Patient Experience Quarterly Report Q2 2018/19 (July October 2018) 3 December 2018 Safe & Effective Kind & Caring Exceeding Expectation Agenda Item No: 7.2
Trust Board Report Meeting Date: 3 December 2018 Title: Patient Experience Quarterly Report Q2 2018/19 (July October 2018) Executive Summary: Action Requested: For the attention of the Board This report provides an update to the Board of the progress of agreed patient experience metrics, an overview of key issues arising out of feedback from patients, carers and relatives about their experience of care and an overview of progress of work programmes to improve the experience of patients at RWT. Divisional dashboards are attached which detail performance at divisional level and also show comparisons against national averages where available. Receive Compliance with statutory regulations for complaint handling i.e. The NHS and Social Care complaint Regulations 2009 1 Complaint handling approach based on the principles of good complaints handling. These have been published by the Parliamentary and Health Service Ombudsman and endorsed by the Local Government Ombudsman and the principles are: Assure Getting it right Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement Compliance with all mandatory patient surveys. Advise Alert Number of cases breaches occurred. Internal data for complaints management. Calculations made against organisational timeframe in accordance with complaints policy. The Royal Wolverhampton Trust are below national results for FFT recommendation rate None Author + Contact Details: Tel 01902 695363 alison.dowling1@nhs.net Links to Trust Strategic Objectives 1. Create a culture of compassion, safety and quality 2. Proactively seek opportunities to develop our services 1 http://www.legislation.gov.uk/uksi/2009/309/pdfs/uksi_20090309_en.pdf
Resource Implications: None CQC Domains Equality and Diversity Impact Safe: patients, staff and the public are protected from abuse and avoidable harm. Effective: care, treatment and support achieves good outcomes, helping people maintain quality of life and is based on the best available evidence. Caring: Staff aim to involve and treat everyone with compassion, kindness, dignity and respect. Responsive: services are organised so that they meet people s needs. Well-led: the leadership, management and governance of the organisation make sure it's providing high-quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. N/A Risks: BAF/ TRR Risk: Appetite Public or Private: Other formal bodies involved: References NHS Constitution: None Risk will be dependent upon compliance with statutory timeframes for complaint handling and PHSO recommendations. Public None In determining this matter, the Board should have regard to the Core principles contained in the Constitution of: Equality of treatment and access to services High standards of excellence and professionalism Service user preferences Cross community working Best Value Accountability through local influence and scrutiny Page 2 of 11
Report Details 1 Formal Complaints The Trust received 110 formal complaints in Q2 2018/19, compared to 86 in Q1 2018/19. This represents an overall increase of 28% when compared to the previous quarter and an increase of 8% compared to Q2 in 2017/18. The top 3 categories were General Care of Patient, Clinical Treatment and Diagnosis. In Q2 18/19, 99 complaints were closed compared to 84 in Q1 18/19, which is an increase of 15%. From the 99 cases closed 100% of complaints were investigated and responded to within the organisational timeframe of 30 working days or with consent to breach which shows consistency with the previous two quarters 100% compliancy (Q4 2017/18 and Q1 2018/19). This quarter Divisions 2 and 3 have seen an increase in the number of complaints received (77% and 27% respectively) with Division 1 experiencing a 22% decrease. The volume of complaints received this quarter compared to the number of inpatient episodes equates to 0.3%. No new complaints were received for Estates and Facilities or Corporate Directorates which is consistent with Q1. One case was re-opened and closed for Estates and Facilities in Q2 2018/19 within the 30 working day timeframe. In Q2 2018/19, from the 99 cases closed it can be noted that 100% of complaints were investigated and responded to within the organisational timeframe of 30 working days. In accordance with the Complaints Management Policy OP08 consent to breach was agreed due to extenuating circumstances or complexity for those cases which exceeded the 30 working day timeframe. In terms of outcomes for all closed complaints (60%) were not upheld, with 34% partially and 5% upheld compared to 68% of cases not upheld, 27% partially and 5% upheld in Q1. It is pleasing to note that all the Division s 1 (58%); 2 (65%) and 3 (56%) are above the national average of 35.7% for complaint cases not being upheld, and again all divisions are significantly lower than national average of 33.60% for cases upheld. The outcome of a complaint is determined by the investigating officer and is substantiated by information gained as part of the investigation process and categorised using the methodology used by NHS Digital. Their rationale to determine the outcome of a complaint is that if a complaint is received which relates to one specific issue and substantive evidence is found to support the complaint, then the complaint should be recorded as upheld. Where there is no evidence to support any aspects of a complaint this should be recorded as not upheld. If one or more of the issues complained about are upheld (but not all), the complaint should be recorded as partially upheld. As in Q1 the key theme, general care of patient features across all Divisions, with the sub-subject of general lack of care which can relate to a perceived delay in receiving treatment and attention from the nursing/clinical staff. However of all the cases attributed to this category there was only one case where the outcome was upheld. Each quarter a summary of all actions is provided to the divisional management teams in order to assist in promoting an ethos of reflection and learning Trust wide and to ensure that accountability at divisional level is customary. In conjunction with the information provided on the Divisional Dashboards the Patient Experience Team liaise Page 3 of 11
with relevant directorates to monitor and ensure compliance to identified actions. Data from the various feedback mechanisms such as complaints, PALS concerns and FFT is triangulated and used as a trigger for the areas which will be subject to inclusion in the Patient Experience Outreach program. The feedback received during outreach is fed back directly to the area concerned in real time, which allows for any immediate changes required to be made in order to improve the current patient experience. 16 complaints were reopened this quarter compared to 12 complaints in Q1. All complaints where a further letter is received are reviewed by the Deputy Head of Patient Experience. The rationale for re-opening a complaint is determined by whether all aspects of the initial complaint were fully responded to. This quarter, 3 cases were referred to the PHSO for consideration which represents 2.72% of the total complaints received. These cases relate to Community Adults, Renal and Renal and Haematology (joint). In terms of outcomes from investigations undertaken by the PHSO and completed, there were 6 cases which were closed in this period of which 3 were not upheld (Trauma & Orthopaedics, Dermatology and AMU/Respiratory); 2 were partly upheld (Gynaecology and Oncology) with the identified failures relating to documentation, record keeping and delay in receiving diagnostic tests (CT scan). The investigation into one case was suspended as the patients family no longer wished to continue with the complaint. There was no financial redress for those cases where the outcome was partially upheld. The PHSO refer to their Principles of Remedy when determining the outcome of their investigations and recommendations. The rationale for partially upholding these complaints was because they consider that poor service has led to injustice or hardship. Where a complaint has been partly or fully upheld the Trust will be asked to provide an action plan which sets out how it will improve services in the areas where the failings have been identified. Any identified learning can be shared Trust wide via the Risky Business newsletter. To enhance the learning process and share good practice the Patient Experience Team will, in conjunction with their complaints awareness training, approach the PHSO to deliver some bespoke training to investigating offers around the investigative process and how to compose a complaint response which is open, honest and meets the needs of the complainant. This will help to further reduce the number of complaints re-opened. There has been a 6% quarter on quarter reduction in the volume of PALS concerns received Trust wide (Quarter 1 285; Quarter 2 268), although the top 3 categories have remained consistent (General Care of Patient, Delay and Attitude). Friends and Family Test As at September 2018, it is noted that the Trust has an overall FFT recommendation rate of 92% and a response rate of 21%. (NHS England no longer report on an overall recommendation rate). It is pleasing to note that the Trust remains above the national average for recommendation rates for Outpatients and some Maternity areas, as have the response rates for the Emergency Department, Inpatients & Daycase and Outpatients. The Patient Experience Team has designed promotional leaflets and posters to raise awareness of FFT in conjunction with implementing an outreach service. Page 4 of 11
Further promotional work undertaken for FFT for Paediatrics has seen an increase in the surveys undertaken and responses received with the Paediatric Emergency Department and Children s Ward reporting recommendation rates of 96% and 100% respectively. The Trusts FFT providers have updated the paediatric locations on their system which will allow for additional surveys to be undertaken in each of these internal and external areas. This will provide the directorate with more meaningful data and assist the Patient Experience Team in their outreach approach. Appendices 1 Emerging Issues/Themes and Assurance 2 Q2 2018/19 Dashboards for Division 1, 2 and 3 Page 5 of 11
OVERVIEW REPORT TO BOARD The key headlines/issues and levels of assurance are set out below, and are graded as follows: Assurance level* Colour to use in Assurance level* column below Assured Green there are no gaps in assurance Partially assured Amber - there are gaps in assurance but we are assured appropriate action plans are in place to address these Not assured Red - there are significant gaps in assurance and we are not assured as to the adequacy of current action plans If red, commentary is needed in Next Actions to indicate what will move the matter to full assurance Key issue Below national results for FFT recommendation rate Assurance level* Committee update Next action(s) Each the reports in relation to FFT are analysed and where appropriate, the lowest five performing areas for response and recommendation rate are targeted with direct work for improvement. Timescale March 2019 Compliance with statutory regulations for complaint handling i.e. The NHS and Social Care complaint Regulations 2009 2 Outreach to be undertaken in conjunction with the dissemination of promotional FFT material to raise awareness. Ensuring complaints training delivered annually and is based on principles from the PHSO, and this is also reflected in the current policy. Complaint handling approach based on the principles of good complaints handling. These have been published by the Parliamentary and Health Service Ombudsman and endorsed by the Local Government Ombudsman and the principles are: Additional Bespoke complaints training to be delivered by the PHSO focussing on the investigation process and composition of response letters. March 2019 2 http://www.legislation.gov.uk/uksi/2009/309/pdfs/uksi_20090309_en.pdf Page 6 of 11
Key issue Getting it right Being customer focused Being open and accountable Acting fairly and proportionately Putting things right Seeking continuous improvement Compliance with all mandatory patient surveys. Assurance level* Committee update Next action(s) Timescale Page 7 of 11
Appendix 1 Theme Number of cases breaches occurred. Emerging issues/themes and Assurance Specific Item Reviewed (Data source) Specific data in relation to complaints management for Q2 activity Information used to make the judgement of assurance (inc independent assurance indicate timeliness by completing next column) Positive Negative Internal data for complaints management. Calculations made against organisational timeframe in accordance with complaints policy. These are not necessarily statutory timescales. Internal data although is nationally reported. Comparisons against previous quarters previously meant there had been a downward trend of compliance although since the new policy this has subsequently reduced. IA * (use key belo w) Emerging Issue/Outcome and any on-going risk (So what factor) 3 Low compliance with timescales given in complaints policy or no compliance with ensuring consent sought from complainant. Audit of six s indicated high level of extensions sought completed. Action required Lead Action due date Audit of complaint checklist outcomes to continue to ensure full compliance with the policy Council of Members to undertake complaints audit to give assurance around compliance with the NHS complaint regulations and outcomes. A Dowling A Dowling March 2019 March 2019 Non-compliance with identified local and Trust wide actions. Below national results for FFT Monitoring of complaint outcome recommenda tions. NHS England and on TDA Comparisons of results Reputational damage for noncompliance with recommendations. Low comparison for some areas, 3 Low compliance with recommendations noted on action plans. 3 Potential for recommendation To monitor continual recommendation rates ly and compare to national/regional average. (a) Patient Experience to A Dowling Patient Experience March 2019 Page 8 of 11
Theme recommendation rate Percentage of FFT non-recommend for some areas above 10%. Specific Item Reviewed (Data source) website. NHS England and on TDA website. Information used to make the judgement of assurance (inc independent assurance indicate timeliness by completing next column) Positive Negative published on websites and those received from our FFT provider. Directorate information not reported on nationally although the response rate is greater for some. Directorate information not reported on nationally although affects Trust s national average score. IA * (use key belo w) Emerging Issue/Outcome and any on-going risk (So what factor) rate to continue to decline when compared to national and regional averages. 3 High % of non - recommend may be indicator for declining care although must be taken into context for volume of survey responses. Action required Lead Action due date deliver some outreach sessions for areas where higher than 10% would not recommend. (b) Wards C22 newly appointed receptionist to speak to patients/relatives on the ward on a weekly basis. (a) Play specialists are targeting children in PAU, A21 and Day Care specifically to encourage submission of FFT. Team Senior Sister Matron Plant Dec 2018 Dec 2018 FFT provider to include specific community areas in the ly FFT report. This will enable Matron and Matron Winfield/ Patient Experience Team Dec 2018 Page 9 of 11
Theme FFT lack of uptake on survey for community and paeds areas. Specific Item Reviewed (Data source) NHS England and on TDA website. Information used to make the judgement of assurance (inc independent assurance indicate timeliness by completing next column) Positive Negative Internal data for complaints management received for the quarter. Directorate information not reported on nationally Directorate information not reported on nationally although effects Trust s national average score. IA * (use key belo w) Emerging Issue/Outcome and any on-going risk (So what factor) 3 Lack of surveys in key areas does not allow accurate information to identify declining performance of delivery of care. Action required Lead Action due date Patient Experience Team to target underperforming areas and include in outreach. (b) Any independent assurance provided in the above table is time limited please indicate (x) the overall level of independent assurance based on descriptions below (where applicable in the IA* column above). 3 *** Recent (less than one year old) independent assurance. 2 ** Less Recent (more than one less than two years old) independent assurance. 1 * Historical (more than two years old) independent assurance. Dec 2018 March 2019 Page 10 of 11
Appendix 2 - Dashboard Page 11 of 11
Patient Experience Feedback - Division One Quarter Two 2018/19 Formal Complaints, PALS Concerns and Compliments Complaints Received by Directorate Top Five Themes of Closed Complaints Response s were closed within 30 days or consent to breach was sought. However: (9 cases) 31-40 days (5 cases) 51-60 days (3 cases) Over 60 days (16 cases) 30 days or less Total complaints recorded represent a decrease of 18% Highlights PHSO 2 cases closed this quarter T&O not upheld; Gynaecology partly upheld with no financial redress. No new cases referred. FFT recommendation rate for all inpatient areas is rated amber/green (80% and above). Obstetrics and Gynaecology have seen a 64% decrease in the number of complaints received this quarter. Lowlights General Surgery have received the highest volume of complaints this quarter. Actions FFT promotional leaflet to be devised by Patient Experience Team. Outcomes for complaints closed RWT Outcomes (Div 1) NHS Digital National Average 58% Not upheld 35.7% Not upheld 39% Partially upheld 30.7% Partially upheld 3% Upheld 33.6% Upheld Safe & Effective Kind & Caring Exceeding Expectation MI_4906014_14.11.18_V0.1
Division 1 Quantitative (Response s) Inpatients Division 1 2 3 4 5 6 Responses Eligible Last RR Safe & Effective Kind & Caring Exceeding Expectation Response A12 1 10 1 0 0 0 0 11 45 35% 24% A14 1 19 5 1 0 0 0 25 72 30% 35% A21 1 14 0 0 0 0 0 14 6 20% 233% A23 1 17 2 1 0 0 0 20 89 32% 22% A5 1 10 4 0 0 0 0 14 58 32% 24% A6 1 12 0 0 2 0 0 14 49 30% 29% A9 SEU 1 57 13 3 1 5 1 80 294 24% 27% B14 1 55 9 0 0 2 1 67 166 38% 40% B8 1 36 8 0 1 0 0 45 139 40% 32% C39 BSSU 1 46 13 1 1 1 0 62 151 41% 41% D7 Gynae 1 52 13 3 1 1 1 71 164 37% 43% HILTON 1 44 15 1 0 0 1 61 132 41% 46% ICCU 1 0 0 0 0 0 0 0 5 0% 0% Antenatal 1 2 3 4 5 6 Last Total Total Total 0 0 0 0 0 0 0 0 Birth 1 2 3 4 5 6 Last RR Response Birth CDS 2 0 0 0 0 0 1% 1% MLU 25 1 0 0 0 0 19% 13% Total 27 1 0 0 0 0 10% 7% Postnatal Ward 1 2 3 4 5 6 Last Total Total Total 0 0 0 0 0 0 0 0 Postnatal Community 1 2 3 4 5 6 Last Total Total Total 0 0 0 0 0 0 0 0 Day Cases 1 2 3 4 5 6 Responses Eligible Last RR Response ADML 102 18 2 1 1 1 125 359 35% 35% C41W 13 3 0 0 0 0 16 89 16% 18% DCU 71 10 1 0 0 0 82 235 37% 35% DURNALL 28 7 1 1 2 0 39 312 13% 13% MJW 94 13 3 0 1 3 114 311 36% 37% REHAB DAY UNIT Outpatients Trustwide 4 1 0 0 0 0 5 5 100% 100% 1 2 3 4 5 6 Total Eligible Last RR Response Total 3396 710 92 40 58 41 4337 20137 20% 22% Trust vs National Average Response Non Department Trust National Average A&E 17% 13% Inpatients & Day Case 31% 25% Outpatients 22% 7% Birth 7% 21% A&E 86% 87% Inpatients & Day Case 94% 96% Outpatients 95% 94% Birth 100% 97% A&E 9% 7% Inpatients & Day Case 3% 2% Outpatients 2% 3% Birth 0% 1% Qualitative (Recommendation ) Inpatients Total Surveys Non % Non % A12 11 11 0 100% 86% 100% A14 25 24 0 0% 100% 96% A21 14 14 0 0% 100% 100% A23 20 19 0 0% 93% 95% A5 14 14 0 0% 87% 100% A6 14 12 2 14% 100% 86% A9 SEU 80 70 6 8% 86% 88% B14 67 64 2 3% 93% 96% B8 45 44 1 2% 98% 98% C39 BSSU 62 59 1 2% 94% 95% D7 Gynae 71 65 2 3% 94% 92% HILTON 61 59 0 0% 96% 97% ICCU 0 0 0 0% 100% 0% Antenatal Total Surveys Non % Non % Total 0 0 0 0% 0% 0% Birth Total Surveys Non % Non % Birth CDS 2 2 0 0% 100% 100% MLU 26 26 0 0% 100% 100% Total 28 28 0 0% 100% 100% Postnatal Ward Total Surveys Non % Non % Total 27 26 0 0% 96% 96% Postnatal Community Total Surveys Non % Non % Total 0 0 0 0% 0% 0% Day Cases Total Surveys Non % Non % A16 Appleby 125 120 2 2% 96% 96% MJW 114 107 1 1% 97% 94% C41 16 16 0 0% 91% 100% DCU 82 81 0 0% 99% 99% DURNALL 39 35 3 8% 83% 90% REHAB DAY UNIT 5 5 0 0% 100% 100% Total 381 364 6 2% 95% 96% Outpatients (Trust wide) Total Surveys Non % Non % Total 4337 4106 98 2% 94% 95% RAG Rating Key 90% and above recommendations 80 89% 79% and below MI_4906014_14.11.18_V0.1
Patient Experience Feedback - Division Two Quarter Two 2018/19 Formal Complaints, PALS Concerns and Compliments Complaints Received by Directorate Top Five Themes of Closed Complaints Response s were closed within 30 days or consent to breach was sought. However: (9 cases) 31-40 days (4 cases) 41-50 days (1 cases) 51-60 days (1 cases) Over 60 days (34 cases) 30 days or less Total complaints recorded represent a increase of 77% Highlights PHSO 2 cases closed this quarter (Oncology/ Haematology partly upheld with no financial redress. AMU/ Respiratory not upheld). 3 new cases referred (Renal/ Haematology - jointly; Renal and Community Adults). FFT recommendation rate for the majority of inpatient areas is rated amber/green (80% and above). Lowlights Ward C25 FFT recommendation rate is rated red (score below 79% or below) quarter on quarter. Actions Division 2 - FFT promotional leaflet to be devised by Patient Experience Team. Outcomes for complaints closed RWT Outcomes (Div 2) NHS Digital National Average 65% Not upheld 35.7% Not upheld 33% Partially upheld 30.7% Partially upheld 2% Upheld 33.6% Upheld Safe & Effective Kind & Caring Exceeding Expectation MI_4906014_14.11.18_V0.1
Division 2 Quantitative (Response s) Emergency Department 1 2 3 4 5 6 Responses Eligible RR last Response AE 1046 211 64 43 95 19 1478 8246 18% 18% MIU 152 14 4 3 4 3 180 946 21% 19% ED > PAEDS 20 2 1 0 0 0 23 23 100% 100% PHOENIX 144 51 5 4 16 5 225 2282 10% 10% Total 1362 278 74 50 115 27 1906 11497 16% 18% Inpatients Division 1 2 3 4 5 6 Responses Eligible Last RR Response A7 2 3 0 0 0 0 0 3 12 31% 25% A8 2 4 3 0 0 0 0 7 24 18% 29% B11 CHU 2 7 2 0 0 0 1 10 46 29% 22% B12 ASU 2 13 1 0 1 0 0 15 54 30% 28% C15 2 4 4 0 0 1 0 9 55 23% 16% C16 2 4 4 0 0 1 0 9 38 24% 24% C17 2 4 0 1 0 1 0 6 19 28% 32% C18 2 2 3 1 1 0 0 7 36 34% 19% C19 2 12 2 0 0 0 0 14 49 14% 29% C21 AMU 2 37 18 1 1 2 1 60 263 23% 23% C22 2 3 0 0 0 0 0 3 25 12% 12% C24 2 13 2 2 1 0 0 18 65 31% 28% C25 2 4 3 1 0 2 0 10 44 16% 23% C35 Deansley 2 3 0 0 0 0 0 3 20 35% 15% FAIROAK 2 1 2 0 0 0 0 3 14 19% 21% W1 2 10 5 0 0 0 0 15 18 75% 83% W2 2 10 3 0 0 0 0 13 18 75% 72% W2 6 2 0 1 0 0 9 16 83% 56% Qualitative (Recommendation ) Emergency Department Total Surveys Non % Non Month % AE 1478 1257 138 9% 87% 85% ED > PAEDS 23 22 0 0% 100% 96% MIU 180 166 7 4% 91% 92% PHOENIX 225 195 20 9% 86% 87% Total 1906 1640 165 9% 87% 86% Inpatients Total Surveys Non % Non % A7 3 8 0 0% 100% 100% A8 7 7 0 0% 100% 100% B11 CHU 10 9 0 0% 93% 90% B12 ASU 15 14 1 7% 95% 93% C15 9 8 1 11% 91% 89% C16 9 8 1 11% 56% 89% C17 6 4 1 17% 71% 67% C18 7 5 1 14% 77% 71% C19 14 14 0 0% 100% 100% C21 AMU 60 55 3 5% 89% 92% C22 3 3 0 0% 50% 100% C24 18 15 1 6% 70% 83% C25 10 7 2 20% 89% 70% C35 Deansley 3 3 0 0% 88% 100% FAIROAK 3 3 0 0% 100% 100% W1 15 15 0 0% 83% 100% W2 13 13 0 0 83% 100% Trust vs National Average Department Trust National Average Day Cases 1 2 3 4 5 6 Responses Eligible Last RR Response C41W 13 3 0 0 0 0 16 89 16% 18% REHAB DAY UNIT Outpatients Trustwide 4 1 0 0 0 0 5 5 100% 100% 1 2 3 4 5 6 Total Eligible Last RR Response Total 3396 710 92 40 58 41 4337 20137 20% 22% *Please Note, national average taken from NHS England statistics for March, this figure will be updated on a quarterly basis Response Non A&E 17% 13% Inpatients & Day Case 31% 25% Outpatients 22% 7% Birth 7% 21% A&E 86% 87% Inpatients & Day Case 94% 96% Outpatients 95% 94% Birth 100% 97% A&E 9% 7% Inpatients & Day Case 3% 2% Outpatients 2% 3% Birth 0% 1% RAG Rating Key 90% and above recommendations 80 89% 79% and below Safe & Effective Kind & Caring Exceeding Expectation MI_4906014_14.11.18_V0.1
Patient Experience Feedback - Division Three Quarter Two 2018/19 Formal Complaints, PALS Concerns and Compliments Response s were closed within 30 days or consent to breach was sought. Highlights PHSO 2 cases closed this quarter where the outcome was not upheld. No new cases referred. 63% of the complaints closed were within the 30 working day timeframe. Complaints Received by Directorate Top Five Themes of Closed Complaints However: (4 cases) 31-40 days (2 cases) 41-50 days (10 cases) 30 days or less Total complaints recorded represent a increase of 23% Lowlights Primary Care received the highest volume of complaints for the quarter Actions Meeting taken place with contracted FFT provider in order to agree the specific Community Adult areas for survey. FFT promotional leaflet to be devised by Patient Experience Team. Outcomes for complaints closed RWT Outcomes (Div 3) NHS Digital National Average 56% Not upheld 35.7% Not upheld 25% Partially upheld 30.7% Partially upheld 19% Upheld 33.6% Upheld Safe & Effective Kind & Caring Exceeding Expectation MI_4906014_14.11.18_V0.1
Division 3 Quantitative (Response s) Location 1 2 3 4 5 6 Responses Eligible Response Paediatric Emergency Department 20 2 1 0 0 0 23 23 100% Children s Day Case 0 0 0 0 0 0 0 0 0% Children s Outpatients 3 0 0 0 0 1 4 6 67% Children s Ward (A21) 14 0 0 0 0 0 14 6 233% Community Children s Nursing Team Gem Centre (Clinical Suite) 0 0 0 0 0 0 0 0 0% 0 0 0 0 0 1 1 26 4% Health Visiting 0 0 0 0 0 0 0 0 0% Looked After Children s Service 0 0 0 0 0 0 0 0 0% Neonatal Unit 0 0 0 0 0 0 0 0 0% Paediatric Assessment Centre 0 0 0 0 0 0 0 0 0% Partnering Families Team 0 0 0 0 0 0 0 0 0% School Nursing 0 0 0 0 0 0 0 0 0% Transitional Care Unit 0 0 0 0 0 0 0 0 0% Total 37 2 1 0 0 2 42 61 69% Qualitative Feedback Community 1 2 3 4 5 6 Total Eligible Last RR Response Total 389 355 88% 91% 8 2% 335 37834 1% 1% Outpatients Trustwide 1 2 3 4 5 6 Total Eligible Last RR Response Total 3396 710 92 40 58 41 4337 20137 20% 22% *Please Note, national average taken from NHS England statistics for March, this figure will be updated on a quarterly basis Qualitative (Recommendation ) Location Total Surveys % Non Paediatric Emergency Department % 23 22 96% 0 0% Children s Day Case 0 0 0% 0 0% Children s Outpatients 4 3 75% 0 0% Children s Ward (A21) 14 14 100% 0 0% Community Children s Nursing Team Gem Centre (Clinical Suite) 0 0 0% 0 0% 1 0 0% 0 0% Health Visiting 0 0 0% 0 0% Looked After Children s Service 0 0 0% 0 0% Neonatal Unit 0 0 0% 0 0% Paediatric Assessment Centre Partnering Families Team 0 0 0% 0 0% 0 0 0% 0 0% School Nursing 0 0 0% 0 0% Transitional Care Unit 0 0 0% 0 0% Total 42 39 93% 0 0% Trust vs National Average Response Non Department Trust National Average A&E 17% 13% Inpatients & Day Case 31% 25% Outpatients 22% 7% Birth 7% 21% A&E 86% 87% Inpatients & Day Case 94% 96% Outpatients 95% 94% Birth 100% 97% A&E 9% 7% Inpatients & Day Case 3% 2% Outpatients 2% 3% Birth 0% 1% RAG Rating Key 90% and above recommendations 80 89% 79% and below Safe & Effective Kind & Caring Exceeding Expectation MI_4906014_14.11.18_V0.1