Download NCH&C Quality Account 2013/14 PDF

Quality Account
2013/14
Looking after you locally
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part One
PART 1
PART 2
2
PART 3
Contents
Part One
1.
2.
3.
4.
Message from the Chairman
Foreword by the Chief Executive
Statement from the Director of Nursing,
Quality and Operations
Our vision, our strategic priorities
and our services
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4
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2.
Priorities for improvement 2014/15
1.1 Quality Goals
1.2 Quality Improvement Initiatives
1.3 Commissioning for
Quality and Innovation (CQuIN)
1.4 Integration programme
1.5 Transformation programme
Mandated statements of assurance
2.1 Review of services
2.2 Participation in clinical audit
2.3 Participation in clinical research
2.4 Goals agreed with commissioners
2.5 Statement from Care Quality
Commission (CQC)
2.6 Data quality
2.7 Information Governance toolkit
attainment levels
2.8 Clinical coding error rates
2.9 Core Quality Account Indicators
3.
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4.
Part Two
1.
2.8
2.9
2.10
2.11
2.12
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5.
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6.
Part Three
Review of quality performance in 2013/14
1.
2.
Summary/Introduction
1.2 Service developments
1.3 Achievement of our Quality Goals
1.4 Commissioning for Quality Innovation (CQuIN)
1.5 Quality Assurance Assessment Visits
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A Well-led organisation
2.1 Workforce introduction
2.2 Safer staffing
2.3 Organisational Development Strategy
2.4 Absence management
2.5 NHS Staff survey 2013
2.6 Mandatory training
2.7 Education and training
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7.
8.
Staff appraisals
Monitor’s Quality Governance Framework
Achievements of staff
Compliments and thanks
Clinical Ethics Group
Responsive services
3.1 Review of Quality performance for 2013/14
Caring services (Patient Experience)
4.1 Summary
4.2 Patient stories
4.3 Friends and Family Test
4.4 Patient Opinion
4.5 Local patient surveys
4.6 Complaints and compliments
4.7 Patient led assessment of the
care environment (PLACE)
Safe services (harm free care)
5.1 Scheme to embed culture of safe,
harm free care
5.2 National Safety Thermometer
5.3 Management and learning from incidents
5.4 Mortality panel review
5.5 Never Events
5.6 Central Alerts
5.7 Infection prevention and control
5.8 Medicines management
5.9 Patient safety and quality benchmarking data
5.10 Safeguarding adults and children
Effective services
6.1 Introduction
6.2 Implementation of NICE guidance
6.3 Specialist Palliative Care
6.4 The Colman Centre for Specialist
Rehabilitation Service (CCSRS)
6.5 Clinical Audit programme
6.6 Research and Development
Explanation of who has been
involved in this Quality Account
7.1 Norfolk Healthwatch
7.2 Norfolk County Council, Health Overview
and Scrutiny Committee
7.3 South Norfolk Clinical Commissioning Group
Directors’ Declarations
Glossary of terms
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Part One
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part One
PART 1
PART 2
3
PART 3
1. Message from the Chairman
It is with confidence,
Norfolk Community
Health and Care NHS
Trust (NCH&C) presents
its Quality Account for
2013/14. The coming
year will see further
improvements in quality
through continuing
transformation in the
way that we deliver our
community-based services.
High quality patient care continues to be at the centre
of all we do. Our major challenges this year will be the
maintenance of our quality whilst we deliver our recurrent
cost improvement programme in an environment of
constrained funding. We shall also continue to strengthen
our quality governance arrangements. The completion
of our Transformation Programme will enable us to be
fit for the future and to keep people in their homes, and
cared for in the community. This Programme will include:
embracing technology; empowering our people; and
reviewing our systems which will result in an increase in
patient contact time.
The Francis and CQC Castlebeck Group Services
Reports offered a timely reminder of those things
each and every one of us within the NHS needs to
remember in everything we do. We need to make sure
that patients are, and continue to be, our first and
foremost consideration. We need to continue to listen
to our patients and staff, encouraging openness and
honesty, and monitoring our performance carefully. Our
approach to transformation and further improvements
to quality are, and will always be, delivered in the
framework for delivery as set out by Francis. We will
also continue to integrate our services with social care
services for the benefit of our patients.
NCH&C’s Chief Executive, Michael Scott, will shortly
be moving on to take up a role with a partner NHS
Foundation Trust provider, Norfolk and Suffolk NHS
Foundation Trust in which we wish him well. The Board
will be looking for an equally strong leader to continue
to build on the progress we have made to date. We
have already appointed an interim Chief Executive, Mark
Easton, who brings with him significant experience. I
am working with the NHS Trust Development Authority
(TDA) and using an external recruitment agency to
assist me in appointing the substantive chief executive.
We continue to be fully committed to the benefits of
becoming an Foundation Trust.
We, the Board of Norfolk Community Health and Care
NHS Trust, with and on behalf of all our staff, commit
ourselves to the delivery of our priorities for 2014/15
and 2015/16, in order to realise our vision: ‘Looking
after you locally’.
Ken Applegate
Chairman of Norfolk Community
Health and Care NHS Trust
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part One
PART 1
PART 2
4
PART 3
2. Foreword by the Chief Executive
I am delighted to write
this statement for the
opening of the 2013/14
Quality Account.
This has been a positive
year for quality and care of
patients in the Trust. You
will see from the Chair’s
statement that this is
closely monitored by the
Board which puts quality
at the heart of everything
we do. Our levels of harm free care remain good and I
personally chair our Pressure Ulcer Taskforce to ensure
we continue to focus on this important initiative. We
have reduced the tolerance level of avoidable inpatient
pressure ulcers to that of a ‘never event’. We are working
with Norfolk County Council on a harm free care
initiative to support independent nursing and care homes
in the reduction of pressure ulcers in their services. In
terms of patient experience, we continue to get very
positive results from our service-based questionnaires and
the Family and Friends questionnaire. These are rigorously
assessed by the Board and whilst noting the very many
positive comments, equally where negative comments
appear, they are followed through for improvement.
The Trust receives relatively few complaints but these are
monitored with the same degree of rigor. I personally
read each complaint letter and ensure that the necessary
learning and actions are taken. This is further analysed
for trends and learning by our Quality and Risk
Committee and ultimately reported to the Board.
Whilst never being complacent, these systems of
assurance offer support for high quality care across the
Trust. This is vital as we continue our foundation trust
journey, having been approved through Phase One
through Monitor we now await a full inspection by the
Care Quality Commission.
This has been a positive year in many respects but one
of the most pleasing has been the extension of our
integration with Norfolk County Council adult care. We
have had a successful pilot of integration in the west and
the principles of this are now extending across the whole
county which will ensure that our community and social
care teams are wrapped around the GP practices.
I hope you enjoy reading this Quality Account, which
details the many ways in which we have focused on
quality in the last year.
Michael Scott
Chief Executive of Norfolk Community
Health and Care NHS Trust
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part One
PART 1
PART 2
5
PART 3
3. Statement from the Director of
Nursing, Quality and Operations
Over the last year we have
made enormous strides
to continue to embed a
culture of high quality
care in all that we do.
The success of our quality
achievements have been
possible through the
hard work, commitment
and compassion of our
frontline staff. With the learning from Francis in the
forefront of our minds we developed our quality goals
to focus on developing our culture of care, developing
our approach to clinical effectiveness and working with
our commissioners to implement locally agreed quality
initiatives for the benefit of our patients. The following
principles guided this work:
• Treating all our patients with care and compassion
• Ensuring that every patient is treated with respect,
privacy and dignity
• Raising the organisational visibility of all our
vulnerable adults and children to improve their safety
• Being open and transparent (Implementing Duty
of Candour)
• Implementing regular mortality reviews
We carried out 42 inspections of our own services using
the Care Quality Commission’s framework which looks
at services using five Quality Indicators. These quality
indicators consider whether services are safe, effective,
caring, well-led and responsive to people’s needs. Our
services were found to be safe and effective with only
minor actions to be taken. We learnt that patients value
the services they access through the Friends and Family
Test survey and messages left on the Patient Opinion
website. The recent staff survey shows that staff are proud
of the services they provide with 92% agreeing that their
role makes a difference to patients.
We have seen the publication of new guidance on
delivering quality from the National Quality Board as
well as early learning from the CQC, our regulator, as
a result of their new inspection regimes. Our quality
priorities for this year have been developed as a result of
new guidance, learning from CQC, and the engagement
activities with our staff in 2013/14.
We have undertaken a review of staffing levels across
our inpatient bed units and our Community Nursing and
Therapy teams. This work will continue across a number
of other services in the coming year and we will be
taking recommendations for safer staffing levels to our
board as a result.
We continue to develop our workforce through
education and training in close collaboration with our
academic partners. This has included pilots, such as the
year of experience pre-nursing pilot.
I am delighted to see how much quality has improved
over the last year and I look forward to building on all
our quality initiatives in the coming year.
Anna Morgan
Director of Nursing, Quality & Operations
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part One
PART 1
PART 2
6
PART 3
4. Our vision, our strategic
priorities and our services
The Trust’s vision is to improve the quality of people’s
lives, in their homes and community by providing the
best in integrated health and social care. We often sum
this up as ‘Looking after you locally’.
The starting point for the Trust is the patient: this means
that quality is at the heart of everything we do. The
Trust’s services are built up around the patient, working
closely with GP partners both as commissioners and
providers. Wherever possible, our services are delivered in
an integrated way with social care. We are therefore part
of an extended primary care team focused around the
patient. The patient should experience care as if it were
from one organisation, seeing the least number of staff
necessary and not having to repeatedly tell their story.
As a Community Trust, we aim to lead out of hospital
community healthcare, giving children a better start and
adults greater independence - we typically do so in their
own home or place of choosing. This, combined with
the fact that we are a major employer and operate from
multiple sites, means that we are both in and of the
community. Our staff are drawn from local communities
and have local knowledge. We want to work with
communities not just serving their needs, but recognising
that we have a role to empower communities to make
the most of the resources within them.
The Trust’s vision will be delivered through the achievement
of a number of longer term, strategic objectives.
The Board has agreed three interconnected and mutually
dependent strategic priorities to achieve the Trust’s vision.
These relate to Our Quality; Our People and Our Future.
Our Quality
Our People
Our Future
Improve the quality of people’s
lives, in their homes and community
through the best in integrated health
and social care...
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part One
PART 1
Our business units provide:
1. Children’s Services, which includes prevention and
health promotion services;
2. Specialist Services such as neurological rehabilitation
or re-ablement services; and,
3. Adult community services delivered on a locality
basis in areas which match those covered by Clinical
Commissioning Groups (CCGs) and working in an
integrated way with social care.
NCH&C in summary;
PART 2
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PART 3
Transformation and Cost
Improvement Programmes (CIP)
Like all NHS organisations we have a number of
challenges such as reducing costs, safeguarding the
quality of patient care and working to continually
improve the quality of our services. Whilst we have
had cost improvement programmes in previous years,
we recognise that delivery year on year becomes more
challenging and the nature of the change moves from
incremental to more transformational.
• Provides services for West Norfolk, North Norfolk, South
Norfolk and Norwich CCGs and Norfolk County Council
The Trust has an ambitious programme of change, referred
to as the Transformation Programme. This covers initiatives
to improve patient care, staff experience as well as deliver
financial savings. The programme has 5 components;
• Employs 2,250 whole-time equivalent staff
• Mobile working
• Delivers care in people’s homes, as well as from over
200 different locations, and through over 400 schools
• Streamlined systems
• Manages 9 community hospitals with 255 actual beds
and 28 community ‘virtual beds’ (these virtual beds
are located in patient’s own homes allowing earlier
discharge where patients are provided with intensive
packages of care at home)
• Supply chain management
• Serves a population of 882,000 people, across Norfolk
The Trust and its commissioners believe that a strong
and independent community services provider can be a
catalyst for systemic change, enabling commissioners to
drive improvements in productivity, quality and outcomes
yet in the context of financial constraint.
Becoming a foundation trust (FT) is a means of
accelerating and embedding the Trust’s values and its
aspiration for a highly engaged workforce, proud of the
services it delivers, their local presence and local delivery.
The Trust’s approach to Membership and Governors
enables a stronger involvement of patients and the public.
• Workforce planning
• Travel/Estates
The benefits of these schemes, as well as being financial,
are also intended to include increased time spent by
clinicians directly engaging with patients, increased staff
wellbeing through working more effectively and better
record keeping (see Part 2 section 1.5 on page 13).
The Trust has a process in place to ensure that those
initiatives designed to reduce costs (Cost Improvement
Programmes or CIPs) are assessed to consider their
impact on the quality of care before approval and
monitored throughout implementation.
All CIP schemes pass through a robust process of
development that maintains clinical quality review
at its core.
Clinical review covers all aspects of the scheme, but
the focus remains on the Quality Impact Assessment
which covers the potential impact on patient safety,
clinical effectiveness and patient experience. This is a
very thorough review stage that has resulted in some
schemes being withdrawn and many requiring further
development before being re-presented for further
clinical review. All scheme documents require the
signature of the Medical Director and Nursing Director
before they can move into implementation.
Part Two
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
PART 2
8
PART 3
1. Priorities for improvement 2014/15
1.1 Quality Goals for 2014/15
1.1.1 Safe, (harm free care)
High quality care means care that is as safe and
effective as possible, where patients are in control and
are treated with compassion, dignity and respect; their
experience of care being as important as the outcomes
of care. High quality care also means focusing on the
prevention of illness.
a. National Safety Thermometer
Within NCH&C, we believe that everyone within
the organisation has a role to play in supporting this
ethos – this is not just about clinical staff and how
they care for patients. Administrative and support staff
are also able to contribute in a number of ways – simple
things like answering a phone for a colleague can make
a real difference.
b1. We will maintain the number of falls causing harm
to patients in our inpatient units at 4.0 falls or less
per 1,000 occupied bed days
In order to support high quality care, each year we
focus on key Quality Goals. These goals are intended to
inform the practice of each member of staff across all
three domains of quality. After consultation with staff,
patients and the wider public we have developed the
following goals for 2014/15.
The Quality Goals have been set under the following
five Care Quality Commission (CQC) Quality Indicators
which are based around the key questions the CQC will
ask about services:
1. Are they Safe?
2. Are they Effective?
3. Are they Caring?
4. Are they Responsive to people’s needs?
5. Are they Well-led?
This year’s Quality Account has been produced
using these key indicators to demonstrate how the
organisation is providing high quality services.
The following Quality Goals have been developed
following implementation of the Engagement Strategy,
which included the delivery of staff workshops,
completion of a staff, public, patient and stakeholder
questionnaire and meetings with our Governors.
We will increase the percentage of patients with harm
free care (new harms only) on the day surveyed to
exceed 97% throughout the year
b. Reduction of falls causing harm
b2. We will ensure that 100% of all patients are
assessed for their risk of falling on admission.
c. Pressure Ulcers
We aim to eradicate avoidable pressure ulcers (grades 2,
3 and 4) in our inpatient units and significantly reduce
the incidence of pressure ulcers in the community (in
patients’ own homes)
c1. We will ensure that 100% of patients in our inpatient
units have a ‘Waterlow’ risk assessment (to assess for
the risk of pressure ulcers)
c2 We will ensure that patients in our inpatient units
will not acquire avoidable pressure ulcers
c3. Our community nursing and therapy teams will
assess patients in the community (patient homes)
for the risk of a pressure ulcer using the Waterlow
system. (Standard is 95%)
c4. We will ensure that all patients who
require equipment will be referred within agreed
guidelines. (Standard is 98% of all relevant patients)
d. Venous Thromboembolism (VTE) risk
assessments
We will ensure that 100% of appropriate patients in
our inpatient units will have a VTE risk assessment
undertaken during their inpatient stay
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
PART 2
PART 3
e. Catheter Acquired Urinary Tract Infections
b. Patient Opinion website
We will reduce the incidence of CAUTIs using the Safety
Thermometer survey data in 2013/14 as the benchmark
We will respond to 100% of submissions by the
public/patients.
f. Effective use of medicines
100% of inpatient will have medicines reconciliation
during their inpatient stay
g. Children Safeguarding supervision
All clinical staff in Children’s Services will receive
safeguarding supervision in accordance with the
NCH&C Safeguarding Children Policy
h. Referrals to Local Authority Children’s Services
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1.1.4 Responsive services
a. 18 week referral to treatment (RTT) time
95% of patients referred to us to commence definitive
treatment within 18 weeks of referral
b. Length of stay
We will reduce the average length of stay in our
community rehabilitation hospitals to 22 days or less
All staff in Children’s Services will undertake referrals
to Local Authority Children’s Services in accordance
with the NCH&C Safeguarding Children Policy / Norfolk
Safeguarding Children Board Policy
c. Community Nursing and Therapy response times
1.1.2 Effective services – (measures
of clinical effectiveness)
1.1.5 A well-led organisation
We will undertake a review of Trust services against key
NICE Quality Standards (QS):
b. Stroke (QS2)
‘Staff recommendation of the trust as a place to work
or receive treatment’ (from the NHS Staff survey). We
will improve our summary score of 3.47 to ensure that
we meet or exceed the average for community trusts
(3.59 out of 5.0)
c. VTE prevention (QS3)
b. Mandatory training
d. End of life care for adults (QS13)
b1. 100% of clinical staff will receive relevant
mandatory training on induction to the Trust
a. Dementia (QS1)
e. Health and wellbeing of looked-after children
and young people (QS31)
Undertake clinical audits of NICE guidance applicable to
our services identified in the clinical audit plan for 2014/15.
1.1.3 Care (and compassion)
A minimum of 95% of patients will be seen with 4
hours of referral for an immediate assessment of their
care needs (Category ‘A’)
a. Friends and family test for staff
b2. At least 90% of clinical staff will receive on-going
mandatory training
b3. At least 90% of clinical staff will receive training in
safeguarding adults basic awareness, which includes
domestic abuse and risks of radicalisation (PREVENT)
a. Friends and Family Test how likely are you to
recommend our service (using the National
Single Metric)
b4. At least 90% of clinical staff will receive training in
safeguarding children
We will maintain or improve our FFT score of 76 for our
Community Nursing & Therapy services
We will ensure that daily staffing levels and skill mix
against assessed patient acuity levels are displayed
publicly on each ward/clinical area. (Standard is 95%
reported quarterly)
c. Safer staffing levels
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
1.2 Quality Improvement
Initiatives for 2014/15
The following quality improvement initiatives have been
identified during the annual planning process and the
development of the Quality Goals for 2014/15. These
initiatives will drive the Quality Improvement Strategy
for 2014/15 and 2015/16:
• Harm Free Care project (in Care homes)
• Falls prevention programme
• Pressure ulcer prevention programme
• Prevention of Venous Thromboembolisms
programme (VTE)
• Development of a plan to minimise the incidence
Catheter Acquired Urinary Tract Infections (CAUTI)
• Development of a Medicines Optimisation strategy
and action plan
PART 2
10
PART 3
• Implementation of the ‘Sustain Appraisal’ action
plan (Children’s Services)
• Development of clinical effectiveness
measures programme
• Providing examples where feedback from patients
is used to drive improvements
• Implementing the ‘hub and spoke’ model in
operational services (transformation)
• Roll out of Foxley Ward discharge liaison model
(reduction in length of stay)
• Implementation of Organisational
Development Strategy
• Development of the ‘eGARB’ tool to support key
learning from Francis and implement ‘Hard Truths’
(NHS England) on safer staffing
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
1.3 Commissioning for
Quality and Innovation
(CQuIN) indicators
for 2014/15
PART 2
PART 3
CQuIN are contractual commitments, some are nationally
mandated and some are developed in partnership with
our commissioners. They are intended to encourage
progress to be made within key areas of local services.
As a reward to meeting these commitments our
Trust will receive significant investment from our
commissioners which is additional funding that can be
used to make further improvements in the future.
Indicators for 2014/15 have been agreed as below.
1. Staff Friends and Family Test
To encourage and improve in service delivery,
and that all staff should have the opportunity to
feedback their views on their organisation.
2. Friends and Family Test – Early Implementation
To improve the experience of patients in line with
Domain 4 of the NHS Outcomes Framework. The
Friends and Family Test will provide timely, granular
feedback from patients about their experience. To
roll-out to Community Nursing and Therapy services,
Muskulo-skeletal physiotherapy and inpatient units.
2.1 Friends and Family – Phased expansion
To improve the experience of patients in line with
Domain 4 of the NHS Outcomes Framework. The
Friends and Family Test will provide timely, granular
feedback from patients about their experience.
Phased expansion but to exclude Adult Speech and
Language and Lymphoedema service.
3. NHS Safety Thermometer
To measure and reduce harm. It is recommended
that organisations’ prioritise improvement in
pressure ulcer prevalence.
4. Inpatient Beds Dashboard
To develop an inpatient Data Management Information
System. This Dashboard will enable Commissioners
and providers to support improved system flow by
making sound and rapid operational decisions.
5. System-wide assurance process
Regarding admission avoidance.
6. Breastfeeding initiative – UNICEF 3
NCH&C contribution across Norfolk to help increase
the numbers of women initiating breastfeeding in
line with the Department of Health target of 2%
increase per annum.
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7. Lymphoedema
Roll out of specialist service to include pre
assessments in the West locality. This will improve
patient experience, bringing care closer to home to
reduce unnecessary admissions.
8. Neurology
Expansion of existing service to provide a specialist
nurse for patients with Multiple Sclerosis. This
service will support patients experiencing problems
with relapse, ongoing symptoms and worsening of
their condition who would otherwise be admitted
to hospital.
9. Development of sepsis education
To develop and produce a clinical competency
training programme for inpatient units and
community teams.
10. Integrated care co-ordination
To develop working 7 days allowing the co-ordination
of placements from the acute trust into the
community setting over a 7 day week.
11. Dementia
Provision of tiered training at 3 different levels to
encapsulate all ranges of staff from non clinical
through dementia link worker.
12. Breastfeeding
To develop the 3rd level of the UNICEF Breastfeeding
Accreditation Programme.
13. Prosthetics
All new patients referred in to the service are to
be triaged within 4 weeks and offered a multidisciplinary team (MDT) assessment within a
maximum of 6 weeks from receipt of the referral.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
1.4 Integration programme
for 2014/15
Integrated health and social care has for many years
been thought of as the ideal way to make sure that
people can gain access to the most appropriate care
and support when required. Fragmented Health and
Social Care services fail to meet the needs of certain
populations of people and that greater integration,
particularly in community -based services, can improve
the patient experience, outcomes and efficiency of care.
In Norfolk, there is a good history of joint working
arrangements between health and social care systems.
Examples of these are the joint learning disability teams,
joint commissioning team and mental health services.
Each arrangement has been different, but all have
provided a useful body of experience and knowledge
in this arena.
Following the publication of “Integrated Care: Our
Shared commitment,” developed by National Voices,
NCH&C and Norfolk County Council (NCC) agreed to
have an external review of the options and consider
the business case for integration. KPMG were asked
to undertake this work and following a consideration
of the benefits and risks for each option, the Director
of Community Services and Chief Executive NCH&C
agreed to continue with a roll-out of existing work
on integration between health and social care staff
to achieve the following aims:
a. Co-location of staff who need to work together
b. Some joint management
c. Multidisciplinary teams centred around GP surgeries
d. Integrated Care Liaison Officers
e. Common case management
f. Development of a joint culture
PART 2
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PART 3
This work has progressed now and our current
proposal is to create a joint management structure
between NCH&C and NCC for a level of management,
to be agreed, which delivers a health and social care
service through co-located teams. This will entail the
construction of an agreement under section 75 of the
National Health Service Act 2006, to enable health and
social care managers to manage a mixture of health
and social care staff. The section 75 agreement will also
enable cross functionality of tasks.
This means that health staff will be able to set up simple
packages of social care and social care staff will be able
to undertake simple monitoring of health care. This is
to allow staff to undertake tasks on behalf of the other
organisation but not have full responsibility for meeting
health or social care needs.
This proposal creates the first part of a journey towards
a level of integration which will, subject to testing and
performance monitoring, allow for a second step, of a
single team management structure for health and social
care staff based together, managed by one team manager.
The vision for the outcomes for people is based on
the National Voices statements for integrated care and
has been developed through work led by the Clinical
Commissioning Groups (CCGs) in Norfolk. These are:
• People will be able to access effective
coordinated care
• Services are shaped around the local community
• People are supported to manage their own care
and wellbeing
• Primary care will be the centre for coordinating care
Planning and development of services will be at a local
level with local CCGs so that services are shaped locally
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
1.5 Transformation
Programme
We will deliver year 2 of our Transformation Programme
and realise the benefits of the Programme to date. It
has been internally developed, but will be externally
validated. It covers improvements such as workforce
productivity through new roles and mobile working,
supply chain management and planned Estate
Rationalisation. Whilst these form the basis of our Cost
Improvement Programme, they are at the same time
the basis for improving quality: they release clinicians
to have more face to face time to care. They draw on
clinical engagement in their design and implementation
with a view to increasing overall staff engagement.
PART 2
13
PART 3
The Programme is sponsored by the Executive Team, with
Senior Managers from the Operations Directorate as the
Programme Owners. Cost Improvement Plans for 2014/15
and 2015/16 are subject to a current validation process
externally validated by PricewaterhouseCoopers and were
formally signed off by the board in March 2014. They will
have been reviewed and approved by the Trust’s Medical
and Nursing Directors as part of this process.
A summary of the Transformation Programme changes
is provided in the table below.
Now
Future
Theme 1:
Mobile working
A delay in recording clinical activity can
occur due to staff needing to return to
base to access the system
Clinicians update patient’s electronic
clinical record contemporaneously
with care delivery, improving safety
and experience
Theme 2:
Streamlined systems
SystmOne inputting requires longhand
entry and is not consistently recorded
SystmOne updating will be relevant and
single touch templates, wherever possible
Theme 2:
Streamlined systems
Clinicians have to access several different
systems to undertake admin and
workforce management tasks
Steamlined IT admin will allow quick and
easy use with single direct access
Theme 3:
Workforce planning
Budget and commissioning driven
workforce models
Activity driven models based on
contractual requirements
Theme 3:
Workforce planning
Clinicians have to share out work based
on staff availability on the day within a
team / service and rota produced manually
each month
Pan Norfolk availability will be identified
through e-rostering and all work will be
directed through a single channel scheduled
accordingly and issued to clinicians
Theme 3:
Workforce planning
Whoever is available being deployed to
see the patient
The most appropriate persion with the
most appropriate skills will see the patient
Theme 4:
Supply chain
management
Differences and inefficiences in stock
storage, ordering and usage, leading to
avoidable cost
Standardisation and streamlining of
procurement practictes, ensuring the right
product / service is available
Theme 5:
Travel / Estates
Excessive travel time between office
and community which reduces available
clinical time
Spending majority of time with patients
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
PART 2
PART 3
2. Mandated statements of assurance
2.1 Review of services
During the period April 2013 to March 2014 Norfolk Community Health and Care NHS Trust (NCH&C) held contracts for
64 service specifications, covering 29 broad service areas as follows:
Community Nursing
Wheelchair assessment
Admission Avoidance
Continence
Rehabilitation
Smoking Cessation
Palliative and End of Life care
Dental services
Long term conditions management
Adult Learning Disabilities
Musculoskeletal services
Health Visiting service
Care management
School nursing
Specialist Neuro- rehabilitation
CASH
Stroke rehabilitation
SureStart
Amputee and post surgical rehabilitation
Children’s Community Nursing
‘Hard to reach’ community care
Children’s Therapies
Diagnostics
Community Paediatrics
Adult Speech & Language Therapy
Children’s Short Breaks
Podiatry
Clinical Support Services
Podiatric Surgery
NCH&C has reviewed all the data available to them on the quality of the care in all of these NHS services.
The income generated by the NHS services reviewed in 2013/2014 represents 100% per cent of the total income
generated from the provision of NHS services by NCH&C for 2013/2014.
14
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
Narrative
The Trust Board receives a monthly Integrated
Performance Report (IPR), which focuses on a
number of domains, including patient experience,
safety, quality and risk. The data is presented in
a dashboard format, using Red-Amber-Green
(RAG) ratings to highlight any areas of adverse
performance against agreed targets, standards and
thresholds and is supported by a narrative explaining
the reason for the variance, and actions being taken
to mitigate future risks impacting on performance.
The Board also receives a monthly Quality Assurance
and Risk report which provides more operational
detail and context on those areas reported in the
IPR. This report is also presented to the Quality
and Risk Assurance Committee, and includes the
following areas:
• Serious Incidents Requiring Investigation (SIRIs)
• Medication Incidents
• Falls causing harm
• Pressure Ulcers
• Infection rates
• Patient Experience surveys (including the Friends
and Family Test and Patient Opinion)
• Complaints and compliments
• Results of external scrutiny (eg, Care Quality
Commission, National Patient Safety Agency)
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PART 3
Aspirant community foundation trust
benchmarking report
NCH&C are part of a group of community trusts
on a journey to achieve foundation trust status in
the future and 13 community trusts have agreed
to share data in order to benchmark performance
against one another to stimulate debate and identify
opportunities for sharing best practice. Following
a meeting with the cohort Trusts In October 2013
the benchmarking report has been refreshed which
has resulted in the refining of existing indicators and
the recalibration of the benchmarking data and the
addition of some new indicators.
Cost improvement plan quality indicator
assessment dashboard
A Cost Improvement Plan Quality Indicator
Assessment (CIP QIA) dashboard has been
developed to highlight to the Quality and Risk
Assurance Committee, Trust-wide quality indicators
and standards that can be tracked over time. The
indicators presented are at an aggregate Trustwide level, and they can be found within a number
of individual schemes. Thus, they are intended to
highlight where a quality issue may be emerging,
which will enable drill down to a specific scheme,
area or locality.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
2.2 Participation in
clinical audit
PART 2
16
PART 3
During that period, Norfolk Community Health and
Care participated in 66% of national clinical audits
which it was eligible to participate in.
During April 2013 – March 2014, 3 national clinical
audits and 0 confidential enquiries covered NHS
services that NCH&C provides.
The national clinical audits that NCH&C was eligible
to participate in during April 2013 – March 2014
are as follows:
Name of National Audit
Lead Organisation
Included participation
from NCH&C?
National Chronic Obstructive
Pulmonary Disease (COPD)
Audit Programme
Royal College of Physicians
(London)
No (NCH&C relevant services not
part of the audit at this stage of
the audit)
Sentinel Stroke National Audit
Programme (SSNAP)
Royal College of Physicians
(London)
Yes – data reported via the NNUH*
as joint pathway
Epilepsy 12 audit
(Childhood Epilepsy)
Royal College of Paediatrics and
Child Health
Yes – data reported via the NNUH*
as joint pathway
Title of National
Confidential Enquiry
Applicable to NCH&C?
Included participation from
NCH&C?
None applicable
N/a
N/a
The national clinical audits that NCH&C participated in,
and for which data collection was completed during
April 2013 – March 2014, 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.
Name
Lead Organisation
Percentage
Sentinel Stroke National Audit
Programme (SSNAP)*
Royal College of Physicians
(London)
Not known – data reported
via NNUH*
Epilepsy 12 audit
(Childhood Epilepsy)
Royal College of Paediatrics and
Child Health
Not known – data reported
via NNUH*
*Norfolk & Norwich University Hospitals NHS Foundation Trust
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
The reports of five national clinical audits were reviewed
by the provider April 2013 – March 2014 and NCH&C
intends to take the following actions to improve the
quality of healthcare provided:
Sentinel Stroke National Audit Programme
(SSNAP) - Clinical audit second pilot public report.
This report focused on the first 72 hours of care and
so was not directly applicable to the services NCH&C
provide. However, the stroke teams reviewed the
report to review their service against the standards
and inform participation in future iterations of the
SSNAP audit programme.
Child Health Reviews – UK Clinical Outcome
Review Programme Overview of child deaths
in the four UK countries. September 2013. This
national clinical audit was reviewed by the Clinical Audit
and Effectiveness Committee in November 2013. There
were no actions directly applicable to NCH&C services.
Child Health Reviews – UK Clinical Outcome
Review Programme. Coordinating Epilepsy Care:
A UK-wide review of healthcare in cases of
mortality and prolonged seizures in children and
young people with epilepsies. September 2013.
This national clinical audit was reviewed by the Clinical
Audit and Effectiveness Committee in November
2013. All care plans for children prescribed emergency
epilepsy treatment have recently been reviewed to
ensure that they reflect current Trust prescribing
guidance and doses are clear and unambiguous.
National Diabetes Audit 2011–2012 Report 1:
Care Processes and Treatment Targets. This national
clinical audit was reviewed by the Clinical Audit and
Effectiveness Committee in September 2013. This
audit is based in primary care and so was not directly
applicable to NCH&C services; however, the standards
measured and the findings will be used to inform future
clinical policy development.
National Diabetes Audit 2011–2012 Report
2: Complications and Mortality. This national
clinical audit was reviewed by the Clinical Audit and
Effectiveness committee in September 2013. The
standards measured and the findings will be used to
inform future clinical policy development.
PART 2
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PART 3
2.2.1 Local clinical audits
The reports of 41 local clinical audits were reviewed
by the provider during the period from April 2013 to
March 2014 and NCH&C intends to take the following
actions to improve the quality of healthcare provided.
The following is a description of a selection of actions
and assurances provided:
Audit of the use of melatonin in shared care
Further work to be undertaken to improve the use
of sleep hygiene measures prior to the initiation of
melatonin and the recording of the benefits seen from
the use of this medicine
Audit of Do Not Attempt Cardiopulmonary
Resuscitation (DNACRR) forms
The new regional forms have been fully implemented
and used in all inpatient units. Clinicians to ensure that
discussions with relatives are fully recorded and patient
information leaflets are available
Inpatient prescription chart re-audit
The inpatient prescription charts are being well used, and
a further reduction in the potential for harm from missed
or delayed administration of medicines was noted
Management of the Diabetic Foot by
community podiatrists
This audit identified the need for a unified clinical policy
across the Trust that will be implemented during 2014
alongside a single clinical template and method of
assessing wounds on the feet of patients with diabetes
Safeguarding Children - record keeping in respect
of child protection records
This audit demonstrated good compliance with the
Trust standards for following up missed appointments
for ‘at risk’ children
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
2.3 Participation in
clinical research
The number of patients receiving NHS services provided
or sub-contracted by NCH&C in 2013/14 that were
recruited during that period to participate in research
approved by a research ethics committee, was 382
(compared with 773 in 2012/13). The decrease is mainly
associated with the ending of a high recruiting study
within the Trust.
Participation in clinical research demonstrates
NCH&C’s commitment to improving the quality of
care we offer and to making our contribution to wider
health improvements. We have developed further
infrastructure within the Trust over the last 12 months
to allow easier access for staff and patients to research
and will continue to take these forward into 2014/15.
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PART 3
Throughout 2013/14 we have taken steps to embed
research as core Trust activity and encourage staff to
continue engagement with the local clinical research
networks. In line with this we have developed a
Trust research policy aligned with the NIHR high level
objectives and have set up a research steering group
to oversee the development, governance and rollout
of research in the Trust. We have dedicated research
clinical space and see patients for research from
NHS Organisations outside of our Trust. Transversely,
we continue to actively support and refer potential
participants to other Trusts engaged in research. We are
also actively engaging with the Academic Health Science
Network and the new CRN Eastern partnership and look
forward to working further with them in 2014/15.
We have a Clinical Lead for Academic Liaison and
Research in post who champions research across the
area, engaging stakeholders and clinicians alike.
We were involved in 56 research studies during
2013/14, similar to the 2012/13 figure of 59. This
includes 20 studies that were new in 2013/14 and
36 studies ongoing from previous years. The National
Institute for Health Research (NIHR) supported 60% of
these studies through its research networks.
We have continued to work with partner organisations
to help develop research ideas and questions of interest
to community care. Three NCH&C staff are currently
in receipt of research bursaries, and we continue to
support these staff to develop their research ideas into
fully funded research proposals.
There were 20 studies which were new in 2013/14, of
which 75% were given permission within 30 days. This
was slightly outside the national target of 80%. Of the
5 studies where permission was given outside of 30
days, 4 were student studies, of which 3 required work
from the R&D Office to bring the project to a standard
where permission was able to be given. Of the 9 NIHR
portfolio studies given permission in 2013/14, 8 (89%)
were given permission within 30 days which meets the
national target.
A further 4 NCH&C staff were also involved as coapplicants on 3 separate research grants that were
submitted to the NIHR for funding in 2013/14, and
NCH&C are collaborators on 2 ‘Research for Patient
Benefit’ grants held by partner organisations in the areas
of stroke rehabilitation and social anxiety and stuttering.
There are currently 9 services hosting NIHR research
within the Trust, 2 of which engage on multiple
NIHR studies.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
2.4 Goals agreed with
commissioners
Use of the Commissioning for
Quality and Innovation (CQuIN)
payment framework
A proportion of NCH&C’s income during April 2013
and March 2014 was conditional on achieving quality
improvement and innovation goals agreed between
NCH&C and any person or body that we entered into
a contract, agreement or arrangement with for the
provision of NHS services, through the CQuIN payment
framework. Details of NCH&C’s achievements against
the agreed CQuIN indicators for April 2013 to March
2014 are set out in Part 3 section 1.4 of this document.
The CQuIN indicators agreed with our commissioners for
the forthcoming year, (April 2014 to March 2015) can
be found in Part 2 Priorities for 2014/15, section 1.3 on
page 11.
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PART 3
2.5 Statement from
the Care Quality
Commission (CQC)
NCH&C is required to register with the CQC and its
current registration certificate issued on 25th February
2014, confirms that the Trust is registered to provide
the following Regulated Activities:
1. Assessment or medical treatment for persons
detained under the Mental Health Act 1983
2. Diagnostic and screening procedures
3. Family planning
4. Surgical procedures
5. Treatment of disease, disorder or injury
6. Personal care
The only conditions of registration are that these
regulated activities may only be provided from the
following registered locations:
Registered Locations
Regulated Activity
(see left)
Cranmer House
1, 2, 5
Little Acorns
5
Adult Learning Disabilities, Mill
Lodge
5
Provider Services HQ
1, 2, 3, 5, 6
Squirrels
5
Benjamin Court
1, 2, 5
Colman Hospital
1, 2, 5
Dereham Hospital
1, 2, 5
Kelling Hospital
1, 2, 5
North Walsham Hospital
1, 2, 5
Norwich Community Hospital
1, 2, 4, 5
Ogden Court
1, 2, 5
Swaffham Community Hospital
1, 2, 5
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
The Care Quality Commission has not taken enforcement
action against NCH&C during the period April 2013 and
March 2014.
NCH&C has participated in seven routine inspections
undertaken by the Care Quality Commission relating to
the following areas from April 2013 to March 2014.
Three routine inspections were carried out at the
following community rehabilitation units and all were
found to have met the essential standards of quality and
safety reviewed on the day.
1. Norwich Community Hospital, Beech Ward
2. Dereham Community Hospital, Foxley Ward
3. Kelling Community Hospital, Pineheath Ward
Routine inspections were also undertaken at four of our
Joint Community Learning Disability Teams (which are
all registered with the CQC by Norfolk County Council)
during the same period. The following three were found
to be compliant against the standards assessed on the day
1. East Norfolk Learning Disability Service
2. South Norfolk Learning Disability Service
3. West Norfolk Learning Disability Service
4. North Norfolk Learning Disability Service was
found not to be meeting outcome 17 complaints.
The CQC assessed that the complaints system was
not wholly effective because it was not accessible and
available to people. The CQC judged that this has a
minor impact on people who use the service.
The North Norfolk Learning Disability Service have
taken action with regard to creating EasyRead versions
of the complaints procedure and patient information
leaflet and making them more readily available.
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PART 3
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
2.6 Data quality
High quality information underpins the effective and
safe delivery of patient care and is key if improvements
in quality of care are to be made. Improving data
quality, which includes the quality of demographic,
ethnicity and other equality data, should improve
patient care and improve value for money.
NCH&C is taking the following actions to improve
data quality:
• A range of data quality reports have been designed to
monitor a range of key performance indicators on a
weekly and monthly basis
• The Secondary Uses Service (SUS) dashboards are
reviewed regularly in relation to a number of national
key indicators
• A selection of these indicators are also reported to
the Data Quality Forum where operational services
are held to account for the quality of data held on the
Patient Administration System (PAS) and SystmOne
(electronic patient record)
• These reports are held on a networked drive and can
also be viewed on an Intranet portal to ensure they
are accessible to key staff involved in the monitoring
and reporting of performance and activity data
The Trust has a Data Quality Strategy which will be
critical to a number of the Trust’s priorities and objectives,
including improving the quality of patient care, compliance
with the NHS Information Governance (IG) Toolkit version
11 for 2014/15 and the need to introduce and monitor
the Community Information Data Set (CIDS).
This strategy is underpinned by a Data Quality Policy which
is subject to annual review. The purpose of this policy is to
ensure the highest standards of data quality throughout
NCH&C are achieved and maintained. This policy is for all
staff collecting and using data and they must adhere to
the local and national standards as laid out in this policy.
The Trust is also reviewing its formal structures for
monitoring data quality ensuring its Data Quality Forum
has the necessary membership and coverage to continue
to drive improvements in data quality.
PART 2
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PART 3
2.6.1 NHS Number and General
Medical Practice Code Validity
NCH&C submitted records during 2013/14 to the
Secondary Use System (SUS) for inclusion in the Hospital
Episode Statistics (HES) which are included in the latest
published data under the organisation code RY3.
The percentage of records in the published data which:
(i) Included the patient’s valid NHS number was:
100% for admitted patient care (APC)
(ii) Included the patient’s valid General Medical Practice
code was: 100% for (APC)
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
PART 2
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PART 3
2.7 Information Governance 2.8 Clinical coding error rate
Toolkit attainment levels NCH&C was not subject to the Payment by Results (PbR)
clinical coding audit during 2013-14.
On the 31st March 2014 the Trust declared Level 2
compliance against 26 of the 37 relevant requirements
on the IG Toolkit. The remaining 11 requirements reached
Level 3 which raised the Trust’s overall score from 66% in
2012/13 to 76% in 2013/14 and is graded green.
Evidence has been submitted to cover the following six
areas where assurance is required:
• Information Governance management
• Confidentiality and Data Protection
• Information Security
• Clinical Information
• Secondary User Information
• Corporate Information
The Information Governance toolkit is available
on the Connecting for Health website:
www.igt.connectingforhealth.nhs.uk
The Information Quality and Records Management
attainment levels assessed within the Information
Governance Toolkit provide an overall measure of
the quality of data systems, standards and processes
within an organisation.
Assessment
Level 2
Level 3
Exempt
Total
Req’ts
Overall
Score
Grade
Version 11 (2013-2014)
26
11
3
37
76%
Satisfactory
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Two
PART 1
PART 2
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PART 3
2.9 The Core Quality Account indicators
Prescribed Information
Related NHS Outcomes
Framework domain and
who will report on them
Data / output
The data made available to the National Health
Service trust or NHS foundation trust by the
Health and Social Care Information Centre with
regard to the percentage of patients aged;
3: Helping people to
recover from episodes of ill
health or following injury
NCH&C considers that this data
is as described for the following
reasons:
All Trusts
NCH&C does not re-admit
patients aged 15 or over following
discharge. All admissions to the
Trust’s beds are received from
acute trusts or from the patient’s
usual place of residence
5: Treating and caring
for people in a safe
environment and protecting
them from avoidable harm.
NCH&C considers that this data
is as described for the following
reasons:
(i) 0 to 14; and (ii) 15 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
The data made available to the National
Health Service trust or NHS foundation trust
by the Health and Social Care Information
Centre with regard to the number and, where
available, rate of patient safety incidents
reported within the trust during the reporting
period, and the numbers and percentage of
such patient safety incidents that resulted
avoidable harm in severe harm or death
All Trusts
Table 1 below; represents the rate
of patient safety incidents reported
against the number of face-to-face
contacts with patients, expressed
as a rate per 1,000
Number of patient safety incidents 2013/14
Harm
2013
Apr
2013
May
2013
Jun
2013
July
2013
Aug
2013
Sept
2013
Oct
2013
Nov
2013
Dec
2014
Jan
2014
Feb
2014
Mar
Total
None
271
247
251
220
223
235
248
224
208
219
180
213
2739
Low
435
360
391
361
296
299
304
298
317
316
304
337
4018
Moderate
114
75
81
79
81
73
75
60
74
102
84
90
988
Severe
9
6
12
4
7
8
4
7
3
4
3
4
71
Death
0
3
0
1
2
0
2
0
2
2
1
1
14
Total
829
691
735
665
609
615
633
589
604
643
572
645
7830
5.59
5.69
6.43
5.74
6.01
6.49
6.30
Total incidents in clinical areas per 1,000 contacts
8.07
6.44
7.32
5.85
6.01
6.28
Norfolk Community Health and Care NHS Trust
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PART 1
PART 2
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PART 3
The Trust has taken the following actions to improve this number and rate, and so the quality of its services, by actively
reporting all incidents through its DATIX incident reporting database, whether they result in harm or otherwise. We
continue to ensure that appropriate staff are suitably trained to report and investigate all incidents, and identify trends,
patterns and risk factors, in order to use this information to improve the quality and safety of our services
Prescribed Information
Related NHS Outcomes
Framework domain and
who will report on them
Data / output
Friends and Family Test Question
number 12d– Staff
4. Ensuring that people
have a positive experience
of care
Whilst this indicator is for Acute
Trusts NCH&C monitors this data
The data made available to the NHS trust
or NHS foundation trust by the Health and
Social Care Information Centre with regard
to 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
All Acute Trusts
Q12d. Staff recommendation of the trust as a place to receive treatment
2012 Results
2013 Results
Average for community trusts
64
66
66
Key finding 24 relates to Q12a, Q12c and Q12D “staff recommendation of the trust as a place to work or
receive treatment”.
On a scale of 0 – 5 (the higher the score the better)
2011 results
2012 results
2013 results
3.13
3.39
3.47
These results show that staff experience has improved within NCH&C year on year and indicator KF24 is one of
our Quality Goals for 2014/15 to ensure that we meet or exceed the average for community trusts which is 3.59.
During 2013 the Trust put in place a process to survey all staff twice a year by location on a rolling basis, so that a
survey happens in one of our business units each month to compliment the national staff survey. The focus is on
generating locally responsive actions. The KF24 question is also asked within this process, and where local issues are
highlighted, they are addressed
Part Three
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
PART 2
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PART 3
1. Review of quality performance
in 2013/14
1.1 Summary/Introduction
We have measurably improved the quality of
our services in 2013/14, delivering better health
outcomes, high standards of safety, leading to
excellent patient experience.
This was in line with our Quality Improvement Strategy
which was approved in September 2013.
1.2 Service developments
Our 2013/14 service developments have contributed to
improving quality for our patients, service users and carers.
a) The Children’s Community Nursing Team has
been expanded. This additional investment has
been facilitated by the commissioners with the
express intention of shifting care from the acute
to the community setting. This has included
the provision of IV therapy and other complex
interventions which mean that children can stay
at home for their treatment.
• These extended hours have allowed families to access
skilled nursing advice and care for longer periods
throughout the day and at weekends
• Since the launch of the service in September 2013,
12 children who require regular blood tests due to
oncology diagnosis, have these done at home
• Since commencement of the IV therapy service the
team have administered IV’s to 6 children for various
durations (from 3 weeks to 4 months). Children on
long term anti-biotics who are receiving treatment on
a daily basis have been able to receive their treatment
at weekends.
b) Urgent Care Centre - During 2013 plans were
developed with other providers across the
county in conjunction with the Urgent Care
Network and CCGs, to set up an Urgent Care
Unit at the Norfolk and Norwich University
Hospital. The unit was piloted in November and
December over two weekends and went live
on 20 January 2014, to run over the period of
winter pressures.
• An early intervention and admission avoidance
pathway is provided in conjunction with GPs, acute,
social care and mental health colleagues, all working
within one unit
• The project brought together a partnership team
of community nurses, therapists and healthcare
assistants from our Trust, alongside GPs, hospital
teams, and social services staff.
• Between 20th January 2014 and 27th April 2014
the unit saw 2467 minor illness presentations, of
these, 141 were admitted to the Norfolk & Norwich
University Hospital Foundation NHS Trust (NNUHT)
with acute presentations, 23 referred to eye casualty,
9 did not wait to be seen and the remaining 2294
patients had their episode of care completed.
• The unit has now been closed - however the project
team continues to meet to review the pilot and reflect
on what went well and where system processes could
be improved with a view to develop a business case
for a future service. There will be a formal evaluation.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
c) Virtual Ward - Another good example of
pathway redesign has been the setting up of
a virtual ward in West Norfolk to assist with
winter pressures. The remit was to free up beds
at the Queen Elizabeth Hospital (QEH) at King’s
Lynn by encouraging and facilitating the timely
discharge of medically fit patients, providing
care at home for up to 6 days following
discharge in order to promote independence.
• The virtual ward opened with 7 beds in December
2013 and this increased to 14 beds at the beginning
of January and 28 beds by the end of January
2014. This has improved flow through the QEH and
supported admission avoidance targets
• 289 patients have been admitted (December 2013
to March 2014) 72 from the community and 217
from QEH
• Length of stay has been below target (maximum
6 days)
• Patient feedback has been very positive some
examples include:
- Service has been absolutely fabulous
- I would not have been able to manage
without the service
- Has given me comfort and courage
- Has got me through being at home
- Been like being in hospital without the down side
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PART 3
d) IV Therapy Service - A new service to deliver
IV therapy to patients in Central Norfolk has
started this year. This was modelled on the
successful service that NCH&C ran in the west
of Norfolk. The pathway design has included
the Medical Director, community clinical leads,
acute nurses, acute microbiology and pharmacy
staff. The service is making a real difference to
the care delivered to patients and to the patient
experience, a good example is the fact that the
service delivered IV’s to 5 patients in their own
homes on Christmas day.
e) A rapid response team has also been piloted,
working with the east of England Ambulance
Trust. This pilot is currently only in the Norwich
locality and is in response to the ambulance
trust identifying a cohort of patients whom
they felt did not need emergency admission,
but they had no choice but to convey. This
service works with the ambulance crew to
respond within 30 minutes and support the
patient at home. Between November 2013
and March 2014, 59 patients were seen and
admission to the Acute hospital prevented.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
1.3 Achievement of Quality
Goals for 2013/14
Our Quality Goals have helped us deliver excellent and
harm free care. We agreed the following quality goals
for 2013/14 following workshop events with our staff:
1. To continue to embed a culture of compassionate
care (integrating the Chief Nursing Officer’s 6 Cs;
care, compassion, competence, communication,
courage and commitment) and act on the learning
from the Francis Report
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These quality goals are underpinned by a number of
elements including:
• Treating all our patients with care and compassion
• Ensuring that every patient is treated with respect,
privacy and dignity
• Raising the organisational visibility of all our
vulnerable adults and children to improve their safety
• Being open and transparent (Implementing Duty
of Candour)
• Implementing regular mortality reviews
2. Developing and promoting our approach to
Clinical Effectiveness
3. Meeting our Commissioning for Quality & Innovation
(CQUIN) goals
By the end of March 2014 we reported the following achievements:
Performance measure
Outcome
Achieved
1A We will treat all our patients with care and compassion
Fewer complaints about staff attitude
Quarter 1, 7 Quarter 2, 4 Quarter 3,
5 Quarter 4, 5
YES
No specific themes emerging. The numbers
of these types of complaints remains very low
and are managed within the localities
1B We will ensure that every patient is treated with respect, privacy and dignity
Implementation of a privacy and
dignity policy
Policy published and essence of care
audit completed
YES
1C We will raise the organisational visibility of all our vulnerable adults and children to improve their safety
Demonstrate an increase in % of staff
undertaking safeguarding adults and
children training
Safeguarding Children training:
YES
Q1 71.09%; Q2 80.4%; Q3 84.58%; Q4 86.6%
Safeguarding Adult training:
Q1 79.83%; Q2 76.68%; Q3 81.46% Q4 80.82%
Review of safeguarding referrals
An action plan has been developed and the
Safeguarding Adults Group is monitoring
progress – to be further reviewed during 2014/15
Partially; ongoing
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
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Performance measure
PART 2
Outcome
PART 3
Achieved
1D We will be open and transparent with our patients/relatives/carers when things go wrong (Duty of Candour)
Implementation of Duty of Candour
reporting (100% of patients/carers/
relatives must be informed of an incident
causing moderate harm, severe harm or an
unexpected death)
100% of all incidents causing moderate
or severe harm or unexpected death are
communicated to patients/carers/relatives. This
data is captured on DATIX incident reporting
database and reported monthly
YES
In addition, this year’s record keeping
audit also reviewed whether there was an
entry in the patient’s record to reflect this
conversation. The results showed that in
78.8% of paper records and 76.3% of
electronic records (77.1% overall) it was
recorded that the patients (or their relatives)
had been informed
1E We will review all deaths (including end of life and palliative care) and those defined as ‘unexpected’ which
occur in the Trust’s inpatient units to identify areas of improvement in care
Development of mortality review panel
Monthly review meetings in place, proforma
developed, Palliative care reviews, and standards
that mortality will be reviewed against
YES
Development of End of Life care implementing
new national guidance
Board seminar provided on death and
dying provided
Goal 2 – Clinical Effectiveness measures
Beech Ward - Review of action plan
and outcomes of patient centred
documentation on the effectiveness of
capturing patient centred goals
Embed practice in service improvement
for 2013/2014
New Goal Setting sheets were trialled by
the Therapy Team on Beech ward, starting
July 2013. They involved detailing a long
term Goal and short term Goals set during
admission with an action plan for each Goal.
An audit in December showed that only 25%
of sheets were being filled in. It was decided
at this point to disestablish the Keyworker role
for each patient on Beech as workloads were
becoming unequal, leading to lack of time to
complete paperwork (including Goal Setting)
and difficulties in maintaining communication
with Patients and their families. Workshops
were held for the Therapy team, including
senior nursing staff, to determine how
communication could be improved on the
ward to help streamline the patient’s journey
through the Stroke Unit
Partially
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Quality Account 2013/14 – Part Three
PART 1
Performance measure
PART 2
Outcome
Achieved
Goal attainment scaling has been introduced
fully into practise in both inpatients and
outpatients. A formal audit of this outcome
tool is in the 2014/15 audit plan for CCSRS
YES
A discharge visit checklist has been devised
which includes a prompt to request the
questionnaire to be completed and returned.
This has corresponded to an increase to
38% return rate for the last quarter. Overall
satisfaction showed 88% of patients rated the
service 10/10. Results from the questionnaires
are fed back at monthly team meetings and
discussed with action plans, as needed
YES
Essence of care - Reporting system of
quarterly reporting agreed. A number of
the 12 outcomes are already captured
through clinical audit, patient safety
thermometer and existing strategies e.g.
reducing pressure ulcers
Essence of Care audits completed for:
YES
Inpatients - Validate use of Barthel as a
consistent quality marker of outcomes for
our patients
Barthel scoring is embedded as a consistent
quality marker of outcomes for NCH&C patients
Goal 2 – Clinical Effectiveness measures
Colman Centre for Specialist Rehabilitation
Service (CCSRS) - Review Goal attainment
scaling (GAS) outcomes and evaluate practice
Continue with GAS as standard for all
admissions to CCSRS
Build the review of GAS outcomes into
the care management model for CCSRS in
patient 2013/14
ESD - Review outcome of questionnaire
to date and impact on service delivery
and quality
Embed patient and carer feedback into
service improvement for 2013/14
• Pressure Ulcers
• Privacy and Dignity
YES
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1.4 Commissioning for
Quality and Innovation
(CQuIN) Indicators and
Quality Goal 3
CQuINs are contractual commitments, some are
nationally mandated and some are developed in
partnership with our commissioners (CCG). They are
intended to encourage progress to be made within
key areas of local services.In return for meeting
these commitments our Trust will receive significant
investment from our commissioners, which is
additional funding that can be used to make further
improvements in the future. A set of CQuIN indicators
were agreed with our commissioners for 2013/14 which
can be seen below and continues on page 32.
No
Description of Indicator
Quality domain
% Achievement
1
To reduce avoidable death, disability and chronic ill health from
Venous-thromboembolism (VTE)
Safety
100%
2
Patient satisfaction; “How likely is it that you would recommend
this service to friends and family within the CN&T services?
Patient
Experience
91.7%
3
Improve collection of data in relation to falls, catheter
acquired urinary tract infections (CAUTI) within inpatient
units (see note below)
Patient safety
62.5%
* For indicator 3
Falls data - NCH&C averaged 4.33 falls per month during Quarter 4,
against a ceiling of 8 per month.
Full Achievement Awarded
CAUTI data – NCH&C averaged 5 CAUTIs per month during Quarter 4,
against a ceiling of 4 per month.
No Achievement Awarded
It should be noted that NCH&C were under the National benchmark of 9.4 per month for CAUTIs
Overall a partial achievement of 62.5% was awarded for this indicator
NCH&C has achieved 97.5% of attainable income by March 2014. This includes an estimate for Quarter 4
achievement of 94.0%.
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Quality and Innovation (CQuIN) Indicators and Quality Goal 3 continued
No
Description of Indicator
Quality domain
% Achievement
4
Development of the care pathway for patients risk assessed as
having dementia within the North Locality Inpatients Units
Patient safety
100%
Effectiveness
Experience
5
Clinical Leadership – To develop and train a clinical lead for
Dementia and to provide appropriate training to staff
Patient
experience
6
Partnership working – As part of the health system-wide drive to
reduce the rate of avoidable emergency admissions (EMAs), 1%
of the total value of CQuIN for 2013/14 has been allocated to
system-wide initiatives designed to reduce EMAs
Patient Safety
100%
• Community IV Service
100%
• Rapid Response Service
98.4%
• Case Manager pull out service
100%
7
Smoking Cessation – The development of a system for
commissioner approved invoicing for all level 2 providers
Effectiveness
91.7%
8
NCH&C to achieve UNICEF Stage 2 Accreditation in line with the
Department of Health breastfeeding initiative
Patient
Experience
100%
9
Demonstrate improvements in relationship, information sharing
and communications between Starfish and CAMHS (Health East)
Patient
Experience
100%
10
West Lymphoedema / Pre-doppler Assessment
Improving provider experience ,through care closer to home and
reduction in the prevalence of leg ulcers
Patient
Experience
100%
11
West Continuing Healthcare – Business case to evidence improved
quality holistic of and continuity of care by passing external agency
Patient
Experience
100%
12
West - Reducing admissions to an acute setting for patients with
highly complex neurology conditions
Patient
Experience
80%
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
1.5 Quality assurance
assessment visits 2013/14
In order to embed a continuous programme of Quality
Assurance assessments across all operational services
in NCH&C, the Quality Assurance Assessments of
compliance with CQC Essential Standards and patient
outcomes were refreshed in March 2013. To support
this process, four Quality Assurance Managers were
appointed who work with operational staff to lead on
quality improvements within their teams.
The quality assessment visits focused initially on the 5
CQC outcomes that the CQC used when they inspected
Benjamin Court.
Between 1st April 2013 and 31st March 2014, 42 Quality
Assurance Assessment visits have been completed across
NCH&C operational services in all localities.
The assessments initially focused on the Community
Rehabilitation Units. Overall, the assessors were
impressed by the quality of care offered to patients by
the Community Rehabilitation Units.
The patients and relatives that were spoken to were
extremely pleased with the care they or their relatives
received. One patient said: “staff are always eager to
please and I couldn’t fault them”. Staff reported that
they are proud of their wards and value the support
provided by their colleagues and managers. The team
observed effective multi-disciplinary and multi-agency
working to ensure the best outcomes for our patients
throughout their care pathway.
Action plans were developed and implemented
following the completion of the Quality Assurance
Assessments of the Community Rehabilitation
Units. The action plans are being monitored using a
standardised quality governance agenda at team and
locality meetings. The Units have on-going processes in
place to review their evidence against CQC outcomes
and monitor actions plans.
The programme of Quality Assurance Assessments
entered phase 2 during the summer, which re-focused
on the Community Nursing and Therapy Teams in all 4
geographical localities, Community Children’s Services
and Specialist Services.
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During this time the process was reviewed by our internal
auditors and it was suggested that not all services were
performing self-assessments to assess their compliance
with CQC outcomes. In response to this report the
Quality Assurance Assessment visits changed focus from
5 specific outcomes to an overview of all 16 of the Care
Quality Commission standards across NCH&C clinical
services. The quality assessment tool was adapted to the
specific needs of the various services and was piloted to
assess the quality of services provided. The results were
extremely positive with patients expressing a high degree
of satisfaction with the services.
The assessing team have been impressed by the general
quality of care offered to patients by the Community
Nursing and Therapy teams, Community Children’s
Services and the Specialist Services. The patients,
relatives and carers were extremely pleased with the
care provided by the staff.
There were two main themes emerging from the Quality
Assurance Assessments across NCH&C, these were:
1. Identification of staff due to lack of visibility of
name badges
2. Lack of formal clinical supervision
Working groups have taken these issues forward to
resolve them. Staff will be issued with pinned name
badges in place of the identity cards on lanyards as
these were an infection control risk and were often
worn in pockets. The name badges will facilitate the
identification of staff by patients and partner agencies.
The supervision policy has been revised by a working
group comprising of operational staff and the quality
assurance team. The policy will be launched on
International Nurses Day on 12th May 2014.
The programme of Quality Assurance Assessment
visits against CQC outcomes continues to evolve
with new national guidance and CQC’s revised
inspection methodology.
Phase 3 of the Quality Assurance Assessments involves
the continuation of planned visits (and follow up visits)
to all NCH&C services and a new targeted approach to
specific operational services, which are identified using
intelligence by the Quality Surveillance group.
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2. A Well-led organisation
2.1 Workforce introduction
Our overarching view is that an engaged, empowered and
compassionate workforce will have a direct impact on the
quality of care received by our patients. The Francis Report
highlights the importance of listening to the workforce
and addressing concerns and issues raised in a timely
and effective manner. They are the eyes and ears of the
organisation and passionate about patient care, driven by a
desire to continuously improve the quality of care provided.
During 2013, the Trust created its own response to the
Francis Report, and this was done through internally
developed Francis workshops made up of 180 staff
members. Actions from the workshops have since been
taken forward as part of the Transformation Programme.
With this in mind, increasing staff engagement is a
continual focus. Our engagement score increased from
3.61 in 2012 to 3.65 in 2013 which is close to the national
average of 3.71 for community Trust. During the year, a
number of staff engagement events were held to consider
the Trust’s response to the Francis Report, to inform our
annual priorities as well as inform key strategies and a
review of our values.
2.2 Safer staffing
The Trust has worked and continues to develop its
approach to safer staffing based on recommendations
from the Francis Report and contained in ‘How to ensure
the right people, with the right skills, are in the right
place at the right time – A guide to establishing nursing,
midwifery and care staffing capacity and capability’. This
has included action in relation to the open display of
staffing levels and reporting to Board. We are also the only
community trust to participate in the year of experience
pre-nursing pilot programme.
2.3 Organisational
Development Strategy
The Trust will be releasing its new Organisational
Development Strategy in 2014. The Trust draws on the new
NHS leadership Academy suite of training programmes.
Both this and the Trust’s internal leadership programmes
(the REAL programme) are underpinned by the new NHS
leadership framework. The Trust’s Management Essentials
programme has continued in 2013, providing first line
managers with the essential skills to manage change in
their areas as well as advocate Trust policy.
2.4 Absence management
Absence management within NCH&C has continued to
be a challenge against the backdrop of increasing demand
and an ageing workforce, but has seen improvement
against last year’s performance. A concerted flu
vaccination campaign for 2013/14 has seen the Trust’s
uptake level (38%) increase significantly on previous years
(23% in 2012/13; 20% in 2011/12). The Trust did fall
short of its own target of 50%, but has now commenced
planning for 2014/15.
We set our sickness target at 4.0% for March 2014, which
decreases to 3.5% for March 2015. Our actual 12-month
sickness rate to March 2014 is 4.35%. Sickness continues
to receive action planning and internal focus and this has
seen a drop in the sickness absence rate for the same
point 12-months previous (5.04% for the 12 months to
March 2013). The Trust is hoping for a further drop in
sickness absence with the launch of its new managing
absence policy in 2014.
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2.5 NHS Staff Survey 2013
2.5.1 Short staff surveys
Results from the national NHS Staff Survey 2013 have
shown that our Trust is steadily moving in the right
direction. However, while the progress we are making in
many areas is positive, it is also slower than we would
want and leaves us with more to do. A total of 92% of
our staff agreed that their role makes a difference to
patients, higher than the national average. Key indicators
such as staff engagement, recommendation of the Trust
as a place to work or receive treatment and staff job
satisfaction have all continued to improve for another
year but remain below average. For 28 key findings and
in comparison with other community trusts, NCH&C
was either better than or average for 20 of the 28 key
findings; specifically, 5 were better than average and 8 of
the 28 key findings in comparison with other community
trusts were below average. This is an improvement on
our position from the previous year’s results when in
2011 23 were below average and 15 in 2012. The Trust
also scores highly on appraisals and effective teamwork
as well as seeing significant increase in ability to make a
contribution to improvements at work and support from
immediate line managers.
The Trust’s short staff survey process was introduced
in 2012 and used as a localised ‘temperature check’
of staff engagement levels, in addition to the annual
national NHS staff survey. The short surveys are now in
their third round of completion and for those services
that have completed this third round, an improvement
in scores has been evidenced from the first to the third
round. Following each survey, the relevant business area
is then tasked with creating an action plan to address
issues raised, which is monitored through the Trust’s
monthly performance meetings.
The short staff surveys have allowed the Trust to
understand the effects of its actions following the
2012 national staff survey feedback. When comparing
the second round of short surveys (as all services have
completed this), the overall average engagement
score within the short survey stood at 3.65 (out of 5)
compared to the 3.61 national 2012 score. Overall staff
satisfaction increased from 3.55 in the national survey
to 3.62, with a further increase in ‘Recommending
NCH&C as a place to work/receive treatment” rising
from 3.39 to 3.52. The Trust is currently developing
plans to introduce the Department of Health’s ‘Friends
and Family Test’ for all staff.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
2.6 Mandatory training
The Trust has continued its roll out of ‘patient centric’
mandatory training during 2013. This involves setting
up training over a two-day period covering a range of
topics, delivered in the ward environment based around
a virtual ‘patient in a bed’. This programme has reduced
training time, by covering the topics in one programme.
It incorporates communication of the Trust’s vision, values
and priorities, reinforcing our focus on further improving
quality and transformation. Further development of this
training is set for 2014 to allow this to be fit for purpose
for our Children’s and Specialist Services staff. This training
forms part of clinical induction ensuring staff are fully skilled
at the point that they join their workplace. In addition, we
are creating a number of distance learning training courses
to be used locally by staff and managers. Due to these
improved delivery methods, Mandatory Training compliance
has seen further increases during 2013, with a compliance
score of 87.1% at March 2014 against a target of 90%.
2.7 Education and training
The Trust has continued to support staff through our
ongoing programme of training and education. This
is provided through a combination of in-house and
external training with local Universities and Higher
Education Institutions.
This supports our staff both in providing high quality
evidence based care and in keeping up to date with
new skills and advances in practice. We also provided
over 400 training placements for student nurses and
therapists across the organisation in 2013. NCH&C has
also participated in a number of new programmes, such
as the pre-nursing year of experience pilot programme.
One student has already commenced her nurse training
from the pilot.
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2.8 Staff appraisals
Our performance for delivering staff appraisals improved
to 90% of staff, meeting the Trusts internal target and
the highest rate recorded in the history of the Trust. The
staff survey consistently suggests a higher compliance level
(94% in the 2013/14 survey).
We will ensure that improved compliance remains in
2014/15. We completed the first stage of ensuring all
NCH&C doctors are compliant with revalidation.
2.9 Monitor’s Quality
Governance Framework
This framework and its 10 quality questions have been
reviewed by the Board on a quarterly basis throughout
2013/14. A full review was undertaken by the Board
in April and May 2013 following the publication of the
Francis Report and a self-assessment score of 2.5 was
agreed. Monitor’s scoring mechanism for the Quality
governance framework requires Trusts to achieve a score
of less than 4 with none of the four categories (strategy,
capabilities and culture, processes and structures and
measurement) to be entirely amber/red rated.
During June 2013 an external review was undertaken and
the Trust’s overall score was assessed as 3.0 and an action
plan was developed.
In September 2013 the Board received an updated Board
Memorandum reflecting the 3.0 score. In December 2013,
NCH&C incorporated Monitor’s findings from phase one
of their assessment process which concluded that the Trust
has a Quality Governance score of 5.0. Principle concerns
related to CIP sign-off, risk management and staff and
public engagement which increased two of the scores
from amber-green (0.5) to amber-red scores (1.0).
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
2.10 Achievements of staff the winners of our
REACH Awards 2014
Clinical Excellence
Christine Harvey, Modern Matron (South)
‘Outstanding role model’ Christine is a shining example of
clinical excellence who works hard to deliver consistently
high standards to our patients in south Norfolk. A patient
safety champion and talented leader, she played an
important role in the development of our Pressure Ulcer
Strategy and was the first matron to include patient safety
data on her ward communication boards.
Emerging Talent
Nicola Smith, Community Physiotherapist, North
Walsham CN&T Integrated Team
Despite joining the South East Norfolk CN&T Integrated
Team at a difficult time, Nicola rose to the challenge and
worked seamlessly with colleagues so that patients could
benefit from a prompt, high quality service. Working with
her team, Nicola championed integrated assessments,
which not only made life easier for colleagues but also
brought huge benefits to patients.
Good Corporate Citizen
Sharon Duneclift, Health Visitor, North and
Broadland Health Visiting Team
When Sharon was tasked with designing a project to
improve health outcomes within her community, she
went the extra mile to ensure her initiative would make a
real difference to local families. After pinpointing speech
and language as an area where pre-school children could
benefit from further development, Sharon designed a
special six-week ‘Chatterboxes’ programme to teach
parents the skills to encourage interaction at home.
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Governors’ Recognition Award
Ann Yaxley, Registered Nurse, Pineheath Ward,
Kelling Hospital
Ann works hard to make sure her patient’s wishes are
met and often goes beyond the call of duty to provide
a first class service. For example, she willingly changed
her personal plans to care for a young cancer patient
who wanted to die at home. Using her clinical skills,
courage and compassion, she kept everyone calm and
enabled the patient to die as peacefully as possible in
the comfort of his own bed.
Innovation
Talk About Project, Children’s Speech and
Language Therapy Service
The innovative ‘Talk About’ project has made a huge
difference to thousands of families after giving nearly
7,500 children access to the best possible speech,
language and communication support. The project
team designed a series of training courses, literature,
and an online toolkit of videos and resources, so that
nurseries and schools could provide effective support to
children with development problems.
Inspirational Leader
Becky Cooper, Assistant Director (North)
Becky has an obvious passion for patient care and
a constant focus on maintaining quality. By putting
our patients at the heart of everything her teams do,
she ensures that all staff share the common goal of
providing the best possible service. Working openly and
transparently, Becky has built strong relationships with
colleagues at all levels as well as our wider partners within
health and social care.
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Integration and Partnership
(joint winners)
Integrated Team, Children with Complex Health
and Disability (Central)
The team works across professions and organisational
boundaries to provide effective care closer to home, for
children with disabilities and other complex health needs.
They are always looking for ways to further improve the
care they provide, embracing best practice and new NICE
guidance to ensure the young people they work with
receive the highest quality service.
Team of the Year
Starfish West, Children’s Learning Disabilities,
Mental Health and Child and Adolescent Service
Caroline House: Specialist Neurological
Rehabilitation Inpatients Service
The team is a shining example of successful integration,
working across organisational boundaries to provide a
vital service which helps children with learning disabilities
overcome mental health and behavioural problems. The
team has embraced close working with social services,
safeguarding teams, education, and other NHS trusts to
ensure the needs of children and families can be met.
A strong and effective team, they work together well to
provide the best possible care for patients with complex
and sometimes challenging needs. The team has broken
down inter-professional barriers, helping ensure the
individual needs of each patient are met. Highly skilled and
always willing to share their expertise, they have become
the region’s only tier one service, able to cater for patients
with a higher level of dependence.
Looking After You Locally
Starfish+, Children’s Learning Disabilities, Mental
Health and Child and Adolescent Service
Committed, dedicated and passionate, our Starfish+ team
has helped scores of vulnerable children aged between
four and 18 who have a learning disability and are at risk
of having to leave their homes because of mental health
issues. Working with other agencies, Starfish+ carry out a
series of intensive visits to support the child, their parents
and siblings so they can overcome their difficulties and go
on to lead a normal, happy life.
Unsung Hero
Carla Nobrega-Holloway, Community Assistant
Practitioner, City 2 CN&T Integrated Team
High quality patient care is always at the forefront
of Carla’s mind. Committed and passionate, she not
only excels in her frontline duties, but often completes
additional tasks behind the scenes, making her a real
unsung hero. A pleasure to work with, who boasts
fantastic relationships with patients, relatives, carers and
colleagues, Carla embodies the six Cs in the daily care
she provides.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
2.11 Compliments
(over 1,000
throughout 2013/14)
Quotations from compliments and
thanks given by patients, their
family and friends
Ogden Court
Thank you for caring so wonderfully for relative.
You have been a shining star in a very difficult
time. Other care organisations could learn
a lot from you...
Priscilla Bacon Lodge
Thank you seems such a small word. You all
fit into the jigsaw that makes a wonderful
picture of loving care, kindness and compassion.
This is a living jigsaw and it is called Priscilla Bacon
Lodge. Each piece as important as the other to
make it complete...
Biomechanics Norwich
Thank you for your help, I appreciated the time
and attention that you gave me. Your
calm, warm and patient manner put me at ease...
Community Learning Disabilities Team, North
Sign a long course, Very interesting and
extremely worthwhile. Very helpful for our
patients. I would recommend this course without
hesitation. I have already...
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Kingfisher clinic
Thank you for being so lovely and making
me smile again. Very professional and
knowledgeable. You are a star...
Good communication, for my Dad.
He felt he was being listened to and
getting somewhere...
City Four case manager
Treated my father with dignity and respect
at all times, whenever we needed any kind
of support or assistance, she was only a phone call
away. All the families were treated with care and
compassion. Her kindness will always be
remembered and you should be proud to
have her as part of the team...
The team has been fantastic. Thank you very
much to you all for your help, professionalism,
friendliness, sense of humour and for making the
rehabilitation process a wonderful experience...
Wheelchair services
Patient in Pine Heath. Has asked me to feed
back that she has seen patient and she is over
the moon with her new wheelchair. It has added a new
lease of life. All concerned are very grateful to
you and the WCS...
Swaffham hospital
Thank you each and every one of you for your
role in comforting, caring, safe keeping
and nursing of our relative...
Coastal Integrated Team
Whilst mum died at home the district nurses
were extremely relliable and supportive. I was
very impressed with interactions between them and the
family and various health groups helping us
(eg. Tapping House, MacMillan, etc)...
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
2.12 Clinical Ethics Group
to support staff
Staff have been encouraged to make the most of
the guidance on offer from our Clinical Ethics Group.
Clinical Ethics is a practical discipline that provides
a semi-structured approach to assist all clinicians in
identifying, analysing and resolving ethical dilemmas in
clinical medicine. This includes areas such as, informed
consent, truth telling, confidentiality, end of life care
and patient’s rights.
The values by which all our staff practice, including mutual
respect, honesty, trustworthiness, compassion and a
commitment to pursue shared goals, all have a particular
resonance following the Francis Report.
Dr Rosalyn Proops, our Medical Director said; “We all, as
clinical professionals, can sometimes feel compromised
and confused by the complexity of our work. Sometimes
we find ourselves in a situation where our views differ
from those of our team members. Sometimes there
are legal uncertainties which we cannot unpick, and
sometimes ethical dilemmas.”
The Clinical Ethics group is there to help support staff
and can, if required, respond to urgent need or plan a
meeting with the team for a general discussion or more
formal training.
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Quality Account 2013/14 – Part Three
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3. Responsive services
3.1 Review of quality
performance in 2013/14
3.1.1 Summary
In 2013/14 NCH&C met or exceeded most of its
commissioner, regional and local targets.
One of the key performance targets to be achieved was
the 18 week wait Referral to Treatment (RTT) target,
where 95% of non-admitted patients and 98% of
podiatric surgery patients should receive a definitive
treatment or intervention within 18 weeks of referral
(a locally agreed target). NCH&C reports 18 week wait
compliance for 30 services.
Three services saw their RTT performance drop below
the agreed target during the year:
• Child psychology
• Pulmonary rehabilitation
• Specialist epilepsy (adults)
These services established robust remedial action plans
and trajectories which enabled them to return to
compliance within deadlines agreed with the Norfolk
Clinical Commissioning Groups (CCGs). All services are
now compliant.
In February 2014, 99.8% of patients were treated
within 18 weeks. However, in podiatric surgery, due
to issues with clinical capacity, the service breached
its local 98% target. Analysis is being undertaken to
establish the exact level of breaches and over how
many months the Trust can expect to incur breaches.
• No patient has waited more than 52 weeks for
any treatment
• NCH&C has improved and maintained waiting times
for diagnostics, with less than 1% of patients
waiting longer than 6 weeks.
In 2013/14, there were three reported cases of
Clostridium Difficile against an annual ceiling of five
cases. All reported cases have been subject to Root
Cause Analysis (RCA) to review lessons learned. There
have been no reported cases of MRSA bacteraemia
since July 2012.
The Trust agreed an annual ceiling of no more than 4.0
injurious falls per 1,000 Occupied Bed Days (OBDs).
Despite in-month variation across the Trust’s inpatient
units, the overall performance year to date was 3.65
falls per 1,000 OBDs.
All community service providers are required to
report the level of Venous-Thromboembolism (VTE)
assessments for patients admitted to its community
hospitals. The Trust established a locally agreed
trajectory for 2012/13, against which it was monitored,
and to sustain a target of 95% thereafter. The Trust
achieved the target by August 2012, and has since
maintained performance above the target.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
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3.1.2 Meeting targets 2013/14
Indicator
Target or upper ceiling
Annual performance
Trend
MRSA Screening - elective
patients
100% of patients having planned surgery
screened for MRSA
100%
Stable
Clostridium difficile
Five cases or less during 2013/14 (cumulative)
3 cases
Decreasing
Injurious falls
Number of falls resulting in harm per 1,000
Occupied Bed Days to be less than 4.0
3.7
Stable
Venous Thromboembolism
(VTE) assessments
At least 95% of admissions have a
VTE assessment
97.2%
Stable
18 week wait referral to
treatment
95% patients receiving definitive
treatment within 18 weeks of referral
99.8%
Stable
Health visiting
Over 95% of mothers receiving a New
Birth Visit within 28 days
97.9%
Stable
3.1.3 Areas of non-delivery
3.1.4 The Smoking Cessation service
Throughout the year, the number of patients whose
discharge was delayed for non-medical reasons
occupied an average of 6.1% of the Trust’s community
hospital beds. However, during the year the overall
trend has been decreasing, with a rate of just 5.0%
compared to the upper ceiling of 5.4%. Whilst there
are no contractual targets in place for this performance
measure, analysis of the data has shown delays have
been attributable to both health service related reasons
(including patient and family choice), as well as social
care delays.
agreed an annual target for 2013/14 of 2,000 quits
with its commissioner, Norfolk County Council. It
became apparent during the autumn that the Trust was
deviating from its trajectory and a contract query notice
was issued by the commissioner in November 2013. The
Trust then developed a remedial action plan to address
performance to improve referrals rates and the number
of quits. However, the number of subsequent referrals
generated was not sufficient to recover the level of
quits required towards the end of the year, and, as
such, the Trust failed this target, with a forecast outturn
of 1,500 quits. However, it is anticipated that a change
in the structure of the service coupled with a number
of actions will place the Trust is in a strong position to
improve performance during 2014/15.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
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3.1.5 Missing targets 2013/14
Indicator
Target or upper ceiling
Annual performance
Trend
Delayed transfers of care
No more than 5.4% of beds occupied
by patients whose discharge is delayed
for non-medical reasons
6.1%
Improving
Smoking cessation service
Achieve a minimum of 2000 quits
per annum
Actual quits to
March 1,498
Decreasing
3.1.6 Mixed sex accommodation
requirements
3.1.8 NCH&C’s Governance
Risk Rating
NCH&C is compliant with mixed sex accommodation
requirements. No breaches were reported during
2013/14 and the Trust will be declaring continued
compliance against this standard.
NCH&C’s Governance Risk Rating has been ‘Green’
throughout 2013/14. The plans in place will ensure a
continued ‘Green’ rating over the next year. The Trust’s
risk rating within the Trust Development Authority’s
Oversight Model is forecast to continue to be ‘Green’.
The Trust’s rates of venous thromboembolism (VTE)
assessments continue to exceed the 95% target, with
annual performance of 97.2%.
3.1.7 Delayed discharges
The average level of community hospital beds occupied
by patients whose discharge was delayed for nonmedical reasons was 6.1% of beds, compared to 5.2%
the previous year. Whilst there are no contractual
targets in place for this measure, this is above the local
target of 5.4%. There have been improvements in the
discharge process as a result of the implementation
of the ‘Productive Ward’ across NCH&C’s community
hospitals. Analysis indicates health system-wide
pressures, including patient and relative choice, and
the provision of social care packages and undertaking
continuing healthcare assessments, as having
contributed to the increase in delayed discharges.
The Board has also risk assessed itself against on-going
compliance with Monitor’s NHS Provider Licence in
preparation for FT status. Compliance with all relevant
conditions has been confirmed and validated with
evidence. The Trust is therefore also compliant with
those conditions identified by the TDA as being relevant
to NHS Trusts.
The Board has confirmed compliance with all TDA
Board Statements, with the exception of statement 10
which relates to achieving all commissioner targets.
The target for smoking cessation is not being achieved.
There is a plan in place to get performance back on
trajectory in the coming year and maintain targets over
the next two years, subject to further negotiations with
commissioners. The Board considers the TDA governance
declarations and Board statements every month.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
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4. Caring services - Patient Experience
4.1 Summary
The Trust has continued to place a premium on patient
experience. Every session of our Trust Board in 2013/14
began with a ‘patient story’, except on one occasion
when the patient withdrew at short notice due to ill
health. The Board receives a Quality Assurance and Risk
report each month, which included Net Promoter scores
(and verbatim comments) from the Friends and Family
Test which was implemented across a range of services.
The report also included local patient survey results and
patient stories from the Patient Opinion website.
As a healthcare organisation we have the privilege
of serving people at their most vulnerable. We know
it is important that the care they receive is safe and
helps them to get better or effectively maintain their
condition. It’s also important that in receiving that care
our patients are treated with care and compassion
by skilled people and in those circumstances we are
committed to delivering the best experience of care
that we can. To help us do that we ask our patients
what they think of the care we deliver and, in response,
celebrate things that go well as well as put right things
that haven’t gone as we would like.
We learn from patients in a variety ways; for example,
we asked our patients from our community rehabilitation
units and Community Nursing and Therapy Teams,
amongst others, “how likely is it that you would
recommend this service to friends and family”, surveyed
patients accessing other services and listened to a
‘patient’s voice’ at our Board meetings. We also use
Patient Opinion to support ‘real time’ feedback and open
dialogue with patients on their experience of care.
Norfolk Community Health and Care (NCH&C)
recognises that to create a truly patient centred
organisation and to deliver the best possible care, there
has to be genuine and meaningful involvement with
our patients, carers and Members so that they can
genuinely influence and inform decisions. We must
ensure we systematically listen to, capture and use
the views and experiences of individuals, groups and
organisations in the delivery, evaluation, improvement
and development of our services.
The benefits of improving patient experience and
involvement mean that for NCH&C:
• Patients have more control over their care and the
ability to make informed choices about their treatment
• Patients who have a better experience of care
generally have better health outcomes
• Patients who have better experiences and better
health outcomes may require shorter stays in hospital
and less treatments, reducing healthcare costs
• Patients who have better experiences impacts positively
on staff experience and the culture of the organisation
• Patients who have better experiences enhance the
reputation of the Trust
During the year, the Board approved a new Patient
Experience and Involvement Strategy, developed
with staff, patients and external organisations. Three
strategic themes were identified:
1. Ensuring a systematic approach to capturing
feedback – empowering staff with knowledge of
how to capture patient experience feedback and
the tools and techniques with which to do it and
ensuring this informs a Trust-wide plan
2. Action for improvement – using patient
experience information alongside other quality data
to make demonstrable improvements to care and
systematically implementing improvement
3. Building meaningful and systematic
engagement and involvement - spreading
and building on where good engagement and
involvement of our patients, carers and Members
exists and supporting development across the Trust
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
In order to deliver the strategy and progress these
themes an annual implementation plan will be
developed. These plans will be structured around some
specific goals described below:
1. Capture and use the views and experiences of
patients, families and carers, service user groups,
Healthwatch, Governors and other voluntary
groups in the evaluation, delivery, improvement and
development of our services
2. Develop and implement effective mechanisms for:
a. Capturing and measuring patient
experience and involvement
b. Systematically implementing improvements
to care
3. Develop effective mechanisms for feeding
back to our patients, families and carers and
commissioners what we have done as a result
of their feedback and involvement
4. Develop a staff culture where listening to and acting
upon the patient experience is embedded into everyday
practice and informs organisational development
5. Empower staff with the knowledge, tools and
techniques available to carry out effective
patient experience and involvement
4.2 Patient Stories
Patient Stories are a key feature of our Strategy and
the ambition of the previous NHS Midlands and East
to ‘Revolutionise Patient and Customer Experience’,
whereby Boards are being asked to capture, use and
triangulate intelligence pertaining to patient and carer
experience from a variety of different sources.
Patient Stories provide a focus on how through listening
and learning from the ‘patient’s voice’. The Trust
Board confirmed that as part of its commitment to
strengthen the patient voice it wished to receive and
consider a patient story at each of its Board meetings.
A programme of “Patient Voice at Board” has been
refined and strengthened over the year, whereby initial
sessions were provided by a staff member describing a
patient story and how that had impacted on the service
with actions and learning points, to, in more recent
months, having patients and carers present at Board,
telling their story in their own words. These stories have
PART 2
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PART 3
often described very positive experiences but also where
there have been concerns and complaints.
We ensure that both the patient/carer and staff
members involved are fully prepared and supported
prior to, during and after Board meetings.
The following are actions arising from recent
Board meetings having heard a patient or carer
share their experiences:
• To work with all referrers, particularly the acute
hospitals, to ensure all information is transferred with
the patient on the day of transfer and to ensure that
the service provided is the same, whatever day of the
week, recognising that these concerns have a greater
impact when patients come from the acute hospital
to one of our community inpatient units on a Friday
• With our Medicines Management Group work to
ensure that self administered medicines, such as gels
and creams, are prescribed properly and that nurses
have sufficient flexibility to ensure no patient is left
without appropriate pain relief
• Further develop and implement care plans for patients so
all patients and staff know what is expected and when
• In relation to the role of the key worker. We know
that currently this is limited but we are keen to see an
extension of this role and will consider how best to
move this forward
• We recognise the difficulties that can occur around
transitions for children and families, particularly as
they move from Children’s Services to Adult Services.
We will continue to work closely with colleagues in
social care to ensure that this transition is as smooth
as possible
• We know that the Children and Families Bill, due
to be implemented in September 2014, will have
significant implications for health services for many
children, but in particular for children with complex
needs. We are committed to working with the Local
Authority to ensure that our services are integrated
with those of social care and education and fulfil the
requirements of the Children and Families Bill
• It was identified that a fax was sent to the GP about
discharge but that this was not received. To identify
how electronic discharges can take place in future to
avoid this type of incident.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
The FFT is expressed as a score and is derived from the
proportion of respondents who would be extremely
likely to recommend minus the proportion of
respondents who would not recommend.
Results for 2013/14
In total, for all services participating in the FFT survey,
the Trust has received 2541 responses and an overall
score of 77 since it commenced in July 2013. This is just
above the benchmark target of 76 set for CN&T teams.
For CN&T Teams since July 2013 to end of March 2014
the overall score is 79 with a continuing upward trend
from 72 in July peaking to 86 in March:
CN&T FFT Score YTD 2013/14
90
85
80
75
70
-1
3
n13
Ju
l-1
A 3
ug
-1
Se 3
p1
O 3
ct
-1
N 3
ov
-1
D 3
ec
-1
Ja 3
n1
Fe 4
b1
M 4
ar
-1
4
Ju
ay
M
A
pr
-1
3
65
% Assessed
Linear (% Assessed)
3
1
O 3
ct
-1
N 3
ov
-1
D 3
ec
-1
Ja 3
n1
Fe 4
b1
M 4
ar
-1
4
p-
Se
3
-1
l-1
-1
ay
M
A
This includes a follow up question “Could you tell us why
you gave that score? Your comments are invaluable to us?”
pr
-1
3
6. Don’t know
ug
5. Extremely unlikely
A
4. Unlikely
Ju
3. Neither likely nor unlikely
3
2. Likely
100
90
80
70
60
50
40
30
20
10
0
13
1. Extremely Likely
Inpatient NPS/FFT Score YTD 2013/14
n-
The Friends and Family Test was included in our Quality
Goals for 2013/14 and was also one of our CQuIN
Indicators (see Part 3 1.4) and asks “How likely are you to
recommend our ward/department to friends and family
if they needed similar care or treatment?” With response
categories from a six point scale to answer the question:
PART 3
The inpatient ward results for April to November 2013
are based on the Net Promoter Score (NPS). From
December they moved over to the FFT. From April 2013
to March 2014 (Combined NPS and FFT) their overall
score for FFT is 74 with a more erratic pattern rising to
88 in October and falling to 63 in March.
Ju
4.3 The Friends and Family
Test (FFT)
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% Assessed
Linear (% Assessed)
In addition
to the scores, patients
are asked for
comments as to why they gave those scores. The
majority of comments are extremely positive.
Comments on being helpful, friendly and kind are
among the most frequent, indicating a continued high
level of care and compassion given by our staff.
An additional question has been included which is
‘Is there anything specific that we, as a team, could
improve on? This was added in December 2013 and
a total of 130 responses to this question have been
received. 59% of these comments responded positively
with words such as ‘No’, ‘Nothing’ or ‘No, I was entirely
satisfied with the care I received’. Of the remaining
41% the top three themes from improvements
comments were staffing levels, time spent with patient
and times not provided for appointments. Improvement
comments are reviewed at team, locality and Trust level.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
4.4 Patient Opinion
Patient Opinion (PO) is a website www.patientopinion.
org.uk where patients and the public can publish their
experiences of local health services. The website allows
health service staff to interact with these patients to help
improve care. There is also the option of giving patients
a hard copy feedback card or they can call a freephone
number and tell their story over the phone.
NCH&C conducted a small pilot from March – July 2013
in 4 services to trial Patient Opinion. These were City
Reach, Community TB service and MSK Physiotherapy
services in Dereham and Thetford. The MATRIX project was
subsequently added to the pilot and went live in July 2013.
Services were issued with credit sized cards which included
the website address that they could leave in clinic areas and
also a supply of hard copy Freepost feedback cards which
could be completed and posted back to Patient Opinion.
For each of the services taking part in the pilot, the service
leads would receive an alert about a posting relating to
their specific service, they could also log on to review
stories and give responses. There was excellent feedback
about all of the services included in the pilot and service
leads had being encouraged to respond to comments
regardless of content to demonstrate that we are actively
engaging with patient feedback to improve care. Service
leads were also encouraged to link into free webex training
session offered by Patient Opinion to support raising
awareness with patients, responding to comments and
how to use reports within the service and organisation.
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After having a fractured ankle I was referred to
physio for rehab and to help me get moving
again. I was allocated a really knowledgeable, helpful
and professional physio, who gave me exercises and
information. I found I was able to discuss my anxieties
with her and she listened, supported me and her
reassurances regarding recovery, what to expect etc,
allayed my fears. I progressed well, after months
of immobility after surgery...
I’ve used the service to help with cannabis
use and behaviour problems...
The support I receive from the service is
excellent. I could not have managed
without them...!
My worker has been amazing...
This is just the start of my care plan and I came
here today to find out how I could be helped,
what could be done and some reassurance that
I didn’t have to deal with this on my own...
Today has been very informative, much more
at ease than I expected and extremely helpful.
I now have an idea where we’re going to start
dealing with my issues...
I’m going away from here today much
less anxious than when I arrived...
Thank you...!
During the pilot - 86 stories had
been viewed 5,761 times
• 93% of the stories were wholly positive and no
feedback was worse than criticality level 2 which
means no issue with clinical care was raised
The most popular stories were about the
physiotherapy team at Dereham Hospital and
the Matrix service, for example;
• 86% (74) of the stories were from the feedback cards
• 14% (12) of the stories were directly from the website
For those teams actively participating in Patient Opinion but
not the Friends and Family Test survey, the facility to answer
the question via Patient Opinion has been added to enable
those teams to measure their score against similar services.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
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4.5 Local patient surveys
4.5.2 Same sex accommodation
4.5.1 Community Learning Disability
teams
A survey was undertaken in all units where there
were 5 patients per unit during the first two weeks of
October 2013 based on a set of 10 questions based
on questions from the CQC Inpatient Questionnaire
(ratified by Picker Institute). Questions 1-5 reflect the
required compliance criteria with regard to sleeping
accommodation and toilet / washing facilities.
Questions 6-10 reflect the patient experience in regard
to wider privacy, dignity and modesty issues.
A survey was conducted in June 2013 to find out what
people think about the service they receive from their
local community learning disability team. A short easy
read questionnaire was designed and given to people
who were visited by a team member over a two week
period. 251 questionnaires were sent out and 119 sent
back (47% return rate).
• 112 (94%) were happy with their care
• 23 (19%) were unsure as to whether they made
choices about their care
• 105 (93%) people were happy with their
appointment; however, several people said that they
did not chose the day or time or place of appointment
• 92 (77%) were happy about the communication
and information they had during their appointment,
however, 33 (27%) people were unsure whether they
understood the information given to them
Overall, the comments received were mainly positive;
however, there were several comments and suggestions
about better communication and information to help
improve their understanding. Having reviewed the
results the Healthcare Co-ordinator is leading on some
work to improve on communication and information
as a result of the survey, which will include seeking the
views of people with learning disability and involving
their expert patients.
• 100% reported that they had only been in sleeping
accommodation with patients of the same sex by
answering no, or that this was not applicable to them
• 100% reported that they had only shared toilet /
washing facilities with patients of the same sex by
responding no or that this was not an applicable
question to them
• 100% of patients surveyed reported that they felt their
modesty had been protected / supported at all times
• 90% reported that staff had asked them their
preferred form of address; however, 6 patients
responded negatively
• 59 of the 60 patients surveyed reported that staff
used the patients preferred form of address, and the
other patient said this was not applicable to them
• 97% of patients surveyed reported that staff knock on
toilet / bathroom doors or ‘knock’ on curtains requesting
permission before entering, one patient answered No,
and one said it was not applicable to them
• Only 1 of the 60 patients surveyed answered No to
staff members of the opposite sex ask permission
before giving care
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
4.5.3 Key Worker Service Family
Feedback Annual Audit
The following was identified following a survey
conducted at the end of the 2012/13 period:
• All of those responding felt that their views had
been listened to and that their child’s wishes
and feelings had been taken into account. The
majority felt that the support received from the
key worker over the year met their family’s needs
and that the meetings were useful. However, there
were a few families who did not feel that they had
enough support. The questionnaire was anonymous
• In general, families felt that they had well
coordinated services which met their needs,
with good communication. However, some
families raised issues about communication between
professionals and one family raised a concern about
professionals not having enough time to attend
meetings, whilst another said that sometimes when
meetings are rearranged, some services get missed
• Disappointingly, most families reported still
having to re-tell their “story”
• Most families felt that they have had the right
information about services and resources, but
this was not the case for everyone, with one family
suggesting a booklet or leaflet detailing support and
care, such as short breaks hours and other services
would be useful
Other issues raised/suggestions for improvement included:
• Extending the age range of the service
• Possible follow up calls/letters between meetings
and for reports to be requested earlier to ensure that
progress is being made regarding agreed actions.
• Having a stand-in key worker to cover holidays and
sickness etc
A ‘results letter’ has been compiled by the service to
inform parents/carers of the results of the questionnaire
and to inform them of actions that will be taken.
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Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
4.5.4 Looked After Children (LAC)
health service
A survey was undertaken from March to May 2013
following a focus group in 2012 and subsequent survey.
Two years on they felt it was important to again capture
the experience of the Looked After Child and to also
include carers views and identify their satisfaction and
comments following either an initial or annual review
health assessment.
The questionnaire comprised two questions which were
asked of both patient and Carer:
Question one included the satisfaction rating score
and asked children, young people and Carers to score
their satisfaction of the Initial/Annual health assessment
between 0 (unhappy) and 10 (happy). The satisfaction
rating score was drawn as a line of numbers between
0 and 10 with 0 showing a grey rainy cloud with a face
and 10 a happy sunny face.
Question two was a comments section for children,
young people and Carers to highlight their experience
following the assessment. The reason for choosing only
two questions was to keep the survey simple and only to
highlight the satisfaction of their experience of the health
assessment, as well as provide an opportunity for further
comments. It was also important to try to use similar style
of questions that had been used in previous surveys in
order to have some ability to compare and validate results.
The results were divided into four groups:
1. Child/Young Person following their Initial Health
Assessment (CYP IHA)
2. Carer following the Initial Health Assessment (C IHA)
3. Child/Young Person following their Annual Review
Health Assessment (CYP RHA)
4. Carer following the Review Health Assessment (C RHA)
Looking at the satisfaction rating score, with the
exception of the CYP IHA group scoring was an average
of nine, with all other groups showing a score of
satisfaction of ten.
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The comments that were gathered in the open ended
question highlight several common themes following
the assessment which identified that assessment as
being mainly ‘helpful’. Comments on the process
included comments such as being ‘friendly, nice’
and children and young people saying there health
assessment was ‘enjoyed’ or ‘good’. The majority of
comments were complimentary, although there was
one comment suggesting they were ‘bored’.
From this survey an action plan has been completed
and agreed follow up plans:
• It should be proposed that the findings of this recent
study should be highlighted at the LAC health service
meetings to allow the team to identify children, young
people and carers views on the health assessment process
• The Action Plan should be discussed and followed
through and reviewed monthly at team meetings.
Consideration should be given to put together a
leaflet to introduce the LAC health team to children,
young people and carers prior to the initial health
assessment, or to those children, young people and
carers that have a limited understanding of the health
assessment and refuse to be seen for review
• A further study should be completed in 2014, a
year following this study, although taking on the
recommendations within this study to revise the
survey design and question structure.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
4.6 Complaints and
compliments
From 1 April 2013 to 31 March 2014, the Trust
received 207 complaints, in comparison to 170 during
the year 2012/2013. There was a spike in complaints
during October 2013 (33 complaints were received).
Following investigation, there did not appear to be
any specific trends in complaints which could have
explained the peak in numbers. As at the year end, the
monthly numbers had gradually reduced again, with 14
complaints being reported during March 2014.
The table below shows the number of complaints
received on a month by month basis:
35
30
25
20
15
10
5
M
A
pr
-1
3
ay
-1
Ju 3
n1
Ju 3
l-1
A 3
ug
-1
Se 3
p1
O 3
ct
-1
N 3
ov
-1
D 3
ec
-1
Ja 3
n1
Fe 4
b1
M 4
ar
-1
4
0
% Assessed
Linear (% Assessed)
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A continual process of learning from complaints is in
place. These are collated from the Investigating Officer
following completion of a complaint investigation,
and overseen by both the Quality and Risk Assurance
Committee, and the Trust Board.
Patient compliments are also measured and this year the
Trust has received around 1,100 compliments. Part 3
section 2.11 page 38 for details.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
4.7 Patient Led Assessments
of the Care Environment
(PLACE)
4.7.1 Patient Assessors
With the dissolution of Norfolk LINk and the formation
of Healthwatch coinciding with the commencement of
the PLACE assessment programme, the requirement
to recruit a group of Patient Assessors was undertaken
by contacting Trust public Members who had been
identified as ”Pioneers” to assess their interest in taking
part. A training session to provide a greater insight into
the role of the Patient Assessor was held at Elliot House
for those who expressed an interest. Patient Assessors
were assigned to each assessment based on geographical
preferences and availability for the assessment dates.
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4.7.2 PLACE assessments
PLACE assessments were carried out at NCH&C’s
nine inpatient sites. Each assessment was divided
into 9 sections (listed below) covering the four broad
categories of: cleanliness, buildings and facilities, food
and hydration and privacy, dignity and wellbeing.
The Health & Social Care Information Centre (HSCIC)
provided comprehensive guidance on the organisation
and conduct of assessments and separate guidance
documents for staff assessors and patient assessors.
• Organisational questions – site
• Organisational questions – food
• Organisational questions - facilities
• The Ward Assessment
• Outpatient areas
• Internal areas
• External areas
• Food Assessment
• Patient Assessment Summary Sheet
The PLACE assessment teams were organised and
attended by the Estates and Facilities Officer, acting
as Assessment Manager and, in line with HSCIC
recommendations, included representation from Business
Support Managers, and Ward Managers/Housekeepers at
each site. Representation from Serco – Estates was also
included to log any maintenance issues arising from the
assessments. Where the Ward Manager/Housekeeper
was not available to join the PLACE team, formal
feedback was provided following the assessment. In line
with the requirements of the assessment, minimal notice
was given to site in advance.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
4.7.3 HSCIC results for 2013
The table below provides an overview of the percentage
results achieved by each unit in 2013. PLACE results
were published nationally on 18th September 2013,
following which a benchmarking exercise was
undertaken, the outcome was provided to the Trust
Board in February 2014.
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The full report can be found on our website;
www.norfolkcommunityhealthandcare.nhs.uk
under Board papers for September 2013.
Site Name
Cleanliness %
Food %
Privacy, Dignity
& Wellbeing %
Condition,
Appearance &
Maintenance %
Benjamin Court
97.01
76.02
82.35
76.47
Colman Hospital
94.81
93.08
83.53
89.06
Cranmer House
77.66
85.59
86.36
72.03
Dereham Hospital
94.59
91.85
76.84
77.70
Kelling Hospital
82.72
77.51
83.78
74.66
North Walsham Hospital
96.73
77.41
90.35
89.19
Norwich
Community Hospital
98.49
79.34
94.33
80.73
Ogden Court
85.56
89.26
75.00
72.81
Swaffham
Community Hospital
82.45
89.26
82.40
79.82
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5 Safe services
(providing harm free care)
5.1 Scheme to embed culture 5.2 National Safety
of safe, harm free care
Thermometer
NCH&C are helping to deliver an innovative, new scheme
to improve health outcomes for Norfolk care and nursing
home residents.
The Harm free Care Project is looking to reduce peoples
risk of suffering a pressure ulcer, infection linked to
urinary catheters, or falls. These 3 major harms can
particularly occur in vulnerable, elderly and frail residents.
Working in partnership via the Norfolk Harm Free Care
Board, NCH&C have joined up with Norfolk County Council
to commission the development of an assessment tool and
supporting guidance and information for care homes.
These tools will help care staff review the potential risks
to residents, looking at their hydration and nutrition
levels, mobility issues and skin condition. They will also
guide staff and carers as to the best actions to take to
prevent harm from occurring.
An online resource centre will also be developed during
2014/15 to signpost people to local and national learning
resources, while a Guide to Harm Free Care for patients
and the public will be made available.
NCH&C has continued to actively work towards reducing
the incidence of the following four harms which has
further improved the quality and safety of care provided
to our patients:
• Pressure ulcers
• Falls causing harm to patients
• Venous thromboembolisms (VTE) (blood clots)
• Catheter acquired urinary tract infections (CAUTI)
The National Safety Thermometer monthly data
collection has demonstrated a consistent level of overall
harm free care of over 90% every month since July 2013
on the day surveyed.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
5.2.1 Pressure Ulcers
During 2013/14 NCH&C implemented a Pressure
Ulcer Validation group which reviews all Grade 3 and
4 pressure ulcer root cause analysis investigations and
validates whether the pressure ulcer was avoidable or
unavoidable. Between April 2013 and February 2014 we
have reported four validated avoidable pressure ulcers
in our inpatient units, with a further three undergoing
validation regarding whether they were avoidable.
Levels of avoidable pressure ulcers in the patient’s own
home have also been reducing since last summer and
we are working in partnership with care homes as part
of a Harm Free Care Project (see 5.1) to deliver pressure
ulcer education and training and the development of a
handbook of information for care home staff.
Our revised Prevention and Management of Pressure
Ulcers policy includes a new Waterlow risk assessment
score, which is the tool of choice for use across the
Trust. From now on, all staff must remember to ‘Think
Waterlow!’ and inpatients must be assessed within six
hours of admission, while community patients should be
assessed at the initial contact by all members of staff.
5.2.2 Falls causing harm
NCH&C’s rolling year-to-date average is for 3.7 falls causing
harm per 1,000 occupied bed days, as at March 2014.
NCH&C has facilitated two inpatient falls workshops
in a bid to continue to minimise the falls rate across all
inpatient units. Alongside which has been the revision
and update of the falls policy for both inpatient and
community pathways in line with best practice. This has
seen the introduction of traffic light system for patients
at risk in inpatient units, update of the inpatient care
plan and increased accountability of the medical staff
regarding the post falls protocol.
There are regular reviews of all recorded incidents
of falls in inpatient units which helps to identify root
causes and learning.
The update of the falls root cause analysis (RCA) form
and implementation of the policy update to have an RCA
undertaken after a patient has suffered two falls in a bid
to implement risk reduction strategies
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Three monthly evaluation visits are undertaken in
each inpatient unit – to address the issues related
to falls, including; patterns, numbers, injuries,
environmental audit, tutorials regarding dementia
and risk reduction measures.
A falls evaluation panel (approximately monthly or as
need demands) has been established to review and
address injurious falls sustained in inpatient units
5.2.3 Venous thromboembolisms
(VTE) risk of blood clots
We maintained our level of VTE assessments on admission
at 98.9% against our target of 95% (NHS Safety
Thermometer Data Apr 13 - Mar 14). We have improved
the reporting of VTEs that have occurred whilst a patient
is within our care by including additional questions within
Datix, our incident reporting system. These are designed
to check that all of the relevant assessments have been
undertaken and that prophylaxis against VTE has been
prescribed and administered, if appropriate.
We undertook a clinical audit in March 2014 which
demonstrated high compliance with our process for
preventing VTEs and confirmed that our patients are
risk-assessed on admission and receive the appropriate
prophylaxis during their stay.
5.2.4 Catheter Acquired Urinary
Tract Infections (CAUTI)
CAUTI for 2013/14 has been monitored through the
Safety Thermometer data collection which shows our
rate as affecting 1.2% of those patients surveyed. We
have been actively monitoring all incidence of CAUTI
which will provide the benchmark data for an action plan
to reduce these infections during 2014/15.
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5.3 Management and
learning from incidents
50
40
All serious incidents have been investigated using root
cause analysis methodology. We aim to submit our 3
day and 45 day reports on time and currently have no
45 day reports overdue.
We reported 5 unexpected deaths of patients in our
inpatient units as SIRIs and these were investigated
using root cause analysis. These incidents are further
reviewed through our mortality review panels alongside
all reported deaths.
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Total SIRIs
Pressure ulcers
Other
SIRIs reported by Type (Excluding Pressure Ulcers)
7
6
Number
5
4
3
2
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The following graphs report the numbers and types of
SIRIs (including and excluding pressure ulcers) for 2013/14.
20
A
Between April 2013 and March 2014, 388 SIRIs were
reported, 354 were grade 3 and grade 4 pressure ulcers
and there were 34 others.
30
10
The policy contains flow charts for incident and serious
incidents requiring investigation (SIRI) reporting (defined
by the National Patient Safety Agency) and describes
the process for escalation through the DATIX system,
assignment of an investigator and level of investigation
required through to the final approval of the incident.
During 2013 NCH&C introduced the new posts of
Quality Assurance Managers to support clinical teams to
improve the performance in incident and SIRI reporting.
This action supports further integration of quality
assurance into operational delivery.
We reported monthly on all our Incidents and Serious
Incidents including any learning and actions taken to
the Trust Board in public throughout 2013/14.
PART 3
SIRIs reported by Type April 2013 to March 2014
Number
NCH&C has an NHS Litigation Authority accredited,
Trust approved, Incident reporting, Investigation and
Management Policy in place which reflects the reporting
requirements of the National Reporting and Learning
System which is monitored by the Trust Development
Agency and the Care Quality Commission.
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Unexpected death
Infection control
Accident - Slip/Trip/Fall
Staffing
Medication
Other
Information Governance
Accident - Other
Allegation of Abuse
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Quality Account 2013/14 – Part Three
PART 1
5.4 Mortality Review panel
The mortality review process has been refined and the
dataset confirmed. All inpatient deaths are reviewed
and screened. This includes all inpatient deaths and
those coded as end of life/palliative care, but excludes all
deaths in Priscilla Bacon Lodge.
Data is reviewed and entered onto an electronic
spreadsheet and screening follows a stepped process which
includes the categorisation of death. Unlikely outcomes
(e.g. deaths occurring within 48 hours or admission or
re-admission to an acute unit, deaths reported to the
Coroner) triggers further scrutiny against the full dataset.
Mortality review meetings with the Norfolk and Norwich
University Hospitals NHS Foundation Trust (NNUH) Older
People’s Medicine Directorate are held quarterly. This
meeting reviews all deaths of patients transferred from
NCH&C to NNUH who die within a short period of time
and any other concerns noted.
The quarterly Mortality Review Group meetings are
reported to the Quality and Risk Assurance Committee
and to the Clinical Commissioning Group’s Clinical
Quality Risk Management meeting.
The number of patients who have died has remained
low with the average percentage across all units
(excluding Priscilla Bacon Lodge) at 3.1%. This is within
the benchmark figure of 3.3% (Aspirant Community
Foundation Trust benchmarking 13 Trusts). No cases of
concern have been highlighted.
It should be noted that the total numbers are small,
hence the variation in percentage. No cases of concern
have been highlighted.
Two themes have been noted, namely ensuring high
quality end of life care, delivered in a comparable
manner across all the units, and the second theme
concerns those patients who do not have a DNACPR
in place but on review, their death is not unexpected.
The team will review these deaths against our current
policies, DNACPR and Unexpected Deaths.
5.5 Never Events
Never Events are defined by the Department of Health as
‘serious, largely preventable patient safety incidents that
should not occur if the available preventative measures
have been implemented by healthcare providers’.
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The Trust is pleased to report that there have not been any
‘Never Events’ during 2013/14 (or in preceding years).
5.6 Central Alerts
Central Alerts are cascaded to the appropriate service
areas for action, and the Executive Directors’ Team (EDT)
monitors their communication and supporting actions
on a monthly basis.
5.7 Infection Prevention
and Control (IPAC)
NCH&C has continued a strong approach to healthcare
acquired infections during 2013/14, including zero
tolerance of MRSA bacteraemia and significantly low
and reducing incidence of Clostridium difficile.
During 2013/14 and to March 2014 we have not
reported any incidences of MRSA Bacteraemia and only
three Clostridium difficile cases against our contractual
ceiling of five.
Negotiations for 2014/15 targets are complete for
Infection Prevention and Control and next year’s ceiling
for Clostridium difficile remains at 5 cases.
5.7.1 Norovirus
There has been little to report on Norovirus throughout
the year from either Acute Hospitals or NCH&C. NCH&C
has not had any incidents of Norovirus despite some
episodes reported in our local acute hospitals.
5.7.2 Water quality
The Water Management Group has completed
instruction and creation of a water safety policy
and management plan. This provides the guidance,
instruction, specification and infrastructure for the
control of Legionella, hygiene, ‘safe’ hot water,
cold water and drinking water systems including
pseudomonas aeruginosa – advice for augmented care
units. The Trust’s estates management and Infection
control teams have the overall responsibility for the
implementation of these procedures to ensure that safe,
reliable domestic hot and cold water supply, storage and
distribution systems operate within the Trust.
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Quality Account 2013/14 – Part Three
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5.8 Medicines management
PART 2
PART 3
Further analysis of incident breakdown is reviewed
through the Trust’s Medication Safety Report at the
Medicines Management Committee.
There have been 426 medication incidents reported
during 2013/14, 420 of these incidents caused no harm
or low harm - none caused severe harm to patients and
only 6 were reported as ‘moderate harm’ as follows:
This report reviews the trends in medicines incidents and
looks in more detail at incidents relating to:
• Controlled drugs
• 2 x incorrect dose of insulin
• Omitted and delayed doses of medicines
• A patient fainted following administration of a vaccine
• Insulin incidents
• Unpredictable adverse reaction
• Moderate or severe harm incidents
• Administration of medicine
• Syringe driver incidents
• Medicine initiated by the acute hospital led
to re-admission
Breakdown of medication incident trends by severity
60
This level of incidents is set against an estimated
200,000 prescriptions written or medicines
administered each month.
50
40
The first graph shows the trend of severity since April
2013, and indicates that moderate harm incidents have
reduced to a mean of 0.5 per month.
30
20
10
5.8.1 Controlled
drugs incidents
No harm
Moderate harm
Low harm
Total
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There were 74 incidents involving controlled drugs
reported during 2013/14, broken down as follows;
57 were classified as ‘No harm’ incidents, for example;
Number of controlled drug incidents by month and severity
• Incorrect TTOs dispensed
• Damaged stock
25
• 2 x discharge issues
25
• Administration issues
17 were classified as ‘Low harm’ incidents, for example;
Number
• A lost CD patch following administration
• Issues relating to stock
20
15
10
5
• incorrect dose
0
There were 0 incidents causing moderate or severe harm
to patients
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• medicine not available
• delay in starting a syringe driver
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No harm
Low harm
Moderate harm
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5.9 Patient Safety and Quality
Benchmarking data
Aspirant community foundation
trust benchmarking reporting period
September 2013 to February 2014
NCH&C are part of a group of community trusts on a
journey to achieve foundation trust status in the future
and 13 community trusts have agreed to share data in
order to benchmark performance against one another
to stimulate debate and identify opportunities for
sharing best practice.
The benchmarking report was been refreshed in October
2013, which has resulted in the refining of existing
indicators and the recalibration of the benchmarking
data and the addition of some new indicators.
The following results are taken from the Safety and
Quality section of the report and compares NCH&C year
to date (YTD) average:
Description
Benchmark
Average (YTD)
NCH&C (YTD)
New Serious Incidents Requiring Investigation (SIRIs)
reported per month (excluding pressure ulcers which are
reported separately) (whole numbers)
0
3.4
2.0
3.8
2.9
Percentage of deaths in community hospitals (expected
and unexpected) compared to all discharges (excluding
end of life and palliative care units and specialties)
Rate of injurious falls per 1,000 occupied bed days
4.0
3.25
3.56
Rate of all falls per 1,000 occupied bed days
7.83
7.83
8.96
Number of incidents (injurious and non-injurious) per
1,000 wte budgeted staff
177.28
177.3
333.3
Number of complaints per 1,000 wte budgeted staff
4.6
4.6
10.2
Net Promoter Score (NPS)
75
80.7
80.7
Net Promoter Score (NPS) response rates
30.4%
30.4%
26.7%
91.1%
97.0%
15.2
12.3
Safety Thermometer – harm free care (new harms only)
New Grade 2, 3 and 4 avoidable Pressure Ulcers acquired
whilst under the care of the provider (whole numbers)
15.2
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5.10 Safeguarding vulnerable
adults and children
5.10.1 Safeguarding children
Safeguarding children work is underpinned by
the Children Act (2004) and Working Together
to Safeguard Children statutory guidance (DOH
2006 & 2010). NCH&C contributes to performance
and quality measures as requested by the CQC,
Norfolk Safeguarding Children Board (NSCB),
the Commissioning Support Unit and Clinical
Commissioning Groups (CCGs) through their host NHS
Great Yarmouth and Waveney (HeathEast).
Following publication of the OFSTED report into
the inspection of the local authority’s multi-agency
arrangements for safeguarding children, the Director of
Nursing, Quality and Operations and the safeguarding
children team are working closely with the local authority’s
children’s services to implement the recommendations.
The safeguarding team has completed the revision of
the Safeguarding Children policy, including updating
supervision processes and practice guidance, and
reflecting the increase in our health visitor workforce
and changes to practice as a result of SystmOne usage.
The safeguarding children team continues to work with
teams in our children’s services to provide support for
increasing the capacity of safeguarding supervision across
the units. Work to ensure safe staffing across both adult
and child safeguarding arenas is ongoing and the Warner
Training for trainers has commenced with the intention
to train appropriate recruiting managers.
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5.10.2 Looked After Children (LAC)
Working with Looked after Children is underpinned
by the statutory guidance on promoting the Health
and Wellbeing of Looked after Children (LAC DOH
2009). The service has seen a significant increase in
the numbers of Looked after Children. Revised figures
including children placed in Norfolk stands at 1340
during 2013 which has placed considerable workload
pressures on the LAC team.
Following publication of the OFSTED report into
the inspection of the local authority’s multi-agency
arrangements for safeguarding children, the LAC team
continues to work closely with the local authority’s
children’s’ services. The LAC service will be actively
involved in the development and implementation of the
LAC Improvement Plan.
We are also working closely with our CCGs under a
joint investigation to address issues around managing
demand and capacity and the challenges arising from
this in terms of meeting statutory times frames for the
delivery of LAC health assessments.
The LAC team are currently implementing an internal
action plan to improve efficiencies within the service.
This is focusing on developments around more effective
use of SystmOne, increasing face to face contacts,
resources for implementing a leaving care service.
It also includes implementing new ways of working
to minimise historical issues arising from duplication
and fragmentation between our Trust and the local
authority children’s services.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
5.10.3 Safeguarding adults
The safeguarding adults work does not have the
same legislative framework as children. However, the
Department of Health (2000), “No Secrets” guidance
provides ‘ a code of practice for the protection of
vulnerable adults. The focus is on working with
multiagency partners and the implementation of an
Adult Safeguarding Board to support best practice
across police, social services and health.
The Safeguarding Adult lead continues to attend the
Adult Safeguarding Board sub groups to ensure NCH&C
keep engaged with local initiatives and is an active
member of the multiagency forums. A current project
is to validate all training providers in Norfolk to ensure
multiagency policies and procedures are being followed.
The training programme for NCH&C staff has been revised
and will be delivered internally. A trial of ‘super classes’
consisting of 40 people commenced in December 2013.
The sessions include ninety minutes of safeguarding
awareness and ninety minutes of mental capacity act
training. The sessions will be held in one venue and
delivered am and pm. The safeguarding lead will be
available to deal with frontline questions and concerns.
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Further work continues in respect of on-line training.
The basic awareness quiz has been reviewed, and The
Safeguarding Adult lead is developing level one and two
compliance papers to be available on the intranet, as per
the children safeguarding model.
The ‘Prevent’ requirements have now been embedded
into the NHS contract as of April 2013, and the Trust
remains on target with contractual requirements, reporting
monthly to the regional NHS England.
The Deprivation of Liberty Safeguards (DOLS) Policy is
nearing review and completion and local training against
the updated policy and the referral process will be
delivered by the Safeguarding Adult lead.
NCH&C made seven DOLS referrals to the Local
Authority during 2013/14 in line with requirements
of the Mental Capacity Act, (2 of which related to the
same patient). Two of the referrals were authorised and
the remaining five were not authorised (mainly due to
the decision that there were no restrictions being placed
on the patient’s liberty)
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6. Effective services
6.1 Introduction
Quality care can be described as care which is delivered
according to the best evidence as to what is clinically
effective in improving an individual’s health outcomes.
There are a number of examples where clinical
effectiveness measures are currently used in the Trust.
Most of these are benchmarking or Patient Outcome
Reporting Measures (PROMS); however, there are also
some examples of Patient or Carer Experience and
Research. Other examples include:
• The use of the Measure Your Own Medical Outcome
Profile (MYMOP) across a number of services
• And in specialist rehabilitation, several tools are used
including the following which are used for inpatient
outcome measurement:
– United Kingdom Rehabilitation Outcomes
Collaborative (UK ROC)
– Goal Attainment Scale (GAS)
– Rehabilitation Complexity Score (RCS).
– Neurological impairment scale.
– Northwick park therapy dependency score
– Northwick park nursing dependency score
– Northwick park care needs assessment
– Goal Attainment Scale for inpatients.
For outpatients in specialist rehabilitation:
– Needs and Provisions Complexity Score (NPCS)
– Neurological impairment scale
– Northwick Park nursing dependency score and
– Northwick park care needs assessment and the
Goal Attainment Scale
• Podiatric Surgery uses the PASCOM audit tool and
Manchester Oxford Foot Health Questionnaire to
compare their performance with the national average
• Children’s Services and Children’s Speech and
Language Therapy both use the East Kent Outcomes
Scale which is an outcome measures system which
is used to identify goals and timetables and an
intervention plan with the family of patients
Most measures are used internally; however, as with
PASCOM, some are used to compare with other similar
services elsewhere.
NICE provides advice and support on putting NICE
guidance and standards into practice through its
implementation programme, and it collates and
accredits high quality health guidance, research and
information to help health and social care professionals
deliver the best patient care through NHS Evidence.
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6.2 Implementation of
NICE guidance 2013/14
There has been a total of 129 pieces of NICE guidance
published in the period April 2013 to March 2014. All
NICE guidance is published together once a month, this
is then filtered to remove guidance not applicable to
Trust services before being sent to relevant services for
assessment and if appropriate action planning.
35 pieces of NICE guidance were assessed as applicable
to NCH&C services.
The following Clinical Guidelines issued have been
deemed relevant to the Trust:
Date
Ref
Name
Relevance to Trust
May-13
CG160
Feverish illness in children
Children's Services
Jun-13
CG161
Falls
All localities (ex. Children services)
Jun-13
CG166
Ulcerative colitis
All localities
Jun-13
CG162
Stroke rehabilitation
Specialist
Aug-13
CG169
Acute kidney injury
All localities
Aug-13
CG170
Autism - management of autism in
children and young people
Childrens services
Sep-13
CG171
Urinary incontinence in women
All localities (ex. Children services)
Sep-13
CG171
Urinary incontinence in women
All localities (ex. Children services)
Nov-13
CG173
Neuropathic pain - pharmacological
management
Yes
Dec-13
CG174
Intravenous fluid therapy in adults in
hospital
Yes - all localities with inpatients
Feb-14
CG177
Osteoarthritis
Yes
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All relevant guidance is reviewed by the applicable
services and risk assessed. Guidance that is particularly
applicable to a Trust service will be reviewed in depth
and, for example, have a baseline assessment tool
completed or a clinical audit planned.
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The following technology guidance has been deemed
relevant to the Trust:
Date
Ref
Name
Type
Relevance to Trust
Mar-14
MTG17
The Debrisoft monofilament
debridement pad for use in acute or
chronic wounds
Medical technologies
guidance
Yes
Jun-13
TA290
Overactive bladder - mirabegron
Technology appraisals
All localities
Jun-13
TA287
Pulmonary embolism and recurrent
venous thromboembolism rivaroxaban
Technology appraisals
All localities
Jun-13
TA288
Type 2 diabetes - Dapagliflozin
combination therapy
Technology appraisals
All localities
As per the Management of NICE Guidance process,
all TAs (technology appraisals) are reviewed and
recommendations made to commissioners by the
Therapeutics Avisory Goup (TAG). All TAs for medicines
that are applicable to Trust services have been added to
the Trust medicines formulary.
63
The following public health guidance has been
deemed relevant to the Trust:
Date
Ref
Name
Relevance to Trust
May-13
PH44
Physical activity: brief advice for adults in primary care
All localities (ex. Children)
Jun-13
PH45
Tobacco harm reduction
Specialist
Jul-13
PH46
BMI and waist circumference - black, Asian and
minority ethnic groups
All localities
Oct-13
PH47
Managing overweight and obesity among children
and young people
For information:
Childrens services
Jan-14
PH49
Behaviour change: individual approaches
For information
Feb-14
PH50
Domestic violence and abuse - how services can
respond effectively
Yes
Mar-14
PH51
Contraceptive services with a focus on young people up
to the age of 25
Yes
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
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PART 2
The following Quality Standards have been deemed
relevant to the Trust and some are being audited as part
of the Quality Goals for 2014/15:
Date
Ref
Name
Relevance to Trust
Apr-13
QS31
Health and wellbeing of looked-after children and
young people
Yes
Apr-13
QS30
Supporting people to live well with dementia
Yes
Jul-13
QS39
Attention deficit hyperactivity disorder
Childrens
Aug-13
QS43
Smoking cessation - supporting people to stop smoking
Specialist
Aug-13
QS40
Psoriasis
Yes
Sep-13
QS45
Lower urinary tract symptoms
Yes
Sep-13
QS44
Atopic eczema in children
Yes
Sep-13
QS48
Depression in children and young people
Yes
Oct-13
QS49
Surgical site infection
POD surgery
Jan-14
QS51
Autism
Yes
Jan-14
QS52
Peripheral arterial disease
Partial
Feb-14
QS53
Anxiety disorders
Yes
Feb-14
QS54
Faecal incontinence
Yes
The NICE quality standards were reviewed by the
Clinical Audit and Effectiveness Committee in January
2014, and will be further considered as part of clinical
audit planning for 2014/15.
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6.3 Specialist palliative care
The Specialist Palliative Care team based at Priscilla
Bacon Lodge meet monthly to cover all aspects
of clinical governance, including monitoring the
effectiveness of their service. They have a very active
audit programme which has included in the last 12
months a number of audits designed specifically to
monitor how effective their processes are, such as
adherence to guidelines. For example, they have
audited the effectiveness of paracentesis, conversion to
methadone and the administration of bisphosphonates
within the Rowan Centre Day Unit. Looking at patient
outcomes, the team have undertaken a number of
surveys and pieces of work to measure effectiveness of
their care:
• Service evaluation of bereaved relatives’ satisfaction
with end of life care
• MYCAW patient rating and feedback survey to measure
the effectiveness of complementary therapy treatments
• Inpatient and Day Therapy focus groups to review
patient and carer satisfaction with the care provided
• Involvement in a multi-centre research study to assess
carers’ needs within palliative care
• Patient feedback surveys around satisfaction and
effectiveness of outpatient clinic consultations at the
Priscilla Bacon Centre
The team have developed a Service User Steering
Group with input from both patients and carers who
input actively into the daily work of the team and allow
opportunities to highlight areas of good practice and
potential areas of concern which the team are then
able to identify as priority areas for further work around
clinical effectiveness.
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Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
6.4 The Colman Centre for
Specialist Rehabilitation
Service (CCSRS)
The Colman Centre for Specialist Rehabilitation service
(CCSRS) is a specialist rehabilitation centre in the NCHC,
providing specialised rehabilitation for patients with
highly complex needs following an acquired brain
injury or amputations of limbs. The CCSRS provides
an interdisciplinary rehabilitation, focused on patient
and family centred goals through the World Health
Organisations (WHO), International Classification of
Functioning (ICF) framework as well as the ethical
framework. The CCSRS neurorehabilitation inpatient
and outreach service is commissioned by NHS England
as a level 1 service, to provide specialised rehabilitation
for patients with highly complex needs. We collect
data on outcomes from our centre on the national
commissioning data set called the United Kingdom
Rehabilitation Outcome Collaborative (UKROC), which
is used to benchmark the service against other similar
level 1 services in England.
The CCSRS team are competent, committed, caring,
compassionate and well-motivated to enable a
culture of empowerment to the service user and
their family. The team deliver a clearly defined goal
oriented, holistic, interdisciplinary rehabilitation
programme which empowers service users and their
family to make positive health and lifestyle choices
that will help to improve the quality of their lives. The
CCSRS team strives to develop integrated pathways
of care with existing and new partners which helps
with supporting the ongoing rehabilitation needs
of service users. We try to access a comprehensive
range of assistive technologies, orthotics, specialist
wheelchair, augmentative communication aids and
other equipments to enhance the patients care and
to support the rehabilitation process. We, as a team,
ensure our service adheres to CQC and NICE quality
standards and we demonstrate continuous quality
improvements through audits and learning from
incident reports.
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The quality requirements of the service, matched to the
NHS outcome framework are:
• Enhancing quality of life for people following an
injury and supporting patients and families to
manage their condition (domain 2)
1. All patients have a defined set of person-centred
goals with a record of achievement- monitored
by UKROC
2. Patients should have a planned timely discharge to
home/an on-going care facility/within 6 monthsmonitored by UKROC
• Helping people to recover their independence and
functional ability following an injury (domain 3)
1. Patients will be assessed within 10 days of referral
by a senior member of the specialist rehabilitation
team – monitored by UKROC
2. Patients will be admitted to a facility assessed as
being best to meet their needs within 6 weeks of
being fit for transfer monitored by UKROC
3. All patients will have achieved some measurable
gain or goal achievement- monitored by UKROC
• Ensuring that people have a positive experience of
care (domain 4)
1. Patients and/or their families are satisfied with
their care – monitored by Friends and Family Test
2. Constructive feedback is recorded, reviewed
and acted upon-monitored by incident reports
and complaints
• Treating and caring for people in a safe
environment (domain 5)
1. No needless harm from pressure ulcersmonitored by NHS safety thermometer
2. No needless harm from VTE- monitored by NHS
safety thermometer
3. Safe staffing levels – monitored by CQC
and Healthwatch
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
6.5 Clinical Audit
programme 2013/14
Definition of Clinical audit — a quality improvement
cycle that involves measurement of the effectiveness of
healthcare against agreed and proven standards for high
quality, and taking action to bring practice in line with
these standards so as to improve the quality of care and
health outcomes. Clinical audit measures existing practice
against evidence-based clinical standards.
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1. Identify problem
or issue
5. Implementing
change
4. Compare
performance
with criteria
& standards
2. Set criteria
& standards
3. Observe
practice /
data collection
The annual clinical audit plan was approved by the Trust
in April 2013. This contained 46 clinical audits across
the Trust’s wide variety of services. The audit plan is
broken down into various sections depending on the
origin of the audit.
Audit type
Description
Number of audits
National clinical audits
These are national audits the Trust participate in
2
Commissioner priorities
These audits are specifically requested by the commissioners
of our services to provide analysis or assurance of a service
4
NICE guidance
These are audits of the Trust’s services against specific pieces
of NICE guidance
8
Trust priorities
These are Trust wide audits of the Trust’s services against
other guidance or standards that are considered a priority
for the Trust
15
Clinical service evaluations
These are service evaluation audits and so measure the
quality of a service rather than the outcome for the patient
17
A further six clinical audits were submitted during the
year that were not included within the approved plan;
these are mainly audits for post-graduate courses. These
still contain valuable information and learning for the
Trust so are included in the final report.
Clinical audits are measures of standards against a
pre-determined target percentage. Where the target
is met the audit is said to have achieved ‘high
assurance’, if the results fall short of the target the
audit is moderate or low assurance depending on the
distance from the target percentage.
The following table outlines the clinical audit results
for 2013-14:
Audits completed
High assurance
11
Moderate assurance
16
Low assurance
0
No assurance level determined
6
Report not yet submitted
7
Audits cancelled
13
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Quality Account 2013/14 – Part Three
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Some clinical audits did not determine an assurance level,
due to their design, and 2 of these are national audits
as these do not use assurance levels. Some audits were
cancelled during the year, either because the standard
they were intending to measure was no longer relevant,
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they were merged with other audits for simplicity, or data
collection took longer than expected and the audit has
been continued into the 2014-15 clinical audit plan. All
clinical audits are reviewed by the relevant committee and
any recommended actions reviewed for implementation.
Examples of clinical audits completed in 2013-14
Audit of inpatient prescription charts
• 90% of charts in use were the NCH&C version
• 82% compliance with key information completion
• Improvement in mean risk score from missed doses
Re-audit of administration of bisphosphonates within the
Rowan Centre day unit
• All patients audited had the correct form
completed, blood results completed, diagnosis and
indication for treatment noted
• Medical review after 4th dose was only completed
in 40% but this was not applicable in a further
40% of cases
Management of the Diabetic Foot by community
podiatrists
• 77% of patients notes reviewed met all of the
standards audited
Community IV audit [Kerry Jones]
• High achievement of standards for completion of
paperwork and transfer of information on referral
• Small number of missing allergy status to be
followed up
Antibiotic prescribing audit
• High compliance with the standards for prescribing
antibiotics in inpatient settings
Attendance at Specialist Palliative Care Multi-Disciplinary
Team (MDT) meetings
• Weekly multi-disciplinary team meetings took place
on 97% of occasions
• Attendance at 97%-100% for all staff groups
except psychological support (80%)
6.5.1 Podiatric surgery
Since last year’s Quality Account, the Norfolk Foot Surgery
Centre has continued with PASCOM-10 the national audit
tool for Podiatric Surgery. There are now 737 surgical
episodes of care with completed audit data. PASCOM-10
includes a patient reported outcome questionnaire
(PATSAT) and a validated foot health questionnaire
(MANOX) which all patient complete prior to surgery
and at 6 months post surgery. This falls in line with the
relatively new commissioning guidelines for treatment of
the painful great toe.
Our scores remain higher than the national average
and we now have a wealth of audit information which
helps prove the quality and effectiveness of our Podiatric
Surgical service.
The department also had a surgical technique
published in the Journal of Foot and Ankle Surgery;
‘Tarsometatarsal Joint Arthrodesis with Trephine Joint
Resection’ and ‘Dowel Calcaneal Bone Graft’. This will
hopefully be the first of many research papers to be
produced by the department.
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
6.6 Research and
development
A new Clinical lead in Academic Liaison, Research and
Development came into post in October 2013 and will
work in conjunction with our Research Coordinator who
is directly supporting recruitment to current studies. A
dedicated research room has been agreed for the Norwich
Community Hospital site, which will aid recruitment and
reduce the need to use other Trusts’ clinical areas.
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A research steering group has been set up to oversee
research with the Trust to ensure that governance and
finances for research are managed effectively.
The following are a summary of a selection of studies
that have patients actively recruited to and are underway.
Study Title
Aim
EXTRAS: A trial to evaluate
an extended rehabilitation
service for stroke patients
To determine whether an extended stroke rehabilitation service (intervention) improves patient
outcomes compared to usual care (control)
UK Infant CDI:
UK standardisation
of Communicative
Development Inventory Words and gestures
The principal research objective is to assess young infants’ language and communication ability,
and enable us to collect normative data for infants across the UK. This is a national NIHR portfolio
study which is being sponsored by Lancaster University
ME/CFS study: Longitudinal
Immunological and
Virological Evaluation of
Myalgic Encephalomyelitis /
Chronic Fatigue Syndrome
(ME/CFS) and the
Establishment of a
Research Resource for
Prospective Studies
This project aims to improve the understanding of the causes and mechanisms involved in ME/CFS
and in chronic fatigue, some of which may also apply to Multiple Sclerosis (MS), by studying and
comparing the characteristics of people with ME/CFS, multiple sclerosis
CSNAT: Carer Support
Needs Assessment Tool
Factors associated with successful implementation of a Carer Support Needs Assessment Tool
(CSNAT) in palliative and end of life care practice
This is a national NIHR portfolio study being hosted in stroke services within the Early Supported
Discharge team. 64 patients are to be recruited until January 2015
The study is being run within NCH&C Health Visiting service. 1300 participants are hoped to be
recruited nationally
This is a NIHR portfolio study sponsored by the London School of Hygiene and Tropical Medicine
running in Norfolk only. Recruitment of 180 participants with ME/CFS, 110 healthy controls and 75
participants with MS is underway. NCH&C neurological specialist nurse service have identified and
approached MS patients, GP practices are identifying ME/CFS cases and participants are seen at
Norwich Community Hospital as well as two further GP Hub sites
This is a national NIHR Portfolio study sponsored by Manchester University and being hosted in
Palliative Care service. It involves staff only, using CSNAT for 6 months in the Trust and evaluating
CSAW: What is the
Clinical and Cost
Effectiveness of
Arthroscopic Sub-acromial
Decompression Surgery for
Patients with
Sub-acromial Pain?
There are three components of the principal aim 1. Is arthroscopic sub-acromial decompression (ASAD)
more effective than investigative arthroscopy only (AO) in terms of pain relief and function in patients
suffering from sub-acromial pain in the shoulder? 2. Is ASAD more effective than “non-operative
management with specialist reassessment” (observational control group C) in terms of pain relief and
function in patients suffering from sub-acromial pain in the shoulder? 3. Is AO more effective than
“non-operative management with specialist reassessment” in terms of pain relief and function in
patients suffering from sub-acromial pain in the shoulder?
The two main objectives in asking these questions are to assess the mechanism of surgery for this
type of shoulder pain and to examine if surgery is necessary for this type of shoulder pain
This is an national NIHR portfolio study being hosted by the Norfolk and Norwich University
Hospital. NCH&C Musculoskeletal physiotherapy service is working with an NNUH Orthopedic
Consultant to refer potential participants into the study
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7. Explanation of who has been involved in
this Quality Account
Norfolk Healthwatch (previously Norfolk LINk) and
public involvement at Trust Board meetings and other
committeess, including Quality and Risk Assurance
Committee, Patient Experience Steering Group and
PLACE inspections.
Development of the annual plan and quality goals was
achieved in conjunction with the Executive Directors,
Assistant Directors, heads of service and clinicians
through a number of staff workshops and discussions
at the Management Forum. Involvement of staff
and public Governors and external stakeholders was
through an online survey and paper questionnaire.
Third party commentary received from Norfolk
Healthwatch, Norfolk County Council Health Overview
and Scrutiny Committee and South Norfolk Clinical
Commissioning Group (our lead commissioners for
2013/14) is presented below.
7.1 Comments from
Norfolk Healthwatch
Healthwatch Norfolk is pleased to have the opportunity to
comment on the Quality Account 2013-14. In considering
the document, being easily accessible by the public, we
believe that a comprehensive glossary is essential. Clear
language throughout the document would aid clarity,
together with information relating to the availability of
the document in a different format. Again, in order to
help with clarity, the report would be enhanced by the
addition of more practical examples to illustrate points
made. For example - actions from the Francis workshops
and examples of issues raised by staff as relevant to the
response to the Francis Report.
Information on the range of scores and whether
higher scores are better should always be given to help
understanding of the Trust’s performance. On some
occasions, figures are given without explanation or
comment to aid understanding. It would be useful to have
a comment on the score, eg, are the scores satisfactory or
is the Trust striving to improve further upon them?
It is very helpful when information is given which
compares the Trust’s performance with other Trusts.
Healthwatch Norfolk is pleased to note that most of the
Trust’s services met their targets. It would however give a
more complete picture and aid transparency if the actual
performances of the three services that did not meet their
targets were also given. It would have been helpful to
know whether the Trust had met the statutory timescales
over the last year for the delivery of Looked After children’s
health assessments.
It is also very pleasing to read about the achievements of
staff. More detail as to the comments where there were
gaps in satisfaction would again help to inform the reader.
The developments in the Children’s Community Nursing
Team and the IV Therapy Service are welcomed. Although
the numbers of patients who received the extended
services are given, it would be useful to know whether
all those who would have benefitted from the service
received it, or whether capacity is still being built.
The performance measure regarding being ‘open and
transparent with our patients/relatives/carers when things
go wrong’ is recorded as achieved. The performance
measure says that ‘100% of patients/carers/relatives must
be informed of an incident causing moderate harm,
severe harm or an unexpected death’. This suggests that
incidents of low harm are not included in the 100%
target, which seems surprising and not consistent with
being truly ‘open and transparent’. It is difficult to see
this performance measure as being fully achieved until all
incidents that result in harm are communicated effectively
to patients/relatives/carers.
Finally, Healthwatch Norfolk confirms that we will continue
to develop effective working relationships with the Trust
in order to ensure that the views of patients, carers and
their families are taken into account in the provision of
healthcare by the Trust.
Alex Stewart
Chief Executive
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
PART 1
7.2 Response from Norfolk
County Council Overview
and Scrutiny Committee
The Norfolk Health Overview and Scrutiny Committee
has decided not to comment on any of the Norfolk
provider Trusts’ Quality Accounts for 2013-14 and
would like to stress that this should in no way be taken
as a negative comment.
The Committee has taken the view that it is appropriate
for Healthwatch Norfolk to consider the Quality
Accounts and comment accordingly.’
7.3 Response from South
Norfolk Clinical
Commissioning Group
Statement of Information Verification within the Quality
Account submitted to NHS South Norfolk Clinical
Commissioning Group (SNCCG) by Norfolk Community
Health & Care NHS Trust (NCH&C) May 2014.
NHS South Norfolk Clinical Commissioning Group, as
lead commissioner for the Trust, acknowledges Norfolk
Community Health & Care NHS Trust in it’s publication
of a Quality Account for 2013/14.
We have reviewed the mandatory data elements required
within this account and can confirm that those included
are consistent with that known to NHS SNCCG.
The report presents detailed and comprehensive
information relating to quality and safety of care
delivered within the prioritised areas identified by the
Trust. The quality goals for 2014/15 are relevant and are
substantiated by involvement with the clinical quality
and patient safety agenda via the Commissioning for
Quality & Innovation payment framework (CQuIN). We
commend staff for their work to improve outcomes
within these areas and we look forward to the inclusion
of an update on achievements in these areas in next
year’s Quality Account.
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NHS SNCCG have appreciated the continued support
of the clinical quality review meetings which are vital in
assuring the local population that services contracted
from the Trust are safe and of good quality. They enable
discussions to take place concerning new initiatives
and current thinking and practice. They also facilitate
challenges regarding current performance.
We have appreciated the ongoing dialog with NCH&C
in respect of the Trusts transformation program and
particular the Cost Improvement Program (CIP).
This transparent approach enables commissioners to
seek assurances about perceived and potential risks
associated with the implementation of any proposed
initiatives that may impact on patient safety and the
quality of care provided.
This has been another year in which the Trust has
demonstrated commitment to working with and
building strong relationships with the five Norfolk
CCG’s as well as Norfolk County Council (NCC) as a
part of the Health & Social care integration agenda.
We look forward to working alongside our providers in
supporting quality initiatives in the coming year.
Yours sincerely
Sandra Corry
Director of Quality and Patient Safety
NHS South Norfolk Clinical Commissioning Group
Norfolk Community Health and Care NHS Trust
Quality Account 2013/14 – Part Three
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8. Declaration by all Directors
The following is a declaration; signed by all directors
in office at the date of the account, certifying that
they believe the contents to be true, or a statement
of explanation as to the reasons any such director is
unable or has refused to sign such a declaration.
I believe the contents of this Quality Account 2013/14
to be true:
Executive Directors
Name: Mark Easton
Interim Chief Executive (from May 2014)
Name: Michael Scott
Chief Executive (until May 2014)
Name: Roy Clarke
Director of Finance
Name: Dr Rosalyn Proops
Medical Director
Name: Anna Morgan
Director of Nursing, Quality and Operations
Name: Paul Cracknell
Director of Strategy and Transformation
Name: Matt Colmer
Director of Performance and Information
Non-Executive Directors
Name: Ken Applegate
Chairman
Name: Alex Robinson
Non-Executive Director
Name: Vivienne Clifford-Jackson
Non-Executive Director
Name: Lisa Gamble
Non-Executive Director
Name: Neil Harrison
Non-Executive Director
Name: Derek Allwood
Non-Executive Director
Name: Professor Ian Harvey
Designate Non-Executive Director
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Quality Account 2013/14 – Glossary
73
Glossary of terms
AHP
Allied Health Professionals
Allied Health Professionals (such as Physiotherapists,
Occupational Therapists, Speech and Language
Therapists, Podiatrists) provide treatment and help
rehabilitate adults and children who are ill, have
disabilities or special needs, to live life as fully as
possible. They often manage their own caseloads.
BAF
Board Assurance Framework
The Board Assurance Framework provides a record of
the principal strategic risks to the Trust achieving its
objectives. It identifies the controls in place, the methods
of assurance and the control and assurance gaps.
BGAF Board Governance Assurance Framework
A key part of achieving FT authorisation is passing a
rigorous assessment of board capability and capacity
by Monitor, the Foundation Trust regulator. To support
aspiring Foundation Trusts to meet this competency,
the Department of Health has developed a mandatory
board governance assurance framework in partnership
with existing Foundation Trusts and other stakeholders.
BNF
British National Formulary
The British National Formulary provides UK healthcare
professionals with authoritative and practical
information on the selection and clinical use of
medicines in a clear, concise and accessible manner.
C. Diff Clostridium Difficile
A form of bacteria that is present naturally in the gut
of around 2/3s of children and 3% of adults. On their
own, they are harmless, but under the presence of
some antibiotics, they will multiply and produce toxins
(poisons), which cause illness such as diarrhoea and
fever. At this point, a person is said to be infected
with C. difficile.
CAUTI Catheter-acquired Urinary Tract Infection
A bladder infection that has occurred as a direct result
of the presence of an indwelling catheter (a mechanism
used initially to help the bladder).
CCG
Clinical Commissioning Group
These are groups of GPs that, from April 2013, will be
responsible for planning and designing local health
services in England. They will do this by “commissioning
“or buying health and care services.
CES
Community Equipment Store
This service provides all types of equipment to patients
who are managed at home (including care homes). For
example, hospital beds, mattresses, commodes, toilet
raisers, chair raisers, Telehealth systems.
CIP
Cost Improvement Plan/Programme
The formal identification of an action which reduces the
budgeted cost base of the organisation. It can relate to
either pay or non pay costs.
CN&T Community Nursing and Therapy
Home delivered nursing and therapy services and
interventions for Adults such as; wound dressings, end
of life care, rehabilitation programmes.
CQC
Care Quality Commission
An organisation that checks whether hospitals,
care homes and care services are meeting
government standards.
CQuIN Commissioning for Quality and Innovation
The Commissioning for Quality and Innovation
payment framework enables commissioners to reward
excellence, by linking a proportion of English healthcare
providers’ income to the achievement of local quality
improvement goals.
COPD Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) is the
name for a collection of lung diseases including chronic
bronchitis, emphysema and chronic obstructive airways
disease. People with COPD have trouble breathing in
and out. This is referred to as airflow obstruction.
Norfolk Community Health and Care NHS Trust
CRR
Corporate Risk Register
The Corporate risk register is the aggregation of the
local team and corporate department risk registers
where the residual risk score is more than 12. It includes
any additional sources of risk such as external or
internal reviews.
CSSD Central Sterile Service Department
A service that provides sterilisation for equipment
used by community services, eg, scissors, scalpels,
tool nail cutters.
CSP
Chartered Society of Physiotherapy
The Chartered Society of Physiotherapy (CSP) is the
professional, educational and trade union body for the
UK’s 50,000 chartered physiotherapists, physiotherapy
students and support workers.
Datix DATIX risk and incident database
DATIX is a web-based risk management monitoring
tool that aids NCH&C staff in the reporting and
management of incidents, risk, complaints and
PALS enquires.
DoLS Deprivation of Liberty Safeguards
These safeguards apply to residential homes, nursing
homes, hospices and hospitals. A person who does not
have capacity (under the Mental Capacity Act 2005)
may only be deprived of their liberty if it is necessary
to protect them from harm. It can only be authorised
by the Local Authority and a ‘best interest assessor’ is
the trained professional who assesses whether or not
deprivation of liberty is in someone’s best interest.
DPA
Data Protection Act (1998)
The Data Protection Act 1998 requires every organisation
processing personal data to register with the Information
Commissioner’s Office, unless they are exempt.
EDT
Executive Directors Team
The Team of Executive Directors of Norfolk Community
Health and Care NHS Trust, that meets weekly.
Quality Account 2013/14 – Glossary
74
EPRREmergency Preparedness, Resilience
and Response
In April 2013 NHS England introduced the EPRR Core
Standards detailing the roles and responsibilities
involved in EPRR, Major Incident and Service Continuity
planning, partnership working, resource allocation and
staff competencies.
EWTT Early Warning Trigger Tool
The Early Warning Trigger Tool is designed to capture and
bring together all of the factors that could impact on the
quality and safety of clinical services, to identify services
that may be at risk, and to help prevent serious incidents
and patient safety issues in the future. It is part of a
package of measures being used to ensure that quality
and patient safety remain a key priority for NCH&C.
FFT
Family and Friends Test
A nationally driven patient satisfaction survey using the
question ‘would you recommend this service to your
friends and family?’
FOIA
Freedom of Information Act (2000)
The Freedom of Information Act 2000 is an Act of
Parliament that creates a public “right of access” to
information held by public authorities. This does not
apply to personal information as this is covered by the
Data Protection Act (see above).
FT
Foundation Trust
NHS foundation trusts are not-for-profit, public
benefit corporations.
FTN
Foundation Trust Network
The Foundation Trust Network is the membership
organisation for NHS public provider trusts. They
represent every variety of trust, from large acute and
specialist hospitals through to community, ambulance
and mental health trusts. Members provide the full
range of NHS services in hospitals, the community and
at home.
IAG
Intelligent Application Gateway
A remote access method for access to IT services from
outside the Trust.
Norfolk Community Health and Care NHS Trust
IBP
Integrated Business Plan
Document setting out the five year strategy of the Trust.
ICO
Integrated Care Organisation
This will build on the Integrated Care Organisation pilot,
the work in the West of the county and the work of
the current health and social care integration project.
External auditors have been commissioned to develop
an options appraisal which highlights the benefits and
risks of moving further on integration or continuing
with our current processes.
IG
Information Governance
Information Governance ensures necessary
safeguards for, and appropriate use of, patient
and personal information.
IG Toolkit
Information Governance Toolkit
The Information Governance Toolkit is an online
system which allows NHS organisations and partners
to assess themselves against Department of Health
Information, Governance policies and standards.
It also allows members of the public to view
participating organisations’ Information Governance
Toolkit assessments.
IMCA Independent Mental Capacity Advocate
Introduced by the MCA 2005: Service that helps
particularly vulnerable people who lack the capacity
to make important decisions about serious medical
treatment and changes of accommodation, and who
have no family or friends that it would be appropriate
to consult about those decisions. The role of the
Independent Mental Capacity Advocate (IMCA) is to
work with and support people who lack capacity, and
represent their views to those who are working out
their best interests.
INR
International Normalised Ratio
A laboratory measurement of how long it takes blood
to form a clot. It is used to determine the effects of oral
anticoagulants (an anticoagulant is a substance that
prevents clotting of blood) on the clotting system.
IPR
Integrated Performance Report
A report used to assure the Trust Board of
organisational performance, to flag exceptions to the
achievement of performance standards and corrective
action as appropriate.
Quality Account 2013/14 – Glossary
KPI
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Key Performance Indicator
Key performance indicators help an organisation
to define and measure progress towards
organisational goals.
LD
Learning Disability
A learning disability affects the way a person learns
new things in any area of life. It affects the way they
understand information and how they communicate.
MCA
Mental Capacity Act 2005
The Mental Capacity Act (MCA) provides a framework
to empower and protect people who may lack capacity
to make some decisions for themselves. It states that:
• you should have as much help as possible to
make your own decisions
• people should assess if you can make a
particular decision
• even if you cannot make a complicated decision
for yourself, this does not mean that you cannot
make more straightforward decisions
• even if someone has to make a decision on your
behalf you must still be involved in this as much
as possible
• anyone making a decision on your behalf must
do so in your best interests
MCA often applies to people with a: learning
disability, dementia, mental health problem,
brain injury and stroke.
MRSA Methicillin-resistant Staphylococcus Aureus
A bacterium responsible for several difficult-to-treat
infections in humans due to its resistance to methicillin
and other beta-lactam antibiotics. MRSA is especially
troublesome in hospitals and nursing homers, where
patients with open wounds, invasive devices, and
weakened immune systems are at greater risk of
infection than the general public.
MUST Malnutrition Universal Screening Tool
This is a five-step screening tool to identify adults who
are malnourished, at risk of malnutrition or obese. It
also includes management guidelines which can be
used to develop a care plan.
Quality Account 2013/14 – Glossary
Norfolk Community Health and Care NHS Trust
NED
Non Executive Director
A non executive director is a member of the board
appointed by the Appointments Commission, to hold
the Executive to account, bring independence, external
skills and perspectives and challenge on strategy
development, risk management, shaping culture, and
the integrity of financial and quality intelligence.
NHSLANational Health Service
Litigation Authority
The NHSLA is a Special Health Authority that
administers the Clinical Negligence Scheme for Trusts
(CNST) which provides indemnity to its members and
their employees in respect of clinical negligence claims.
They are also responsible for resolving disputes between
practitioners and primary care trusts, giving advice to
the NHS on human rights case law and handling equal
pay claims on behalf of the NHS. The NHSLA also aims
to help and support the NHS to improve patient and
staff safety through learning from claims.
NICENational Institute for Health and
Clinical Excellence
The National Institute for Health and Clinical Excellence
provides independent, authoritative and evidencebased guidance on the most effective ways to prevent,
diagnose and treat disease and ill health, reducing
inequalities and variation.
NPS
Net Promoter Score
Net promoter score is a key measure linked to the
Friends and Family Test of individual, team and
corporate performance and is used to drive up positive
patient experience.
NPSA National Patient Safety Agency
The National Patient Safety Agency leads and
contributes to improved, safe patient care by informing,
supporting and influencing the health sector.
OD
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Organisational Development
Plan that which sets out ambitions for the organisation
and its staff.
PALS
Patient Advice and Liaison Service
The Patient Advice and Liaison Service has been
introduced to ensure that the NHS listens to patients, their
relatives, carers and friends, and answers their questions
and resolves their concerns as quickly as possible.
PAS
Patient Administration System
An information collection system that acute and
community hospitals use to collect patient related data.
PEAT
Patient Environment Action Team
This is an annual assessment of inpatient healthcare
sites in England that have more than 10 beds. It is a
benchmarking tool to ensure improvements are made
in the non-clinical aspects of patient care including
environment, food, privacy and dignity. The assessment
results help to highlight areas for improvement and share
best practice across healthcare organisations in England.
PLACEPatient-Led Assessments of the
Care Environment
Details are being finalised but the new assessments
were piloted in October. A total of 68 hospitals
were involved in pilot PLACE assessments. The Pilot
assessments ran from 1 October to 12 October 2012.
The assessments will be similar to the PEAT inspections
but with more lay members/patients on the teams (over
50% of the team members must be patients).
PMO
Project Management Office
A department or group that defines and maintains
the standards of process, generally related to
project management, or a particular project,
within the organisation.
NRLS National Reporting and Learning System
QIPPQuality, Innovation, Productivity
and Prevention
Through the National Reporting and Learning System,
the Patient Safety Division collects confidential reports
of patient safety incidents from healthcare staff across
England and Wales. Clinicians and safety experts help
analyse these reports to identify common risks and
opportunities to improve patient safety.
Quality, Innovation, Productivity and Prevention is a large
scale transformational programme for the NHS, involving
all NHS staff, clinicians, patients and the voluntary sector.
It will improve the quality of care the NHS delivers while
making up to £20billion of efficiency savings by 2014-15,
which will be reinvested in frontline care.
Norfolk Community Health and Care NHS Trust
RATs
Rapid Access Team
A team of nurses, therapists and social workers
who respond quickly to patients who are admitted
to accident and emergency at the Queen Elizabeth
Hospital to find alternative solutions to enable patients
to be cared for at home.
RCA
Root Cause Analysis
RCA is a process designed for use in investigating and
categorising the root causes of events. When incidents
happen, it is important that lessons are learned across
the NHS to prevent the same incident occurring
elsewhere. Root Cause Analysis investigation is a well
recognised way of doing this.
SARC Sexual Assault Referral Centre
SARCs are specialist medical and forensic services for
anyone who has been raped or sexually assaulted. They
aim to be a one-stop service, providing the following
under one roof: medical care and forensic examination
following assault/rape and, in some locations, sexual
health services. Medical Services are free of charge and
provided to women, men, young people and children.
SIRI
Serious Incident Requiring Investigation
The National Patient Safety Agency has developed a
national framework for serious incidents in the NHS,
titled ‘National Framework for Reporting and Learning
from Serious Incidents requiring Investigation’. An
incident or event or circumstance that could have
resulted, or did result, in unnecessary damage, loss or
harm such as physical or mental injury to a patient,
staff, visitors or members of the public. A serious
incident requiring investigation is defined as an incident
that occurred in relation to NHS-funded services and
care resulting in for example Unexpected or avoidable
death of one or more patients, staff, visitors or
members of the public; Serious harm to one or more
patients, staff, visitors or members of the public etc.
SM
Solihull Model
Solihull Approach is an integrated model of working;
open learning resource packs and training programme
for care professionals working with families, babies,
children and young people who are affected by
emotional and behavioural difficulties.
Quality Account 2013/14 – Glossary
77
STEIS Strategic Executive Information System
A system to collect data for the Department of Health.
All serious incidents requiring investigation (SIRIs) are
recorded onto this system by the Trust.
SystmOneSystmOne
SystmOne is a centralised clinical system that
provides healthcare professionals with a complete
management system.
TDA
Trust Development Authority
The NHS TDA will play its part in safeguarding
the core values of the NHS, ensuring a fair and
comprehensive service across the country and
promoting the NHS Constitution. It will be accountable
nationally for the outcomes achieved by NHS Trusts
and for financial stewardship within the NHS Trust
system as it is wound down.
TMT
Trust Management Team
A Team that comprises the Executive Directors, Deputy
and Assistant Directors of the Trust.
TUPETransfer of Undertakings (Protection of
Employment) Regulations 2006
The purpose of the Transfer of Undertakings (Protection
of Employment) Regulations is to protect employees if
ownership of their employer changes hands.
UCC
Urgent Care Centre
During 2013 plans were developed with other providers
across the county in conjunction with the Urgent Care
Network and CCGs, to set up an Urgent Care Unit
at the Norfolk and Norwich University Hospital. The
unit was piloted in November and December over two
weekends and went live on 20 January 2014, to run
over the period of winter pressures.
VTE
Venous Thromboembolism
A blood clot that forms within a vein.
WaterlowPressure Ulcer Risk Assessment
and Prevention Tool
Waterlow pressure ulcer risk assessment/prevention
policy tool is, by far, the most frequently used system in
the U.K. and it is also the most easily understood and
used by nurses dealing directly with patient/clients to
assess risks of the individual.
Head Office: Elliot House, 130 Ber Street, Norwich NR1 3FR
Online: www.norfolkcommunityhealthandcare.nhs.uk
Telephone: 01603 697300