COVENTRY AND RUGBY CLINICAL COMMISSIONING GROUP

Transcription

1 COVENTRY AND RUGBY CLINICAL COMMISSIONING GROUP Report To: Governing Body 11 September 2013 Report From: Title of Report: Purpose of the Report: Jacqueline Barnes, Executive Nurse The Nursing and Quality Team Nursing Report To update the Governing Body members on relevant topics relating to Professional Nursing and actions being taken to improve patient experience, quality of care and outcome. Key Points: This report provides information and updates on the following topics relating to: Patient Experience Friends and Family Testing Quality of Commissioned Services Reducing Harm Primary Care Nursing Care Homes Coventry and Warwickshire Safeguarding for Children and Adults HCAI/infection control Recommendation(s): The Governing Body is asked to note the information held in this report. Implications: Financial: HR / OD: Board Assurance/ Use of Resources: Risk Rating: Equality & Diversity: PPI: none none Supports the objectives of the CCG. Low None known Supports the objectives of the CCG

2 Health Strategy: Other NURSING, QUALITY AND SAFETY REPORT September 2013 Jacqueline Barnes, Executive Nurse Coventry and Rugby Clinical Commissioning Group 1

3 1. What our local population is telling us this month Feedback from patients, their families and carers is sourced in a number of ways. Staffing levels have been highlighted and is one of the priority areas the CCG is focusing on. Workforce plans from all the hospitals have been reviewed, we have visited hospitals and reviewed staffing levels where we have needed further assurance and the CCG is working closely with Health Education England to review nursing and medical staffing numbers, skill mix and education/training needs. 2. Friends and Family Test The Chart below shows the combined A&E and Inpatient Friends and Family Score and Response Rates for each Providers from April to June Whilst we are seeing an overall trend in improvement discussions have taken place with all trusts to understand the reasons for low scores and how response rates. Trust Name Combined FFT Score (A&E and Inpatient) Combined Response Rates (A&E and Inpatient) April May June April May June George Eliot Hospital NHS Trust % 5.5% 5.8% South Warwickshire NHS Foundation Trust % 10.3% 10.6% University Hospitals Coventry and Warwickshire NHS Trust % 19.7% 19.2% 2

4 Combined Friends and Family Score (April-June 2013) George Eliot Hospital NHS Trust South Warwickshire NHS Foundation Trust University Hospitals Coventry And Warwickshire NHS Trust April May June Source from NHS England as at Quality of Commissioned Services Attached for information are the latest versions of the quality dashboards for each of the hospitals. Performance of the clinical effectiveness and quality of services we commission are discussed monthly with each hospital. Announced/Unannounced visits The CCG Quality and Nursing team recently undertook an announced visit to Coventry and Warwickshire Partnership Trust following a number of safeguarding referrals from one ward. The visit provided assurance regarding the quality and safety of patient care provided on the ward. Further work was identified in relation to staff training. The formal report will be sent to the provider in September, Executive leads at the Trust have received a verbal report and action plans are being developed. Progress will be reviewed through monthly clinical quality performance meetings. An inspection by the Care Quality Commission to the Amber ward at Brooklands, an assessment and treatment unit for adults with learning disabilities in July 2013 identified two standards which were not being met which are: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run (outcome 1) and People should get safe and appropriate care that meets their needs and supports their rights (outcome 4). The full inspection report was published on 8 August 2013 and is available on the CQC website. The provider was already aware of the areas of concern and was taking action at the time of the review. The CCG and CQC are working together to monitor progress to address the concerns. 4. Reducing Harm - Safety Thermometer The latest safety thermometer results dashboard for each Trust are appended. Pressure ulcers University Hospital Coventry and Warwickshire and Coventry and Warwickshire Partnership Trust are working in partnership to reduce the prevalence of pressure ulcers. An in-depth review has 3

5 taken place to improve our understanding of the reasons patients are getting pressure ulcers and to identify opportunities to make improvements. Part of the work programme involves raising awareness and understanding across primary care and within care homes on prevention and management of pressure ulcers. Presentations will be made to locality boards during September and October and care home staff are being invited to participate in the root cause analysis investigation when a pressure ulcer is identified. It has also been recognised from the review the need to ensure that patients and their carers understand what a pressure ulcer is and how they can be prevented. Not using pressure relieving equipment that has been supplied is sadly becoming too common a theme. Our Head of Patient Experience and Communications department are supporting the nursing team to help develop a raising awareness campaign, we will bring more details on this in our next report. Falls An Arden wide study day on falls is planned for 18 th September The aim is to raise awareness and disseminate good practice and local initiatives to reduce falls in hospitals and care homes. 5. Primary Care Nursing Monthly General Practice Nurse (GPN) Leads meetings with the Executive Nurse have been established. The purpose is to develop a work plan to improve the quality of nursing services delivered by Nurses and Health Care Assistants (HCA) in general practice and provide professional support and advice. The key areas the GPN lead nurses have identified to be addressed are: Training and supervision for Health Care Assistants Training programmes for immunisation and screening Induction and support for nurses and HCAs new to general practice How GPN s can support the delivery of local QIPP schemes The CCG Clinical Quality & Governance Committee in August discussed the implications of the recent Cavendish Review (2013) for health care assistants working within primary care. The Cavendish review is an independent review into healthcare assistants and support workers in the NHS and social care settings, in response the locality General Practice Nurse Leads collectively raised their concerns to the CCG. Discussion included the need for clinical supervision of HCAs, minimum training recommendations to ensure competence and the need to define the scope of practice. The Cavendish report suggests that failings stem from HCAs being supervised and managed by general managers rather than by nurses. It recommends that HCAs undertake a fundamentals of nursing training programme and on completion they adopt the title of Nursing Assistant. National guidance states that the most appropriate supervisor of Nursing Assistants are Nurses. The Committee agreed to give their support to a letter that would be sent to all practices from the Executive Nurse. It will ask that Practice Managers and Practice Nurses review their current arrangements for the supervision for HCAs and will recommend as best practice that HCAs are supervised by Registered Nurses. This supports the recommendations made in the Cavendish review. Further work to review a programme of training and scope of practice will be developed in the coming months. 4

6 6. Care Homes Coventry and Rugby CCG provide care home clinical support services with a team of nurses from Arden Commissioning Support Unit (ACSU) in May The clinical team work closely with Coventry City Council, CQC and care home providers to ensure that all residents receive safe, high quality care. Where there are concerns raised immediate action is taken by a contract monitoring office and the team. In Coventry there are four homes currently subject to on-going review and monitoring. Two nursing homes remain subject to a Service Safeguard of which one home is also subject to CQC compliance actions, a further home is also subject to CQC compliance actions and one home is subject to a contractual breach notice by both the CCG and Local Authority. In Warwickshire there are two homes currently subject to on-going review and monitoring. Two South Warwickshire nursing homes have placement stop in place. In each cases such as these, the CCG, Local Authority and Care Quality Commission work together to improve the care and ensure the continued safety of the residents. All patients are clinically reviewed and risk assessed, plans are put in place to mitigate any risks. All residents and their GP s are informed of the concerns with quality and safety. A full quality review of the home is completed and action plans put in place which are monitored weekly. Monthly joint review meetings with the CCG, Local Authority and Care Quality Commission take place to review progress provide assurance. Independent provider quality assurance dashboard There are 268 locations providing care in Warwickshire alone. Coventry has 73 nursing and residential care homes and therefore in order to obtain formative intelligence on contract compliance a quality assurance dashboard has been launched in August 2013 across Coventry and Warwickshire nursing homes. This self-assessment tool is internet based and designed to monitor the quality key performance indicators in the NHS contract. This will for the first time capture serious incidents and never event reporting. The system captures equipment compliance and staffing profiles. It also captures vacancies to help with discharge and CHC placements. One unique feature is that every quality indicator is linked to learning material and national guidance. Phase 1 implementation focused on nursing homes and was well attended and received by providers. The live data submission commences in October 2013.It is intended that eventually all care homes will report in. Care Home Website On the 1 st October a designated care home website will be launched. It supports the quality dashboard and is hyperlinked to key learning material and national guidance. Each page signposts further useful websites on the topic and theme. 5

7 7. Safeguarding Below is the current position for safeguarding training. Coventry Rugby NWCCG SWGGC practices practices Children Completed all outstanding sessions 1 outstanding Rescheduled session for September Complete 1 outstanding Rescheduled session for September Adult 32 trained 7 complete 21 complete 36 completed 33 outstanding 3 outstanding 7 outstanding 8 outstanding All GP practices have been contacted to provide assurance that they have sourced Adult and Children s safeguarding training. GP practices as a result have contacted the safeguarding training lead to book or access safeguarding training and to confirm practice requirements. As a response to outstanding adult safeguarding training requirements in Coventry, sessions with increased capacity are being planned for staff from practices. GP Practices are continuing to identify Safeguarding leads and to amend records where there are changes in staffing. Safeguarding Vulnerable Adults The current serious case review in Coventry is nearing completion. It is anticipated that the review will be published in the autumn. A further Coventry case has met the criteria for a Serious Safeguarding Review (May 2013) and is currently being scoped by the Serious Case Review sub-committee. There are no current serious case reviews in Warwickshire. A domestic homicide case review has commenced. The Coventry Safeguarding Annual Event will be held in November The theme of the event is Creating a Safer Coventry and guest speakers include Anthony Sumara, former NHS Chief Executive of Mids Staff NHS Trust and Malcolm Alexander from the Healthwatch & Public Involvement Association. Safeguarding Children and Young People There are currently 3 serious case reviews and one domestic homicide review underway in Coventry: Commenced on and following trial both parents have been found guilty of murder. The independent author and chair have reviewed additional information that arose during 6

8 the trial to ensure that all of the key issues are addressed. The report will be published in the coming weeks. Review has concluded and publication is currently being considered. A serious case review is due to be completed end September Criminal proceedings are ongoing. The first draft authors report has been reviewed by the serious case review subcommittee. DHR - Kent undertook this review and the report is currently being reviewed by the home office. Actions for Coventry have been completed. There are no current serious case reviews for children and young people in Warwickshire. Looked after children A significant number of children from Coventry (600+) are looked after by the local authority. This has led to a four fold increase in demand for adoption medicals and the CCG is supporting the Local Authority in addressing medical capacity needs. An Ofsted adoption inspection took place between th August for Coventry. Feedback is awaited. 8. HCAI/ infection control There have been two cases of MRSA reported by University Hospitals Coventry and Warwickshire during August. A post infection review has been completed for the first case with the outcome that it has been defined as a community case and therefore assigned to the CCG. This will result in the CCG failing to meet its quality premium target for the year. The second post infection review is in progress and the outcome is awaited. Plans are being developed to improve the clinical management of norovirus in our hospitals and community in Coventry and Warwickshire. All four NHS Trusts are working with commissioners to develop a single plan for the health economy by the end of October. Education days are planned for September and October to hospital and care home nursing staff to understand how patients with norovirus can be best cared for in order to prevent admission to hospital. Details of the plans will be sent to our GP s in the coming months. Interviews for the vacant Infection Prevention and Control posts took place end of July and early August and two appointments have been made. 7

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12 CCG Quality Dashboard - Coventry & Warwickshire Partnership Trust (CWPT) Area Indicator Source Frequency Threshold Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Comments Patient Experience CQC National Inpatient Survey CQC Annual > Complaints & PALS Number of complaints CQR Bimonthly Number of PALS Contacts CQR Monthly Number of Serious Incidents reported SORD Monthly Patient Safety Number of overdue Serious Incidents SORD Monthly Number of Never Events SORD Monthly Duty of Candour failures n/a n/a 0 Hospital-Acquired Infections MRSA bacteraemia (post 48 hrs) CQR Monthly C.diff CQR Monthly Falls with harm NHS IC Monthly 2.23% 4.20% 2.67% 2.80% 1.61% 3.91% 1.88% 1.88% 4.42% 2.24% 3.84% Patient Safety Thermometer Pressure Ulcers (New) NHS IC Monthly Pressure Ulcers (All) NHS IC Monthly 1.1 < % 2.10% 1.78% 1.56% 3.38% 2.31% 2.05% 2.57% 0.68% 1.38% 1.75% 9.52% 12.59% 10.47% Catheter-Acquired UTI (New) NHS IC Monthly 0.81% 0.53% 0.71% 0.31% 0.48% 0.36% 0.00% 0.17% 0.00% 0.17% 0.70% VTE risk assessment NHS IC Monthly 6.07% 0.70% 5.17% 9.19% 6.28% 12.46% 2.22% 5.48% 3.06% 8.10% 6.46% Mixed Sex Accommodation Numbers of unjustified breaches CQR Monthly Statutory/Mandatory training Board rpt Monthly 8% 6.85% 14.40% 22.45% Workforce Percentage of Agency Useage Board rpt Monthly 3.6% 4.90% 4.90% 5.00% 5.10% 5.10% 5.20% 5.30% 5.70% 5.10% 5.6% 5.7% PDP Appraisal Compliance Board rpt Monthly 100% 84.30% 85.90% 86.10% 85.30% 82.10% 79.60% 83.40% 83.70% 80.60% 81.3% 81.20% Sickness Absence Rate Board rpt Monthly 4.65% 5.31% 6.00% 6.30% 6.10% 8.57% 5.82% 5.41% 4.91% 4.39% 4.48% 4.37% Please note 4.65% is a new target for in light of national benchmarking information Staff training compliance Level 1 Board rpt Monthly 95% 82% 77% 62% Biannual reporting Safeguarding Children Training Staff training compliance Level 2 Board rpt Monthly 95% 75% 74% 68% Biannual reporting Staff training compliance Level 3 Board rpt Monthly 95% 54% 56% 30% Biannual reporting Safeguarding Adults Training Staff training compliance Level 1 Board rpt Monthly 95% 75% 72% 65% Biannual reporting Staff training compliance Level 3 Board rpt Monthly 95% 75% 63% 64% Biannual reporting Staff training compliance Level 3 Board rpt Monthly 95% 46% 100% 76% Biannual reporting Page 1 of 1

13 CCG Quality Dashboard - George Eliot Hospital NHS Trust (GEH) - Last updated / 2014 Area Indicator Source Frequency 13/14 Threshold Apr May Jun July Comments Hospital Mortality SHMI NHS IC Quarterly 1.1 HSMR Board Rpt 98.6 n/a n/a Last published on (for Jan-Dec12), next publish date will be Oct 13. CQC National Inpatient Survey Board Rpt Annual > Patient Experience Friends and Family Test Board Rpt Monhtly > (Net Promotor Score) Number of complaints Board Rpt Monthly Data from Jess are 71, 78,88,and 71 for Apr-Jul. These are actually the Inpatient score only but we use the combined score for A&E and Inpatient. We need to clarify which one we should use to avoid discrepancy. Complaints & PALS Complaints responded to within 25 working days Board Rpt Monthly 90% 100% 100% 96% July data is not due (Provided 1 month in arrears to allow 25 days after end of month) Number of PALS Contacts Board Rpt Monthly Provider said they will be reporting in the future. Number of Serious Incidents reported SORD Monthly Patient Safety Number of overdue Serious SORD Monthly Incidents Number of Never Events SORD Monthly The date of overdue incidents are from to end of the month (without the valid clock stop) Duty of Candour failures Board Rpt n/a 0 By exception from the end of June. (2 months behind) Hospital-Acquired Infections MRSA bacteraemia (post-48h C.diff (Monthly data) C.diff (Cummulative data) Public Health England Public Health England Public Health England Monthly Monthly Monthly Falls with harm NHS IC Monthly 1% 0% 0% 1% Pressure Ulcers - All NHS IC Monthly 11% 7% 6% 8% Patient Safety Thermometer Pressure Ulcers - New NHS IC Monthly 4% 2% 2% 5% Catheter-Acquired UTI NHS IC Monthly 1% 1% 3% 2% VTE risk assessment NHS IC Monthly 90% 95% 95% 96% 96% All data from Jess Mixed Sex Accommodation Workforce Numbers of unjustified breaches Statutory training compliance Mandatory training compliance Agency spend as a % of Trust Paybill CQR Monthly Board Rpt Quarterly 80% 91% 92% 91% 90% CQR Quarterly 80% 86% 87% 87% 85% Board Rpt Monthly 4.4% 11.70% 13.80% 12.30% 13.57% PDP Appraisal Compliance Board Rpt Quarterly 85% 82% 83% 83% 84% Safeguarding Children Training Safeguarding Adults Training Waiting Times Sickness Absence Rate Board Rpt Quarterly 3.39% 3.85% 3.55% 4.05% 3.88% Staff training compliance 90% 93% 93% 86% 86% CQR Quarterly Level 1 Staff training compliance 90% 62% 66% 81% 81% CQR Quarterly Level 2 Staff training compliance 90% 55% 61% 68% 65% CQR Quarterly Level 3 Staff training compliance CQR Quarterly 80% 96% 98% 97% 96% A&E (from arrival to transfer/admission/discharg C&P Monthly 95% 90% 95% 98% 96% e) All cancers (62 day wait for C&P Monthly 85% 96% 79% 87% 86% 1st treatment) All cancers (31 day wait from diagnosis to 1st C&P Monthly 96% 97% 100% 96% 98% treatment) RTT waits - % 18 weeks - C&P Monthly 90% 90% 91% 92% 92% admitted RTT waits - % 18 weeks - C&P Monthly 95% 96% 96% 97% 96% non-admitted All providers facing challenge to meet Level 3 training target due to availability of multidisciplinary training. Page 1 of 2

14 Compliance with use of the WHO Safer Surgery Checklist Safer Surgery Checklist Compliance with full completion of the WHO Safer Surgery Checklist CQR Quarterly 100% % 99.79% % 100% CQR Quarterly 100% % 99.57% % 100% Page 2 of 2

15 CCG Quality Dashboard - South Warwickshire NHS Foundation Trust (SWFT) - Last updated / / 2014 Area Indicator Source Frequency 13/14 Threshold Base rate (Pls do not change Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Comments Hospital Mortality SHMI NHS IC Quarterly 1.1 n/a 12 months to Sept months to Dec 1.03 Last published on (for Jan-Dec 12), next publish date will be Oct 13. RAMI (month in arrears) Trust Monthly 100 n/a Data not yet available. Patient Experience CQC National Inpatient Survey CQC Annual > n/a National In Patient survey score for 2012 was 7.88 rated over 10 outcomes Acute Friends and Family Test (Net Trust Monthly > Promotor Score) Correct data inserted - the Acute score is required. Community data inserted hence the discrepancy. Number of complaints CQR Monthly n/a Data validated by Complaints team. Complaints & PALS Acknowledgment letter sent within 3 CQR Monthly n/a 100% 96% 100% 79% 94% 89% 93% 91% 75% 84% 84% 100% Data validated by Complaints team. working days (%) Number of PALS Contacts CQR Quarterly n/a Q4 data not yet available Number of Serious Incidents reported SORD Monthly n/a Patient Safety Hospital-Acquired Infections Number of overdue Serious Incidents n/a Number of Never Events SORD Monthly Duty of Candour failures n/a n/a 0 0 National quality requirement intoduced as part of 13/14 Duty of Candour measure to go live as of 1st April Provider Contract regarding informing patients/relevant representative of patient safety incidents. Public Health MRSA bacteraemia (post-48hr) Monthly England Public Health C.diff (Monthly) Monthly England Public Health C.diff (Cummulative data) Monthly This is a cumulative data and SWFT are within trajectory. England Falls with harm NHS IC Monthly n/a 0.93% 0.34% 0.51% 0.81% 0.33% 0.64% 0.43% 0.53% 0.25% 0.58% 0.08% 0.16% 0.35% Patient Safety Thermometer Pressure Ulcers - All NHS IC Monthly % 7.38% 7.45% 6.44% 5.48% 7.21% 6.06% 7.19% 5.57% 6.21% 2.96% 3.17% 3.23% Pressure Ulcers - New NHS IC Monthly % 0.51% 0.43% 0.82% 0.99% 0.73% 0.52% 0.77% 0.57% 0.84% 0.57% 0.65% 0.52% Catheter-Acquired UTI NHS IC Monthly n/a 1.69% 1.26% 1.61% 1.25% 1.06% 0.80% 1.12% 0.61% 0.50% 0.50% 0.02% 0.73% 0.35% VTE risk assessment NHS IC Monthly n/a 35.84% 37.22% 31.39% 34.79% 30.61% 31.09% 35.90% 25.51% 29.87% 93.60% 81.10% 85.50% 90.73% Cervical Screening Programme Mixed Sex Accommodation Workforce Immunisation rate for girls aged around for human papilloma virus vaccine (HPV) 80% (one jab) % of eligible patients screened Numbers of unjustified breaches CQR Monthly Statutory/Mandatory training CQR Quarterly 80% 80% 75% 81% 83% 86% Target changed 2013 to 80% Agency spend as a % of Trust Paybill n/a Data not available. PDP Appraisal Compliance CQR Quarterly 80% 80% 59% 61% 60% 83.5% Data from technical dashboard. Sickness Absence Rate CQR Quarterly 3.8% 3.8% 4.81% 4.62% 4.86% 4.20% 4.13% 3.79% Data not yet available. Target changed 2013 to 3.8%. Safeguarding Children Training Safeguarding Adults Training Staff training compliance Level 1 CQR Biannual 90% 90% 96% 93% 93% 92% Staff training compliance Level 2 CQR Biannual 90% 90% 95% 96% 98% 97% Staff training compliance Level 3 CQR Biannual 90% 90% 80% 87% 86% 89% Staff training compliance CQR Biannual 90% 90% 89% Report due in October A&E (from arrival to transfer/admission/discharge) C&P Monthly 95% 95% 96.6% 98.6% 97.7% 95.3% 93.6% 91.8% 90.7% 89.8% 84.7% 92.7% 96.5% 96.5% 94% All cancers (62 day wait for 1st treatment) C&P Monthly 85% 85% 85.2% 85.2% 86.0% 91.2% 85.9% 85.5% 85.4% 71.1% 84.7% 90.4% 81.3% 85.0% July data subject to validation by SWFT informatics team. Waiting Times All cancers (31 day wait from diagnosis to 1st treatment) C&P Monthly 96% 96% 100.0% 91.0% 98.9% 98.7% 100.0% 98.7% 100.0% 98.7% 99.1% 100% 100% 98.60% July data subject to validation by SWFT informatics team. RTT waits - % 18 weeks - admitted C&P Monthly 90% 90% 92.2% 92.3% 91.1% 88.1% 86.8% 87.5% 90.0% 89.9% 90.0% 90.2% 90.87% July data subject to validation by SWFT informatics team. RTT waits - % 18 weeks - non-admitted C&P Monthly 95% 95% 97.1% 97.1% 95.9% 95.9% 95.5% 96.8% 97.0% 96.8% 96.5% 96.7% 96.35% July data subject to validation by SWFT informatics team. Compliance with use of the WHO Safer Surgery Checklist Safer Surgery Checklist Compliance with full completion of the WHO Safer Surgery Checklist CQR Monthly 100% 100% 100% 100% 100% 100% 100% 100% 100% 96.00% 97.00% 97.50% 96% 97% 97.30% CQR Monthly 98% 98% 92.30% 87.00% 90.10% 92.70% 90.10% 97.70% 98.00% 97.00% 96.00% 98.3% 97.0% 98.5% 98.40% This was interpreted as the 'Use' of WHO checklist. The wording differs from the Technical dashboard. If it is the same - numbers now match. This was interpreted as the 'Use' of WHO checlkist. The wording differs from the Technical dashboard. If it is the same - numbers now match. Page 1 of 1

16 CCG Quality Dashboard - University Hospitals Coventry & Warwickshire (UHCW) Area Indicator Source Frequency Threshold Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Comments Hospital Mortality SHMI NHS IC Quarterly months to Sept months to Dec months to Mar Patient Experience CQC National Inpatient Survey CQC Annual > Friends and Family Test (Net Promotor Score) Annual report UHCW Monthly > 34% 42% 55% Please note, this indicator is now based on the Combined FFT report published by NHS England Friends and Family Test (response rate) UHCW Monthly 20% 22.8% 19.7% 19.2% Please note, this indicator is now based on the Combined FFT report published by NHS England Number of complaints Board rpt Quarterly Complaints & PALS Complaints responded to within timescale (%) Board rpt Quarterly Not reported Not reported Not reported 65% To be reported by exception Number of PALS Contacts Board rpt Quarterly Not reported Not reported Not reported Not reported To be reported by exception Number of Serious Incidents reported SORD Monthly Patient Safety Number of overdue Serious Incidents SORD Monthly Number of Never Events SORD Monthly Duty of Candour failures n/a n/a 0 Hospital-Acquired Infections MRSA bacteraemia (post 48 hrs) CQR Monthly C.diff CQR Monthly Falls with harm NHS IC Monthly 0.5% 0.2% 0.3% 0.0% 0.0% 0.1% 0.1% 0.2% 0.09% 0.09% 0.47% Patient Safety Thermometer Pressure Ulcers (All) NHS IC Monthly 3% 3.21% 3.69% 2.75% Pressure Ulcers (New) NHS IC Monthly 0.50% 4.5% 3.2% 3.9% 3.0% 3.6% 4.6% 3.3% 2.5% 0.18% 0.09% 0.19% Catheter-Acquired UTI NHS IC Monthly 0.5% 0.6% 0.9% 1.1% 0.6% 0.8% 0.1% 0.4% 0.28% 0.28% 0.19% VTE risk assessment NHS IC Monthly 90% 93.2% 92.6% 93.0% 93.0% 93.7% 93.6% 92.68% 94.38% 92.29% 95.83% 91.76% Mixed Sex Accommodation Numbers of unjustified breaches CQR Monthly Statutory/Mandatory training Board rpt Monthly 100% N/A 64.76% 65.83% 65.07% 62.03% Workforce Agency spend as a % of Trust Paybill Board rpt Monthly 4.10% 2.84% 4.23% 3.70% 3.17% 4.00% 3.86% 5.17% 5.51% 6.28% 6.44% PDP Appraisal Compliance Board rpt Monthly 59.96% 58.77% 55.05% 54.55% 53.20% 53.49% 54.46% Sickness Absence Rate Board rpt Monthly 3.39% 4.32% 4.56% 4.79% 5.23% 5.00% 5.06% 4.46% 4.24% 4.43% 4.19% 4.06% Safeguarding Children Training Safeguarding Adults Training Staff training compliance Level 1 90% Not reported in 2012/13 Biannual reporting (Sept & Mar) Staff training compliance Level 2 90% Not reported in 2012/13 Biannual reporting (Sept & Mar) Staff training compliance Level 3 90% Not reported in 2012/13 Biannual reporting (Sept & Mar) Staff training compliance 80% Not reported in 2012/13 Biannual reporting (Sept & Mar) A&E (from arrival to transfer/admission/discharge) CPPM Monthly 95% 96.16% 95.54% 94.36% 91.09% 86.96% 86.25% 86.00% 81.60% 81.44% 92.83% 95.66% All cancers (62 day wait for 1st treatment) CPPM Monthly 85% 85.71% 85.14% 85.00% 84.66% 87.50% 86.58% 82.10% 87.40% 86.38% 82.76% 78.57% Please note that the figures for Apr-Jun have been updated Waiting Times All cancers (31 day wait from diagnosis to 1st treatment) CPPM Monthly 96% % % 99.50% 99.48% % 98.92% 98.70% % % 98.37% 99.46% RTT waits - % 18 weeks - admitted CPPM Monthly 90% 96.20% 95.33% 94.94% 95.11% 95.22% 94.63% 94.50% 94.37% 91.90% 90.54% 89.50% RTT waits - % 18 weeks - non-admitted CPPM Monthly 95% 97.99% 97.56% 97.69% 98.07% 97.85% 97.82% 98.10% 97.77% 97.57% 97.53% 97.56% Safer Surgery Checklist Compliance with use of the WHO Safer Surgery Checklist CQR Monthly 100% 99.00% 99.60% 99.16% 99.50% 99.70% 99.40% 99.70% 99.70% 99.70% % 99.34% Page 1 of 1