
KGH
96.57%
98.40%
99.30%
National Score
95.48%
96.10%
96%
2013/14
2014/15
2015/16
Admissions
16510
17789
18737
VTE Assessed
15963
17544
18620
Q2
KGH
96.69%
98.60%
99.40%
National Score
95.83%
96.20%
95.90%
2013/14
2014/15
2015/16
Admissions
17443
17849
19987
Q3
VTE Assessed
KGH
16872
97%
17725
99.31%
19829
99.20%
National Score
96%
96%
95.50%
2013/14
2014/15
2015/16
Admissions
17722
17365
19370
VTE Assessed
17179
17283
19234
Q4
Kettering Score
97%
99.53%
99.3%
National Score
96%
96%
96%
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- %!
Measurement of Clostridium Difficile (C Diff) cases:
Period
From
To
Number
01.04.2015
01.04.2014
01.04.2013
31.03.2016
31.03.2015
31.03.2014
26
33
22
Rate per
100,000 bed
days
13.2
17.5
11.4
National
Average
**
15.1
14.7
** The national average for 2015/16 is not yet available at the date of producing this quality
account.
A clinical service receiving their award for remaining ‘C Diff free’
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- %"
Prescribed information
The rate per 100,000 bed days of cases of C
Difficile infection reported within the Trust
amongst patients aged 2 or over during the
reporting period.
Kettering General Hospital NHS Foundation
Trust considers that this data is as
described for the following reasons:
It is apparent that there are indications that the
level of Clostridium infections may be
approaching their irreducible minimum level
and these cases will occur, due to some
people carrying C Difficile in their bowel and
will develop symptoms due to their underlying
clinical conditions or as a consequence of the
antibiotics they have to take. These are
factors outside the control of the NHS
organisation. Following each episode of a
patient being identified with C Difficile in the
Trust, a full root cause analysis is undertaken.
As at the date of producing this quality account
(11 May 2016) 5 cases of avoidable C Difficile
are confirmed. 5 root cause analysis reports
are with our commissioners for discussion and
to determine avoidability.
Kettering General Hospital NHS
Foundation Trust has taken the
following actions to improve this rate,
and the quality of its services, by:
The Infection Prevention & Control Team
(IPaCT), devised a “Diarrhoea” Roadshow,
using the lesson learnt gathered from
reviews of all cases of hospital acquired
Cdifficile.
These included:
" Launch of “…..days since the last
Cdifficle” by ward. This allowed the
team to do a league table and
present wards that achieved 50,
100, 200, 365 days Cdiff free with
medals of achievement
" SIGHT mnemonic to remind staff of
how to manage patients with
diarrhoea
" The best practice train screensavers
getting the message out to everyone
in the Trust as to how well we were
doing.
" Use of social media to promote the
campaign
" Accessing board rounds when
wards had a C.Difficile case, to
ensure quick feedback and learning
to all members of staff.
" Adoption of a mascot for the
campaign.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- %#
Measurement of patient safety incidents
Period
Number of Patient Safety
Incidents (including near
misses)
Rate of patient
safety incidents
per 1,000 bed
days
Percentage of
severe harm as
reported to NRLS
Percentage of
death as
reported to
NRLS
*1&0
(&-+!
(&))!
+)&*
)&(0!
(&)(!
*1&+
)&-0!
(&))!
Data for the years shown above has been subject to validation and rates are lower than
reported in previous years quality accounts, the quality dashboard and patient safety reports. This is
being addressed by an upgrade to the Datix Reporting System and appointment of further staff to
ensure clinical staff are supported in reporting patient safety incidents and that data quality is assured.
2015/16
2014/15
2013/14
5933
5823
5520
Prescribed information
The number of patient safety incidents
reported within the Trust during the reporting
period, and the number and percentage of
such patient safety incidents that resulted in
severe harm or death.
Kettering General Hospital NHS
Foundation Trust considers that this data
is as described for the following reasons:
A validation exercise has been undertaken to
ensure that the patient safety incidents are
correct.
The reduction in percentage of severe harm
incidents for 2015/16 reflects the revision of
the Serious Incident Policy, aligning guidance
on grading of harm with the NHS England
Serious Incident Framework published in
March 2015. For example, in previous years,
pressure tissue damage and fractures as a
result of falling were categorised as severe.
National guidance is that these should be
reported as moderate unless the harm caused
was permanent.
Staff are encouraged to report incidents in a
blame free culture. Our incident reporting
system is monitored to ensure all services in
the Trust are able to report incidents.
The NRLS (National Reporting and Learning
System) which is the patient safety function of
NHS England, considers that organisations
with a high level of reporting low/near miss
incidents and a low level of incidents causing
harm is indicative of a positive reporting
culture.
Encouraging the reporting of all incidents and
feedback about changes in practice
implemented locally which may be usefully
shared more widely to improve the quality of
care and safety. Sharing lessons learned
from the analysis of incidents is vital to
ensuring improvements and reducing the risk
of similar occurrences.
Kettering General Hospital NHS
Foundation Trust has taken the following
actions to improve this number and/or
rate, and the quality of its services by:
" Ensuring that staff are able to report
incidents;
" Improving awareness on the
importance of incident reporting,
including near misses;
" Increased scrutiny of reported incidents
to ensure grading and learning from all
incidents is in place.
" Improving the frequency of uploading
patient safety incidents to the NRLS.
" Improved the timeliness of review of
incidents by our clinical staff before
upload to the NRLS.
" Upgraded our Datix Incident Reporting
Database for improved feedback to
staff reporting incidents with ability to
produce improved reports.
" Improved analysis of incidents
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- %$
PART THREE: Other information
How we performed against the priorities set for 2015/16
NHS Foundation Trusts must specifically use
Patient Safety 2015/16
Part Three of the quality account to present an
overview of the quality of care offered by the
Preventing Avoidable Deterioration
NHS Foundation Trust based on performance
in 2015/16 against indicators selected by the
This indicator was made a priority in the
board in consultation with stakeholders.
quality and continues our commitment to
prevent avoidable deterioration in hospital.
The indicators set must include:
This is also part of the Trust’s Patient Safety
Campaign; “I will keep you safe”.
" At least three indicators for patient
safety
We said we would:
" At least three indicators for clinical
effectiveness
" Throughout the year complete at least
" At least three indicators for patient
98% of Venous Thromboembolism
experience
(VTE) risk assessment for patients on
admission (National target 95%).
On quarterly basis ensure that in
quarter 1 at least 92% of patients will
have a correctly calculated National
Early Warning Score (NEWS) that
indicates deterioration and that this
performance will increase by 2% each
quarter during 2015/16.
" That the number of patients
experiencing a cardiac arrest during
quarter 1 will not exceed 45 and that
this will reduce by 5 each quarter
during 2015/16.
What we achieved in 2015/16 to prevent avoidable deterioration:
The quality indicators for 2015/16 were
chosen following consultation with Trust
Governors to determine what was important.
The indicators were approved by our Trust
Board.
2014/15 % VTE risk assessments on admission
2015/16 % VTE risk assessments on admission
2014/15 % of patients with correctly calculated NEWS score*
2015/16 % of patients with correctly calculated NEWS score
2014/15 Number of cardiac arrests outside of A&E
2015/16 Number of cardiac arrests outside of A&E
"
Qtr 1
Qtr 2
Qtr 3
Qtr 4
98.4
99.3
94.4
97.2
33
28
98.6
99.4
97
98.8
41
36
99.3
99.2
98
98.1
37
34
99.5
99.4
94.9
99.1
43
28
*During 2014/15 for NEWS scores reported, May 2014 reported zero cardiac arrests outside of A&E
We did not fully achieve our targets through the year and are giving priority on the
management of NEWS and prevention of cardiac arrests outside of A&E.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- %%
15/16
Target
Achieved?
Partially
Partially
Reducing Risks Associated with Surgery
The World Health Organisation (WHO) surgical checklist is intended to systematically and
efficiently ensure that all conditions are optimum for patient safety before, during and after
surgery. Additionally, it is vital to ensure that those patients requiring surgery for a fractured
Neck of Femur are operated on within a priority timescale. Reducing the risks associated with
surgery are a priority in our Patient Safety Campaign supported by our “I will keep you safe”
pledge. The Trust aimed to achieve during 2015/16:
"
"
100% compliance with the WHO checklist completion for the year
Achieving a quarterly % target on the proportion of patients operated on within 36
hours:
Qtr 1 15/16
85%
Qtr 2 15/16
85%
Qtr 3 15/16
86%
Qtr 4 15/16
87%
What we achieved in 2015/16 to reduce risks associated with surgery:
Qtr 1
2014/15 % WHO checklist completion
2015/16 % WHO checklist completion
2014/15 Proportion of patients with a
fractured Neck of Femur operated on within
36 hours
2015/16 Proportion of patients with a
fractured Neck of Femur operated on within
36 hours
Qtr 2
Qtr 3
Qtr 4
Target
Achieved?
100% 100% 100% 100%
100% 100% 100% 100%
77.8% 72.1% 76.5% 82.9%
89%
84%
79%
Not fully
achieved
78.4% throughout
2015/16
We did not fully achieve the targets set for ensuring that patients with a fractured neck of femur
were operated on within 36 hours. This continues to be a quality improvement focus during
2016/17.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- %&
Reducing Risks Associated with Medication
Linked to the Trust’s Patient Safety Campaign and ‘I will keep you safe’ pledge, minimising
risks associated with medication is one of the key ways in which hospitals can keep patients
safe. The Trust set improvement trajectories, monitored through the Medication Safety
Thermometer audits. The Trust also aimed to improve how we store medication and to
progress towards an electronic system for prescribing and administration of medicines.
Our local quality indicator of ‘omitted doses of critical medications’ is measured by an audit
each month on a specific day.
Trajectories during 2015/16:
Qtr 1
9%
(1) Proportion of patients with omitted dose without a
documented reason
(2) Proportion of patients with omitted doses of critical
medications
(3) Proportion of patients with medicines reconciliation
undertaken within 24 hours of admission
(4) Proportion of patients with allergy status documented
(5) Number of actual and near miss medication incidents
(6) Number of medication incidents reported with harm
* (7) Number of medication errors per 1,000 bed days
Qtr 2
7%
Qtr 3
6%
Qtr 4
5%
2%
1%
1%
<1%
63%
65%
68%
70%
85%
290
15
6.00
90%
305
14
6.00
95%
320
13
7.00
98%
335
12
7.00
*This trajectory was a reporting error in our 2014/15 Quality Account
What we achieved in 2015/16 to reduce the risks associated with medication
Trajectory
(1)
(2)
(3)
(4)
(5)
(6)
**(7)
2014/15
2015/16
Qtr 1
Qtr 2
Qtr 3
Qtr 4
Qtr 1
Qtr 2
Qtr 3
Qtr 4
12.2%
3.5%
62.6%
70.6%
337
11
0.24
7%
2.3%
78.4%
80.8%
265
14
0.30
7.9%
3%
75.4%
77.9%
350
10
0.21
6.6%
1.3%
60.3%
80.3%
309
5
0.11
6%
1.5%
63.4%
81.8%
350
12
0.24
9%
3.9%
70%
75.2%
309
14
0.28
6.9%
1.9%
64.6%
66.5%
267
10
0.20
11.3%
3.7%
59.4%
71.4%
254
8
0.20
**Due to the trajectory error in the 2014/15 Quality Account, the measurement used here is whether the
error rate is reducing through 2015/16.
"
"
"
The Trust completed a programme of work to ensure that adequate medication storage
with sufficient capacity and of the required quality is available in all clinical areas of the
hospital which store medicines. Clinical areas are keeping record of temperatures
medicines are stored at both refrigerated and room temperature conditions.
The Trust remains committed to implementing a Trust wide electronic prescribing and
medicines administration system to deliver improvements in the safe, effective and
efficient use of medicines within the organisation.
Throughout 2015/16 the Trust has progressed plans for electronic prescribing within
chemotherapy as an area associated with high risk medicines and this is planned to go
live in quarter 1 of 2016/17.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- %'
Patient Experience 2015/16
"
End of Life Care
End of life care (EOLC) is the care
experienced by people who have an incurable
illness and are approaching death. Good
EOLC enables people to live in as much
comfort as possible until they die, and to make
choices about their care. It is about providing
support that meets the needs of both the
person who is dying and the people close to
them, and includes management of
symptoms, as well as provision of
psychological, social, spiritual and practical
support.
"
"
"
End of Life Care covers the care received by
people who are likely to die in the next 12
months, as well as care in the last days and
hours of life, and care after death, including
bereavement support for families and loved
ones.
"
The CQC told us during their inspection in
2014 that the Trust needed to improve care
for EOL patients.
Our actions to improve quality for EOL
patients during 2015/16:
Implementation of an EOL Care Strategy that
ensures:
" Provision of an EOL Care Bundle
(evidence based interventions)
" A document based on the 5 priorities of
care for EOL patients;
" Prior to implementation of the EOL
Care Bundle, a baseline audit of
practice followed by a post
implementation repeat audit to ensure
that improvements are realised
" Provision of and delivery the EOL Care
Strategy to improve training and
education.
What we achieved in 2015/16 to improve
Patient Experience in EOLC
•
End of Life Care Strategy 2015-2020
•
Medical and Nursing Leads for EoLC
•
EoL Care Bundle in all adult wards
"
"
"
"
"
"
EoL Care Champions, nurses and
allied health professionals received
enhanced training in care of the dying
patient and support to their
family/friends.
Cascade of enhanced training to
wards/area by EoL Care Champions.
Staff have attended a dedicated
communication course.
In December 2015 The Healthier
Northamptonshire collaborative case ‘Northamptonshire end of life strategy A Case for investment in education and
skills development’ document has been
sent to the Commissioners. We are
currently awaiting the outcome. The
Transformation Lead is currently
liaising with Loros Education and
Training Dept. and NHFT End of Life
Care Practice Development Team to
develop a robust EoLC education and
training prospectus for KGH.
The EoLC Clinical Lead has conducted
a survey aimed at Consultants across
the Trust on Advanced Care Planning
and potential training requirements.
The results of this survey will contribute
to planning appropriate future training
The End of Life Care Champions are
carrying out an Training and Education
Needs Survey for their ward areas so
further ward specific training can be
developed.
Process mapping of the patients
journey through KGH has commenced
for future service design/development
Expansion of the Palliative Care Team
for dedicated in-house training.
6 month contract with NHFT End of Life
Care Practice Development Team for
the delivery of embedding the 5
Priorities of Care into the Adult wards
HEEM bid submitted for education for
Advanced Care Planning,
Communication Skills Training and the
5 Priorities of Care.
Development of Nurse Sensitive
Indicators on EoLC linked to Ward
Accreditation
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- %(
Discharge Experience
Patients and General Practitioners continued to tell us during 2014/15 that our discharge
processes could be improved; in particular we need to improve upon the timeliness and
accuracy of discharge letters which are produced following in-patient admissions.
Quality improvements for 2015/16:
" Implement an Integrated Discharge Team
" Re-launch our discharge process booklet (Moving On)
" Implement ‘Criteria Led Discharge’ for wards and medical teams
" Communicate an estimated/accurate date of discharge to patients
" Implementation of a Predicted Discharge Model
" Re-launch discharge action cards for our Capacity and Discharge Team
What we achieved in 2015/16 to improve discharge experience
Our overall aim was by implementation of the above, to reduce the concerns being raised from
patients and GPs.
GP concerns relating to discharge
Month
Apr
May Jun
Jul
Aug
Internal 22
22
22
22
22
Target
2014/15 40
39
34
61
88
2015/16 48
22
23
23
40
Patient complaints relating to discharge
Sep
22
Oct
22
Nov
22
Dec
22
Jan
22
Feb
22
Mar
22
41
41
50
44
26
25
32
36
17
36
25
33
29
18
Dec
2
Jan
3
Feb
2
Mar
2
7
6
10
6
4
7
6
8
Month
Apr
May Jun
Jul
Aug Sep Oct
Nov
Internal 3
2
2
3
2
2
3
2
Target
2014/15 3
1
5
6
7
3
3
1
2015/16 6
3
5
6
4
4
4
6
Percentage of discharge letters produced on day of discharge
Month
Apr
May Jun
Jul
Aug Sep Oct
Nov Dec Jan
Feb Mar
Internal 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%
Target
2014/15 70.7 72.4 72.4 86.9 86.2 92.7 92.7 72.4 67.7 88.1 89.3 87.0
2015/16 87.1 71.2 90.5 85.1 87.8 81.2 80.7 62.9 59.9 52.6 56.2 55.4
What we achieved in 2015/16 to improve patient discharge experience
" Review of discharge paperwork and of the checks being made in the discharge lounge.
" Increased support for the discharge process for people with dementia.
" Improvements to post-operative information leaflets for patients to take home on
discharge.
" Ward teams giving additional focus on high quality communications with
patients/carers/families on discharge arrangements.
" GP attendance at Junior Doctors Induction to emphasise the important of accurate and
timely discharge letters.
Further improvements are required to our discharge processes and this remains a quality
improvement focus during 2016/17.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- %)
Complaints Management
Listening and acting on feedback, including complaints, is essential to improve engagement
with patients and to improve quality. Monitoring the timeliness of responses to complainants
can be an indication of the priority organisations give to acting on feedback. Reducing the
number of formal complaints received can be an indication of issues being resolved in other
ways; Patient Advice and Liaison Service (PALS) and directly by staff “on the spot” which is
often an immediate resolution, learning action and personalised outcome for the person.
Quality improvements for complaints management in 2015/16:
" A complaints improvement plan to improve performance.
" Strengthened complaints team and centralisation of the function.
" Reduction of number of delayed formal complaint responses.
" New Complaints Charter.
" Improved learning mechanisms.
What we achieved in 2015/16 to improve complaints management
Number of formal complaints:
Month
Apr
May Jun
Jul
Aug Sep Oct
Nov Dec Jan
Feb Mar
Internal 28
28
28
28
28
28
28
28
28
28
28
28
Target
2014/15 25
29
34
29
35
26
37
34
27
36
27
28
2015/16 38
33
37
29
33
32
38
31
26
35
53
43
Percentage of complaint responses completed within the agreed timescale:
Month
Apr
May Jun
Jul
Aug Sep Oct
Nov Dec Jan
Feb Mar
Internal 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%
Target
2014/15 6%
5%
26% 40% 14% 36% 22% 37% 24% 33% 44% 42%
2015/16 43% 43% 51% 28% 42% 38% 33% 43% 37% 61% 54% 68%
Portion of complaints resolved with a first response:
Month
Apr
May Jun Jul
Aug Sep Oct
Nov Dec Jan
Feb
Mar
Internal 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%
95%
Target
2014/15 79% 89% 81% 67% 88% 69% 80% 70% 93% 83% 83%
91%
2015/16 67% 89% 72% 89% 75% 86% 67% 65% 89% 100% 97%
98%
" Our complaints improvement plan was refreshed during the year with improved
response performance and engagement with complainants improving.
" Our quarter 4 Patient Experience Report analyses learning and seeks assurances.
" There is improved engagement with complainants and where appropriate agreement on
revised completion dates when investigations are complex.
" We seek feedback from complainants on their experience of raising a complaint and
effectiveness of resolution.
" Our policy for complaints management was reviewed in quarter 4, together with revision
of our information leaflet, publicity material and accessibility to raise concerns and
complaints.
" Despite the increase in formal complaints during the last quarter of 2015/16 we
improved response performance (see feedback from NCC at page 61).
Our complaints improvement objectives were not sustained during the year and complaints
management is identified as a patient experience priority in this Quality Account for 2016/17.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- %*
Clinical Effectiveness 2015/16
Cancer Care
NHS England (Jan 2015) reports that more than 1 in 3 people in the UK develop cancer. We
recognise that early diagnosis and treatment is essential. Alongside this, support for those
living with cancer is of equal importance.
Commissioners have a quality framework “Commissioning for Quality and Innovation” (CQUIN)
and this can be used as a payment framework to reward NHS healthcare providers on the
achievement of local improvement quality goals. Whilst we did not set any payment incentives
for a Cancer Care CQUIN, we agreed two quality improvement targets with our commissioners
with a focus on support following treatment:
"
"
Cancer chemotherapy services – telephone follow ups for chemotherapy patients 7
days post day 1 treatments.
Cancer – inpatient pre chemotherapy assessment in emergency admissions for
chemotherapy
What we achieved in 2015/16 for this quality improvement initiative
Telephone follow up for chemotherapy patients 7 days post day 1 treatments
2015/16
Eligible
Telephone
% Achieved
% Target for
Target
patients
Consultations
Quarter
Achieved?
Qtr 1
123
118
95%
50%
Qtr 2
670
586
87.5%
60%
Qtr 3
663
598
90%
70%
Qtr 4
745
673
90%
75%
Inpatient pre chemotherapy assessment in emergency admissions for chemotherapy
2015/16
Eligible
Inpatient Pre
% Achieved
% Target for
Target
patients
Chemotherapy
Quarter
Achieved?
Assessments
Qtr 1
3
3
100%
60%
Qtr 2
12
12
100%
70%
Qtr 3
11
11
100%
80%
Qtr 4
9
9
100%
90%
"
"
We are ensuring that patients are given a consistent standard of nurse led information
pre-treatment.
We are improving secondary to primary care communications (nurse-led).
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- &!
Stroke Care
High quality care provided in the dedicated specialist inpatient facility is essential for patients
experiencing a stroke. The stroke pathway of care between Northampton General Hospital
NHS Trust and our Trust was identified as important to measure compliance against to ensure
improvements to the pathway are continued and maintained.
Quality improvements for 2015/16:
"
"
"
"
To meet target % of patients seen within 24 hours following a TIA (transient ischaemic
attack)
To achieve target % of patients seen on a designated stroke ward for 90% of the time.
CQUIN: Improved speech and language therapy service for stroke patients
CQUIN: Improved psychology support for stroke patients
What we achieved in 2015/16 to improve stroke care
% of patients seen within 24 hours following a TIA based on national target (70%)
Month
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2014/15
Target
Achieved
2015/16
Target
Achieved
70%
70%
70%
70%
70%
70%
75%
75%
75%
75%
75%
75%
77%
80%
77%
80%
77%
80%
77%
80%
77%
80%
100%
80%
88%
80%
100%
80%
100%
80%
100%
80%
66%
80%
60%
80%
54%
48%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
% of patients seen on a designated stroke ward for 90% of the time
Month
2014/15
and
2015/16
Target
2014/15
Achieved
2015/16
Achieved
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
90%
87%
87%
87%
87%
87%
84%
100%
97%
83%
90%
75%
57%
75%
38%
88%
64%
68%
76%
60%
57%
70%
50%
75%
70%
CQUIN achievements:
"
Speech and language – fully achieved
" No patients have waited more than 24 hours for a high risk appointment and low
risk patients are being seen within 7 days.
" Increase in number of clinics taking place.
" Psychology support – partially achieved
" Monthly training events for all staff with action learning sets in staff forums
" Improved availability of referral forms included in stroke admission packs
" Improved data collection tools for audit
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- &"
Dementia Care
An early diagnosis of dementia is beneficial because some causes of dementia are treatable
and fully or partially reversible, depending on the nature of the problem. Conditions such as
some vitamin deficiencies, side effects of medications and certain brain tumours may fall into
this category. Identifying and diagnosing dementia is essential to ensure treatment and
support can commence as soon as possible. Dementia care is a national CQUIN to which we
measure ourselves against in our Quality Dashboard reporting.
Quality improvement targets for 2015/16, monitored and supported by the Dementia Working
Group:
"
"
"
"
"
"
"
Compliance with national CQUIN target
Dementia steering group progress on screening, creation of a patient passport, core
care planning, implementation of a care bundle and audit of carers.
Development of Nurse Practitioners to undertake dementia assessments.
Electronic recording of initial dementia screening
Promotion of mental health service provision specific for dementia, support from the
Trust’s Admiral Nurse for Dementia and the Trust’s Carer’s Badge
Development of a carers/family support service with increased used of carer’s audit.
Additional education for medical staff in Dementia, together with e-learning options.
% of screening
Month
National
Target
2014/15
2015/16
Apr
90%
May
90%
Jun
90%
Jul
90%
Aug
90%
Sep
90%
Oct
90%
Nov
90%
Dec
90%
Jan
90%
Feb
90%
Mar
90%
66.6%
58.3%
65%
61.4%
72.2%
91.2%
97.3%
81.5%
94.1%
81.5%
94%
48.8%
92%
34.3%
90.8%
33.9%
90%
45.7%
78.7%
33.3%
86.4%
26.3%
61.4%
27.2%
% undergoing further assessment prior to discharge
Month
National
Target
2014/15
2015/16
Apr
90%
May
90%
Jun
90%
Jul
90%
Aug
90%
Sep
90%
Oct
90%
Nov
90%
Dec
90%
Jan
90%
Feb
90%
Mar
90%
78.6%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
65.1%
100%
60.5%
100%
71.7%
100%
56.7%
100%
57.1%
% of patients referred appropriately
Month
National
Target
2014/15
2015/16
Apr
90%
May
90%
Jun
90%
Jul
90%
Aug
90%
Sep
90%
Oct
90%
Nov
90%
Dec
90%
Jan
90%
Feb
90%
Mar
90%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
35.7%
100%
66.7%
100%
57.1%
100%
100%
100%
80%
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
+,.- &#
Performance against 2015/16 key national priorities
The Trust continues to review the services it
provides and the systems and processes that
support them, in order to make sure that they
are accessible to patients. Kettering General
Hospital NHS Foundation Trust recognises
that providing timely access contributes to a
positive patient experience.
The table below sets out the performance of
the Trust against the key national priorities
from Monitor’s Risk Assessment Framework.
Other information
The Trust must provide a copy of the draft
quality account to the Clinical Commissioning
Group which has responsibility for the largest
number of people to whom the provider has
provided relevant health services during the
reporting period for comment before
publication and we include thee comments as
follows:
Annexes:
The Trust has struggled to deliver and sustain
acceptable levels of performance against the
key operational standards, namely RTT 18
week admitted performance and the A&E 95%
four hour standard. In terms of the 62 day
wait for first treatment from urgent GP referral
for suspected cancer, the Trust struggled to
achieve the 85% compliance per quarter.
"
"
"
"
"
"
Comments (obligatory) from
commissioners
Comments (voluntary) from
Healthwatch Northamptonshire
Comments (voluntary) from
Northamptonshire County Council
Comments (voluntary) from governors
Statement of directors’ responsibilities
in respect of the quality account
External auditors’ limited assurance
report (see page 2)
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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1
1
1
1
85%
90%
94%
98%
1
1
1
1
96%
93%
93%
14/15 = 28
15/16 = 26
Not
Applicable
1
Weighting
95%
Threshold
Q3
99.1
100
97.4
92
85.1
10
9
96.8 98.3
95.7 96.6
100
100
100
93.8
86
96.9 99.1
Q2
Fully achieved
9
98.6
97.5
100
99.3
100
95.2
83
98.4
Q1
2014-2015 %
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Shaded Areas on Referral to Treatment – Please see Information on Data Quality on page 27.
Certification against compliance with requirements regarding
access to health care for people with learning disability
Maximum time of 18 weeks from point of referral to
treatment in aggregate – admitted
Maximum time of 18 weeks from point of referral to
treatment in aggregate – non-admitted
Maximum time of 18 weeks from point of referral to
treatment in aggregate – patients on an incomplete
pathway
A&E: Maximum waiting time of four hours from
arrival to admission/transfer/discharge
All cancers: 62 day wait for first treatment from
urgent GP referral for suspected cancer
All cancers: 62 day wait for first treatment from
NHS Cancer Screening Service referral
All cancers: 31 day wait for second or subsequent
treatment comprising surgery
All cancers: 31 day wait for second or subsequent
treatments comprising anti-cancer drug treatments
All cancers: 31 day wait for second or subsequent
treatment comprising radiotherapy
All cancers: 31 day wait from diagnosis to first
treatment
Cancer: 2 week wait from referral to date first seen
comprising all urgent referrals (cancer suspected)
Cancer: 2 week wait from referral to date first seen
comprising symptomatic breast patients (cancer not
initially suspected)
Clostridium (C.) difficile – meeting the C. Diff
objective
Access
Outcomes
Indicator
Area
Monitor Risk Assessment Framework – Targets and Indicators with thresholds
5
99.5
96.1
99.1
100
94.6
95.9
81.8
82.4
Q4
33
98.3
96.5
99.5
99.8
98.1
94.2
84
92.4
14/15
Total
Q2
100
98
6
6
98.3
97.9
99.7
100
100
95.3
87.8
87.8
Q3
Fully achieved
10
96.2 98.4
94.7 92.7
99.4 99.7
99.3
97.1
95.8 99.2
78.9 76.7
84.5 88.5
Q1
2015-2016 %
99.8
4
26
97.2 97.5
96.3 95.4
98.0 99.2
100
96.9 98.7
95.4 96.5
83.4 81.9
78.9 84.9
Q4
15/16
Total
Other information – Annexes
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Feedback from Healthwatch Northamptonshire
Healthwatch Northamptonshire statement on Kettering General Hospital NHS
Foundation Trust (KGH) draft Quality Account 2015/16
During 2015-16 Healthwatch Northamptonshire (HWN) has continued to work closely with
KGH. Our dedicated volunteers have gathered a wealth of patient experience observations and
feedback and have shared this with KGH through its Patient Experience Steering Group and
other meetings. We are pleased that KGH values this work, listens to the feedback and acts on
it, and has used it to inform the development of their new Patient Experience and Involvement
Strategy. We are glad this Quality Account demonstrates that patient experience is an integral
component of quality at KGH.
We support the reduction in length of this document and desire to make it more accessible to
the public and are glad to see the inclusion of an Easy Read summary.
We believe KGH has chosen appropriate quality priorities for 2016/17 and support their aim to
make them specific and measurably. We recommend including some more specific actions for
those priorities where ‘reviewing’ is the main suggestion.
It is our opinion that this Quality Account demonstrates KGH is an open and transparent
organisation and are pleased to see evidence of learning from complaints and incidents and
good progression on their action plan in response to the CQC inspection that took place in
2014.
Comments on priorities for improvement for 2016/17
We agree with the importance of the priorities listed although would like to see more details
about what public consultation took place to determine them.
Patient Safety
Reducing risks associated with medication: We fully support KGH’s desire to learn from
errors and use national guidance.
Reducing the risk of falling in hospital: We look forward to seeing the outcomes of the
reviewed policies.
Patient Experience
HWN are pleased Patient Experience is included as a quality priority. We note that the three
patient experience priorities have been carried over from last year and fully support the desire
of KGH to build on progress and ‘effectively fully embed [progress] in our practice.’
End of life care:
We agree that this is an important priority for patient experience, particularly that
communication with relatives and carers of patients at the end of their lives is sensitive and of
a good standard.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Discharge experience:
We agree with the need for this to remain a priority and the specific points mentioned. HWN
have heard examples of the problem delayed discharge letters can cause GPs and patients.
We have also heard of occasions when patients were discharged before they or their relatives
felt they were ready or that the appropriate after care was in place. We support KGH working
with other providers to facilitate safe and timely discharge and suggest they include voluntary
sector organisations, such as Serve, in this work.
HWN volunteers have regularly visited the hospital wards and Discharge Lounge at KGH to
gather patient experience. We heard that some patients still experience delays in waiting for
take-home medication and discharge letters so recommend KGH keeps this under review. We
also had concerns about the physical environment of the old discharge lounge but have found
the new Discharge Lounge and extended facilities to be a great improvement.
Complaints management:
We appreciate that KGH are making progress in this area and hope to see the targets
achieved this year. Learning from complaints is important and we hope this will be an integral
part of the complaints management process.
Clinical Effectiveness
Implementation of John’s Campaign – Dementia Care:
We are pleased to see the valuing of relatives and carers and acknowledgement that they
need to stay with the patient outside of visiting hours. Allowing carers to stay with the patient
can bring many benefits to the patient and ward. We feel that ensuing appropriate and dignified
care for patients with dementia is something that requires continuous monitoring.
Dementia Discharge Process – discharge lounge reports:
We support this proactive approach to supporting people with dementia and the plan to give
follow on recommendations. We have heard how the understanding of dementia and
communication between departments and services about the needs of people with dementia is
variable and see this as a positive step to address some of the issues and support carers too.
Review of quality performance 2015/16
We congratulate KGH for the progress made against the targets set for 2015/16. We note that
a number of quality priorities have been carried over to 2016/17 but would like to see a brief
mention of how KGH plan to progress the targets not met that are not priorities for this year.
We welcome that KGH are taking action to improve and validate their data quality and
recommend they take this action as soon as possible so they can measure progress against
Referral to Treatment (RTT) targets.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Additional HWN patient experience findings from 2015-16
120 respondents to our 2015 ‘Make Your Voice Count’ survey told us about an experience of
KGH. Two thirds of these were good experiences and one third poor experiences. Additionally,
the HWN office has received 9 positive, 19 negative and 3 mixed pieces of feedback during the
year.
The most common themes to the poor experiences were: appointment availability and waiting
times, staff attitudes (including poor or impersonal care), communication with patients
(including the giving of information and listening), and communication between
wards/departments and with other health and care organisations. We also heard many
examples of great care and treatment. We therefore recommend that staff communication with
patients and communication systems between departments and providers are considered an
ongoing priority for enhancing the quality of patient experience and that good practice is
shared.
HWN volunteers have carried out over 60 visits to wards at KGH during 2015-16. Findings and
recommendations are fed back directly to the wards and to the Director of Quality and Nursing
and are acted on, demonstrating that KGH is an organisation committed to improving patient
experience. Recommendations have covered areas such as staffing levels, ward environment
and safety issues, patient and visitor information, and ensuring patients get the care they need.
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Feedback from Northamptonshire County Council
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Feedback from Governors
It was generally agreed by Governors that the Quality Account was very good in content and
that it had been improved by the substantial reduction in the size of the report in 2015-16
making it more accessible to the general public. It was recognised that in order to improve the
report there needed to be better presentation and a further in-depth explanation of some of the
campaigns and initiatives to engage the public better.
Governors acknowledged that although the hospital performance in certain areas was not
good, they were pleased that plans were in place to improve those areas as detailed.
It was recognised that KGH continued to create quality initiatives in respect of staff working
practices following "I Will" with "We will together" campaigns which were proving beneficial for
staff morale and for the patient experience.
Governors were very positive about the C Diff. "Launch days" which had been a great success
and was highly motivational for all staff across the organisation and increased patient safety in
the Trust.
The Trust’s participation in National Clinical Audits shows its commitment to quality of patient
care and it has taken action on areas identified as requiring attention which Governors were
pleased with.
In Part one of the report there are many areas of "How will we Improve" and Governors
stressed that close monitoring will be needed to ensure that slippage does not take place.
Continual pressure will be needed from the Governors to ensure the targets are achieved in
particular with relation to the communication between patients and their care pathways.
Recognising the good work being undertaken as highlighted in the Quality Account, Governors
sought further reassurances with regard to sustainability and innovation as the key drivers for
the NHS.
Governors have committed to ensuring that there is greater engagement with the public across
the communities that KGH serves. Through attendance at health and community events we
strive as a Council of Governors to bring the public and patient experience to the fore front of
the Trust by listening to patient concerns and feedback and ensuring that this is brought to the
appropriate forum. We are confident that the staff and Executive team in the Trust will drive
forward the patient experience agenda to improve patient care across the organisation.
Council of Governors
May 2016
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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Statement of Directors’ Responsibilities
The Directors are required under the Health
Act 2009 and the National Health Service
Quality Accounts Regulations to prepare
quality accounts for each financial year.
Monitor has issued 2015/16 guidance to NHS
Foundation Trust Boards on the form and
content of annual quality accounts (which
incorporate the above legal requirements) and
on the arrangements that Foundation Trust
Boards should put in place to support the data
quality for the preparation of the quality
account.
In preparing the quality account, directors are
required to take steps to satisfy themselves
that:
"
"
"
"
The content of the quality account meets the
requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2015/16;
The content of the quality account is not
inconsistent with internal and external sources
of information including:
" Board minutes and papers for the
period April 2015 to May 2016
" Papers relating to quality reported to
the Board over the period April 2015 to
May 2016.
" Feedback from Trust Governors dated
May 2016
" Feedback from Healthwatch
Northamptonshire dated April 2016
" Feedback from NHS Nene Clinical
Commissioning Group dated 12 May
2016.
" Feedback from Northamptonshire
County Council dated 18 May 2016.
" The National Staff Survey published in
February 2016.
" The Head of Internal Audit’s annual
opinion over the Trust’s control
environment dated May 2016.
" The Trust’s complaints/patient
experience report published under
Regulation 18 of the of the Local
Authority Social Services and NHS
Complaints Regulations 2009, dated
April 2016
"
The Quality account presents a
balanced picture of the NHS
Foundation Trust’s performance over
the period covered;
The performance information reported
in the Quality Account is reliable and
accurate. The concerns around
Referral to Treatment (RTT) and A&E
indicators are identified, together with
how this is being addressed;
There are proper internal controls over
the collection and reporting of the
measures of performance included in
the Quality Account, and these controls
are subject to review to confirm that
they are working effectively in practice;
The data underpinning the measures of
quality indicators reported in the Quality
Account is robust and reliable,
conforms to specified data quality
standards and prescribed definitions, is
subject to appropriate scrutiny and
review and
The Quality Account has been
prepared in accordance with Monitor’s
annual reporting guidance (which
incorporates the quality account
regulations (published at www.monitornhsft.gov.uk/annualreportingmanual) as
well as the standards to support data
quality for the preparation of the quality
account also available from the web
address above.
The directors confirm to the best of their
knowledge and belief they have complied with
the above requirements in preparing the
Quality Account for 2015/16.
By order of the Board
Graham Foster
Chairman
Date: 24 May 2016
David Sissling
Chief Executive
Date: 24 May 2016
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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EASY READ PRIORITIES FOR 2016/17
THINGS THAT THE HOSPITAL WILL DO NEXT YEAR
TO MAKE YOUR CARE BETTER
WE WILL help you receive good care:
By making sure staff know about you
and your illness
By making sure family and carers are
involved in your care with us
By talking to you and others that help
care for you
WE WILL look after you when you are
close to death
WE WILL involve you in what will
happen when you leave hospital
WE WILL help you if you want to
complain or raise a concern
WE WILL make sure that the hospital is
a safe place for you:
So that we know quickly if you are
getting sicker
So that you do not fall
So you receive the right medicine at the
right time
Kettering General Hospital NHS Foundation Trust 2015/16 Quality Account
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