Quality Account. Croydon Health Services NHS Trust Quality Account /1601

Transcription

1 Quality Account 2015/1601

2 Contents Part 1 Information about the Quality Account Statement on quality from the Chairman and Chief Executive of Croydon Health Services NHS Trust Part 2 Priorities for improvement and statement of assurance from the Board 2.1 Priorities for improvement Statements of assurance from the Board of Directors 2.3 Reporting against core indicators Part 3 Review of Quality Performance Review of Quality Priorities Performance against national priorities 3.3 Statements from Croydon Clinical Commissioning Group, Healthwatch Croydon, Croydon Council Health, Social Care & Housing Scrutiny Sub Comittee & External Auditors Appendicies 1. National Clinical Audits - actions to improve Quality 2. Local Clinical Audits - actions to improve Quality 3. Glossary 3

3 Part 1 Information about the Quality Account Statement on quality from the Chairman & Chief Executive Caring for Croydon together Welcome to our 2015/16 Quality Account. At Croydon Health Services NHS Trust, we are determined to continue improving our care and deliver excellent services, all the time, for our patients and service users across our community. We are always challenging ourselves to do better. An important part of this is looking back over the past year to assess the quality of care provided and to take stock of our improvements in patient safety, what our service users say about their care, and the responsiveness and effectiveness of our treatments. This is a challenging time for NHS organisations all across the country. The demand for health services is soaring. Here in Croydon our population is expected to rise by 20,000 to over 400,000 people by The proportion of over 65s in the borough - many of whom have complex health needs - is also increasing. To enable us to meet this growing demand, we are changing patient pathways and improving care 24/7. Our incredible and caring staff are crucial to all of our aspirations. Croydon Health Services was the first NHS organisation to receive accreditation for Listening into Action (LiA), our way of engaging with all staff from the ground up to continuously improve our services. Now entering its fourth year (2016/17), LiA is continuing to help us galvanise staff at every level of the organisation to always look objectively at how far we ve come, and what we need to achieve next. 4 5

4 Significant progress In its latest inspection report (published October 2015), the Care Quality Commission praised many aspects of our services, including our gentle, kind and caring staff. The health regulator said we had made significant progress since its previous inspection two years ago, with Listening into Action playing a key part in empowering our staff to bring about rapid and real changes that benefit our patients and community service users. The CQC noted 13 areas of outstanding practice, including our special care baby unit, our 24-hour community nurses and specialist palliative care team for the support they give patients in the last days or hours of life. The inspectors also rated three services as good - A&E, maternity and gynaecology, and children and young people. However, the CQC also highlighted 14 areas which required improvement, including in outpatients, diagnostics, medicine and surgery. Overall inspectors rated the Trust as requires improvement and gave us four areas where we must take action. We immediately began to address some of the issues and are pleased with progress so far. Our three new clinical directorates and their leadership teams are now in place to improve clinical governance and risk management across the Trust. We are in the process of agreeing an extensive refurbishment plan for our nine main surgical theatres in 2016/17. Croydon University Hospital performs more than 30,000 surgical operations every year. More than 1million has already been spent (2015/16) on new theatre equipment, including new anaesthetic machines, and operating tables. These include: Reminiscence tea parties suggested and run by our nursing teams to enhance our support for patients with dementia, and improve their experience of care in hospital; Innovative research projects to pioneer new treatments and medical advances, involving clinical staff right across the Trust; A new clinically-led sepsis taskforce, to improve diagnosis and treatment of this very serious condition; A wide-range of initiatives to minimise delays for patients waiting to be admitted or discharged after a hospital stay, by booking patient transport and medicines to take home a day in advance. However, we know there is more to do and as a Trust we are working tirelessly at every level to constantly improve. A survey by Healthwatch Croydon (published February 2016) found that vast majority of our patients (82%) now wait less than an hour in the Discharge Lounge to go home after a hospital stay, but just one in four said we could have been much clearer in how we involve patients more in decisions about their care, and keeping their families and carers up-to-date should plans unavoidably change. Continued improvement here will be an on-going quality priority for the year ahead. There has also been rapid progress on ensuring staff complete up-todate safeguarding and mandatory training, with a 12 per cent rise since the CQC inspection and action plans for every directorate to get 90 per cent of staff to the required level. Additionally, we have improved our scheduling system for operations to improve efficiency and patient communication and invested in new IT for our community nurses, therapists and midwives. As you will see from this report, there are also excellent projects by individual teams who are driving up the quality of care we provide. 6 7

5 Placed-based care for all Continued improvement We need to do much more to keep people well, and prevent ill-health. This means working in partnership to join-up services and look beyond institutional hospital-based care. Keeping people healthy is not something we can achieve in isolation, which is why this year we have forged crucial new alliances with other health organisations, charities and the London Borough of Croydon to deliver fully integrated care. We believe this will bring about real benefits to the whole of our community. Our vision is working together to care for Croydon. We are starting with our services for the young and old. We will be one of the first UK boroughs to fully combine services for under 5s and their families. Croydon Best Start with Croydon Council will bring together our health and local authority services, including: health visiting, children s centres, early years and midwifery. We have also formed an alliance across the borough to transform our care for thousands of older people living in Croydon. Croydon Clinical Commissioning Group and Croydon Council have chosen an Accountable Provider Alliance (APA) model to take forward Outcome Based Commissioning for over 65s. Working together with social care (local authority), the Croydon GP Collaborative, South London and the Maudsley NHS Foundation Trust, and Age UK Croydon, we aim to joinup health and social care services in across the borough. The Alliance will be focused on the delivery of set outcomes, as defined by people who use our services, including how to keep people well, socially active and more independent for longer. For Croydon citizens, this will mean more coordinated care, built around their needs and not individual organisations. For our staff, this means working in partnership with the voluntary sector, GPs, social care, hospital and community health services and mental health services as we cannot achieve this alone. This report demonstrates just what the Trust has achieved during 2015/16, so that we can continuously monitor our improvement journey and set clear targets for what more needs to be done. Over the past year, we have continued to invest heavily in our services, but like the majority of acute trusts, we have a significant financial deficit. To address this, we must find sustainable ways of increasing our efficiency, while not compromising on care. A large part of this is putting our staff in the driving seat, to prevent duplication and act on their ideas on what we can and should do better. Last year, as part of Listening into Action, we asked our staff to come together to discuss what we could do differently to manage higher demand during the busy winter months. As a result, our consultants put forward a new one stop unit for rapid medical treatment without having to wait in A&E. Patients, including the frail and elderly and people with breathing difficulties caused by lung disease or infection whose conditions mean they frequently need urgent care, can now be referred direct to the Edgecombe Unit by their GP or from within the hospital. This is a consultant-led service available seven days a week. Engaging our staff has also led to a step-change in our A&E performance. Whilst like many Trusts we did not consistently meet the national four hour waiting time standard throughout the year, the Emergency Department s performance at Croydon University Hospital has gone from 127 to the top 30 in the country. As we end the financial year (2015/16), our A&E performance is in the top five in London but we are far from complacent and we are working together with our partners in Croydon, including social care, to coordinate services for our patients and deliver the right care in the right care setting. We are looking forward with confidence and excitement at the further improvements we believe we can achieve over the next 12 months. In 2017 we will open a new 21.25m Emergency Department (Accident & Emergency) at Croydon University Hospital. Designed by our very own Emergency Department clinicians, this state-of-the-art facility will be bigger, brighter and better, to give us the flexibility to cope with changes in demand, and give people in Croydon the very high standards of care that we work hard to provide. This will begin the next chapter in our care for Croydon. This report sets out our ambitious improvement priorities for the year ahead to deliver this and more, to continuously enhance the quality, experience and safety of our care. We are pleased to confirm that the Trust Board has reviewed the 2015/16 Quality Report and to the best of our knowledge all the information in this document is accurate. Mike Bell Chairman John Goulston Chief Executive Croydon Health Services NHS Trust 28 June

6 Executive summary Key achievements last year All Trusts are required to produce a Quality Account to describe past and future activities to improve the quality of services they provide. In this report (from page 12) we describe our main priorities for 2016/17. We are required to include specific data from 2015/16 that we have provided to National Bodies such as the Care Quality Commission and the Health and Social Care Informatics Centre (from page 30). In section 3 of this report we describe our achievements against the quality priorities we set in 2015/16. We have explained our acronyms and terms in the main text; there is also a full glossary at the end of the report. Croydon s population is aging and increasing but is not matched by sufficient growth in health funding. This is alongside rising expectations of care and standards. Croydon faces a number of key challenges, including: the highest overall population and number of looked after children of any London borough; increasing deprivation; significant variation in life expectancy and high rates of emergency hospital attendances and admissions per thousand population. Croydon has a population of approximately 383,000 and is growing by about one per cent per year. Over the next five years this will result in; a higher number of people aged over 85; a larger proportion of younger people; and an increase in the proportion of Black and Minority Ethnic Groups. Croydon Health Services NHS Trust is an integrated care organisation providing healthcare in both the hospital and community setting. Our clinical directorate structure is designed to maximise the benefits of this for our patients, their families and carers. In June 2015 we reviewed our clinical directorate structure and streamlined it to three clinical directorates, each led by a clinical director (a senior clinician) supported by a senior nurse and a senior operational manager: Integrated Adult Care Integrated Women Children s and Sexual Health Services Integrated Surgery, Cancer, and Clinical Support Our priority is to ensure that the population we serve receive high quality, safe and compassionate care irrespective of what time or day they require it. As an Integrated Care Organisation, providing both hospital and community services, we will be shifting our focus of care towards prevention and early intervention to provide safer, more effective and more economic healthcare. We set ourselves five quality priorities in 2015/16 covering the five CQC domains of (Safe, Effective Caring, Responsive and Well Led). Staff across the Trust have used these domains in assessing and reporting their services with the aim of making this business as usual. We achieved many of the priorities that we set ourselves last year and a detailed review can be found from page 14 of this report. There are some priorities that we have not progressed to the level that we would have liked and with this mind we are building on the progress we have made this year and carrying over into next year s priorities. Examples of good practice include: We received a CQC rating good for caring and also received 30 GOOD rating for services across the board First NHS Trust to be accredited by LiA We obtained level 2 for information governance compliance We achieved 96% for Harm Free Care against a national average of 94% We have achieved a 45% reduction in pressure ulcers We have achieved a 44% reduction in hospital cardiac arrests since 2013/14 We were featured in day 64 NHS 100 stories for LiA work Areas for improvement that are reflected in our priorities for 2016/17 Improve how we share the learning from incidents and complaints Improve our incident reporting with a focus on no harm and low level reporting Reduce the number of incidents of avoidable harm with a focus on medication safety, Sepsis and Acute Kidney Injury Improving quality lies at the core of all we do as a Trust. Our aim is to deliver excellent integrated care for the people of Croydon, when and where they need it

7 We constantly strive to improve the services we offer by placing quality at the heart of any planned developments. Therefore we monitor quality activity and improvements in order to determine how well we are doing, and report quality outcomes and information both locally at clinical delivery level and at Board level. Trust-wide information relating to safety, effectiveness and patient experience is analysed and reported via the Board subcommittee structure. A formal Executive Quality Report is presented monthly to the Board. This offers analysis of performance across all these areas to inform current state and future developments. In September 2015 we appointed a new Director of Quality Assurance and Governance who is the executive lead for quality and is responsible for keeping the Board informed of quality issues, risks, provision of assurance on corporate governance. External review and monitoring also occurs from a variety of stakeholders including NHS Commissioners and regulators (such as the Care Quality Commission). Information relating to each of the sections throughout this Quality Account is a true reflection of quality performance for 2015/16. This includes where things have not gone as planned or where we have made errors from which we have learned lessons resulting in changes to practice. Unless otherwise stated, tables/diagrams throughout this report are Trust-wide and reflect performance across the Trust s portfolio of services. We have mechanisms in place to help us to learn from adverse events, complaints and patient experience feedback and many examples of this are included throughout the relevant sections. At Croydon Health Services NHS Trust we are keen to share information publicly about the quality of our services and about our continuous improvement work. You will be able to access a copy of our Quality Account by: Viewing it on NHS Choices Viewing it on Croydon Health Services NHS Trust website Requesting a hard copy from our communications team at CH-TR.Comms@nhs.net We hope that you find our Quality Account informative. If it prompts further questions, or you have any comments about our services, we would like to hear from you

8 2.1 Part 2 Priorities for improvement and statements of assurance from the Board Priorities for Improvement 2016/17 The safety of our patients is an important priority for the Trust. Our vision is for a safety culture that is fully embedded and integral to our everyday business, where we are leaders in the field for driving improvements in the safety of our patients, and where we have achieved a 50% reduction in the number of patients who suffer avoidable harm. To achieve this a key challenge for the Trust will be to continue to maintain and grow quality in a financially challenged and workforce constrained era, and our key areas of focus have been informed from national regulatory (including CQC targets post inspection), Royal Colleges, NICE and CQUIN targets. In addition we have also used our local intelligence gained via triangulating data from serious incident (SI) investigations, complaints, and patient and staff feedback. This has helped inform a long list of objectives for our Quality Account from which key strands of intertwined work emerged. Our priorities for 2016/17 were developed in discussion with our Clinical Directorates, Patient Safety and Mortality Committee, our Commissioners Croydon CCG (Croydon Clinical Commissioning Group), and Healthwatch. They reflect a review of themes from incidents and serious incidents (SI s) and also feedback from patients and carers and staff. We also reviewed clinical audits, NICE guidance and peer reviews and took into account local and national changes. We have kept those priorities from 2015/16 which remain key or because we had not made as much progress as we had hoped and where we consider further improvement is required such as Sepsis and Acute Kidney Injury and to continue to allow us to make sustained improvement and build on the good work that we have achieved in the previous year

9 Our priorities are set out below and each makes reference to the five CQC domains 1 and our specific objectives for these. 1. We will reduce the number of incidents of avoidable harm Priorities Safe Caring Effective Responsive Well Led 1 Reduce the number of incidents of avoidable harm X X X X X 2 Participate in the implementation of the Maternity Ambition Programme 3 X X X X X This will enable our service to be safe, caring and effective, responsive and well led. We will focus on areas of medication safety, mortality review, sepsis and acute kidney injury. We will review and refresh our Sign up to Safety pledges to ensure that patient safety and quality of services are at the forefront of the organisation whilst taking into account the financial challenge and report quarterly on the progress. 4 5 Review paediatric pathways with a focus on the implementation of Best Start and a Paediatric Assessment Unit Build more robust systems to document and disseminate incidents and key learning to minimise patient harm and maximise staff well-being Look at provision of LQS 2 and compliance with seven-day services X X X X X X X X X X X X X We will link our pledges to priority areas and ensure that this is weaved throughout the organisation whilst linking with our Listening into Action (LiA) work, CQUINs and local priorities. We will monitor the progress of our pledges by reporting quarterly to our Quality Experience Safety Programme (QESP) that will oversee the delivery of the Quality Account priorities. We will achieve this by: a) Improving the quality of care and clinical outcomes of patients with Sepsis 6 Implement the Perfect Patient Journey Programme X X X X X b) Improving the quality of care and clinical outcomes of patients 17 with acute kidney injury (AKI) c) Reducing omitted medication incidents 7 8 Improve how we capture and act on patient and carer feedback Implement the CQC recommendations made in September 2015 X X X X X X X X d) Reducing in hospital cardiac arrest and patient deterioration e) Maintaining improvement with Harm free Care f) Maintaining low Hospital Standardised Mortality Ratios g) Monitoring how patients food and nutritional needs are met 1 Five CQC Domains, Safe, Effective Experience, Responsive, Well Led 2 London Quality Standards 16 17

10 a 1b Indicator Measure Monitoring Committee Frequency Data Source By when 30% decrease 10% decrease Patient Safety and Mortality Committee Patient Safety and Mortality Committee Quarterly CRS Millennium 2016/17 Quarterly CRS Millennium 2016/17 2. We will participate in the implementation of the Maternity Ambition Programme and focus on reducing the risk of intrauterine deaths and stillbirths 1c 20% reduction Medication Safety Committee Quarterly Datix Incident 2016/17 This will enable our service to be safe, caring, effective, responsive and well led. 1d 1e Sustained improvement Sustained improvement Deteriorating Patient Committee Patient Safety and Mortality Committee Quarterly Datix Incident 2016/17 Quarterly Catheter associated urinary tract infection - Data 2016/17 This will be achieved under broad themes which include: Building strong leadership in maternity services Building capability and skills for all maternity staff Sharing progress and lessons learnt across the system Improving data capture and knowledge in maternity services Focusing on early detection of the risks associated with perinatal mental illness 1e < 16 Patient Safety and Mortality Committee Monthly Hospital acquired infections including Clostridium Difficile (C. Difficile) 2016/17 We will achieve this by: 1e Nil Patient Safety and Mortality Committee Monthly Methicillin Resistant Staphylococcus aureus (MRSA) 2016/17 a) Participating in the Maternity Safety Thermometer b) Setting up an infrastructure to achieve the Maternity Ambition programme c) Implementing the agreed process and seek a sustained improvement 1e Sustained improvement Patient Safety and Mortality Committee Quarterly Pressure ulcer data 2016/17 1e 100% root cause analysis completed Patient Safety and Mortality Committee Quarterly VTE data / informatics 2016/17 Indicator Measure Monitoring Committee Frequency Data Source By when 1e Sustained and consistent improvement of compliance above 95% Patient Safety and Mortality Committee Quarterly VTE data/ informatics 2016/17 2a Sustained Improvement Patient Safety and Mortality Committee Quarterly Harm Free Care 2016/17 1e Sustained Improvement Patient Safety and Mortality Committee Quarterly Falls Data 2016/17 1f Sustained Improvement Patient Safety and Mortality Committee Monthly CRS Millennium / Mortality Review 2016/17 2b Infrastructure in place Quality and Clinical Governance Committee Quarterly NA Sept g 100% MUST compliance Nursing and Midwifery and Allied Health Professional Board Monthly CRS Millennium 2016/17 2c Sustained improvement Quality and Clinical Governance Committee Quarterly Datix Incident CRS Millennium 2016/

11 We will review paediatric pathways with a focus on the implementation of Best Start and a Paediatric Assessment Unit This will enable our service to be safe, caring, effective, responsive and well led. Development of the first phase of a Paediatric Assessment Unit (PAU) in 2016/17 will allow improved access and responsive, consultant-led care of paediatric patients at CHS. The development of Best Start will build upon the partnership between the NHS and the local authority. Specific focus on the interface between paediatrics and surgery through co-creation of robust pathways and agreed internal professional standards will also improve service delivery and compliance with London Quality Standards (LQS) for this service. We will achieve this by: a) Rolling out the Best Start programme to provide a coordinated and integrated service for the children of Croydon b) Developing and implementing a paediatric surgical pathway to ensure that there is coordinated care provided to children requiring surgical input c) Developing Inter-professional standards for paediatrics d) Implementing phase 1 of a paediatric ambulatory unit Indicator Measure Monitoring Committee Frequency Data Source By when 3a Best Start in place Quality and Clinical Governance Committee Quarterly NA 2016/17 3b Pathway in place Patient Safety and Mortality Committee Quarterly CRS Millennium / Datix Incidents 2016/17 3c Inter professional standards agreed Quality and Clinical Governance Committee Quarterly Standards agreed 09/2016 3d PAU in place Executive Management Board/ Performance Quarterly NA 2017/

12 We will build more robust systems to document and disseminate incidents and key learning to minimise patient harm and maximise staff well-being 4a 4b Indicator Measure Monitoring Committee Frequency Data Source By when Sustained improvement of clinical documentation Sustained improvement of clinical coding Quality and Clinical Governance Committee Patient Safety and Mortality Committee Quarterly CRS Millennium / Patient records 2016/17 Quarterly CRS Millennium 2016/17 4c Dashboard development Quality and Clinical Governance Committee Annual CRS Millennium / Datix 09/2016 This will enable our service to be safe, caring, effective, responsive and well led. 4d Increases in ranking in learning from mistakes league Quality and Clinical Governance Committee Annual Datix incidents / Staff Survey results 2016/17 This includes improvement in clinical documentation, clinical coding, dashboard development and translation of data into meaningful messages to inform improvement. This will encompass all staff groups at all levels of seniority to build a culture of clear governance, openness to learning and patientcentred practice. 4d 4e Sustained improvement in Governance processes Increase in incident reporting Quality and Clinical Governance Committee Quality and Clinical Governance Committee Quarterly Minutes of Directorate Quality Boards & Directorates Quality Reports 2026/17 Quarterly Datix Incidents 2016/17 Sharing the lessons learned from any incident is the only way that we can keep improving our care. We have introduced new systems and anonymous reporting to encourage all incidents to be recorded. Three key messages are also published every week within the Trust to share our findings from incidents and complaints. We will achieve this by: a) Improving clinical documentation b) Improving in clinical coding c) Developing a dashboard and translation of data d) Building a culture of clear governance, openness to learning and patient-centred practice e) Sharing the lessons learned from any incident and complaint and compliments 22 23

13 We will look at provision of LQS 3 and compliance with seven-day services We will implement the Perfect Patient Journey Programme This will enable our service to be safe, caring, effective, responsive and well led. This will enable our service to be safe, caring, effective, responsive and well led. Programme of Work Proposed Structure Around clinical sustainability we will and look at provision of LQS and compliance with sevenday services strategically - both as an individual Trust and also critically in partnership discussion with regional Trusts. This focuses not just on service redesign but on workforce innovation. We will look at clinical pathway discussions refining not only the front door operations but also the back door discharge practices targeted through the Perfect Patient Journey programme (see priority 6) and through the roll out of internal professional standards. We will achieve this by: a) Provision of LQS and compliance with seven-day services By bringing together all the work currently being undertaken to support patient flow under one umbrella providing a robust framework including pharmacy led TTO s System of care focusing on providing care where it is most appropriate for the patient Community Independent Living Acute Independent Living Community b) Redesigning services and pathways c) Implementing inter professional standards We will achieve this by: a) Implementing the perfect patient journey Indicator Measure Monitoring Committee Frequency Data Source By when Indicator Measure Monitoring Committee Frequency Data Source By when 5a LQS and 7 days service compliance Performance Committee Quarterly National Audit 2016/17 6a Pharmacy led TTO s in place Quality and Clinical Governance Committee Quarterly CRS Millennium / Patient records 2016/17 5b Agreed new pathways EMB Resilience and oversight Quarterly New Pathways in place Sept a CQUIN Quality and Clinical Governance Committee Quarterly CRS Millennium / Reduction in length of stay 2016/17 5c & 3c Inter professional standards agreed Quality and Clinical Governance Committee Quarterly Inter professional standards in place 2016/17 6a Reduction in length of stay Quality and Clinical Governance Committee Quarterly CRS Millennium / Reduction in length of stay 2016/17 3 London Quality Standards 24 25

14 We will improve how we capture and act on patient and carer feedback This will enable our service to be safe, caring, effective, responsive and well led. Improving patient experience and listening to our patients will continue to be a key priority for the Trust. We will continue to improve on our complaint performance and work with our stakeholder partner to ensure patient involvement in quality activities. We want to improve our Friends and Family Test (FFT) response rate and through providing excellent care be the provider of choice for our patients and their families We will implement the CQC recommendations made in September 2015 This will enable our service to be safe, caring, effective, responsive and well led. The Trust will continue to deliver the QESP in 2016/17 to drive improvements in quality, safety and patient experience and to achieve a 95% FFT score. Throughout 2016/17 the QESP will oversee the four must do s and the 31 should do s in response to the CQC inspection which have been added to the overall Quality Improvement Plan. We will achieve this by: a) Improving on our complaint performance b) Improving patient involvement in quality activities c) Improving our FFT response rate We will achieve this by: a) Continuing to improve and embed systems to monitor the quality and safety of care provided (Trust wide). b) Improving clinical governance and risk management in the surgical services (CUH). c) Implementing plans to refurbish theatres and to put in place an equipment replacement programme (CUH). d) Ensuring that 90% of staff receives up-to-date safeguarding and mandatory training (CUH) Indicator Measure Monitoring Committee Frequency Data Source By when Indicator Measure Monitoring Committee Frequency Data Source By when 7a Sustained improvement Quality and Clinical Governance Committee Quarterly Complaint response 2016/17 8a Reduction of Complaints and SI s Quality and Clinical Governance Committee Quarterly Datix incident / complaints 2016/17 7b Patient representatives Quality and Clinical Governance Committee Quarterly Membership on committees 2016/17 8b Governance Process in place Quality and Clinical Governance Committee Quarterly Quality Board Minutes 2016/17 7c 95% response Quality and Clinical Governance Committee Quarterly FFT Response 2016/17 8c Full Business Case in place Finance and Planning Committee Quarterly Finance and Planning Committee Minutes / NHSI approval 2016/17 8d 90% compliance Quality and Clinical Governance Committee Quarterly Mandatory training data 2016/

15 Statement of Directors responsibilities in respect of the Quality Account Statements of assurance from the Board of Directors The following statements are mandated by regulation for inclusion in all NHS Quality Accounts: The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of the Annual Quality Account (in line with the requirements set out in Quality Accounts legislation). In preparing the Quality Account, directors are required to take steps to assure themselves that: the Quality Account presents a balanced picture of the Trust s performance over the reporting period; the performance information reported in the Quality Account is reliable and accurate; there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm they are working effectively in practice; the data underpinning the measure of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and the Quality Account has been prepared in accordance with Department of Health guidance. The directors confirm to the best of their knowledge and belief that they have complied with the above requirements in preparing the Quality Account. Review of Services Throughout we have been privileged to continue to provide services to the people of Croydon whether in their own home, at one of our community facilities or at one of our hospitals. There are three Clinical Directorates within the Trust and each Directorate reviews service provision through Quarterly Quality and Performance meetings with the Chief Operating Officer and reporting to the Quality and Clinical Governance Committee, monthly Quality Boards and Clinical Governance meetings. The Trust reviews quality indicators using a dashboard and reports so that performance can be analysed on a monthly basis. This enables services to identify priorities and actions needed to deliver improvements. The Trust organogram depicting the directorate services is on the following page. During Croydon Health Services provided and/or sub-contracted 53 NHS services. The Trust has reviewed all the data available on the quality of care of 100 percent of these services. The income generated by the NHS services reviewed in represents 100% of the total income generated from the provision of NHS services by Croydon Health Services NHS Trust for Table of activity by quarter Q1 Q2 Q3 Q4 Total Total number of admissions 16,078 16,035 16,526 16,734 65,373 Total number of occupied bed days 42,874 41,045 39,717 42, ,409 Average number of occupied beds * Face to face contacts 81,665 81,971 84,661 82, ,974 Mike Bell Chairman By order of the Board Chair 28 June 2016 *Number of occupied bed days divided by the number of days in the period 28 29

16 Chief Executive John Goulston Service and quality accreditations Medical Director Nnenna Osuji Director of Finance Azara Mukhtar Director of Planning & Information Lisa Chesser Chief Operating Officer & Deputy Chief Executive Jayne Black Director of HR & Organisational Development Michael Burden Director of Quality Assurance & Governance Helen Astle Director of Nursing, Midwifery & AHPs Michael Fanning CHS was the first Trust to receive LiA accreditation. It has also achieved or is working towards external accreditations and external peer reviews a full list can be found on page 97 (external visits). ADOs Maria Knopp (community) Samantha Goldberg (acute) Acute Medical Unit Adult Therapies A&E Liaison Team Community Matrons Community Nursing Cardiology Services Diabetes Eldery Care Emergency Department 24/7 Team Endocrine Endoscopy Gastroenterology HV for Older People Learning Disabilties Minor Injury Unit Neurology Nurse Specialists PACE Renal Medicine Respiratory Medicine Rheumatology Safeguarding Adults Stroke Services Wheelchair Services CD Enas Lawrence Integrated Adult Care Directorate Director of Transformation Anouska Adamson-Parks ADN Kate Falkner ADO Melissa Morris CD Stella Vig Integrated Surgery, Cancer & Clinical Support Directorate Anaesthetics Breast Surgery Cancer Services Day Surgery Dentistry Dermatology ENT General Surgery Haematology Head & Neck Specialists Health Records ITU/HDU Maxillo-facial Neurophysiology Neurosurgery Orthodontics / Oral Surgery Out-patients & Admissions Palliative Care Pathology Pharmacy Plastic Surgery Pre-operative Assessment Radiology Restorative Sickle Cell Theatres Trauma & Orthopaedics Urology Chief Pharmacist Louise Coughlan ADN Claire Jones ADO Kathy Wocial Deputy COO Alison Smith CD Rosol Hamid Integrated Women s & Sexual Health Directorate Breast-feeding Support Children s Hospital at Home Children s Medical Services Children s Therapies Colposcopy Continence Service Early Pregnany Unit Gynaecology Maternity Services Out-patient Gynaecology, Fertility Paediatrics (except A&E) Safeguarding Children Sexual Health School Nursing Special Care Baby Unit (SCBU) Audiology Health Visiting Homeless Health Urogynaecology Director Midwifery Ann Morling ADN Tina Hickson March 2016 Participation in national clinical audits and national confidential enquiries Participation in national clinical audits and confidential enquiries enables us to benchmark the quality of the services that we provide against other NHS Trusts, and hence highlight best practice in providing high quality patient care and drive continuous improvement across our services. The Clinical Audit priorities are selected on the basis of National requirements, commissioning requirements and local evidence that has emerged from themes from incidents or complaints. During , 39 national clinical audits and 3 national confidential enquiries covered NHS services that Croydon Health Services NHS Trust provides. During that period Croydon Health Services NHS Trust participated in 100% national clinical audits and 100% national confidential enquiries of which it was eligible to participate in. The list of national audit reports reviewed and actions planned or undertaken are detailed in Appendix 1. The Trust also completed 34 local clinical audits in 2015/16 as listed in Appendix 2. The national clinical audits and national confidential enquiries that the Trust participated in, and for which data collection was completed during 2015/16, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry

17 National Clinical Audits and Participation Title of Audit Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP) Bowel Cancer Audit Programme (NBCA) Cardiac Rhythm Management (CRM) Case Mix Programme (CMP) Coronary Angioplasty / National Audit of Percutaneous Coronary Interventions (PCI) Diabetes Paediatric (NPDA) Elective Surgery (National PROMS Programme) Emergency Use of Oxygen End of Life Care Audit Falls and Fragility Fractures Audit Programme (FFFAP): Fracture Liaison Service Database Inpatient Falls National Hip Fracture Database Head and Neck Cancer Audit Inflammatory Bowel Disease (IBD) Programme - IBD Biologics Major Trauma Audit - The Trauma Audit & Research Network (TARN) National Audit of Intermediate Care National Cardiac Arrest Audit National Chronic Obstructive Pulmonary Rehabilitation (COPD) Programme - Pulmonary Rehabilitation National Comparative Audit of Blood Transfusion Use of Blood in Haematology Audit of Patient Blood Management in scheduled surgery National Diabetes Audit - Adults National Foot care Audit National Inpatient Audit National Pregnancy in Diabetes National Emergency Laparotomy Audit National Heart Failure Audit National Joint Registry National Lung Cancer Audit National Prostate Cancer Audit Number of cases submitted In Progress 123 In Progress In Progress In Progress 307 In Progress organisational 30 In progress Data from St. Georges In progress 60 In Progress In Progress In Progress % submitted In Progress 100% In Progress In Progress In Progress 100% In Progress 100% 65% 100% 100% In progress Data from St. Georges 40% 50% In progress 100% In Progress 100% 100% In Progress 100% 100% In Progress In Progress In Progress In Progress National Confidential Enquiries and Clinical Outcome Review Programmes Title of Audit Medical and Surgical Clinical Outcome Review Programme, National Confidential Enquiry into Patient Outcome and Death (NCEPOD): Provision of Mental Health Care in Acute Hospitals Acute Pancreatitis Non Invasive Ventilation Maternal, New born and Infant Clinical Outcome Review Programme Perinatal Mortality Surveillance Perinatal Mortality and morbidity confidential enquiries Maternal morbidity and mortality confidential enquiries Maternal mortality surveillance Number of cases submitted 5 5 In Progress In Progress % submitted 100% 100% In Progress In Progress Neonatal Intensive and Special Care (NNAP) In Progress In Progress Oesophagi-gastric cancer Audit (NAOGC) % Paediatric Asthma % Procedural Sedation in Adults (Care in Emergency Department) % Rheumatoid and Early Inflammatory Arthritis Clinician / Patient Follow up Clinician / Patient Baseline Sentinal Stroke National Audit Programme In Progress In Progress UK Parkinson s Audit % Vital signs in children (Care in Emergency Department) % VTE risk in lower limb immobilisation (Care in Emergency Department) % 32 33

18 Research Use of the Commissioning for Quality and Innovation (CQUIN) framework Research is a core part of the NHS, enabling it to improve the current and future health of the people it serves. Clinical research means research that was approved by the research ethics committee. The number of patients, receiving NHS services provided or sub-contracted by Croydon Health Services NHS Trust in Jan 2015 Dec 2015, that were recruited during that period to participate in research approved by a research ethics committee was 500 (based on the Clinical Research Network registered file). Participation in clinical research demonstrates our commitment to improving the quality of care we offer and to making our contribution to wider health improvement. Our clinical staff stay abreast of the latest possible treatment availabilities, and active participation in research can lead to successful patient outcomes. In , 67 clinical research studies were being conducted in the Trust; 35 of which were funded by the CRN. There were 18 studies concluded by December 2015 of which 63% were completed as designed within the agreed time and to the agreed recruitment target. This is an improvement from last year s 44%. During , we approved 13 studies, of which 7 were supported by the CRN. In 42% of the cases the CRN Cluster Office gave permission in less than 30 days from receipt of a valid complete application. This is a drop from last year and is understood to result from delays in getting contracts signed off. The research applications funded by the CRN are being carried out by the CRN cluster office based in Guys and St Thomas NHS Foundation Trust. This year the HRA are introducing a new system of approvals for studies that aim to reduce the work load required for the ethics and local approvals. There were 66 clinical staff participating in research approved by research ethics committee at Croydon Health Services during % of these were Research Passport Personnel supporting the research studies. These staff participated in research covering 11 specialities. In October 2015 the HOT clinic and R&D team completed the second year on the WELCOME study which is an EU-funded study. The team and consortium partners are preparing to run a trial prototype of the telehealth vest later this year. The aim is to develop the system for remote monitoring of COPD patients to aid their self-care and develop it further into a commercial product. A second EU-funded project called AEGLE completes its first year in April This is a large data analytics programme that will analyse anonymised patient data to try to improve the treatment of diabetes. The system is being designed and tested at present with the infrastructure being put in place. The OPTIMAL project, funded by Innovate UK, is completing its first year. Working with the discharge team it will look to streamline the discharge of patients in order to reduce readmission rates within 30 days. This would potentially reduce penalties incurred when patients are readmitted within this timeframe. The Urology and Gynaecology team have been successful in a grant application to The Health Foundation and DoH where they were awarded a grant of over 420,000. This will fund a project looking reducing the rate of obstetric anal sphincter injury (OASI). The project will provide materials and a training programme to clinicians that highlight the risks factors, the long-term impact of this condition and the methods of prevention. In the last three years, 39 publications have resulted from our involvement in Research. Of these 39 publications 8 were directly from NIHR studies. Commissioners hold a health budget for the Croydon population and decide how to spend it on health care services (in both the hospital and community setting) such as those provided by Croydon Health Services NHS Trust. Our local commissioners (Croydon Clinical Commissioning Group) and NHS England set us annual goals based on quality and innovation in order to bring health gains for patients. This system is called the CQUIN payment framework. A proportion of Croydon Health Services NHS Trust income in 2015/16 was conditional on achieving CQUIN goals agreed between Croydon Health Services NHS Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. For 2015/16 we are on target to achieve over 80% of our CQUIN income from the NHS England and Croydon Clinical Commissioning Group (CCG) and 100% of the specialist CQUINs from NHS England

19 2.2 The national CQUINS for 2015/16 were as follows: Acute Kidney Injury This CQUIN focused on Acute Kidney Injury diagnosis and treatment in hospital and the plan of care to monitor kidney function after discharge, measured through the percentage of patients with AKI treated in an acute hospital. The Trust performed well against this CQUIN for 2015/16 and has sought to have this CQUIN continued as a local CQUIN for 2016/17. Sepsis This CQUIN focused on patients arriving in the hospital via the Emergency Department (ED) or by direct emergency admission to any other unit (e.g. Medical Assessment Unit) or acute ward. It sought to incentivize providers to screen for sepsis in all those patients for whom sepsis screening was appropriate, and to rapidly initiate intravenous antibiotics, within 1 hour of presentation, for those patients who have suspected severe sepsis, Red Flag Sepsis or septic shock. The Trust now has a robust system in place and achieved the targets in the latter part of the year. These systems remain in place and the Trust is in a good position to continue this CQUIN into 2016/17. Dementia This CQUIN aimed to measure the proportion of patients identified as potentially having dementia or delirium who are appropriately assessed and the proportion of those identified, assessed and referred for further diagnostic advice in line with local pathways agreed with commissioners, who have a written care plan on discharge which is shared with the patient s GP. This CQUIN also aimed to ensure that appropriate dementia training was available to staff through a locally determined training programme and to ensure that carers of people with dementia and delirium felt adequately supported. The Trust has performed excellently against this CQUIN for 2015/16. These practices have embedded and are now business as usual. Local CQUINS Urgent and Emergency Care London Quality Standards Reduce emergency admission rates Reduce time spent waiting for diagnostics Patient Safety and Mortality Medication Management Seven Day Services (Community) The Nationwide CQUINS for 2016/17 were released in March 2016 and are as follows: Improving the health and wellbeing of NHS Staff; Identification and Early Treatment of Sepsis; Antimicrobial resistance The local CQUINS are currently being agreed. 2.2 Use of the Statements from the Care Quality Commission (CQC) The CQC is the independent regulator for health and social care services in England. They make sure that we capture the care provided by hospitals meet government standards to provide people with safe, caring, effective, compassionate and high quality care. The Trust is required to register with the CQC; its current registration status is registered without conditions. This means that CQC has not taken any enforcement action against CHS in 2015/16. The CQC monitors these standards of care through inspections, patient feedback and other external sources of information gathered. They publish which Trusts are compliant with all the essential standards of care which and which organisations have conditions requiring improvement. The Trust was inspected by the CQC in June 2015 and a report was published on 7th October 2015 stating the Trust was given an overall rating of Requires Improvement. A rating was given for the domains of Effective and Caring with the remaining domains of Safe, Responsive and Well Led given the rating of Requires Improvement. CQC has not taken enforcement action against the Trust during 2015/2016 and the Trust has not participated in any special reviews or investigations by the Care Quality Commission during the reported period. At a service level Urgent & Emergency Services, Maternity & Gynaecology and Services for Children & Young People were all given an overall rating of. All other services in the hospital and community were given an overall rating of Requires Improvement. The Trust was given 4 must do actions and 31 should do actions and these are included in the Trust priorities for 2016/17. A comprehensive action plan with 188 milestones has been drawn up to address these areas of improvement that has been incorporated into the Trust s Quality, Safety and Experience Programme (QESP). The Trust has identified the achievement of these actions as a key priority for 2016/17 (priority 8). Each of the must do and should do actions has a designated Executive and Project Lead and comprehensive action plans have been developed. These action plans include the high level milestones, risks & mitigations, assurance required to evidence delivery and a project summary for audit purposes. The action plans are updated regularly and progress and exceptions are reported to the fortnightly QESP Delivery Group for action as required. The QESP reports monthly to the Quality & Oversight Executive Management Board, the Quality & Clinical Governance Committee and the Trust Board. Care Quality Commission rating of Croydon Health Services NHS Trust Last rated 7th October 2015 Overall Trust Rating Requires Improvement 36 37

20 2.2 Croydon University Hospital 2.2 Community Services Are services... Safe? Effective? Caring? Responsive? Well led? Are services... Safe? Effective? Caring? Responsive? Well led? Requires Improvement Requires Improvement Requires Improvement Requires Improvement Requires Improvement Requires Improvement Requires Improvement Requires Improvement Safe? Effective? Caring? Responsive? Well led? Overall? Safe? Effective? Caring? Responsive? Well led? Overall? Urgent & Emergency Services Requires Improvement Community Adults Requires Improvement Requires Improvement Requires Improvement Requires Improvement Medical Care Requires Improvement Requires Improvement Requires Improvement Community Children & Young People Requires Improvement Requires Improvement Requires Improvement Surgery Intensive / Critical Care Requires Improvement Requires Improvement Requires Improvement Requires Improvement Inadequate Requires Improvement Requires Improvement Requires Improvement Health & Safety Executive Maternity & Gynaecology Services for Children & Young People Requires Improvement Requires Improvement During 2015/16 there was only one incident that occurred which was investigated by the Health and Safety Executive (HSE). The incident involved a patient fall on the escalator. The HSE investigated the escalator maintenance and servicing and the Trust cooperated fully with the investigation. There were no enforcements placed on the Trust following this incident from the HSE and the Trust put in place and has implemented an action plan following the learning from this incident to minimise any future risk of reoccurrence. End of Life Care Outpatients Requires Improvement Requires Improvement Requires Improvement Not yet rated Requires Improvement Requires Improvement Requires Improvement Requires Improvement Patient Led Assessment in the Care Environment audit (PLACE) Every NHS patient should be cared for with compassion and dignity in a clean, safe environment. PLACE assessments provide a framework to review how the environment supports patient privacy and dignity, quality of food provided, cleanliness and general building maintenance. The inspectors are a mix of Trust members, external inspectors and patient representatives. The group is at liberty to visit any ward or department in which patient care is provided. The assessments take place every year, and results are reported publicly. The most recent PLACE assessment completed in 2015 and report produced on 1st April 2016 showed no major concerns

21 Data Quality Information Governance The Trust submitted records during 2015/16 to the Secondary Users Service (SUS) which is the single, comprehensive repository for healthcare data in England. The Trust data quality score has improved significantly in 2015/16 achieving 98.8% overall at the 31 March 2016 compared to 96.4% for London, and 96.3% nationally. This performance ranks 4th best out of the 35 providers in London compared to 30th out of 35 at the start of 2015/16. There are three areas for improvement where the Trust is below the national average in respect of NHS number, postcode and GP Practice Code as set out in the table below. Level 2 Compliance achieved (67%) Compliant Information forms a key component of the Government s Information Revolution for the NHS. This restates the NHS s intention to ensure effective decision making, inform and empower patients through the provision of accurate, accessible and coherent information. Criteria Included the patient s valid NHS number CHS National Average Included the patient s valid Postcode CHS National Average Included the patient s valid General Practice Code CHS National Average Information Governance (IG) describes how information is handled in health and social care. The Health and Social Care Information Centre (HSCIC) Information Governance Toolkit (IGT) measures compliance by NHS organisations annually against a number of requirements for different organisation (45 requirements for Acute Trusts). % for inpatient care 96.6% 99.3% 97.1% 99.7% 98.9% 99.9% % for outpatient care 97.6% 99.5% 97.9% 99.8% 98.9% 100% % for accident & emergency care 96.6% 95.8% 99.0% 99.8% 100% 98.9% The Trust was not subject to the payment by results clinical coding audit during the reporting period by the Audit Commission. The key actions the Trust is taking to further improve data quality in 2016/17 are: Using Listening into Action methodology to further improve clinical documentation, including discharge summaries Undertaking an agreed schedule of clinical coding audits with peer review and a specific deep dive in maternity Community services information review as part of the implementation of a new community services IT system Review of ambulatory care pathways following service redesign Standard Operating Procedure compliance audits Refreshed clinical information system champion user programme and training Croydon Health Services NHS Trust s submission score for the HSCIC Information Governance Toolkit v13 on March 31st 2016 was 67% with all requirements being level 2 compliant. The Trust is committed to ensuring that its information is managed to the highest standards and in accordance with the Health and Social Care Act 2014, Care Standards Act 2000, The Data Protection Act 1998, The Freedom of Information Act 2000, Central Government policies and guidance from the Information Commissioner s Office. The Trust complies with the Information Commissioner s Office checklist for reporting, managing and investigating information governance incidents. The Trust declared five information governance incidents through the HSCIC IG Toolkit in , three serious level 2 incidents (classified as disclosed in error) and two level 1 incidents (disclosed in error). The ICO also issued an undertaking that committed the Trust to a particular course of actions in order to improve its compliance, completion of these actions were confirmed by the ICO April 2016 with further management of Staff IG training and legacy records destruction. The review demonstrated that CHS has taken appropriate steps and put plans in place to address some of the requirements of the undertaking. However, further work needs to be completed by CHS to fully address the agreed actions

22 Reporting against core indicators (Department of Health mandatory indicators) This section includes data on nationally specified indicators for the current and previous reporting periods as part of the statutory requirements Domain Preventing people from dying prematurely Enhancing quality of life for people with long-term conditions Domain Helping people recover from episodes of ill health following injury Helping people recover from episodes of ill health following injury Indicator The value and banding of the summary hospital-level mortality indicator (SHMI) for the Trust. % of admitted patient deaths with a palliative care coded at either diagnosis or specialty level for the trust. Indicator Patient reported outcome measure score for groin hernia surgery. Patient reported outcome measure score for varicose vein surgery. 2013/ % No Data provided by HSCIC 2013/14 Trust started participating in PROMS from December, 2015 (No performance report available) Trust started participating in PROMS from December, 2015 (No performance report available) 2014/ % B and 2 (as expected) 19.8% July June / / % Data being validated 2015/16 Most recent results for trustees % 19.8% Most recent results for trustees Time period for most recent trust results Oct Sept 2015 Dr Foster July June 2014 HSCIC Time period for most recent trust results Best result nationally % 7.4% Best result nationally Worst result nationally % 49% Worst result nationally National Average 1.000% 24.8% National Average Actions The Croydon Health Services NHS Trust is categorised as Band 2 for SHIMI which is as expected. Actions The Croydon Health Services NHS Trust considers that this data is as described for the following reasons: The Trust has not participated in PROM in the three previous reports. The Trust intends to take the following actions to improve indicators and percentages, and quality of its services quality: By providing executive oversight to ensure that the critical and surgery directorate fully participate in future hernia and varicose vein surgery

23 Domain Helping people recover from episodes of ill health following injury Helping people recover from episodes of ill health following injury Domain Preventing people from dying prematurely Enhancing quality of life for people with long-term conditions Indicator Patient reported outcome measure score for groin hernia surgery. Patient reported outcome measure score for knee replacement surgery. Indicator % of patients aged 0 to 15 readmitted to hospital within 28 days of being discharged from hospital. % of patients aged 16 and over readmitted to hospital within 28 days of being discharged from hospital. 2013/14 The Trust did not submit data for this PROMS The Trust did not submit data for this PROMS 2013/ % 14.10% 2014/ / % April March % April March / / % Data being validated Most recent results for trustees Most recent results for trustees 6.35% 14.52% Time period for most recent trust results Time period for most recent trust results April March 2015 April March 2015 Best result nationally Best result nationally 1.58% 1.24% Worst result nationally Worst result nationally 67.86% 79.52% National Average National Average 4.33% 3.74% Actions The Croydon Health Services NHS Trust considers that this data is as described for the following reasons: The Trust has not participated in PROM in the three previous reports. The Croydon Health Services NHS Trust considers that this data is as described for the following reasons: The Trust has not participated in PROM in the three previous reports. Actions The Croydon Health Services NHS Trust intends to take the following actions: Continue with the work programmes associated with safe patient flow and discharge from the hospital. The Croydon Health Services NHS Trust intends to take the following actions: Continue with the work programmes associated with safe patient flow and discharge from the hospital. The Trust intends to take the following actions to improve indicators, percentages and quality of its services quality: The Trust intends to take the following actions to improve indicators, percentages and quality of its services quality: By providing executive oversight to ensure that the critical and surgery directorate fully participate in future hernia and varicose vein surgery. By providing executive oversight to ensure that the critical and surgery directorate fully participate in future hernia and varicose vein surgery

24 Domain Ensuring people have a positive experience of care Ensuring people have a positive experience of care Domain Ensuring people have a positive experience of care Ensuring people have a positive experience of care Indicator The trust s responsiveness to the personal needs of its patients. Percentage of staff employed who would recommend the trust as a provider of care to their friends or family. * Indicator Friends and Family Test - Percentage of inpatients who would recommend the trust as a provider of care to their friends and family. Friends and Family Test - Percentage of patients discharged from A&E (type 1 and 2) who recommend the trust as a provider of care to their friends and family. 2013/ % 41% 2013/14 91% 88% 2014/ % 47% 2014/15 91% 90% 2015/16 Data being validated 57% 2015/ % 92.6% Most recent results for trustees 60.3% 47% Most recent results for trustees 92.68% 92.6% Time period for most recent trust results HSCIC (National Inpatient Survey) HSCIC (National NHS Staff Survey 2015) Time period for most recent trust results April March 2016 April March 2016 Best result nationally 54.4% 89% Best result nationally 100% 98% Worst result nationally 85% 38% Worst result nationally 75% 53% National Average 67.4% 67% National Average 96% 88% Actions The Croydon Health Services NHS Trust intends to take the following actions to improve the indicator and percentage and so the quality of its services: The Croydon Health Services NHS Trust intends to take the following actions to improve the indicator and percentage and so the quality of its services: Actions The Croydon Health Services NHS Trust intends to take the following actions to improve the indicator and percentage and so the quality of its services: The Croydon Health Services NHS Trust intends to take the following actions to improve the indicator and percentage and so the quality of its services: Continue with the QES Programme and add additional actions following CQC assessment. Continue with improving staff engagement programme using Listening Into Action change methodology. Continue with the QES Programme Continue with the QES Programme Continue with our visible leadership and improve face to face communications with colleagues throughout the organization. *Excludes specialist acute trusts and independent providers. Only counts agree or strongly agree. Not neutrals

25 Domain Treating and caring for people in a safe environment and protecting them from avoidable harm Treating and caring for people in a safe environment and protecting them from avoidable harm Domain Treating and caring for people in a safe environment and protecting them from avoidable harm Treating and caring for people in a safe environment and protecting them from avoidable harm Indicator Percentage of patients who were admitted to hospital and who were risk-assessed for venous thromboembolism. The rate per 100,000 bed days of C.Difficile infection, amongst patients aged 2 or over. Indicator The number of patient safety incidents reported within the trust. The rate of patient safety incidents reported per 1,000 bed days 2013/14 93% 7.30% 2013/ (per 100 bed days) 2014/15 96% 9.85% (Trust Reported) 2014/ (per 100 bed days) 2015/ % 13.22% 2015/ (per 1,000 bed days) Most recent results for trustees 95.28% 13.22% Most recent results for trustees Time period for most recent trust results Quarters April March 2016 Time period for most recent trust results April September 2015 HSCIC (NRLS) April September 2014 HSCIC (NRLS) Best result nationally 100% 2014/15 Data not available Best result nationally Worst result nationally 81% 2014/15 Data not available Worst result nationally National Average 96% 2014/15 Data not available National Average Not Available Not Available Actions The Croydon Health Services NHS Trust considers that this data is as described for the following reasons: The Croydon Health Services NHS Trust considers that this data is as described for the following reasons: Actions The Croydon Health Services NHS Trust considers that this data is as described for the following reasons: The Croydon Health Services NHS Trust considers that this data is as described for the following reasons: The Trust has improved in the number of incidents reported. The rate of clinical incidents that resulted in severe harm or death has improved over the last period with a lower rate in this period. The Trust intends to take the following actions to improve the indicator and percentage and so quality of our services: The Trust has improved in the number of incidents reported. The rate of clinical incidents that resulted in severe harm or death has improved over the last period with a lower rate in this period. The Trust intends to take the following actions to improve the indicator and percentage and so quality of our services: The Trust has improved in the number of incidents reported. The rate of clinical incidents that resulted in severe harm or death has improved over the last period with a lower rate in this period. The Trust intends to take the following actions to improve the indicator and percentage and so quality of our services: The Trust has improved in the number of incidents reported. The rate of clinical incidents that resulted in severe harm or death has improved over the last period with a lower rate in this period. The Trust intends to take the following actions to improve the indicator and percentage and so quality of our services: Continue to build our safety culture through our Sign Up to Safety Programme and Listening into Action Continue to build our safety culture through our Sign Up to Safety Programme and Listening into Action Continue to build our safety culture through our Sign Up to Safety Programme and Listening into Action Continue to build our safety culture through our Sign Up to Safety Programme and Listening into Action Increase our internal surveillance for accuracy coding Increase our internal surveillance for accuracy coding Increase our internal surveillance for accuracy coding Increase our internal surveillance for accuracy coding 48 49

26 2.3 Domain Treating and caring for people in a safe environment and protecting them from avoidable harm Indicator Percentage of patient safety incidents reported that resulted in severe harm or death. 2013/14 2.3% 2014/15 1.3% 2015/16 0.5% Most recent results for trustees 1.3% Time period for most recent trust results April September 2014 HSCIC (NRLS) Best result nationally 0% Worst result nationally 3.03% National Average Not Available Actions The Croydon Health Services NHS Trust considers that this data is as described for the following reasons: The Trust has improved in the number of incidents reported. The rate of clinical incidents that resulted in severe harm or death has improved over the last period with a lower rate in this period. The Trust intends to take the following actions to improve the indicator and percentage and so quality of our services: Continue to build our safety culture through our Sign Up to Safety Programme and Listening into Action Increase our internal surveillance for accuracy coding 50 51

27 3.1 Part 3 Review of Quality Performance Review of Quality Performance Review of quality priorities This section demonstrates the Trust s achievements throughout in the areas of patient safety, clinical effectiveness and patient experience. Performance against the priorities in our Quality Account is included in each section. To provide an at-a-glance view of performance we are using a tick, a dash and a cross system. Key: indicates that we met our objectives for the year made good progress but did not quite reach our objective means we did not meet the objective and further work is required and will be undertaken 52 53

28 3.1 Priority 1 Safety Pledge 1: Put Safety First 3.1 Develop a programme to review acute kidney injury Acute Kidney Injury - AKI Promote safe and secure discharge, and look after people in their own home, or close to where they live rather than having to come into hospital Promote safe and secure discharge The Trust has worked hard on this initiative ensuring that patients are discharged in safe environment and providing service in the community to ensure that they can receive care in their own home. This will continue to be a priority for the Trust with next year rolling out the Perfect Patient Journey and will be a Listening into Action (LiA) priority for the Trust We have carried out awareness and further education on Acute Kidney Injury. We have identified a Trust lead who provides expert advice on patients who have developed AKI. We held an awareness day in September and this will also continue to be a priority for 2016/17. We will continue to improve the quality of care and clinical outcomes of patients with acute kidney injury (AKI) building on the use and upgrade of the Vitalpac hand held electronic patient monitoring system and imbedding the work started as part of the National CQUIN for 2015/16. Review all patient deaths, report our findings and take action to improve Launch a sepsis campaign to ensure our staff improve the management of patients with symptoms of sepsis Sepsis We have developed and put in place a Sepsis task force to increase the awareness of how to treat Sepsis. The taskforce reviews all Sepsis serious incidents to identify further learning and has introduced Sepsis awareness cards for all staff and carried out further education and training including customised simulation training. This will continue to be a priority for the Trust going into 2016/17. For 2016/17 we are making changes to our electronic patient record system which will include automatic order set for Sepsis and medication for those patients who maybe showing signs of sepsis. We will also be trialing the use of a Sepsis box. Review all patient deaths, report our findings and take action to improve A trust mortality review group has been set up to monitor the reporting and review of all categories of in hospital deaths. The group reports monthly to The Patient Safety and Mortality Committee. The multi-disciplinary group started meeting on a monthly basis from August 2015 under the clinical leadership of a consultant physician. In addition to the group membership a consultant is invited to attend the monthly meetings on a rotational basis to discuss/present cases. Clinical leads for the mortality review process have been identified in the following specialities Medicine and Elderly Care, Surgery & Orthopaedics, Paediatrics, Maternity, Emergency Department, ITU, Medical Assessment Unit and Cardiology. A multidisciplinary review of deaths for patients with fractured neck of Femur is in the process of being developed. The mortality review group has oversight of all in hospital deaths for all specialities. The Patient Safety and Mortality Committee and Quality and Clinical Governance Committee have received deep dives report into bronchitis deaths revealing issues with how deaths had been coded. Further deep dives into Endocrine and Cardiac arrhythmias have also been undertaken due to repeat but not persistent flagging. The mortality review process is also subject to a CQUIN and the Trust is on track to meet the CQUIN

29 Continue work to reduce the number of patients who acquire pressure ulcers and have falls Harm Free Care including to reduce the number of patients who acquire pressure ulcers and have falls Harm Free Care is a national programme that helps NHS teams in their aim to eliminate harm in patients from four common conditions: Pressure ulcers Falls Urinary tract infections in patients with a catheter New venous thromboembolism (VTE). Graph showing Harm Free care in Croydon Health Services March 2013 March 2016 The Trust continues to outperform the national average for delivery of harm free care with 96.67% of patients experiencing harm free compared to 94.17% nationally. Data is taken directly from the Health and Social Care Information Centre website that calculate the harm free percentages overall and for each subcategory monthly and can be viewed by everyone. Pressure ulcers During 2015 the incidence of pressure ulcers continues to reduce in all areas with the biggest reduction demonstrated in nursing homes. Trust incidence data shows an overall reduction in pressure ulcers of all grades of over 800 across the year which equates to a 45 per cent reduction. Pressure ulcer prevalence data shows the Trust is out performing the national average by 40 per cent. This has been achieved by: A Trust-wide action plan that is monitored via the multi-agency pressure ulcer strategy group A follow up Big Conversation to develop further plans. This was attended by the acute trust, community staff, nursing home managers, NICE representative and the CCG Development of a single pressure ulcer pathway for use by all health professionals and healthcare settings in Croydon Falls CHS remains significantly below the national average for falls prevalence. A national falls audit was undertaken in May Results show that the Trust out-performed most of the London Trusts against which we were benchmarked. Overall Croydon performed well against other Trusts regarding: Number of falls per 1000 bed days Delirium assessments completed Medication reviews Mobility assessments undertaken Call bell within reach Areas that the falls group have highlighted for improvement are: Recording of lying and standing blood pressure Continence assessments The falls and pressure ulcer taskforces are cross referencing falls and pressure ulcer data as elderly care wards reported an increase in falls rates but significant decrease in acquired pressure ulcers across all grades

30 3.1 Pledge 2: Staff continually learn 3.1 Continue with our executive safety walk rounds and ask patients for their views using the Friends and Family Test Actively listen to our patients to see how we can improve and provide ways of user friendly Feedback Actively listen to our patients to improve our Friends and Family Test (FFT) scores The FFT can help mark progress over time for organisations and still provides patients with useful data to inform choice, alongside other information. The real strength of the FFT lies in the follow up questions that are attached to the initial question, and a rich source of patient views can be used locally to highlight and address concerns much faster than more traditional survey methods. Overall response rates for the Trust are comparable with surrounding Trusts with Croydon reporting a 22.6 per cent response rate The headline measure is the percentage of respondents who would recommend a service to their friends and family. There are no nationally set targets for this score however the internal standard at Croydon Health Services is currently at 90 per cent, with a further stretch target to 95 per cent. Executive quality rounds have continued throughout 2015/16. Each member of the executive team and the non-executives have been allocated a clinical area either within the acute Trust or community setting and are expected to visit that area at least monthly. Themes that were identified include staff lack of awareness of three key messages and in some instances Knowing How We are Doing (KHWD) Board showing out of date data. The feedback from patients was positive overall. Share patient stories with Trust Board and at other key meetings Over the past year the Trust has hosted five patient stories at our public Board meetings. These included a story around the launch of our innovative Edgecombe Unit, and a cancer care story. This is an area the Board is keen to expand to work with our community and patient representatives. We will be continuing this initiative into 2016/17 but see this now as business as usual. Respond promptly to concerns raised and feedback our actions taken The Trust has made a number of changes and improvements in response to patient complaints by adopting the Parliamentary and Health Service Ombudsman (PHSO), universal expectations of good complaint handling, My expectations for raising concerns and complaints. Indeed, the sub-titles of two major Government reports into patient experience, the Clwyd-Hart report and Hard Truths (respectively, Putting Patients Back in the Picture and The Journey to Putting Patients First) provide the point of departure for the work by the PHSO, and set the founding principle for the creation of a user-led vision for raising concerns and complaints. The Trust has adopted the principles of the user-led vision as a clear demonstration about how seriously it treats complaints, complaint handling and learning from complaints. The Trust s Complaint Handling Policy was completely revised in 2015 based on new national guidance and best practice

31 Look at our systems to understand how we can learn from serious incidents, inquests, claims and complaints Monitor our internal intelligence and use this for improving and developing services The Trust has improved the standard of the serious incident reports and has put in place a system to share learning more widely. It has linked the categories between incident and complaints to ensure that there can be easier correlation when identifying themes and trends. It now produces three key messages to staff which is a direct response following learning from inquests, complaints, claims and incidents and this is an area that the Trust will continue to see as a priority going into 2016/17. During 2015/16 the Trust has taken significant steps to improve how we record actions and learning from resolved complaints. We share these with staff and complainants in order to ensure change is recorded, embedded and the needs of service users are outcomes based. Actions and learning are now captured via Datix (our online incident reporting tool) upon closure of a complaint to ensure that evidence is held of what we have done. Where appropriate, this is shared with the complainant ( you said, we did approach). The Complaints Department now produce a formal quarterly newsletter which is sent to all Trust users and is hosted on the Trust intranet as a downloadable PDF. At the CEO s Trust Focus briefing, every other month, there is a formal learning from complaints section where a real complaint is shared and lessons learnt/actions taken discussed. The Complaints Team now have a structured and well-populated presence on the Trust intranet which serves as a detailed resource and repository for everything related to complaints and complaintshandling. The site has a large section on learning from complaints, where real complaints and actions taken are shared with staff. The Trust has identified ways in which we can be proactive, instead of reactive, and seeks continuous improvement. The philosophy of the Complaints Department is that complaints provide a rich source of information and learning for the organisation. A weekly complaints report goes to the Executive Review Group and monthly updates on complaints performance, trends and lessons learnt goes to the Trust Board via the Quality Report. The Trust Board also receives a formal yearly Complaints Annual Report which shows complaints performance, trends and lessons learnt as well as the monitoring of PHSO cases. One way we do this is to carry out monthly Quality Rounds continue to take place weekly and the themes are collated into a report and recommendation at Nursing and Midwifery Board monthly. During this period Executive Quality rounds were undertaken and we also held an annual peer review of all services to see how we can improve and invited members from the CCG, and other external stakeholders. Pledge 3: Honesty We will continue to be open and honest with patients and their families when things go wrong The Trust continues to demonstrate openness and honestly with patients and their families in line with the CQC Regulation 20 Duty of Candour statutory obligation. As stipulated in the regulation, the Trust is committed to carrying out Duty of Candour conversations with patients and families within a 10-day time frame. The Trust has recruited a family liaison officer to support the Duty of Candour process and to act as link between patients and their families. The process has been embedded within and promoted across the Trust. A patient information leaflet is now accessible on the Trust s website in addition to the staff leaflet available on the Trust intranet which has been cascaded to all staff. Additional plans include a presentation at Trust Focus and attendance at key meetings to further promote and inform staff of the Trust s obligation. New starters continue to receive Duty of Candour training as part of their induction as well as additional master classes, if requested. A revised training presentation is being developed to ensure its content reflects the current Being Open process. During training Trust staff are fully briefed on the Trust s Duty of Candour obligation to ensure they receive the necessary information to assist them in delivering an open and honest service to patients and their families

32 3.1 We will seek to strengthen the membership of the Serious Incident Review Group to ensure that all serious incidents are reviewed by an established multi professional committee The Serious Incident Review Group has been strengthened over the past year and provides robust challenge on the scrutiny of investigation reports. The group now also reviews all critiques that are provided on report submissions to provide wider learning and improve the quality of reports. All directorates are represented at this group that is chaired by the Medical Director and co-chaired by the Director of Nursing, Midwifery and Allied Health Professionals. Prior to submission all serious incident reports are reviewed by the group and are approved for submission by an Executive Director. We will look to see how we can strengthen involvement of patients in our quality governance activities 3.1 Pledge 4: Collaborate We will seek to take every opportunity to share good practice with our partners We will improve communication between the hospital and primary care (GPs) as patients move between different settings The Trust meets regularly with the Clinical Commissioning Group and reviews the quality of services at the Quality and Clinical Review Group. The Trust takes every opportunity to work collaboratively with partners and produces a GP newsletter to share communications. The Trust also holds monthly educational meetings with GPs that are well attended. The Trust has been actively involved in the Health Improvement Network and the patient safety collaborative and has led some improvement work with colleagues across the health economy in South London. The Trust has made some progress in this area however there remains room for improvement. The Trust has appointed an equality and diversity lead and it is hoped that the work that is being completed with our community partner and closer working with Healthwatch will continue in 2016/17. Pledge 5: Support We will create a non-blame culture to encourage staff and patients to be able to raise concerns so that we can put things right quickly We will continue and build upon the Listening into Action (LiA) projects and celebrate success LiA continues to empower staff to identify, lead and deliver further improvements to the quality of our services and ways of working. Each of the Wave Four teams follow the LiA 7-step approach to identify a shared mission, set up a sponsor group, get people on board, and develops the case for change. The groups held structured LiA conversations with relevant people from across the Trust and implemented actions that came out from the conversations. These teams have delivered improvement actions which are already making impact and some are provided below

33 The Perfect Ward The Perfect Ward concept emerged out of the need to work differently to proactively manage the patient journey from admission, improve the experience of an inpatient stay, and deliver safe and timely discharges from hospital on a daily basis. Like all NHS Trusts, winter pressures put a huge strain on the whole organisation, therefore identifying the avoidable blocks and barriers to discharge processes and embedding new operational ways of working for patients admitted to the wards was required. The Perfect Ward team reports that there have been substantial improvements to the patient experience of their journey through the hospital on these wards. Some of these improvements include: Introduction of multidisciplinary ward rounds with doctors and nurses leading to greater effectiveness and more timely communications between professionals as well as with patients about treatment plans. This is also impacting the timeliness of diagnostic tests for inpatients in a positive way. Radios for patients patients who previously had no form of entertainment and had complained of boredom can now listen to the radio and pick up on current affairs locally and around the world. This is of particular importance as studies have showed the importance of the active mind on health and wellbeing. Flexible visiting hours - relatives who had complained about restricted visiting hours can now visit patients more flexibily with visiting hours increased to 12-8pm. Ward teams report that patients have fed back that this has greatly improved their experience and accessibility to friends and family. Outpatients The Trust provided 337,000 outpatients appointments last year with more than 95 percent happy with the care they received (FFT). As part of Waves 3 and 4, the Outpatients Department had made significant improvements such as the introduction of text reminder service, white boards to communicate waiting times, an outpatient s information leaflet providing useful advice and information before a patient s appointment and a more streamlined process which enables clinicians to have more time review the notes before the patient is seen. The goal is to achieve excellence through further improvements. The team s mission was to improve patients experiences through developing clinical roles and they held a LiA conversation attended by 44 members of staff including doctors, nurses, AHPs and administration staff on 30 September Presentations were provided by the sponsor group and round table discussions resulted in recommendations that the team took forward. Improvement actions to date and key achievements include: Development of the clinical skills of outpatient nurses to conduct ECG tests, phlebotomy and giving specialist injections in clinics. This has had a great positive impact as patients no longer have to leave the outpatients department for basic tests. This is particularly important for managing patients outpatient journeys and also of great benefit for elderly and fragile patients who previously had to walk to other areas of the hospital for basic tests. Improving patient flow and outpatients capacity through improving nurse delivered activity in outpatients has also resulted in improved patient experience. Purchase of new wheelchair weighing scales had led to improved compassionate care for patients with disabilities during the weighing process as they no longer have to experience the indignity of staff transferring them from their wheelchair to the standup scale. Patient respect and dignity are maintained throughout the weighing process as patients are simply wheeled on and off. Nurses are spending more time with the patients carrying out basic tests. The team has reported that there has been a positive impact on team morale as staff now feel more empowered, and open up to the opportunities for development. Outpatient nurses are now trained to provide specialist injections in the Rheumatology clinic which have improved the time spent with patients. The transformation of a very bare area into a child-friendly zone to improve children s experience of their outpatients appointments has been very popular and received positive comments from patients

34 Operating Theatres Staff Health and Wellbeing Workforce Diversity and Inclusion Operating theatres are an essential aspect of the services provided at CHS and ensuring theatres is adequately staffed to provide safe, compassionate and high quality care is critical. The theatre LiA team focused on improving patient safety through improving recruitment and retention in staffing levels. The Big Conversation was attended by 48 members of staff on 25 September The need for a better working environment, improved educational opportunities, pay and a change in team culture were some of the key issues highlighted at the conversation. The outcomes from this team are listed below: The Practice Educator has developed a programme specifically for theatres staff to prioritise personal development plans. The team has increased the number of student Operating Department Practitioners (ODP) from 3 to 4 to encourage retention of more students following their graduation. Development of a theatres newsletter to promote communication of good news within the team. Focusing PDRs on career development with a clear link to matching department needs with individual objectives. In-house development for lower grade staff to encourage formal education. Organisational development programmes provided by the OD team on clinical governance days to support a positive culture of change and team building within theatres. The positive impact to improve care and motivate staff was referenced in the CQC inspection report. The CQC noted for example: The day surgery unit had listened to staff and patients and introduced changes, such as improved information for patients about what they should expect when they came. Staff Health and Wellbeing was highlighted through Staff Friends and Family test results as one of the key areas to aid recruitment and retention of staff at CHS. The event was attended by 60 members of staff who were very enthusiastic about this LiA conversation and the opportunity to help shape improvement actions for staff health and wellbeing. In responding to the feedback received, the sponsor group has delivered a number of changes which are impacting in a number of areas including workforce and catering. The Trust supported the provision of free staff health checks to approximately 60 staff on 17 September This had a positive impact as some members of staff were referred onward to their General Practitioner for further management. Another health check is planned for 17 February 2016 at CUH & Lennard Road community site. In December 2015 the Trust delivered free samples of aftershave donated by an organisation called Work Perks to all staff. This was a first and was well received by staff. Cycle to Work Scheme Roadshow took place on 17th September to encourage staff to keep fit. The Trust has introduced a number of after work exercise classes such as yoga, Tabata, and Pilates. The uptake of these classes has been great with all the classes booked to capacity. A committed Healthy Staff e-bulletin was introduced to keep staff up to date on health and wellbeing matters. The Trust introduced a hospital wide Smoke- Free policy for staff from 1 January It is widely recognised that smoking tobacco is the single most preventable cause of death in the world. Smoking caused an estimated 101,000 deaths in the UK in almost a fifth (18%) of all deaths from all causes. The Trust seeks to further support staff wellbeing by promoting a no smoking culture with the support of a dedicated smoking cessation team who provide staff with the resources required. A Slimming World group was launched on 31st December 2015 and already has 39 members. Members are already seeing the results of joining with a total weight loss of 154lb reported for the month of January. The Trust launched creating a mentally healthy workplace training programme for leaders and managers. A take the stairs / walking campaign was launched across the board to keep staff fit and healthy. For the first time ever at the Trust, a Diversity and Inclusion Manager has been appointed to work with staff to address issues of inequality in employment and service delivery. Understanding the individual needs of patient and carers is an integral aspect of providing high quality care and this team is focused on engaging patients and staff to deliver the CHS Equality and Diversity Strategy. This will ensure patients and service users are engaged in the process of designing and delivering services that are appropriate and staffing structures are relevant as well as improving the equality agenda throughout the organisation. With the mission to make CHS a place where diversity and inclusion is promoted and celebrated, the Big Conversation took place on 24 September with just over 40 staff. The LiA team has already introduced a Practice Development Nurse who has led career surgeries for nursing staff. This has been a key issue identified by staff through LiA conversations so it is hoped this will positively influence recruitment and retention within the Trust. Other achievements of the team include: The diversity calendar shared on the intranet to create a sense of community and celebration of the diverse culture present at CHS. LiA methodology is an integral part of the development of the Equality, Diversity and Inclusion Strategy which is set for consultation with staff, patients and external agencies in March This has had an organisational impact as the Trust started to prepare to deliver the Equality Delivery System 2 and Workforce Race Equality Scheme due for submission in May Developing the required Staff Working Groups and reviewing the Trust Access to Equality & Diversity Committee. Using LiA to promote cross agency working with CCGs, Healthwatch and Croydon BME Forum

35 We will provide support and feedback to staff following incidents to look at how we can do things differently We will hold an annual Croydon Stars awards for staff and volunteers to celebrate success Learning from past incidents, best practice and other educational sources are key ingredients to a culture of continuous improvements for high quality service provision. The LiA Shared Learning sponsor group set out to establish and embed a culture of shared learning whereby practice is improved to benefit patient care. More than 130 staff attended the Big Conversation on 25 November 2015 to discuss actions required for the Trust to embed a culture of continuous improvement for greater patient safety, care and experience. This team is making great impact across the organisation through the delivery of various shared learning resources to embed a culture of continuous improvement. Some of the actions to date include: A patient safety newsletter introduced to focus attention on key patient safety issues and new patient safety developments as they impact the Trust. Creating a shared learning hub on the intranet for all staff to have easy access to the resources that make a difference in patient care, safety and experience. All Trust newsletters with learning elements which were previously held by individuals have been centrally archived through the Trust library services to ensure retention of knowledge and accessibility. Opportunities for shared learning mainstreamed through Trust focus and Medical Director s section on grand rounds. Datix incident reporting system was upgraded to make incident reporting easier for staff. Anonymous reporting and automated feedback functionality were also activated in this system. A Podcast on how to use Datix was created on the shared learning hub. Three key safety messages are published every week to spread best practice, as well as learning from incidents and complaints. The first patient safety week took place in September This team has encouraged 475 staff to make individual pledges to continuously improve patient safety. Recognition of outstanding service and commitment by our staff is an important part of ensuring that our workforce understand that their work is valued. The Croydon Stars scheme is open year-round, with patients, carers and colleagues able to nominate staff for outstanding conduct across four categories: Amazing Achievement, Incredible Customer Service, Tremendous Teamwork and Landmark Leadership. Each person or team then receives a personal acknowledgement from our Chief Executive and their nomination is put on a long list for our annual awards night. The Croydon Stars awards take place in late spring every year, where nominations from the previous 12 months are shortlisted and then reviewed by a panel of staff, where winners from each category are selected. The shortlist nominees are all invited to and acknowledged at the awards dinner, with the winners receiving certificates presented by the Chairman of the Trust. As well as those nominated for awards, the Croydon Stars event also provides the opportunity for the Trust to publicly thank members of staff who have a history of long service to the organisation, in some cases going back more than 40 years

36 We will hold an annual quality event to share good practice Priority 3 Experience We hosted a quality event titled What we learned last year which attracted 200 clinical trust staff of all grades attending the event including our guests, Dr Frankel (Post Graduate Dean Dr Helen Massil ( HESL Liaison Dean ). Speakers discussed incidents and how they have changed practice since. The learning that was shared spanned multiple specialties and was well received across the Trust. We also held our first internal Patent Safety Week where we had a focus on different specialties and conditions with staff making safety pledges in line with the Sign up to Safety ethos. Throughout the week we spoke to staff and public about Sepsis, Diabetes, Acute Kidney Injury, pressure ulcers, falls and medication incidents. We received over 475 pledges. Following this event we have seen a greater awareness of these areas and an increase in incident reporting. This is something that we will continue with going into 2016/17. To continue to embed the Quality, Experience and Safety Programme (QESP) to improve quality, safety and patient experience practices into our daily work across the Trust. The Quality, Experience & Safety Programme (QESP) was established in January The primary aim of the programme was to build upon the previous CQC Inspection Quality Improvement Plan to improve the quality of patient care, patient safety and patient experience across the Trust and embed Best Practice processes and procedures. In order to achieve this schedule, weekly strategic and operational meetings were established to drive forward actions resulting from a range of initiatives such as the Matrons Quality Rounds, Executive Walk Rounds and Mock Inspections. Following the CQC Inspection in June 2015 the QESP has overseen the development of a comprehensive CQC Quality Improvement action plan to respond to each of the must do and should do actions. Priority 2 Effectiveness To make our discharge process more effective A project was introduced where one patient from each ward is identified as a priority to be safely discharged by 10.00am each day. By having plans in place this means that there can be clear communication with the patients, their relatives and carers. This will enable the Trust to create capacity and reduce delays for incoming patients. This project has been reviewed and is to be re-launched in under the umbrella of the Perfect Patient Journey. Matrons Quality Reviews The Matrons Ward Rounds have continued in 2016/16 and are undertaken monthly in all clinical wards and departments. In 2015/ quality rounds were undertaken. They aim to make clinical leaders more visible and enable them to engage actively in improving the environment of care and the experience of our patients. They focus on these main areas: Environment Communication Privacy and Dignity Safety Nutrition Pathway tracking Leadership Improvements Achieved Across all in-patient and out-patient areas consistent improvement has been achieved as assessed by the matrons. All wards and departments have developed action plans in response to issues identified on these rounds which are monitored monthly by the ward managers

37 3.1 Further Improvements Identified The matron ward round process is being reviewed for 2016/17 to include the Emergency Department and amalgamate them with the executives visible walk rounds. This means the Trust will have one tool used by everyone undertaking quality reviews and will develop the assessment framework so that it incorporates a level of assurance between executive and Matrons Quality Reviews. All quality review tools will be available on the Real Time Experience (RaTE) system. This will allow all data to be inputted at the time of the review and reports and charts to be produced benchmarking all areas of the Trust. 3.1 Priority 5 Well-led Implement agreed recommendations from the pilot of the Well led Framework to strengthen our approach to governing quality. In 2015, the Well-Led Framework for Governance Reviews was piloted by the NHS Trust Development Authority (NHS TDA) with three NHS Trusts of which Croydon Health Services NHS Trust was one. Following the Trust Development Authority s (TDA) field work and their assessment of the Trust s own self-assessment, the TDA provided a report and action plan with 38 recommendations under the four headings of. Priority 4 Responsive To work towards achieving full compliance with the London Quality Standards, to ensure that we have the right person available at the right time for patients in our care. It is expected that by 2018/19 the NHS will be offering a seven day service. This will be achieved through adopting 10 evidence-based clinical standards. Full implementation of these standards should reduce current variations in outcomes for patients admitted to hospitals at the weekend. We are committed to the strategic and rational provision of seven day services across specialities. As part of this process, we partook in the Urgent and Emergency Care Peer Review led by the South West London CCG against the London Quality Standarsd (LQS), which incorporates seven day services provision. CHS has been working with clinical directorates to strategically identify and prioritise resource gaps for achievement of the LQS as well as delivery of seven day services whilst continuing to provide the current safe level of service. Continuing progress with LQS compliance in 2015/16 was delivered in part through recruitment and service redesign as well as via use of internal professional standards. Strategy and Planning how well is the Board setting direction for the organisation? Capability and Culture is the Board taking steps to ensure it has the appropriate experience and ability, now and into the future, and can it positively shape the culture to deliver care in a safe and sustainable way? Process and Structures do reporting and accountabilities support the effective oversight of the organisation? Measurement does the Board receive appropriate, robust and timely information and does this support the leadership of the Trust? In summary the key themes / areas that were identified for development were Governance Arrangements, Framework and Risk Management Board, Committee and Sub-Group Effectiveness and Structure Leadership Development including NED Challenge and ED Support Stakeholder Engagement and Management Transformation and Sustainability 72 73

38 Performance against national priorities A significant amount of work has been undertaken throughout 2015/16 to progress the recommendations identified from the Well-led report and a highlight of these is included below. Director of Quality Assurance & Governance was appointed in September 2015 with responsibility for both clinical and corporate governance to provide leadership at Board level. Standards Targets 2013 / / / 2016 Meeting the MRSA objective Clostridium Difficile The Trust s Audit Committee approved the separation of the Corporate Risk Register (CRR) and Board Assurance Framework (BAF) into two separate documents. The Board Assurance Framework has been significantly revised to provide additional assurance to the Trust Board that the risks to the strategic objectives are being managed. RTT Waiting Times for Admitted Pathways: Percentage within 18 Weeks RTT Waiting Times for Non-Admitted Pathways: Percentage within 18 Weeks 90.00% 90.93% 90.45% 80.10%* 95.00% 96.12% 95.89% 92.8%* The Risk Management Strategy has been revised and a Risk Management Framework has been developed. Board/Committee Forward Plans have been developed and action trackers are in place for all Board, Board sub committees and Executive Management Board meetings. RTT Waiting Times for Incomplete Pathways 92.00% 94.29% 95.67% 94.53% Diagnostic Waiting Times for Patients Waiting Over 6 Weeks for a Diagnostic Test 1.00% 0.70% 6.49% 0.22% A&E 4 Hour Time in Department (All Types) 95.00% 95.29% 93.78% 92.33% A Governance review of committees was undertaken and the introduction of weekly Executive Management Board meetings to provide additional scrutiny and challenge of Trust Board papers prior to presentation at the Trust Board. Annual reports for each Board sub-committee have been produced and were presented to Trust Board. A series of Board development days to further develop srategic planning and Board leadership & effectiveness has been undertaken. A Board development away day has also been undertaken. Cancer Waits - Referral to First Appt for Urgent Suspected Cancer (14 Days) Proportion of patients seen within 14 days of urgent GP referral Proportion of patients with breast symptoms seen within 14 days of GP referral Cancer Waits - Diagnosis to First Treatment (31 Days) Cancer Waits - Proportion of patients receiving subsequent treatment within 31 days (Drug) 93.00% 95.55% 95.85% 95.28% 93.00% 95.26% 97.84% 96.08% 96.00% 99.68% 97.95% 98.61% 98.00% % % % Cancer Waits - Referral to First Appt for Urgent Suspected Cancer (31 Days) Proportion of patients receiving subsequent treatment within 31 days (Surgery) 94.00% 97.95% % % Cancer Waits - Referral to Treatment for Urgent Suspected Cancer (62 Days) 85.00% 86.90% 87.77% 85.61% *Not mandatory report for 2015/

39 The Trust continues to benchmark positively for a number of indicators, including cancer targets, RTT year to date, VTE, Harm Free Care, Falls and FFT response rates. The key area for improvement remains achieving the A&E 4 hour target on a sustainable basis together with reporting of triage time. Infection control Overall has been a challenging year in terms of infection control, however, the Trust management, staff and infection control team have managed the challenges. July 2015 saw a higher than usual incidence of C.difficile cases, with 8 cases occurring in a 13 day period, against a usual incidence level of 1-2 per month and a C.difficile-specific action plan was implemented. This included: Enhanced infection control measures, including a matron-led weekly infection control walkabout, weekly commode spot checks along with regular audits of PPE use and antibiotic prescribing, with senior nursing staff reviewed these findings. Deep cleaning and, on some wards, use of hydrogen peroxide vapour to aid cleansing. Enhanced infection control training for staff who manage patients with diarrhoea. These actions effectively addressed the increase in cases, which dropped back to 2 in August 2015 and remained well controlled for the remainder of the year; the actions implemented in the C.difficile specific action plan will continue and ensure rates remain as low as possible. Despite the spike of cases in July, overall the Trust had 20 cases of hospital-acquired C.difficile against a planned trajectory of 16 or less for the year. There was one hospita-acquired MRSA bacteraemia. The Trust screens all emergency admissions for MRSA and offering decolonisation to those found positive. In addition, the infection control team review all individuals who have MRSA on a weekly basis, work closely with ward teams on treatment, screening and documentation of these patients and other patients who are at higher risk of infection. This year Croydon University Hospital has seen more cases of confirmed flu this winter than previous years. From November 2014 to 08th April 2015, we have seen 202 patients with confirmed influenza at CUH. 123 of these were due to Influenza A H1N1, 59 were due to Influenza B and 20 were due to Influenza A (not typed). The current flu vaccine (for winter 2015/16) contains these three types of flu. The high number of cases put tremendous pressure on the requirement for siderooms and infection control staff time. The infection control team worked closely with operational teams to optimize isolation and follow up of contacts. To support this work, the Trust produced printed guidelines for handling flu patients for staff, the communication department produced posters for main entrances to further educate patients, staff and visitors, and staff flu immunisation was widely promoted throughout the winter. In July and August 2015, the four midwifery staff were confirmed with whooping cough. The midwifery, infection control, occupational health and communications teams, along with the Trust s Medical Director and Director of Nursing, Midwifery and Allied Health Professionals worked closely with Public Health England to address this issue. Women using the service and staff were offered precautionary treatment and immunisation and, as a result, no mothers or babies contracted whooping cough. A&E Croydon s A&E has been in the top ten best performing Trusts in London during the busy winter peak in demand for 2015/16 (93.2% in Dec 2015; and 91.8% in Jan 2016; 83.6% Feb 2016). The monthly A&E performance data published by NHS England showed that 81.6% of patients nationally were seen within four hours in February Referral to Treatment (RTT) The Trust has significantly developed its management of RTT as a performance target. In the last year it has seen a significant reduction both in the backlog and number of long waiters. The Trust has almost eliminated the 52 week waiters and has been successful in reducing the back log by 38% and has sustainably maintained the incomplete RTT performance target. There is still further work to be done but with robust processes and infra structures now being developed and implemented and the Trust is in an excellent position to achieve RTT as part of business as usual. Cancer Waits The Trust has regularly delivered a strong performance in meeting all cancer waiting time standards. The Trust achieved consistently the 62 day cancer target and in March 2016 achieved all 8 cancer targets

40 3.2 Other Patient Safety Activities At Croydon Health Services NHS Trust we aim to reduce harm. We measure outcomes of much individual harm to identify the impact of any improvement work we undertake. While we are proud of our achievements which we have highlighted here, we still have work to do to further reduce clinical impact harm and its impact. Edgecombe Unit We have opened our new unit to offer patients rapid access to specialist hospital treatment without having to wait in line in our Emergency Department (ED). The new Edgecombe Unit at Croydon University Hospital brings together four specialist services into one, to offer patients faster access to diagnostic scans and expert medical treatment. Patients arriving at the hospital s Emergency Department (also referred to Accident & Emergency or A&E) can be fast-tracked directly to the unit. Local GPs can also call a dedicated hotline and speak directly to hospital consultants for expert advice, and rapid referral for their patients. The four specialist services included within the Edgecombe Unit are: Rapid Assessment Medical Unit (RAMU) for patients referred from ED or by their GP for fast clinical assessment and medical treatment; Chronic Obstructive Pulmonary Disease HOT (Hospital Outpatient Treatment) clinic, for specialist care for patients with this form of lung disease; Ambulatory Emergency Care Unit (AECU) for urgent hospital care when referred by a GP, for example for the treatment of blood clot in the veins and lungs, skin infection requiring intravenous antibiotic; Acute Care of the Elderly (ACE), which provides rapid response and specialised care for frail and elderly people in Croydon through outpatient clinics and a short-stay inpatient facility. This unit is further supported through targeted and focussed therapy and social care support. 3.2 The new Edgecombe Unit opened on 2 November 2015, and within just a few weeks has seen a step-change in the Trust s A&E four hour waiting time performance. The Edgecombe Unit is taking an entirely new approach to the delivery of emergency care. This is helping to unblock delays in A&E but most importantly, it means our patients can be seen by senior hospital medical staff within hours for early clinical decision making something that is not always possible via the traditional A&E route. Croydon s new model of care is built around getting our patients cared for in the right place, at the right time, first time. All patients referred to the Edgecombe Unit either from A&E or by their own GP will be met by an experienced nurse and medical team on arrival. They will have a senior consultant review within two hours, and a treatment and management plan in place within four hours. This can include a referral for on-going specialist treatment, or to be discharged from hospital with follow-up care at home. The Edgecombe is a consultant-led service, available 7 days a week. This is only possible by bringing our senior consultants together, with the right expertise and support around them to deliver emergency care in a revolutionary way. This is also helping to reduce waiting times and improve patient experience for those waiting in A&E, by easing the pressure in the department. Since opening the Edgecombe Unit, the Trust has seen a turnaround in its performance to see at least 95% of A&E patients within four hours. Provisional data shows that Croydon has been one of the best performing Trust for A&E performance across London in November 2015 achieving above 95% on a total of 23 days throughout the month. Compared to the same period last year, the Trust had often struggled to achieve 90% on a day-by-day basis. New figures also show that fewer patients in Croydon have had to be admitted into hospital since the Unit opened, with no increase in the number of patients who re-attend its services. When compared with the same period last year (November 2014 to November 2015); the number of hospital admissions has fallen by up to 25% (an average of 20 patients) on a daily basis

41 Nutrition The Nutrition Task Force was re-established in June 2015 to monitor nutrition and hydration standards across the organisation and ensure compliance with national guidance. Maternity Whose Shoes Whose shoes is one of the ways the Trust listens to stakeholders and maternity service users. It was established in April 2013 as part of the London Maternity Strategic Clinical Network. The first session in the Trust was attended by more than 60 stakeholders and maternity users. The service heard bespoke maternity stories and the whose shoes board game was played in six teams enabling scenarios to be discussed. The feedback was collected throughout the session and then fed into an artist who created Croydon s colourful collage (below) which is now displayed in the maternity unit. There have been a number of achievements to date. Areas of improvement have been highlighted and an action plan developed that is presented to Nursing Midwifery and AHP Board monthly. Development of a Trust-wide nutrition and hydration action plan that is monitored by the nutrition and hydration taskforce which meets monthly and included membership from the acute and community setting. Increase reporting of nutrition and hydration incidents by 20% Nutritional Study days organised The aim is that 50% of trained nurses on in patient wards will attend nutrition study session at ward level or in training department by April The programme covers all aspects of nutrition assessment and Malnutrition Universal Screening Tool (MUST) management in the acute setting. Bespoke MUST training provided to wards. Nutrition related Vt. These are ward based sessions delivered by the practice development team and dieticians. Weekly audits to assess compliance with MUST. Overhead bed boards now in use across all wards to identify specific dietary needs Clear identification of thickened fluids by the use of labels and orange coloured jugs implemented in August LiA project led by the Matrons to improve communication at ward level regarding nutritional needs of vulnerable patients Coloured jugs have now been rolled out across the Trust and are as follows: o Blue lid for normal fluids o Red lid and glass for those who are on red trays and therefore need assistance o Orange jug and glass for those on thickened fluids. These jugs should be empty until thickened fluids are made up or patient is given a drink i.e. the orange jugs should never contain non thickened fluids. Main themes identified included: More support for traumatic delivery Reach out to communities so that their voices are heard Improve retention of staff More education for men with regard to breast feeding and birth Support women s choice Improve communication Normalise birth for high risk women Individualised women centred care These are being planned to be part of one of the LiA directorate big ticket items. Schwartz rounds In the 2015/16, six Schwartz rounds were conducted which were attended by 410 members of staff. One of the topics discussed was is sorry a difficult word? The session was attended by 50 staff. Feedback from the session was very positive with 67% expressing their interest in attending the session, and 63% indicating that they will recommend the session to other staff

42 3.2 Children s Hospital At Home The Children s Hospital at Home Team celebrated their 20 year birthday with an establishment of children s asthma nurse specialist service in April 2015 to reduce hospital attendance, admissions and improve self-management through education. They have recruited new team members including an Oncology Nurse specialist to support children, young people and their families in Croydon. The service s hard work has been recognised with a nomination for an award for innovation in school nursing through the Cavell Trust. Delivering more integrated care out of hospital To address the health and wellbeing, quality and significant financial challenge within the local health economy, Croydon Clinical Commissioning Group and Croydon Council are commissioning a 10-year outcome based contract for managing and delivering health and social care services for the over 65s from 1 April Commissioners have decided that an Accountable Provider Alliance (APA) model will deliver the best outcomes for Croydon and have selected five providers including Croydon Health Services NHS Trust as the Most Capable. Establishing a provider alliance with South London and Maudsley NHS Foundation Trust, Age UK Croydon, Croydon GP Collaborative and Adult Social Care. The five providers have selected Croydon Health Services NHS Trust as the Host for the alliance. The ambition of this Programme is to: Improve the health and wellbeing outcomes for older people Improve the experience and quality of care and support amongst older people Reduce cost pressures in the local health and social care economy Support and deliver transformational change to the whole system with the older person at the centre 3.2 Emergency Department On 8 November 2015, the Emergency Department at Croydon University Hospital was temporarily relocated to the opposite side of the hospital all whilst continuing to safely care for patients. The move was to allow construction to begin on a 21.25m Emergency Department at Croydon University Hospital. The new and bigger facility will open in Staff have also been involved in a Trust-wide campaign and Listening into Action (LiA) events to discuss how better to manage winter demand and unblock delays for patients. This includes initiatives to order prescriptions and book patient transport in advance when patients are well enough to be discharged from hospital. Neil Hawkins Lifeblood Suite The new Neil Hawkins Lifeblood Suite was officially opened by the Mayor of Croydon on 8 January It is an important service that supports many patients who have serious and debilitating illnesses such as cancer and sickle cell anaemia. The newly refurbished facility has been expanded to three times its original physical size, and provides a bright, clean and peaceful environment for patients to receive blood treatments. The Trust worked closely with the Friends of Croydon University Hospital to develop plans for the project. With the generosity of the Friends of Croydon University Hospital in the form of a substantial donation of 330,000 and additional funding from the unit s own Lifeblood Charity, refurbishment began in summer The Trust also supported the project with 122k of its own capital funding. The facility is named in honour of Neil Hawkins, the previous Chairman of the Friends who passed away in 2014 and who championed and conceived the idea of the bigger and better Lifeblood suite. In a survey, patients said that while they had positive views of the staff, they felt improvements were needed to the environment and to enhance privacy. The refurbished suite is not only more spacious but provides greater privacy to patients. The Lifeblood suite provides more than 3,000 individual treatments to patients every year on a day case basis, where care is provided on the day and patients are able to return to the comfort of their own home following treatment. This model of care helps patients to manage their illnesses and reducing their need to attend A&E or be admitted to hospital as an inpatient

43 Mortality Croydon is one of six Trusts whose Hospital Standardised Mortality Ratio (HSMR) is as expected within the London Peer group. Below are the highlights of Croydon performance: For the past three quarters, the Trust has been within the expected range for HSMR. Croydon is one of six Trusts whose HSMR is as expected within the London Peer group. Trust crude rate = 4.15%, Group crude rate = 4.29% There are two diagnosis groups within the HSMR basket that are within the statistically significantly higher than expected banding: Acute bronchitis and other gastrointestinal disorders. However, for the last financial year FY14/15, HSMR at the Trust has been inaccurately recorded as above expected at During the financial year 2105/16 due to a data corruption issue the published data for CHS for the past 12 months is not accurate. Data predating and post-dating the corruption and did not highlight alerts for mortality. The issue was raised with our regulators and a caveat placed on the HSCIC website. The board and our patients should be assured of the mortality issue at CHS. The following represents the most recently available data for the Trust s HSMR monthly trend. Patient safety incidents Following the publication of the Francis Report in February 2013, the Trust has been clear in its expectation that staff report near miss and unexpected adverse events using the Trust s web-based (Datix) incident reporting system. Use of this reporting system enables the Trust to use its data well, regularly interrogating the information recorded, carrying out investigations and trend analysis and interpreting outcomes in relation to patient experience and safety. The Trust s Datix system is electronically linked to the National Reporting and Learning System (NRLS) and patient safety incidents are uploaded to this central reporting and analysis centre. Local investigation of all adverse events is supported within the Trust to ensure that appropriate challenge to existing practice is encouraged and good practice identified is rewarded. Periods of reflective practice in supervision and learning from investigations through regular learning events (known as clinical governance) are two ways in which learning is shared throughout the organisation. The Datix incident report form captures information to drive the quality and usefulness of safety information captured such as: Being Open meetings with patients and their representatives (Duty of Candour) Flagging safeguarding concerns, including rationale for why a safeguarding referral is not indicated Recording root cause and lessons learnt. During the 2015/2016, 6905 adverse events and near misses (4466 clinical incidents and 2439 non clinical) have been reported by Trust staff using the Trust s reporting system; of which 124 were reported and investigated as Serious Incidents. Of the serious incident s reported 40 were de-escalated as following investigation the Trust identified that on further investigation the incident no longer met the Serious Incident criteria or where there were no care or service delivery issues identified During this period the Trust reported one Never Event. Never Events are serious incidents that are wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers, are available, at a national level and should have been implemented by all healthcare providers. Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a Never Event. The Never Event in related to a temporary retention of a swab. Serious Incidents are investigated using root cause analysis (RCA) investigation techniques. Investigation panels are convened to bring together multidisciplinary senior colleagues to complete the investigation including a colleague who has been trained in RCA techniques. Serious Incident final reports are also subject to an internal quality assurance programme, with sign off by either the Medical Director or the Director of Nursing, Midwifery and Allied Health Professionals prior to being sent on to the Clinical Commissioning Group for external scrutiny of the report and appropriateness of the actions before final closure of the Serious Incident. Root causes and lessons learned are reported in a quarterly report to the Patient Safety and Mortality Committee

44 3.2 Friends and Family Test The results for this reporting period show that response rates and recommendation are stable for the majority of services. ED Performance decreased in February and management actions have been strengthened. High recommendation scores were met in many areas and wards and departments are supported by the Patient Experience Team to optimise the information available on the RaTE system (FFT database) to continue to be responsive to patients and clients. The overall majority of FFT respondents highly recommend care across all services at Croydon Health Services. FFT results across the Trust are monitored locally by Knowing How We re Doing (KHWD) methodology and results and actions are displayed publically. All areas met the target for 5 of patients who would recommend the service. Apart from OPD there was a dip in all services response rate targets for February The graph below shows the response rates from April 2015 to February There was a significant dip in December 2015 and work is underway to return response rates to above the national target. Actions implemented include a weekly update on response rates by ward. This update will be sent to ADN s and Matrons who will be expected to monitor progress in their areas. All Trust services met the target of 90%. Day Cases, Community Services achieved recommendation rates greater than 95% Service Standard Feb 2016 Service Recommendation Rate (February 2016) CHS FFT % Response Rates internal standards A&E (combined Adult & Paeds) 20% 14.4% Inpatients 30% 26.8% A&E (combined Adult & Paeds) 90.6% Inpatients 91.7% Maternity (aggregate) 20% 28.1% Day Cases 93.5% OPD none 7.8% OPD 94% Day Cases 20% 23.4% Community 96.8% Community none* N/A 86 87

45 3.2 The graphs below show comparative data for the percentage of respondents who would recommend our services between April 2015 and February The graphs show that Outpatients and Maternity have outperformed other areas throughout this period and A&E has seen a decline in those recommending the service since November PALS and Complaints Complaints During 2015/16 the complaints team received 499 formal complaints. There has been a 15% decrease of complaints compared to 2014/15. This decrease is due, in part, to how complaints are now handled within Croydon Health Services NHS Trust. In agreement with the complainant, complaints can be resolved much earlier and informally without the need for the formal complaints process. This is part of a proactive and supportive strategy adopted by the Trust following national best practice. In terms of complaint response, the Trust seeks to acknowledge complaints within 3 working days of receipt and at present we achieved an average of 96% for the 2015/16 period. The Trust standard is that we are committed to responding to 80% of formal complaints within an agreed timescale with the complainant. We achieved and maintained 80% compliance with this standard throughout 2015/16. The graph below shows the significant increase in response performance compared to 2014/15. Community Services FFT results February 2016 Response rates cannot be calculated for community patients because, depending on the service and the care plan for the patient, a patient can be seen by a community service for two weeks (A&E Liaison) or for the rest of their lives (Heart Failure team). Community patients are not expected to complete an FFT form every time they visit the service therefore the response rates cannot be determined using the number of patients seen by the community each month. As a result the Trust data available relates to recommendation scores only. The aggregate recommendation rates for Community Services improved to 96.2% in February. Improvement Actions The Patient Experience Team continues to support wards and departments to improve response rates and recommendation scores and has initiated and directly supported a number of improvement actions during February

46 New innovations in our handling of complaints The Complaints Team have developed a bespoke, one-day, in-depth complaints training day which is now available to all staff. The purpose of the training is to explore the fundamental elements that Trust staff need to consider in order to be able to provide an excellent experience both to patients and their families on both investigating and responding to complaints. It is also designed to encourage staff to recognise that they are part of one single team, and that joined-up working is essential if we are to succeed in giving our patients and their families the best possible experience when they come to access our services. Patient Advice and Liaison Service (PALS) The PALS office provides information about Trust services and seeks to resolve current patient concerns. During 2015/16 the PALS team received 1790 contacts. There has been a decrease in PALS contacts by 10%. The decrease is due to staff addressing concerns as they arise. In February 2016, the team discussed ways in which it could improve and promote the service and it was decided to take a look at the PALS provision in some of the adjoining Trusts, with a view to seeing whether there were any best practices which could be learnt. PALS staff subsequently visited St Helier Hospital and St George s Hospital and have since introduced a number of changes, including: The PALS office layout has been changed and a smaller reception desk introduced to make more effective use of the limited space available. The information monitor positioned outside the office has been upgraded and replaced with a larger screen for easier patient access. The PALS officer is now making more ward visits to resolve concerns, improving patient satisfaction and making staff aware of their PALS contacts. We now have a regular display outside of the office in main reception to highlight national awareness campaigns to the public and to brighten the office exterior. Safe staffing All hospitals in England are still required to publish information about the number of nursing and midwifery staff working on each ward, together with the percentage of shifts meeting safe staffing guidelines. A letter from the Chief Nurse in October 2015 provided additional advice on safe nursing staffing levels and urged hospitals to take a rounded view of staffing that shows they are making the best use of resources as well as providing safe care. It lists a set of variables, including how ill patients are. CHS continues to display daily nurse staffing levels on each ward on a daily basis for each shift. A report on safe staffing is reported to the Trust Board on a 6 monthly basis and included information on nurse staffing on all in patient wards as well as how our staffing compares to our peers across London. On a local level the Trust continues to report the actual staffing levels against our planned staffing levels on a monthly basis and these results are published nationally via UNIFY data published on the NHS Choices website. The Trust continues to monitor staffing levels on a daily basis triangulated against the acuity of the patients on that day. This enables us to escalate areas where additional resources may be needed and respond quickly. The graph below shows the average fill rate for registered nurses across the in-patient wards and is an assimilation of day and night shifts. CHS remains comparable with our peers. The reduction in January 2016 is due to the opening of escalation wards in response to higher admission rates across the winter months

47 A report to the Nursing, Midwifery and Allied Health Professionals Board forms part of the organisation s commitment to providing open and transparent information, through the publication of this data on the Trust s Website. It includes an overview of the monthly UNIFY data submission that is published on the NHS Choices website and further local analysis by clinical specialty. The Trust is required to report on the actual against planned/ staffing levels for each month. The wards where staffing pressures have been identified are highlighted, and the potential impacts on patient care are assessed using the Nursing Quality indicators. Staff are encouraged to report staffing issues on Datix. International Nurses Day The Trust celebrated International Nurses Day and heard from the President of the Royal College on Nursing. On 12 May, International Nurses Day, Croydon Health Services (CHS) said a big thank you to its incredibly hardworking nurses and midwives, who work in Croydon University Hospital and across the local community. The day s activities included afternoon cream tea and inspirational talks by both our Homeless Health Team, who recently won a Nursing Times award for exceptional student nurse placements, and by the Head of Acute and Older People for NHS England, who spoke about our nurses vital contribution to compassionate, safe care. A special awards ceremony was also held on the day, to recognize staff who have demonstrated exemplary levels of the Six Cs of Nursing in their work: Care, Compassion, Competence, Communication, Courage and Commitment. They were nominated and shortlisted by their colleagues. Tea Parties A new initiative which will help people with dementia feel less isolated was launched on the dementia zone in Put together by the Croydon Health Services Patient Experience team, the tea party let patients recollect their younger years through familiar music and objects. The event gives the older people on our wards the opportunity to enjoy themselves and share personal memories with the staff that care for them, as well as providing mental stimulation that can help to fight conditions such as loneliness and dementia. As well as supporting patients to use their memories and keep mentally active, the party also helps patients connect with staff. Reminiscence boxes are used to help dementia sufferers recall memories thought he use of retro household items, clothes and music. Staff Pledges The Staff Pledges were introduced in December 2014 as a direct result of staff feedback from a LiA Big Conversation where staff came to discuss customer service. The pledges are about staff commitment to making a difference every day by committing to always introduce themselves. The pledges are: Always let patients know who you are, in line with the hello my name is initiative; If someone needs help or looks lost always stop to help; If you can t help, always ensure that you refer them to someone who can; and If bad behaviour is witnessed always feel empowered to challenge it. Workforce Development The Trust is committed to developing and enabling a working environment that promotes the health, safety and wellbeing of its staff to the benefit of patients and other service users. Everyone working at the Trust has an important role in caring for our local community safely, effectively and with the highest standards of dignity and compassion. Our approach to workforce and organisational development is strongly linked to staff engagement, ensuring effective leadership, service improvement and transforming our workforce to help us achieve higher levels of quality to improve the patient experience. Staff engagement is a key ingredient in helping the Trust to achieving this, both individually through Listening into Action and through productive working relationships with recognised trade unions. By involving staff in decisions and communicating clearly with them, we are seeking to maintain and improve staff morale to deliver better care for patients

48 Staff Survey The Trust had encouraging results for a third year in the NHS Staff Survey 2015, which was conducted nationally in autumn 2015 and published in February 2016, with results for the majority of findings on par or better than the national average. Among the findings were that our staff feel amongst the most enfranchised of any NHS organisation, with 75% feeling that they are able to contribute to improvements at work a testimony to the organisation s efforts over the past two years to create an environment where staff feel engaged and empowered to deliver improvements to our patients. The percentage of staff feeling pressure in the last 3 months to attend work when feeling unwell was 61%. This performance equals the average score when compared with all combined acute and community trusts in The percentage of staff/colleagues reporting most recent experience of harassment, bullying or abuse was 32%. This performance is worse than the average score when compared with all combined acute and community trusts in The Trust s performance on the percentage of staff believing that the organisation provides equal opportunities for career progression or promotion improved from 79% to 82%. The performance remains below the national average of 87% when compared with all combined acute and community trusts in The Trust is working hard to improve its performances in areas where performances were worse than or equals the national average. Recruitment and Retention Nurse recruitment remains one of the key challenges facing the Trust. Croydon Health Services is not alone in facing this challenge and the nurse recruitment situation across London is formally acknowledged. A recent survey by the Royal College of Nursing (RCN) shows that across London the average vacancy rate for qualified nurses is 17%. The CHS vacancy rate Key Performance Indicator (KPI) that the Trust works to is 11.5%, and the Trust is currently reporting a vacancy factor in nursing of 20.42% which equates to 274 WTEs across all qualified nursing grades. However, to put these figures in perspective it should be noted that the Trust now employs 150 more nurses than it did in 2012/13. In recognition of this challenge, the Trust has created a role of Workforce Matron who will work with their peers and Human Resource specialists to develop new initiatives to nurse recruitment. The Trust s recruitment campaign, Could You Be A Croydon Nurse, is continuing by utilising concerted recruitment drives at graduate nursing recruitment fairs alongside a distinctive visual, online and social media presence. Indications are that the Trust s recruitment efforts, both in the UK and in the EU were not yielding the expected result. Consideration is currently being given to extending recruitment into non-eu countries. Freedom to Speak Up / Whistleblowing All of our staff should feel able to raise concerns if they have them, and know that they will be listened to and supported. This is crucial if we are to continue improving how well we look after our patients and staff, and for people to have confidence in their local NHS services. We have and always will take all concerns about patient safety extremely seriously as well as any allegations of bullying or a lack of support for our employees. Every NHS Trust and NHS Foundation Trust will be required to have appointed a Freedom to Speak Up Guardian during the coming financial year (2016/17). This is, however, not an appointment to be rushed. Trusts are expected to have plans in place by September 2016, based on local needs and how confident staff already are about raising concerns and speaking up. Managers and trade union representatives recognise their interdependence and agree that matters affecting their interests shall be considered jointly, both by consultation and negotiation through the Joint Staff Consultative Committee (JSCC), which acts as the overarching body of the organisation and is concerned with all employee relations issues. In addition to the JSSC a Trust-wide Medical and Dental Negotiating Group (LNC) also exists. However, it should be noted that the LNC only covers matters exclusive to Medical and Dental (M&D) employees and the JSCC deals with other employment matters which cover all staff such as general HR policies and procedures. Diversity, Equality and Inclusion The Trust is committed to developing and delivering an Equality, Diversity & Inclusion (EDI) Strategy to meet the requirements of the Equality Act 2010 and requirements set out by NHS England. This Strategy will set out our priorities for delivering the equality and inclusion agenda over the next few years. We will embed the principles of equality, diversity and inclusion at the heart of the services we provide, our key strategies and policies and in our employment practices. Our aim is to ensure that the diverse needs of our patients, communities, service users and staff are met and that we improve their experience when using our services. We are committed to working with our partners and stakeholders to tackle health inequality in Croydon and ensure that our staff have a positive experience and view Croydon Health Services NHS Trust as an attractive place to work

49 Patient and Public Voice Since its launch in September 2012, Listening Into Action has been the Trust s chosen engagement and empowerment initiative. It enables staff to identify, lead and deliver change and improvements locally, as a result of listening to feedback from staff, patients and stakeholders. External Visits Summary Report for April 2015 March 2016 In April 2015 to March 2016, 20 visits, assessments, audits and reviews specific to the Trust were reported. Of these, nine are closed, eight still remain open and three are awaiting their reports. See the table below and on the following pages for more information. We have taken the opportunity to engage with staff and patient representatives throughout the year in order to inform our key quality priorities for 2016/17. In March 2015 the Trust hosted two listening events: the first attended by over 60 patients, relatives and members of the Croydon community; and the second attended by our local stakeholders, to hear their views about where the organisation should focus its attention next, to impact most on patient care and how staff feel about working here. Listening into Action (LiA) Croydon Health Services NHS Trust was described has having made significant progress following a routine inspection by the Care Quality Commission last year. One patient quoted in the inspection report (published October 2015) said that they were gobsmacked at how much better it is than before. Another told the CQC that staff [were] gentle, kind and caring, and that care at Croydon University Hospital had improved since their last admission. In its findings, the CQC commented how the Trust s use of Listening into Action had helped to deliver many of these improvements. CHS was one of 26 trusts in England to pioneer LiA as a key way of working. Now in its fifth year (2016/17), LiA is no longer something that we do. It is now the way that staff at all levels of the organisation approach continuous improvement initiatives. Visit Name PLACE Patient-Led Assessments April 2015 CQC Trust wide June 2015 LSA SoM Audit 30 June 2015 SGS Surveillance Audit 13 July 2015 Executive Lead / Clinical Director Allan Morley Helen Astle Rosol Hamid Allan Morley Directorate Estates and Facilities Trust wide Integrated Women, Children and Sexual Health Estates and Facilities No. of Recommendations /Actions No. of Open Actions Outcome/ Comments Actions relating to Privacy and Dignity still remain open. Providing dedicated quiet rooms and communal/social areas on the wards still remain a challenge due to lack of suitable space. Recommendations and actions are managed and monitored by the QESP Team Closed. All 4 Domains were met. No significant issues or concerns were raised. Recommendations included ensuring every midwife had an annual review and setting up a system of support and advocacy for women and midwives which will replace Statutory Supervision. Recommendations implemented and set out in the SoM Strategy. Closed. 7 minor nonconformities identified. All actions have been corrected. RAG Amber Amber Green Green Our adoption of LiA, and the positive impact that it is continuing to have in enabling staff to drive forward change, was one of four CHS finalists at this year s Health Service Journal Awards (November 2015). One of our other finalists was the Trust s success in reducing painful pressure ulcers for Croydon residents cared for in the community by 45% - almost twice the original target. This achievement was led by our nursing teams and was celebrated by Optimize nationally as the first of 100 Stories of Staff-Led Change across the NHS through Listening into Action. London Fire Brigade 15 July 2015 UKAS - CPA for Haematology 14 September 2015 Allan Morley Stella Vig Estates and Facilities Integrated Surgery, Cancer and Clinical Support No significant issues or concerns raised Closed. Lab maintains its CPA accreditation. All actions have been completed and cleared by UKAS. Green Green Through LiA we have galvanised staff and generated real momentum. CHS was the first NHS Trust in the country to be awarded LiA accreditation for staff engagement and empowerment (March 2015). HTA Mortuary Visit 15 September 2015 Stella Vig Integrated Surgery, Cancer and Clinical Support 4 0 Closed. No significant issues or concerns. All recommendations completed. HTA have revisited to see temp storage unit and signed it off. It is now ready to use. Green 96 97

50 Visit Name Executive Lead / Clinical Director Directorate No. of Recommendations /Actions No. of Open Actions Outcome/ Comments RAG Visit Name Executive Lead / Clinical Director Directorate No. of Recommendations /Actions No. of Open Actions Outcome/ Comments RAG London Fire Brigade Lee Harvey Post Fire Audit (Duppas Ward) 1 October 2015 London Fire Brigade Familiarisation Visit (Sean Almandras) 9 October 2015 Aseptic Services Unit Audit of Pharmacy - Quality Assurance Pharmacy Services 13 October 2015 Peer Review of Services for People with Haemoglobin Disorders UK Forum for Haemoglobin Disorders & the UK Thalassaemia Society and Sickle Cell Society 22 October 2015 Allan Morley Allan Morley Stella Vig Stella Vig Estates and Facilities Estates and Facilities Integrated Surgery, Cancer and Clinical Support Integrated Surgery, Cancer and Clinical Support No significant issues or concerns raised This was a familiarisation visit and did not involve any audit, assessment or inspection. There were 7 majors, 9 moderate and 4 minor deficiencies. The outstanding actions are on-going long term. There are funding issues with regards setting up a computer system and getting an up-to-date software for labelling, recording batch numbers and training staff. No immediate risks. Final report due in April Green Green Amber Awaiting Report HESL Quality Visit - Trust Wide Reviews 27 January 2016 London Fire Brigade Familiarisation Visit 9 October 2015 London Fire Brigade Familiarisation Visit 28 January 2016 The London Screening Programme - QA Visit Colposcopy - 5th round 04 February 2016 Michael Burden Michael Burden Allan Morley Rosol Hamid PGMC PGMC 7 7 Estates and Facilities Integrated Women, Children and Sexual Health 0 0 Recommendations and actions plan received. The Trust to send our response for each action back to HESL by the 10th March Recommendations and actions plan received. The Trust to send our response for each action back to HESL by the 10th March This was a familiarisation visit and did not involve any audit, assessment or inspection. - - Awaiting draft report. Report just received. Working on actions to address recommendations. Amber Amber Green Awaiting Report JAG Accreditation / Assessment October 2015 SGS Surveillance Audit January 2016 Enas Lawrence Allan Morley Estates and Facilities Estates and Facilities Passed assessment and CUH has received accreditation for The 2 major non-conformities are: Failure to check, test and record findings of heat sealers. Products with labels that had been misprinted excluding expiry date with affected products to customers. Green Amber Croydon Environmental Health Officer Visit for Catering 9 March 2016 Quality Assurance Visit of Antenatal & Newborn Screening Programmes 16 March 2016 Allan Morley Rosol Hamid Estates and Facilities Integrated Women, Children and Sexual Health Trust already in negotiation to provide chef laundry service and started the process of providing food service training. CUH is in negotiation with Croydon College to develop a training partnership and apprenticeship schemes. Amber Awaiting Report HESL Quality Visit: Foundation 27 January 2016 Michael Burden PGMC Recommendations and actions plan received. The Trust to send our response for each action back to HESL by the 10th March Amber 98 99

51 Statement from Croydon Clinical Commissioning Group Croydon CCG welcomes the opportunity to be able to comment on Croydon Health Services NHS Trust Quality Account 2015/16. We congratulate the Trust on its achievements this year and in particular note the CQC areas that were marked as outstanding or good in their review earlier in the year. We recognise the Trust s priority areas for 2016/17 as consistent with those identified by the CCG and we look forward to continuing to work with the Trust and supporting them in the delivery of these priorities and the sustainability of the improvements made to date. The Trust has continued to work hard to improve its safety culture, which reflects the on-going and required commitment to improve incident reporting with a focus on the no harm and low level reporting. Although the most up to date data on NRLS shows CHS have increased reporting incidents from 2,053 in Oct 14 to March 15 to 2,319 April 15 to September 15, there are still delays in reporting (50% of incidents submitted more than 11 days after occurrence in Oct 14 to March 15 against 21 days in April 15 to September 15) and CHS are still one of the lowest reporting organisations. We have seen an increase in SI reporting over the past six months, and note the improvement in the quality of the investigation reports. The CCG continue to work collaboratively with CHS, gaining assurance of lessons learnt, and noting the actions taken through the monthly SI Review Meetings, whose Term of Reference have recently been amended to enable this to be embedded. The CCG note the work the Trust has done to ensure improvements in performance for the 18 weeks RTT and the cancer pathway is recognised and noted; we hope to see these improvements continue. While The CCG recognises the challenges of the Emergency Department decant, the performance against the NHS four Hour standard continues to be underperforming and the CCG would like to see some sustainable improvement in achieving the agreed trajectory. The continued positive improvement on harmfree care is recognised, and the system wide work on the reduction on pressure ulcers is to be commended. While the Trust is pleased with its progress on the acute kidney injury CQUiN, the CCG would like to see this to be continued and an improvement for 2016/17 in the quality and outcomes for this group of patients. While the CCG recognise the improvements and increased awareness of Sepsis in the Trust there is some outstanding work required to have this embedded across the Trust in all patient areas. Croydon CCG remains committed to the collaborative working with the Trust for 2016/17, to assist the delivery of its priorities and actions, and to achieve and sustain improvements

52 Statement from Healthwatch Croydon The Quality Account is the local NHS service providers opportunity to reflect on quality improvements in 2015/16 and consider areas for further quality improvement in the year ahead. This Quality Account was considered by the local and national Patient Champion Healthwatch Croydon (Health and Social Care 2012 legislation), and in their opinion it is a fair reflection of the range and the quality of healthcare services provided by Croydon Hospital Services (CHS). Healthwatch Croydon (HWC) collates and analyses the views, experiences, needs and requirements of Croydon residents by asking people at healthcare venues, attending community groups, utilising online feedback tool NHS Choices and many more ways. Patient, carer and staff experience and involvement The local Healthwatch in Croydon would like to congratulate CHS on providing staff and patient engagement opportunities. Listening into Action is a valuable initiative. We recognise there is more work to be done by CHS, particularly in service user and carer involvement, developing and implementing this initiative to bring about genuine user led service improvements. Reference to patients being involved in quality governance procedures should be succinctly documented and on the website. Alongside the Clinical Commissioning Group (CCG, funder of NHS services), better informed decision-making by involving patients by experience would potentially save CHS resources. Co-designing by patients and clinical staff may have improved experience and reduced costs. CHS have action plans, and monitoring of CQC recommendations are in process. HWC is surprised CHS nor its commissioner the CCG have a Patient Forum or is linked in with a local Patient Forum, the engagement strategy is not available in the public domain. There are a number of ways in which CHS obtains and acts upon patient and relatives/carers views, it would have been useful to have a summary. More radical patient engagement needs to be implemented, the Quality Account states CHS is to improve Friends Family Test (FFT) response and through providing excellent care be the provider of choice for our patients and their families (page 19). FFT responses are very positive but, partly negated by low response rate. FFT is largely a satisfaction tick box exercise. The PALS service logs formal complaints, some complaints are dealt with informally, and logging these would provide shared learning. Friends and Family Test (FFT) is a satisfaction tool not a robust mechanism of using feedback for service design or ongoing improvement. FFT is not helpful to plan ahead and use resources effectively and efficiently. Older People Wards The real time quality dashboards available on the wards and electronically is excellent best practice. In some areas such as some of the Older People s Wards the patient and carer feedback is quite low overall and not improved from last year. It is not clear what the plan of action is to improve the poor performing areas. HWC offers its support to CHS to maintain its focus on three key areas: improving patient healthcare; improving staff experience; patient and carer involvement. CHS have many opportunities to use external organisations such as HWC to support the quality improvements and financial viability. CHS is to continue to report on low level quality issues, rather than only the serious incidents. CHS to continue to engage in staff/patient/carer feedback as this enables CHS to deal with ongoing delivery issues and track improvement over time. Orthotics and Physiotherapy departments HWC would like to thank CHS for accommodating two Enter and View visits this year, trained volunteers ask staff and patients their experience, and make observations on the healthcare venue environment. HWC hope the volunteers recommendations are embedded in the administration, staff support and culture. The reports are available in the Enter and View section on the HWC website: CHS priorities for 2016/17 (Page 12) In reference to CHS priorities for 2016/17 (Page 12), HWC would have welcomed the opportunity to develop CHS s priorities in discussion with their Clinical Directorates, Patient Safety and Mortality Committee, the CCG as referenced in the Quality Account. HWC hope this window is still open. HWC were at the Care Quality Commission stakeholder event with commissioners and CHS to work through the requires improvement recommendations; attendees agreed community ownership, mandatory training and shared decision-making. If the aim is for the Perfect Patient Journey then priorities should be set more clearly around improving outcomes for patients, how the hospital admittance and discharge feels from the patient and carer perspective and assess CHS impact on a patient s terms. What support do nurses have to speak to their team and patients? How long did it take? What was the patient s experience of the environment and treatment and care from the Doctor/Consultant? Accountable Provider Alliance (APA) with continued consultation of coworking with patients and professionals is positive initiative. The Edgecombe Unit opened in November 2015, with consultant/nurse led acute provision, has reduced waiting times, increased seven-day working and improved joined up working with community services

53 The CHS performance for 2015/16 highlights eight amber areas and all others are green but they are not specific enough to measure the impact. Reducing pressure ulcers and robust activity to ignite a positive staff culture is great but what shared decision-making, joint working mechanisms, assurance that co-design of commissioning are in place? It would be good to have more data about the outcomes for identified issues such as different ethnic groups and different life stages. It is commendable of CHS to appointment a Diversity/Inclusion Manager to address this. Safe, caring, effective, responsive and well-led HWC are pleased CHS are driven to continue to make improvements in quality, safety and patient experience particularly the need for a better working environment, improved educational opportunities, pay and a change in team culture. Transparent, Plain English, Accessible Website CHS would benefit greatly from clear, plain English policies and procedures on the CHS website, for professionals and patients. Documents such as the Carers and Visitors guide, the Complaints procedure to be in the public domain in a clear and simple form is an opportunity for CHS to lighten their burden in the busy Croydon market and the UK s era of austerity. CHS would benefit greatly from plain English information on the CHS website for patient and carer healthcare advice and support. Many other organisations are available to support CHS to improve the lives of Croydon residents. Healthwatch across England has long been championed by user groups and the NHS. CHS can benefit from patient, carer and staff input. HWC would however like to see CHS recognise the value and contribution of user led community groups and voluntary organisations in delivering well-commissioned services such as Rapid Assessment Medical Unit (RAMU, the side-line venue to A&E). We would like to support CHS initiatives to work closely with user groups for a safe, caring, effective, and responsive and well-led CHS. Integrated Care Another issue that regularly comes up in discussions with service users is how services join up. Service users report issues with hospital, community health services and social services not working together and also with wider services like housing, police, and voluntary sector services. It would be good to see how Accountable Provider Alliance sets up quality working arrangements with the local service providers it works alongside and how that is monitored. There have been problems in accessing some quality results from departments. Recently CHS have only been reporting Serious Incidents. To ensure that safety of patients HWC would like CHS to carry out regular quality audits of departments. Some of HWC s community feedback has identified a problem with pressure ulcers, and inconsistent communication between health professionals in the community. CHS to provide assurances that once a patient is admitted a discharge plan is formed involving relevant patient, staff and carer within 24 hours of the decision to transfer care. We congratulate CHS for producing this comprehensive Quality Account 2015/16. It would help if it there could be a clear focused summary about quality and patient feedback: what is not working well and the plan rectify it. Thank you to CHS for their continued commitment to keeping Croydon well. To find out more about your local and national official Patient Champion or get involved in influencing change please visit the HWC website: or attend HWC s Patient Experience Panel at am on Fridays at The Carers Centre on 24 George Street info@healthwatchcroydon.co.uk Diversity Croydon is one of the most culturally diverse parts of the country but it is also has some of the most deprived areas. Yet there is no joint partnership between decision-makers/budget holders across Croydon for a concrete target set out to monitor whether different BAME communities access, experience or have different outcomes of services. HWC recommend that in the next Quality Account CHS includes a section on diversity, pulling together in one section all the work it is doing to ensure that it is offering a quality service to all sections of the local population

54 Statement from Croydon Council s Health, Social Care and Housing Scrutiny Sub Committee Members of the Health, Social Care and Housing Scrutiny Sub Committee welcomed the opportunity to comment on the draft quality account. Whilst the Committee acknowledged and welcomed the actions and initiatives being explored to improve the quality and standards of care currently provided within the acute and community arms of the organisation, it recognised that there is still a journey towards success and to sustain overall satisfactory standards of care. The Committee were encouraged to hear that nationally and at a local level the Trust s reputation appeared to be improving and that the Care Quality Commission are in agreement, as demonstrated by the outcome of the re-inspection and subsequent quality improvement plan, with four must dos and 31 should dos. This could be attributed to the reorganisation at executive level and that all senior and non-executive posts have been filled. The Trust boasts an A&E rating within the top five across London; this rating should be improved upon, following delivery of the new A&E department in the summer of The current temporary premises has resulted in a dip in performance but has been successful in achieving collaborative working between the wards and A&E with ward based colleagues supporting A&E during this unsettling time by accepting service users. Recruitment and retention remains an issue as key roles across all disciplines are nationally hard to recruit to. Croydon being further disadvantaged with its outer London weighting status coupled with the central government decision to remove the nursing bursary; the full impacts of which are still to materialise. The Committee questioned the effectiveness and the validity of the results arising from the national Friends and Family test as the information reporting is limited and cannot provide qualitative data. You explained that the Trust is seeking alternative methods of feedback using electronic devices. We will welcome this development and believe it will capture a more representative sample of patient s views. You continue to build on the success of your Listening into Action programme which you have extended to various specialities and to service users, which you report has contributed to improvements in your work practices. This includes your current programme targeting the patient experience in your theatres. We look forward to helping you achieve even better standards of care for the residents of Croydon by building on our working relationship, while ensuring we remain a critical friend. The HealthWatch Croydon co-optee was able to report good feedback from their working relationship with the Trust which continues to be open and honest regarding information requests and enter and views. The home by lunch discharge initiative when working well reduces the length of stay. Pharmacy and medical assessments at an earlier stage also contribute to the success

55 Statement form External Auditors Independent Auditor s Limited Assurance Report to the Directors of Croydon Health Services NHS Trust on the Annual Quality Account We are required to perform an independent assurance engagement in respect of Croydon Health Services NHS Trust s Quality Account for the year ended 31 March 2016 ( the Quality Account ) and certain performance indicators contained therein as part of our work. NHS trusts are required by section 8 of the Health Act 2009 to publish a quality account which must include prescribed information set out in The National Health Service (Quality Account) Regulations 2010, the National Health Service (Quality Account) Amendment Regulations 2011 and the National Health Service (Quality Account) Amendment Regulations 2012 ( the Regulations ). Scope and subject matter The indicators for the year ended 31 March 2016 subject to limited assurance consist of the following indicators: Percentage of patients risk-assessed for venous thromboembolism (VTE) Percentage of patient safety incidents resulting in severe harm or death We refer to these two indicators collectively as the indicators. Respective responsibilities of directors and auditors The directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the Regulations). In preparing the Quality Account, the directors are required to take steps to satisfy themselves that: the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and the Quality Account has been prepared in accordance with Department of Health guidance. The Directors are required to confirm compliance with these requirements in a statement of directors responsibilities within the Quality Account. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that: the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations; the Quality Account is not consistent in all material respects with the sources specified in the NHS Quality Accounts Auditor Guidance issued by DH in March 2015 ( the Guidance ); and the indicators in the Quality Account identified as having been the subject of limited assurance in the Quality Account are not reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance. We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations and to consider the implications for our report if we become aware of any material omissions. the Quality Account presents a balanced picture of the Trust s performance over the period covered; the performance information reported in the Quality Account is reliable and accurate; there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice;

56 We read the other information contained in the Quality Account and consider whether it is materially inconsistent with: Board minutes for the period April 2015 to April 2016; papers relating to quality reported to the Board over the period June 2015 to March 2016; feedback from the Commissioners (Croydon CCG) dated June 2016; feedback from Local Healthwatch (Croydon) dated June 2016; the Trust s complaints report published under regulation 18 of the Local Authority, Social Services and NHS Complaints (England) Regulations 2009, dated feedback from the Croydon Overview and Scrutiny Committee as other named stakeholder involved in the sign off of the Quality Account, dated June 2016; the latest national patient survey dated June 2016; the latest national staff survey dated 2015; the Head of Internal Audit s annual opinion over the trust s control environment dated May 2016; the annual governance statement dated 31 May 2016; and the Care Quality Commission s Intelligent Monitoring Report dated May 2015; We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with these documents (collectively the documents ). Our responsibilities do not extend to any other information. This report, including the conclusion, is made solely to the Board of Directors of Croydon Health Services NHS Trust. We permit the disclosure of this report to enable the Board of Directors to demonstrate that they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permissible by law, we do not accept or assume responsibility to anyone other than the Board of Directors as a body and Croydon Health Services NHS Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing. Assurance work performed We conducted this limited assurance engagement under the terms of the guidance. Our limited assurance procedures included: evaluating the design and implementation of the key processes and controls for managing and reporting the indicators; making enquiries of management; testing key management controls; analytical procedures; limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation; comparing the content of the Quality Account to the requirements of the Regulations; and reading the documents. A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Account in the context of the criteria set out in the Regulations. The nature, form and content required of Quality Accounts are determined by the Department of Health. This may result in the omission of information relevant to other users, for example for the purpose of comparing the results of different NHS organisations. In addition, the scope of our assurance work has not included governance over quality or non-mandated indicators which have been determined locally by Croydon Health Services NHS Trust

57 3.3 Basis for qualified conclusion The indicator reporting the percentage of patients risk assessed for VTE did not meet the six dimensions of data quality in the following respects: Accuracy, validity and reliability The Trust operated a manual system to record the number of patients risk-assessed for VTE during the first six months of the year before changing to an electronic recording system for the second six months. Our testing of cases in the first six months identified cases where a VTE assessment had taken place, but the Trust were unable to prove that the case was included within the numerator. The extent of these data accuracy errors prevents us from forming a conclusion on whether the indicator is reasonably stated in all material respects in accordance with the Regulations and the accuracy, validity and reliability dimensions of data quality set out in the Guidance. Qualified conclusion Based on the results of our procedures, with the exception of the matter(s) reported in the basis for qualified conclusion paragraph above, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2016: the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations; the Quality Account is not consistent in all material respects with the sources specified in the Guidance; and the indicators in the Quality Account subject to limited assurance have not been reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance. Grant Thornton UK LLP Melton Street London NW1 2EP 30 June

58 Appendix 1 National Clinical Audits - actions to improve Quality BTS Pleural Procedures Current practice in the Trust is partially compliant to the standards audited. There are plans to set up an ambulatory pleural service and the use of an online pleural pro forma. BTS Pulmonary Rehabilitation Organisational Audit Supervised Pulmonary Rehabilitation is offered to and available across the range of severity. Patients admitted with Chronic Obstructive Pulmonary Disease are seen by Croydon Respiratory Team during admission and booked into Pulmonary Rehabilitation on discharge. PR capacity and flexibility is in line with Quality Standards. CHS Pulmonary Rehabilitation services have signed up for the pilot accreditation scheme for Pulmonary Rehabilitation Services in the UK. CEM Assessing Cognitive Impairment in the ED The Trust was partially compliant to the standards audited. All patients have an Early Warning Score assessment. Trust performance of 98% for Early Warning Score is above the national median. All clinicians have been sent an reminder on screening patients over 75 for dementia/delirium in the Emergency Department. This was also raised at departmental meetings. CEM Initial Management of Fitting Child The Trust was partially compliant to the standards audited. Following publication of the report, a pro forma was developed for recording information about fits. Patient and carers are provided information leaflets for febrile seizures and first fit from patient.co.uk. Training is on-going for the management and treatment of hypoglycaemia. CEM Mental Health in ED Mental Health risk pro forma was developed and is used for all patients presenting with psychiatric complaints. There is a 24/7 Psychiatry Liaison nurse presence in the Trust under a contract with South London and Maudsley NHS Foundation Trust. A rapid cycle audit is planned to be carried out to assess the documentation of provisional diagnosis. MBRRACE Perinatal Mortality Surveillance report A local audit to monitor compliance of maternity guidelines on booking and antenatal care has been undertaken. All stillbirths are offered Post Mortem and annual stillbirth audit reviews whether PM is offered in all cases. A bereavement midwife is in post to ensure follow-up. Cases are followed up using a database. There is an allocated lead for the reporting of information to MBRRACE. All cases are reported and currently up to date for transfers. National Audit of Rheumatology and Early Inflammatory Arthritis The Trust has actively participated in the Early Inflammatory Arthritis national audit and is committed for participation in future national audits. Data collection of follow up data items needs to be addressed and will be improved on. Patient Reported Experience Measures (PREM_ were conducted locally in early 2015 and the overall response was patients reporting positive experience of care provided. The PREM will be repeated in late Drug information and condition information leaflets are available in clinics. National Emergency Laparotomy Audit High risk emergency Laparotomy patients are cared for on the critical care unit dependent on the availability of ITU beds. This is not compliant at all times due to bed pressures. Hospital level expertise for care of older people is already in place. Local policy exists for management and identification of sepsis. Case submissions are regularly reviewed by the NELA Lead and CHS case ascertainment figures are one of the highest. National Joint Registry Following publication of the national report, the Trust has participated in local data validation/ compliance audit as part of urgent requirement to enhance the quality of the data National Joint Registry holds for the Trust. The purpose of this programme is to help hospitals assess data completeness and quality for hip and knee procedures submitted for the financial year 2014/15. Supported by NHS England, this data audit represents a significant programme to gauge and ensure that the quality of the data held by the registry is representative of activity, accurate and robust. The Trust is awaiting the findings of this exercise. National Oesophago-gastric Cancer Audit Trust is partially complaint to the standards audited. Oesophageal stent data is currently not recorded Plans are in place for this data to be recorded on the database for future submissions. A Gastro in reach same day service is to be established. National Pregnancy in Diabetes Audit Current practice is compliant with the national standards. Pre-pregnancy counselling service currently sits with GPs. The department is planning to assess the feasibility of setting up a pre-pregnancy counselling at the Trust to see women that are of fertile age group and would be seen and counselled about contraception, HbA1C and folic acid depending on the provision of funding Croydon Health Services Croydon NHS Trust Health Quality Services Account NHS Trust Quality Account

59 Audit Title Actions to improve quality AKI- Adding insult to injury Consider stopping nephrotoxics in all medical admissions Appendix 2 Local Clinical Audits: actions to improve Quality Case review Learning Disabilities Intrapartum CTG audit Are we using continuous CTG appropriately and interpreting the CTG trace correctly in the management of labour? Highlight at trust and nurse induction training who should add the learning disabilities flag Community Learning Disability Nurse to add flag to Cerner on case load Create work flow for ward clerk to give advice as to when to add flag Continue to give feedback via LD health update as to who is adding flags To liaise with Provider Commissioning Team to ensure HCP are part of the provider contract To include the EPEX community LD team data for the next audit Highlight good practice on monthly scorecard To Datix issues regarding the discharging process/patient experience To highlight key development areas for MCA compliance to trust MCA lead To continue to monitor MCA compliance for adult patients with learning disabilities as part of the ALN function Re-audit in 2016 Cord gases need to done and documented for all pathological CTG and operative deliveries Re-audit in 6 months time according to the latest NICE guidelines published in December 2014 Regular weekly CTG meeting to be attended by maternity clinical staff Audit Title Actions to improve quality Tongue Tie Audit To continue to monitor the number of tongue tied referrals on the database and produce 6 monthly reports Syphilis Guidelines Audit Doctors to ensure repeat testing before prescribing treatment Health Visitors to ensure PN tab is complete are reviewing each patient with syphilis Still Birth Audit (2014 data) Future audit to include the incidents of reduced foetal movements in line with findings and the implementation of growth charts from MBRRACE report (2015) Implementation of growth charts in line with findings MBRRACE report (2015) Management of Coeliac disease in Croydon Assessing The Use Of The VTE Risk Assessment Tool And Chemoprophylaxis In Elective Gynae Admissions EBME Medical Equipment Management Walk around Denosumab for the prevention of osteoporotic fractures in postmenopausal women Findings have been presented at Croydon Coeliac UK group To complete a larger survey with the help of Coeliac UK group Assign responsibility for prescription as it is currently unclear which leaves opportunities for error. The recommendation of this audit is that the surgeon is responsible for performing both the VTE assessment and prescription. To include VTE assessment and prescription as part of the recovery checklist to ensure patients are not sent up to the ward if this has been overlooked. To alter the VTE assessment tool to require completion of prescription or documentation of reasons for withholding before assessment can be completed. Include mandatory field for weight on VTE prescription/ weight documentation on Cerner as part of theatre checks. Signs in theatre reminding team to assess & prescribe. Re-audit in 6 months to see if department improving. Complete this audit across other surgical specialties to identify whether this is a departmental or trust-wide problem Issues need to be updated onto Datix Report findings to the ward matrons Continue to carry out monthly audits Creation of Denosumab database Clinical Audit of Surgical Weekend Handover Management of Acute Gout at CUH Staff to be reminded through training about the use of hospital syringe pump monitoring forms for all T34 syringe pumps The monitoring form will be redesigned to include a reminder of the first 15 minute check of infusions, needleless devise use reminder and confirmation of action by staff and re-order of site of the pump section Hospital monitoring form to be given to staff at all training sessions to familiarise staff and allow questions to be asked if unclear Update the T34 syringe pump policy on intranet to incorporate changes to hospital monitoring form Entry of monitoring form onto Cerner Further education of staff working in key areas regarding best practice in the management of gout to include presentation of audit findings at Clinical Governance, development of posters clearly explaining key themes of gout management in AMU, geriatric and orthopaedic wards, facilitate the availability of patient information leaflets in key areas to inform patients about gout and lifestyle changes that can improve disease course, direct education of FY1 cohort during their regular training sessions Gout order set to put onto Cerner Consider the development of the Gout guideline, readily available on the intranet, to aid decision making when prescribing therapy for acute gout flares, consider the development of paragraph of general information that can be inserted into patients discharge summaries informing GP s of best practice in Gout and associated co-morbidity management Discuss with coding department whether a specific code for pseudo gout exists, or whether it needs to be created Elective Surgery Coding Audit in Trauma and Orthopaedics Re-audit when theatres run by Surginet Improve documentation Surgical Scrub Audit To share clinical result with Clinical Leads Re-audit June

60 Audit Title Actions to improve quality Audit Title Actions to improve quality Case review Learning Disabilities Highlight at trust and nurse induction training who should add the learning disabilities flag Community Learning Disability Nurse to add flag to Cerner on case load Create work flow for ward clerk to give advice as to when to add flag Continue to give feedback via LD health update as to who is adding flags To liaise with Provider Commissioning Team to ensure HCP are part of the provider contract To include the EPEX community LD team data for the next audit Highlight good practice on monthly scorecard To Datix issues regarding the discharging process/patient experience To highlight key development areas for MCA compliance to trust MCA lead To continue to monitor MCA compliance for adult patients with learning disabilities as part of the ALN function Re-audit in 2016 Still Birth Audit (2014 data) Sharps Bin audit June 2015 (retrospective registration) Trust guidelines to be reviewed to clearly state delivery of Magnesium Sulphate from 24+0 weeks 34+0 weeks gestation Magnesium Sulphate to be delivered in all cases where indicated Education of department about delivery of antenatal therapies When re-auditing the audit tool needs to be updated for the Sharps bins held in the nurses cars Re-audit in 6 months Intrapartum CTG audit Are we using continuous CTG appropriately and interpreting the CTG trace correctly in the management of labour? Cord gases need to done and documented for all pathological CTG and operative deliveries Re-audit in 6 months time according to the latest NICE guidelines published in December 2014 Regular weekly CTG meeting to be attended by maternity clinical staff Neonatal oxygen saturation screening Inform midwives of excellent results regarding numbers of babies screened Emphasise the need for review if results are abnormal Educate regarding optimal timeframe of 6-24 hours of age Tongue Tie Audit To continue to monitor the number of tongue tied referrals on the database and produce 6 monthly reports Emergency CT Head Requests Post Head Injury Continue to ensure standards are maintained Monitor sustained improvement after a suitable timeframe Still Birth Audit (2014 data) Future audit to include the incidents of reduced foetal movements in line with findings and the implementation of growth charts from MBRRACE report (2015) Implementation of growth charts in line with findings MBRRACE report (2015) Audit of the completion of the Dermatology Department Skin Surgery Safety Checklist Training and awareness regarding the completion of the surgical checklists will be carried out at departmental meetings, surgical governance meetings and by to clinicians who only work in the department once or twice a week Ensure the availability of checklists for the surgical lists Encourage clinicians to complete the checklists themselves Clinical Audit of Surgical Weekend Handover Management of Acute Gout at CUH Staff to be reminded through training about the use of hospital syringe pump monitoring forms for all T34 syringe pumps The monitoring form will be redesigned to include a reminder of the first 15 minute check of infusions, needleless devise use reminder and confirmation of action by staff and re-order of site of the pump section Hospital monitoring form to be given to staff at all training sessions to familiarise staff and allow questions to be asked if unclear Update the T34 syringe pump policy on intranet to incorporate changes to hospital monitoring form Entry of monitoring form onto Cerner Further education of staff working in key areas regarding best practice in the management of gout to include presentation of audit findings at Clinical Governance, development of posters clearly explaining key themes of gout management in AMU, geriatric and orthopaedic wards, facilitate the availability of patient information leaflets in key areas to inform patients about gout and lifestyle changes that can improve disease course, direct education of FY1 cohort during their regular training sessions Gout order set to put onto Cerner Consider the development of the Gout guideline, readily available on the intranet, to aid decision making when prescribing therapy for acute gout flares, consider the development of paragraph of general information that can be inserted into patients discharge summaries informing GP s of best practice in Gout and associated co-morbidity management Discuss with coding department whether a specific code for pseudo gout exists, or whether it needs to be created Termination of Pregnancy Audit Controlled Drugs Audit To develop an FA referral database to:- track referrals to SGH to monitor whether patients are being managed at SGH or should be returning to CUH for followup; track each patient s timeline, including date of referral from screening to FM/ SGH, the date of decision for TOP and date of TOP; Document actions such as administration of anti-d for rhesus negative patients returning from undergoing procedures at SGH; Be able to audit at the end of each year To develop a new revised pathway and update the guidelines accordingly; this process has already been started To allocate roles and responsibilities as set out in the guidelines To clarify in the guidelines the timeframe for offering treatment, particularly with respect to the 14 day target and whether this is from initial referral for further investigation or from the date of decision for TOP To send the HSA4 forms that were completed but not sent To refer to the yellow form as the HSA4 form in the guideline, to incorporate a link in the TOP guidance for completing the HSA4 form electronically and to include an explanation of what to do with the HSA4 form once it has been completed Separate CD record book for patients own medication Ensure all new CD ward registers have the notice about correct entries of CD Ensure wards keep CD keys separately Consult with matrons to consider the possibility of enforcing 24 hour checks which include monthly expiry date checks Consult with matrons to discuss the possibility of ensuring that all nurses include CD checks within the discharge process. Surgical Scrub Audit To share clinical result with Clinical Leads Re-audit June 2015 Uterine fibroid embolisation - Technical aspects Radiologists should remain mindful of radiation dose and try to minimise the use of digital subtraction angiography Continuous re-audit of UFE as recommended by NICE 118 Croydon Health Services Croydon NHS Trust Health Quality Services Account NHS Trust Quality Account

61 Audit Title Actions to improve quality Audit Title Actions to improve quality Anaesthetic recordkeeping in Obstetrics Mortality outlier- Bronchitis Newborn Infant Physical Examination (NIPE) Audit 2015 Improve documentation by anaesthetics Continue review all mortalities within the trust to ensure the all deaths are reviewed and that reviews are undertaken rigorously Submit report to the CQC Staff to reminded to enter the date and time of the examination onto NIPE smart Medical reports and EHCP proposals: an audit of the time taken for medical reports to be submitted for children undergoing EHCP assessment The identification and management of children with neutropenic sepsis EHCP reports on children known to service should be submitted within 6 weeks Arrange regular dedicated Education Medical clinics Highlighting importance to families of the education clinics Production of a specific clerking proforma for paediatric oncology patients on Cerner which will improve awareness of the oncology supportive guideline and help to improve documentation. Documentation Audit to assess the compliance in VIP scoring for intermittent cannulas used in the Neonatal Unit Present the findings of this audit at the next nurses Practice Update meeting. Ensure that all nurses who are certified to administer IV medication are aware of the need and importance of the VIP score chart and its completion. Ensure that the nurses are aware that the IV cannula is inspected and the score sheet must complete at least twelve hourly. The VIP score chart must be attached to the drug chart to remind staff to complete the chart and for its filling in the notes. Another Audit to be under taken in April to see if the compliance has improved. Antenatal Booking Audit 2015 Recommend that the next audit look at the first trimester USS in relation to the booking appointment Use of insulin infusions and concomitant basal insulin prescribing Re-fresher course for Nursing staff Re-education of junior doctors Empower pharmacists to monitor practice VTE Chemoprophylaxis Following Elective Gynae Surgery Assign responsibility for prescription from to surgeon Include VTE assessment and prescription as part of the recovery checklist Alter the VTE assessment tool to require completion of prescription or documentation of reasons for withholding before assessment can be completed Include mandatory field for weight on VTE prescription Include weight documentation on Cerner as part of theatre checks Signs in theatre reminding team to assess and prescribe Re-audit in 6 months to see if department is improving Complete this audit across other specialities to identify whether this is a departmental or trust-wide problem Pulmonary Embolism in Ambulatory Emergency Care ED Education this may prevent AECU & AMU admissions with MSK CP Well s Score and PESI score charts on walls of AECU and ED to provide easy access to calculation Make the MedCalc App available for staff to calculate Well s and PESI scores on the go in the same way the BNF is available electronically on staffs phones. Cerner pro forma for all? PEs to aid diagnosis and severity assessment MUST All MUST scores are to be recorded accurately and electronically on Cerner as per policy standard Electronic Nurse Care Plans started April 2015 Ward based training: wards to receive 1 to 1 training with diabetic assistant Matron and Senior sister representation and attendance at Nutrition and Hydration task force to own this quality standard and improve performance management Improve accuracy of reporting by extending data collection to 100% of patients

62 Appendix 3 Glossary Acute Trust A trust is an NHS organisation responsible for providing a group of healthcare services. An acute trust provides hospital services (but not mental health hospital services, which are provided by a mental health trust). Clostridium difficile or C. Difficile Commissioners of services Commissioning for Quality and Innovation Clostridium difficile also known as C.difficle or C. diff, is a gram positive bacteria that causes diarrhea and other intestinal disease when competing bacteria in a patient or persons gut are wiped out by antibiotics. C. difficile infection can range in severity from asymptomatic to severe and lifethreatening, especially among the elderly. People are most often nosocomially infected in hospitals, nursing homes, or other institutions, although C. difficile infection in the community and outpatient setting is increasing. Organisations that buy services on behalf of the people living in the area that they cover. This may be for a population as a whole, or for individuals who need specific care, treatment and support. For the NHS, this is done by primary care trusts and for social care by local authorities. The host commissioner was NHS Croydon (Croydon PCT) and their delegated managerial function is led by the SWL Acute Commissioning Unit (SWL ACU). Please note that during 2012/13 local implementation of the Health and Social Care Act was undertaken and Croydon Clinical Commissioning group has now been established. From1 April 2013 this is now a statutory commissioning authority. High Quality Care for All included a commitment to make a proportion of providers income conditional on quality and innovation, through the Commissioning for Quality and Innovation (CQUIN) payment framework. Visit: Publications and statistics/publications/ PublicationsPolicyAndGuidance/DH_ Audit Commission The Audit Commission regulates the proper control of public finances by local authorities and the NHS in England and Wales. The Commission audits NHS trusts, primary care trusts and strategic health authorities to review the quality of their financial systems. It also publishes independent reports which highlight risks and good practice to improve the quality of financial management in the health service, and, working with the Care Quality Commission, undertakes national value-for-money studies. Visit: Complaint Croydon Clinical Commissioning Group (CCG) An expression of dissatisfaction with something. This can relate to any aspect of a person s care, treatment or support and can be expressed orally, in gesture or in writing. The CCG became legally responsible for commissioning/buying healthcare services for Croydon residents from 1st April 2013 as authorized by NHS England Board (of trust) The Trust Board is accountable for setting the strategic direction of the Trust, monitoring performance against objectives, ensuring high standards of corporate governance and helping to promote links between the Trust and the community. Culture Datix Learned attitudes, beliefs and values that define a group or groups of people. This is the name of the incident reporting system at Croydon Health Services NHS Trust. Care Quality Commission The Care Quality Commission (CQC) replaced the Healthcare Commission, Mental Health Act Commission for Social Care Inspection in April The CQC is the independent regulator of health and social care in England. It regulates health and adult social care services, whether provided by the NHS, local authorities, private companies or voluntary organisations. Visit: Department of Health The Department of Health is a department of the UK government but with responsibility for government policy for England alone on health, social care and the NHS. Cerner millennium system (CRS) Cerner millennium is the newly introduced IT system at Croydon Health Services. This is an electronic system that captures patient data. Dignity Dignity is concerned with how people feel, think and behave in relation to the worth or value that they place on themselves and others. To treat someone with dignity is to treat them as being of worth and respect them as a valued person, taking account of their individual views and beliefs. Clinical Audit Clinical Coding Clinical audit measures the quality of care and services against agreed standards and suggests or makes improvements where necessary. Clinical Coding Officers are responsible for assigning codes to all inpatient and day case episodes They use special classifications which are assigned to and reflect the full range of diagnosis (diagnostic coding) and procedures (procedural coding) carried out by providers and enter these codes onto the Patient Administration System. The coding process enables patient information to be easily sorted for statistical analysis. When complete, codes represent an accurate translation of the statements or terminology used by the clinician and provides a complete picture of the patient s care. Discharge EWS Family and Friends Test The point at which a patient leaves hospital to return home or be transferred to another service, or the formal conclusion of a service provided to a person who uses services. This is the Early Warning System is based on vital signs such as blood pressure, heart and breathing rates. Introduced in 2013 it is an opportunity for family and friends to give feedback to hospitals regarding their care and experience. Clinical Directorate During 2015/16 Croydon Health Services clinical services were organised into three Directorates: Integrated Adult Care; Integrated Surgery, Cancer & Clinicla Support; Integrated Women s, Children s & Sexual Health. The directorates are led by a Clinical Director

63 Foundation trust Global Trigger Tool (GTT audit) Healthcare A type of NHS trust in England that has been created to devolve decision-making from central government control to local organisations and communities so they are more responsive to the needs and wishes of their local people. NHS foundation trusts provide and develop healthcare according to core NHS principles free care, based on need and not on ability to pay. NHS foundation trusts have members drawn from patients, the public and staff, and are governed by a board of governors comprising people elected from and by the membership base. The Global Trigger Tool is a recognised and validated audit tool developed by the Institute for Healthcare Improvement (IHI) In Boston USA. It can be used as part of an organisation s safety improvement programme to identify and so learn about harm and safety incidents which occur as part of the patient s treatment. Twenty records are reviewed each month using the GTT and the findings plotted over time on a run chart to establish a harm rate. Barts and The London NHS Trust has been undertaking GTT auditing since Healthcare includes all forms of healthcare provided for individuals, whether relating to physical or mental health, and includes procedures that are similar to forms of medical or surgical care but are not provided in connection with a medical condition, for example cosmetic surgery. Malnutrition Universal Screening Tool (MUST) National Confidential Enquiry into Patient Outcome and Death - NCEPOD National Institute for Health and Clinical excellence National Patient Safety Agency MUST is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese. It also includes management guidelines which can be used to develop a care plan. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reviews clinical practice and identifies potentially remediable factors in the practice of anaesthesia and surgical and medical treatment. Its purpose is to assist in maintaining and improving standards of medical and surgical care for the benefit of the public. It does this by reviewing the management of patients and undertaking confidential surveys and research, the results of which are then published. Clinicians at Croydon Health Services NHS Trust participate in national enquiries and review the published reports to make sure any recommendations are put in place. The National Institute for Health and Clinical Excellence is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. Visit: The National Patient Safety Agency is an arms-length body of the Department of Health, responsible or promoting patient safety wherever the NHS provides care. Visit: Healthcare- associated infection Hospital Episode Statistics An avoidable infection that occurs as a result of the healthcare that a person receives. Hospital Episode Statistics is the national statistical data warehouse for England of the care provided by NHS hospitals and for NHS hospital patients treated elsewhere. NHS Number This is the national unique patient identifier that makes it possible to share patient information across the whole of the NHS safely, efficiently and accurately. The NHS Number is fundamental to the development of the National Programme for IT. Indicators for Quality Improvement The Indicators for Quality Improvement (IQI) are a resource for local clinical teams providing a set of robust indicators which could be used for local quality improvement and as a source of indicators for local benchmarking. The IQI can be found on the NHS Information Centre website at: measur ing-for-quality improvement. NHS Litigation Authority (NHSLA) The NHSLA is a special health authority in the NHS responsible for handling negligence claims made against NHS bodies in England. In addition it has developed an active risk management programme to raise NHS safety standards and reduce the incidence of negligence. It also monitors human rights case law on behalf of the NHS, co-ordinates claims for equal pay in the NHS and handles Family Health Service appeals (i.e. disputes between doctors, dentists, opticians and pharmacists and NHS Primary Care Trusts). Information Governance The structures, policies and practice to ensure the confidentiality and security of health and social care service records, especially clinical records which enable the ethical use for the benefit of the individual to whom they relate and for the public good. Overview and scrutiny committees Since January 2003, every local authority with responsibilities for social services (150 in all) have had the power to scrutinise local health services. Overview and scrutiny committees take on the role of scrutiny of the NHS not just major changes but the ongoing operation and planning of services. They bring democratic accountability into healthcare decisions and make the NHS more publicly accountable and responsive to local communities. Quality and Clinical Governance Committee This committee monitors, reviews and reports on the quality of services provided by the Trust. This includes the review of: Governance, risk management and internal control systems to ensure that the Trust s services deliver safe, high quality, patientcentred care. Performance against internal and external quality improvement targets and follow-up whenever required. Progress in implementing action plans to address shortcomings in the quality of services if any have been identified. Patient A person who receives services provided in the carrying on of a regulated activity. This is the definition of service user provided in the Health and Social Care Act 2008 (Regulated Activities) Regulations HealthWatch MRSA HealthWatch is made of individuals and community groups which work together to improve local services. Their role is to find out what the public like and dislike about local health and social care. They will then work with the people who plan and run these services to improve them. This may involve talking directly to healthcare professionals about a service that is not being offered or suggesting ways in which an existing service could be made better. HealthWatch also have powers to help with the tasks and to make sure changes happen. Methicillin-Resistant Staphylococcus Aureus (MRSA) is a bacterium responsible for several difficult-to-treat infections in humans. MRSA is, by definition, any strain of Staphylococcus aureus bacteria that has developed resistance to antibiotics including the penicillins and the cephalosporins. MRSA is especially troublesome in hospitals, where patients with open wounds, invasive devices and weakened immune systems are at greater risk of infection than the general public. Patient and Public Voice Periodic reviews This used to be called Patient and Public Involvement (PPI) but has recently been renamed. It highlights ways in which the public and patients are involved in a trusts patient care. Periodic reviews are reviews of health services carried out by the Care Quality Commission (CQC). The term review refers to an assessment of the quality of a service or the impact of a range of commissioned services, using the information that the CQC holds about them, including the views of people who use those services. Visit: periodicreview2009/1 0.cfm 124 Croydon Health Services Croydon NHS Trust Health Quality Services Account NHS Trust Quality Account

64 Picker Institute UK The Picker Institute Europe is a not-for-profit organisation that supports the healthcare sector to help make patients views count in healthcare. It works to build and use evidence to champion the best possible patient-centred care working with patients, professionals and policy makers to achieve the highest standards of patient experience. In Europe and the UK, Picker research and gather patient s views of healthcare using surveys, focus groups and other methods as for example by supporting the national survey programme in the NHS for the Care Quality Commission. Privacy and dignity To respect a person s privacy is to recognise when they wish and need to be alone (or with family or friends), and protected from others looking at them or overhearing conversations that they might be having. It also means respecting their confidentiality and personal information. To treat someone with dignity is to treat them as being of worth and respect them as a valued person, taking account of their individual beliefs. Providers Providers are the organisations that provide NHS services, for example NHS trusts and their private or voluntary sector equivalents. Quality monitoring A continuous system of monitoring to ensure that local quality measures are effective. Quality monitoring is part of quality assurance. Registration From April 2009, every NHS trust that provides healthcare directly to patients must be registered with the Care Quality Commission (CQC). Research Clinical research and clinical trials are an everyday part of the NHS. The people who do research are mostly the same doctors and other health professionals who treat people. A clinical trial is a particular type of research that tests one treatment against another. It may involve either patients or people in good health, or both. Safeguarding Ensuring that people live free from harm, abuse and neglect and, in doing so, protecting their health, wellbeing and human rights. Children, and adults in vulnerable situations, need to be safeguarded. For children, safeguarding work focuses more on care and development; for adults, on independence and choice. Secondary Uses Service (SUS) A single repository of person and care event level data relating to the NHS care of patients, which is used for management and clinical purposes other than direct patient care. These secondary uses include healthcare planning, commissioning, public health, clinical audit, benchmarking, performance improvement, research and clinical governance. Visit: using-this-service/data-quality-dashboards Adult social care TSocial care includes all forms of personal care and other practical assistance provided for people who by reason of age, illness, disability, pregnancy, childbirth, dependence on alcohol or drugs or any other similar circumstances, are in need of such care or other assistance. For the purposes of the Care Quality Commission, it only includes care provided for, or mainly for, people over 18 years old in England. This is sometimes referred to as adult social care ViEWS VitalPAC Early Warning System is a tool for bedside evaluation incorporated into VitalPAC. It is based on seven physiological parameters: pulse; temperature; systolic blood pressure; respiratory rate; AVPU (the level to which the patient responds), oxygen saturation, plus the patient s inspired oxygen requirements. VitalPAC An electronic track and trigger system that provides a recording mechanism for patient s vital signs and essential screening tools. The data entered generates an Early Warning Score (EWS) and when appropriate prompts the clinical practitioner to escalate the patient s condition appropriately. 126